Transcript Philhealth core standards_MSA

PhilHealth Core Standards
PhilHealth Benchbook
• A yardstick against which the quality of health
care rendered by accredited health care
providers can be measured
• Contains accreditation standards that evaluate
processes and outcomes of health care
• Represents a significant change from the current
standards that govern only inputs to health care
Performance
Improvement
Patient Rights
and
Safe Practice
and
Environment
Organizational
Ethics
Patient Care
Information
management
Leadership and
Management
Human
Resources
Management
Element of a Performance Area
Goal:
Declares the overall intent of the
standards under it
Standard:
Statement of ideal performance
Criteria:
Provide specific and measurable indicators that
will help determine whether or not the standard
has been met
INDICATORS
– These are tools to monitor conformance to
standards with respect to specific criterion.
– Performance indicators of these 79 standards
have been developed by PhilHealth for your
guidance.
Benchbook Core Indicators
• Characteristics that should be present for a
hospital to function as a facility providing care,
treatment and diagnosis in a manner that is
safe and efficient for the patients and its staff.
• Non-negotiable, absence of any of them may
mean no accreditation
(Linden workshop 2007)
Scale for Scoring the Indicators
For Core indicators
• 1 = 0% compliance
• 4 = 100% compliance
Code
Evidence
SelfSurveyor
Assessment
score
score
Patient Care
2.3.2.c.1
Core
Chart Review
1
1
Patient chart from medical records
4
4
Note: The progress notes should be done
regularly and documented in the patient
chart either as separate “progress notes”
sheets or side notes in the doctor’s order
sheets.
Formula: Number of charts with progress
notes by attending health care
professional/ total number of charts
reviewed x 100
Sample size: Rule of 10
Performance Area
Standards
(79)
Criteria
(141)
Indicators
(239)
Core
Indicators
(51)
Patient Rights
6
14
19
1
Patient Care
30
75
112
15
Leadership & Mgt
5
4
14
3
HR Mgt
8
19
27
2
Info Mgt
5
11
15
3
Safe Practice
17
16
40
25
Improving Performance
7
2
12
2
4 Things Surveyors will do:
•
•
•
•
Review document – medical records
Interview staff including doctors
Interview patient to validate
Observe patient care processes and structure
Performance
Improvement
Patient Rights
and
Safe Practice
and
Environment
Organizational
Ethics
Patient Care
Information
management
Leadership and
Management
Human
Resources
Management
1. Patient Rights and Organizational Ethics
Standard 1: Organizational policies and procedures respect
and support patient right’s to quality care and their
responsibilities in that care
Criteria
Indicator
a. Informed consent is
1. All patient charts have
obtained from patients prior to signed informed consent
initiation of care
12
Examples
Performance
Improvement
Patient Rights
and
Safe Practice
and
Environment
Organizational
Ethics
Patient Care
Information
management
Leadership and
Management
Human
Resources
Management
2. Patient Care
Access
• 2 standards, 9 criteria, 10 indicators, 4 core
Entry
• 5 standards, 13 criteria, 17 indicators, 1 core
Assessment
• 6 standards, 15 criteria, 21 indicators, 4 core
Care planning
• 3 standards, 6 criteria, 6 indicators
Implementation of care • 7 standards, 26 criteria, 45 indicators,
Evaluation of care
Discharge
• 3 standards, 5 criteria, 7 indicators
• 4 standards, 6 indicators, 1 core
5 core
2. Patient Care
• 1.Access
Standard 2:
Physical access to the organization and its services is facilitated
and is appropriate to patients' needs.
Criteria
a. Entrances and exits are
clearly and prominently
marked, free of any
obstruction and readily
accessible.
Indicator
1. CORE
Presence of entrances and exits
that are readily accessible and free
from obstruction
Evidence:
1. Entrance and exit signs. Check ER,
OPD, wards, ICUs, OR, imaging and
laboratory
2. Entrances and exits are accessible
and free from any obstruction
2. Patient Care
• 3. Assessment
Standard 1:
Each patient's physical, psychological and social status is
assessed.
Criteria
Indicator
a. An appropriately comprehensive
history and physical examination is
performed on every patient within
24 hours from admission. The
history includes present illness, past
medical, family, social and personal
history.
