Transcript Accreditation Canada

Accreditation Canada
Critical care team
By
Norah Khathlan MD
Assistant Prof. Pediatrics
Consultant Pediatric Intensivist
Director PICU
January/ 2009
Accreditation Canada ?
• Vision is to be the leader in raising the bar for
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health quality.
Mission is to drive quality in health services
through accreditation.
Accreditation is a continually evolving process.
provides organizations with a roadmap for
improvement that focuses on actions and results
Accreditation Canada defines accreditation
as:
– A process to evaluate and improve the quality
of services.
– Involves examining everyday activities and
services against standards of excellence.
• Define
• Measure
• Report on
• Improve
QUALITY
Quality definition
“The degree to which health services for
individuals and populations increase the
likelihood of desired health outcomes and
are consistent with current professional
knowledge”.
Note that the above definition implies that Evidence based
management and measurement improve outcomes.
Accreditation Canada the guidelines
• Recognition levels :
– Accreditation
– Accreditation with condition: Report
– Accreditation with condition: focused visit
– Accreditation with condition: report & focused
visit.
– Non Accreditation
Accreditation recognition
• Five factors are considered in determining the
most appropriate recognition award:
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Quality
Risk
Repeat recommendations
High priority recommendations identified by
Accreditation Canada.
• Quality improvement at an organization wide level.
• Ethics at an organization wide level.
• Patient safety issues, including patient safety goals & ROPs
– Number of other high priority recommendations in
any team. 4 or more high priority recommendations.
KAUH Vision
KAUH will be internationally
recognized among the best
evidence-based health
centers in the Middle East
Patient safety
• Safety is ”freedom from accidental injury
because of medical care or medical errors”.
• Patient Safety is defined as the prevention and
mitigation of unsafe acts within the health care
system
Critical care team
• 17 standards: “Client Centered Care”
– Process of preparing client for Intensive care:
• Admission criteria
• Orientation
• Informed consent.
– Process of assessment to confirm diagnosis.
– Care & treatment planning process:
• Timely access to diagnostic services
• Information exchange between team
• Informing clients & family of preparation & results of tests.
Critical care team
• Standards cont.:
– Care & treatment process includes developing,
implementing and monitoring a therapeutic plan to
achieve intended results.
• Options for care are explained to family.
• Key components identified for each client.
• Team members understand each other’s roles.
– Processes for implementing care & treatment.
• Client/family education.
• Appropriate team members implement care & treatment.
– Keeping integrated health records.
– Code of ethics, standards of practice and legislations.
Critical care team
• Standards Cont. :
– Processes for appropriate implementation &
integration of clinical practice guidelines and EB care.
– Process for review and revision of individual plan of
care & treatment.
– Continuing care needs of client assessed &
documented and communicated at transfer.
– Process for monitoring quality of care.
– Process for reviewing clinical practice guidelines.
Critical care team
• Standards Cont. :
– Indicators of performance are identified.
– Quality improvement items:
• Identifying priorities of care. Needs & expectations vs.
outcome
• Improvement of selected processes.
• Communicating the results of quality improvement.
– There is ongoing monitoring of improvements in the
selected processes eg. Survey/evaluation.
– When necessary changes are initiated to maintain QI
Critical care team
• Actions:
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Admission & discharge criteria.
Transfer rules and policies.
Reconciliation of medication.
Templates for admission to PICU orders.
Obtaining informed consent on admission to PICU.
Regular updates of families with documentation.
Daily goals sheet utilization.
Patient education form utilization.
Critical care team
• Protocols and guidelines for:
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Hyperglycemia & insulin.
Status Epilepticus.
Infusions of K
Infusion of Ca
Mg infusions
Acidosis
Sepsis early goal directed therapy.
Intubation: preparation, medications & indications
Sedation vacation.
Extubation : pre, peri and post extubation management
Ventilation strategy documentation.
Feeding protocols
Critical care team
• Our indicators: 5 were selected
– Improve medical record documentation.
• Consultations
• Date, time, name, signature and stamp on every sheet.
• Physician order sheet.
• Medication sheets.
• Admission sheet.
– Patient / family education.
– Improve infection control surveillance.
– Improve medication practices.
– Patients bill of rights and responsibilities.
Critical care team
• Improvement plan include:
– Patient/family satisfaction survey.
– Providing information to patient/family
through leaflets and flyers.
– Multidisciplinary team involvement.
– Regular family meetings.
– CVC care bundles. fair
– Weaning ventilation bundles. poor
Critical care team
• Code sheet: Unused Desktop April 2008\Desktop July
2007\Code_Sheet_3(1).xls
• Eye care for the comatose patient: Sep 2008\Quality
care in ICU\BPISeye.pdf
• Daily goals sheet: Sep 2008\PICU\Daily Goals Worksheet
PICU final .doc
• Sepsis bundle: Sep 2008\PICU\Severe Sepsis Bundles
PICU.doc
• IV Infusions of K Sep 2008\PICU\PROTOCOLS\Intravenous
Potassium guidelines in PICU.doc
Critical care team
The provision of optimal and
safe critical care services
is our aim