1. CORE
All patients have
comprehensive history and
PE within 24 hours from
admission
Evidence:
– Patient chart from wards AND
ER
• NOTE: comprehensive
history includes present
illness, review of systems,
past medical, family and
personal history
2. Patient Care
• 3. Assessment
• Standard 2:
Appropriate professionals perform coordinated and sequenced
patient assessment to reduce waste and unnecessary repetition.
Criteria
Indicator
c. Previously obtained information is 1. CORE
reviewed at every stage of the
All patient charts have
assessment to guide future
progress notes by doctors
assessments
Progress Notes
Evidence:
Patient chart from
medical records
Note: The progress notes should
be done regularly and
documented in the patient chart
either as separate 'progress
notes' sheets or side notes in
the doctor's order sheets.
• Progress notes format in:
–
–
–
–
Subjective
Objective
Assessment
Plan
PROGRESS NOTES
2. Patient Care
• 3. Assessment
Standard 3:
Assessments are performed regularly and are determined by
patient's evolving response to care.
Criteria
d. Qualified personnel give
patients for surgery pre-operative
physical and pre-anesthetic
assessment.
Indicator
3. CORE
All patients for surgery have
undergone pre-operative
anesthetic assessment
PRE-ANESTHESIA
EVALUATION FORM
Evidence:
– Patient chart from
medical records
(surgery patients)
• Note: Look for preoperative anesthetic
evaluation in the patient
chart. Pre-operative
assessment should be done
for patients requiring more
than local anesthesia.
PRE-ANESTHESIA EVALUATION FORM
2. Patient Care
• 5. Implementation of care
Standard 5:
Drugs are administered in a standardized and systematic
manner in the provider organization.
Criteria
Indicator
a. Drugs are administered in a 2. CORE
timely, safe, appropriate and All drugs are administered in a
controlled manner
timely, safe, appropriate and
controlled manner to the right
patient
Evidence:
– Patient chart from the
medical records
• For the timeliness of drug
administration, check the
hospital policy. If hospital does
not have policy, frequency of
drug administration in the chart
should be checked and validate
it thru patient interview
2. Patient Care
• 5. Implementation of care
• Standards 2.5.5:
Drugs are administered in a standardized and
systematic manner in the provider organization.
Criteria
c. Only qualified personnel
order, prescribe, prepare,
dispense and administer
drugs
Indicator
1. CORE
All doctors, nurses and
pharmacists have updated
licenses
Evidence:
– Randomly check the licenses of doctors,
nurses and pharmacists if they are updated
2. Patient Care
• 7. Discharge
Standard 1:
The discharge plan is part of the patient's care
plan and is documented in the patient chart
Criteria
X
Indicator
1. CORE
All charts have discharge
plans
Evidence:
– Patient chart from
medical records, look at
the discharge orders. It
should contain all of the
following:
1. May go home order
2. Home medications
(if applicable)
3. Follow up
visits/schedule
4. Home care/advise
Performance
Improvement
Patient Rights
and
Safe Practice
and
Environment
Organizational
Ethics
Patient Care
Information
management
Leadership and
Management
Human
Resources
Management
Performance
Improvement
Patient Rights
and
Safe Practice
and
Environment
Organizational
Ethics
Patient Care
Information
management
Leadership and
Management
Human
Resources
Management
Standard 1
Planning ensures that appropriately trained and
qualified (and where relevant, credentialed) staff
are available to undertake the type and level of
activity performed by the organization. This
includes those who are consulted when suitable
expertise is not available within the organization.
Criteria
4.1.1.b
The organization documents and follows policies
and procedures for hiring, credentialing, and
privileging of its staff
Indicator
4.1.1.b.2
Presence of policies and procedures for
credentialing and privileging of staff (CORE)
Evidence
• Document Review
– Policies and procedures on
credentialing and privileging of staff
Performance
Improvement
Patient Rights
and
Safe Practice
and
Environment
Organizational
Ethics
Patient Care
Information
management
Leadership and
Management
Human
Resources
Management
Information management
Data
collection,
aggregation
and use
• 4 standards
• 7 criteria, 8 indicators, 1
core
Records
Management
• 1 standard
• 2 criteria, 4 indicators, 1
core
Information management
Standard
5.1.1 Relevant, accurate, quantitative and qualitative data are collected
and used in a timely and efficient manner for delivery of patient care
and management of services.
Criteria
Indicator
e. Policies and
procedures on record
storage, retention and
disposal are documented
and monitored
5.1.1.e.1
Policy on record storage,
safekeeping, retention and
disposal
CORE
Evidence
• Policies and Procedures on record
storage, safekeeping and maintenance,
retention and disposal.
For out-patients: records
should be kept for 10 years
after last consultation or visit
Standard
5.2.1. Clinical records are readily accessible to facilitate patient care,
are kept confidential and safe, and comply with all relevant statutory
requirements and codes of practice
Criteria
Indicator
b. The organization has policies
and procedures, and devotes
resources, including
infrastructure, to protect records
and patient charts against loss,
destruction, tampering and
unauthorized access or use. Only
authorized individuals make
entries in the patient chart
5.2.1.b.1
Presence of procedures to
protect records and patient
charts against loss,
destruction, tampering and
unauthorized access or use
CORE
Evidence
• Document
– Policies and procedures on records management
for the entire hospital to maintain privacy,
accuracy, and prevent loss and destruction
• Observation
– Observe nurses in the wards and records
personnel on how they protect patient chart
against loss, tampering, and unauthorized use
Performance
Improvement
Patient Rights
and
Safe Practice
and
Environment
Organizational
Ethics
Patient Care
Information
management
Leadership and
Management
Human
Resources
Management
OUTLINE
5 Sub-areas (Goals)
• Standards
– Criteria
» Indicators
25 core indicators
SAFE PRACTICE AND ENVIRONMENT
Sub area
Standard
Criteria
Indicators
Core
indicators
Patient and Staff
Safety
3
11
17
10
Maintenance of
the Environment
of Care
4
-
5
3
Infection Control
5
4
10
9
Equipment and
Supplies
3
1
3
1
2
-
3
2
Energy and
Waste
Management
6.1 Patient and staff safety
Standard 3: The organization routinely collects and evaluates information to
improve the safety and adequacy of the environment of care
Criteria
Indicator
b. An incident reporting system identifies
potential harms, evaluates causal and
contributing factors for the necessary
corrective and preventive action
1. Presence of incident
reporting system/sentinel
event monitoring system
(CORE)
Evidence
Incident/ sentinel event reports or
communications/memoranda/orders/proceedings on sentinel events
Interview: How the incident reporting system works?
PhilHealth Definition of
SENTINEL EVENT
• Refers to injuries caused by medical
management (and not necessarily the disease
process) that either caused death, prolonged
hospitalization or produced a disability during
the time of confinement or by the time of
discharge.
Incident Reporting System
Adverse events occurrence
report to TQS within 24-48 hours
root cause analyses / structure, process & system review
monitor improvement
make necessary changes
Incidences
Transfusion reactions
Complications during
moderate or deep
sedation and
anesthesia use
Security incidences
Adverse drug events
Falls (patients/visitors
/employees)
Complications during
invasive or non-invasive
procedures (diagnostic
or therapeutic)
Medication errors
Needlestick injuries
Any undesirable or
potentially dangerous
occurrence in the
hospital
6.3 Infection Control
Standard 5: When needed, the organization reports
information about infections to personnel and public
health agencies
1. Policies and procedures on reporting of infections to public
health agencies -- through Infection Prevention and
Control Office
6.3 Infection Control
Communicable diseases (34) reportable to Makati Health
Department ASAP or within 5 days of diagnosis:
Chlamydia
H. Influenza
Mumps
Cholera
Hepatitis A, B, or C
Pertussis
Conjuctivitis
HIV/AIDS
Poliomyelitis
Dengue Fever
Influenza
Rabies
Diphtheria
Legionella
Roseola
E.Coli (enterohemorrhagic)
Leprosy
Rubella
Chickenpox
Encephalitis
Leptospirosis
Salmonellosis / shigellosis
Streptococcal (Inv) disease
Enteric / Typhoid /
paratyphoid fever
Malaria
Measles
Meningitis
Syphilis
Tetanus
Toxic shock syndrome
Gonorrhea
Meningococcal disease
Tuberculosis
6.5 Energy and Waste Management
Standard 2: The organization implements a waste disposal program which
involves reuse, reduction and recycling
Indicator
Evidence (Core)
1.
DOCUMENT
Memos, guidelines on waste disposal
Contracts with waste handlers
Hospital policy
INTERVIEW on:
SOPs on waste disposal
OBSERVATION
Segregation of waste
Proper labeling of receptacles
Recyclable waste staging areas
Proper management of temporary storage
areas prior to hauling for disposal
Proof of implementation
of policies and
procedures on waste
disposal
PROPER
WASTE & SHARPS DISPOSAL
Health Care Waste Management Manual
Department of Health
Color-coding for Waste Segregation:
METRO MANILA ORDINANCE No. 16: regulation of hospital
waste disposal in Metro Manila
•
•
•
•
•
•
Black
Green
Yellow
Orange
Red/Lavander
Clear Plastic
BLACK
(Non-infectious Dry Waste)
• Paper & paper products
(used paper, paper
cups, tetra packs,
boxes)
• Bottles (glass & plastic)
• Packaging materials
(styropore, aluminum,
plastic, candy/food
wrapper)
GREEN
(Non-infectious Wet Waste)
•
•
•
•
•
Kitchen left-over food
Used cooking oil
Fish entrails, scales & fins
Fruits & vegetable peelings
Non-infectious left-over
foods
YELLOW
(Infectious & Pathological Waste)
• Gauze, swabs, cotton
soaked in blood/body
fluids from wound
dressings, immunization,
Pap smear, etc.
• Foreign bodies removed
from body parts
• Placenta, umbilical cord
ORANGE
(Radioactive/Nuclear Waste)
1125 (Iodine 125)
H3-Thymidine
Cesium –137
Things contaminated
with these radioactive
materials (gloves,
tissue papers, swabs,
gauze, test tubes,
syringes, etc.)
• Used x-ray films,
developers, fixers
•
•
•
•
RED / Lavander
hazardous waste
–cytotoxic/ antineoplastic agents or
drugs used for cancer chemoRx, vials &
bottles containing such agents
–solusets & IV tubing's used for their
infusion
–Insecticides
–used batteries
Clear Plastic Bags
• All other vials & used I.V. bottles
Performance
Improvement
Patient Rights
and
Safe Practice
and
Environment
Organizational
Ethics
Patient Care
Information
management
Leadership and
Management
Human
Resources
Management
7. Improving Performance
Code
7.1.x.1
core
Standards
The organization
has a planned
systematic
organization- wide
approach to
process design and
performance
measurement,
assessment and
improvement.
Indicator
Evidence
- Policy creating the QI
Presence of Quality
Improvement Program program
- Proof of meetings or
similar documents of QA
Committee activities
- Policies and
procedures on
performance
measurement and
improvement
- Validation of QI
activities thru interview
of pertinent staff
including front liners
and Committee
members
7. Improving Performance
Code
7.6.x.1
core
Standards
The organization
provides better
care service as a
result of
continuous
quality
improvement
activities.
Indicator
Presence of patient
satisfaction survey
Evidence
- Patient satisfaction
survey results
- Patient satisfaction
survey questionnaire
Accreditation Award
(Subject to Approval of PhilHealth President)
Center of
Safety
Compliance to 100% of CORE indicators AND
60% Compliance to each of the following:
•Patient’s Rights and Organizational Ethics,
•Safe Practice and Environment
•Patient Care
Center of
Quality
Compliance to 100% of CORE indicators AND
75% Compliance to each of the following:
•3 performance areas above
•Information Management
•Human Resource Management
•Leadership and Management
Center of
Excellence
Compliance to 100% of CORE indicators AND
90% Compliance to each of the 7 performance
areas
Accreditation Awards
Provisional Accreditation
(subject to PhilHealth President’s approval)
•
•
•
50-59% safety standards AND
at least 70% of core indicators
– Plan for attainment of those indicators incldg target time of
achievement
– Temporary plan/action to address the gap
– Monitoring of PhROs
– Results at the end of timetable, subject to validation of PhilHealth
6 months to comply