WHO-EMIHCDIO4WEIL Distribution: Limited
Report on the
Expert group meeting on hospital accreditation Cairo, Egypt 23-26 September 2002
World Health Organization Regional nfficc? for the Fnstnrn Mediterranean
Cairo 2003
0 World Health Organization 2003 This document is not issued to the general public and all rights are reserved by the World Health Organization (WHO). The document may not be reviewed, abstracted, quoted, reproduced or translated, in part or in whole, without the prior written permission of WHO. No part of this document may be stored in a retricval system or transmitted in any forin or by any means-electronic, mechanical or other-without the prior written permission of WHO.
Document WHO-EM/HCDI044WO6.03/30
CONTENTS INTRODUCTION ............................................................................................................ -1 TECIINICAL PRESENTATIONS ................................................................................... -2
COUNTRY PRESENTATIONS ........................................................................................ 4 3.1
3.2 3.3 3.4 3.5 3.6 3.7 3.8 3.9 3.1 0
.................................................................................. 4 Egypt ........................................................................................................................ 7 ..................................................................................................................... Jordan 10 .................................................................................................................... Kuwait 12 Morocco ........................................................................................ ,..................... 1 5 Oman ...................................................................................................................... 16 .............................................................................................................. Pakistan 1 7 Saudi Arabia ........................................................................................................... 19 Syrian Arab Republic ............................................................................................ -20 ................................................................................................................... Tunisia -21 Hahmin
PROPOSED MODEL OF ACCREDITATION ............................................................... 22 MAJOR CHALLENGES IN IMPLEMENTING HOSPITAL ACCREDITATION ....... 26
GROUP WORK .............................................................................................................. 28 6.1 Clverview ................................................................................................................ 28 6.2 Preparation for launching hospital accreditation .................................................. -29 6.3 Implementing hospital accreditation in countries of the Region ........................... 30 6.4 Hospital accreditation at the local level ................................................................. 31 6.5 PIan of action for hospital accreditation at the country level ................................. 31 6.6 Surveyors .............................................................................................................. 32
Annexes AGENDA .................................................................................................................... -35
.......................................................................... PROGRAMME ................................ . . 36 .............................................................................................. LIST OF PARTICIPANTS 38 D M F T hlANUAL ON HOSPlTAL ACCREDITATION .............................................. 43
An intercountry Expert Group Meeting on Hospital Accreditation was organized by the World IIealth Organization Regional Ofice for ihe Easlem Mediterranean (WHOIEMRO) in Cairo, Egypt, from 23 to 26 September 2002 to discuss implementation of a process of hospital accreditation in countries of the Region. Participating countries were Bahrain, Egypt, Jordan, Kuwait, Libyan Arab Jarnd~iriya,Morocco, Oman, Pakistan, Saudi Arabia, Syrian Arab Republic and Tunisia. The meeting had the following objectives: Exchange information and opinions among the different participants with a view to building a regional consensus on the relevance, usefulness, and feasibility of the proposed accreditation programme. '
Review the draft WHO/EMRO Manual on Hospital Accreditation. Advise on implementation, at the national level, of a process of continuous improvement of the quality of care through the periodic accreditation of hospitals, with the establishment of a multi-institutional National Hospital Accreditation Commission.
The meeting was opened by Dr Moharned A. Jama, Dcputy Regional Director, WHO/EMRO. who delivered a message from Dr Hussein A. Gezairy. WHO Regional Director for the Eastern Medjterrancan Region. In his message, Dr Gezairy highlighted the pressing need for a highly rccognized quality improvement and accreditation process as a result of the national health reform policies in various countries of the Region. He explained that hospital accreditation in the Region was a method of ongoing consensus, rationalization, and hospital organization and that the expert meeting would be helping to develop the first instrument for the explicit and objective technical evaluation of quality, the accreditation manual. He stressed that the national response, in the form ot creating the national accreditation body, was of great importance. Such an entity should be apolitical, multirepresentational, and should undertake its work energetically, prudently and periodically. This ciltity would be respollsiblz ful tilt: ddlllirlistriltiur~
puli~y-llldkillgur t l i~ l~~1cditativ~1
system at the country level. It would be responsible for the setting of national standards for accreditation, adopting WHO guidelines for accreditation, identifying and training the surveyors, conducting and monitoring the site surveys and making the decisions rclatcd to the
awarding and maintaining of accreditation. Dr Gezairy concluded by emphasizing that this national ownership was crucial for laying the foundation and for maintaining, from the beginning, a high degree of integrity and accountability of the national accreditation system.
Dr Ahmed Abdullatif, Regional Adviser, Health Care Delivery, WHOEMRO, described the meeting objectives and expected outcomes. The first objective was to exchange information and opinions among participants with regard to the proposed accreditation programme. The second was to review the draft EMRO manual on hospital accreditation and the third objective was to give advice on implementation of accreditation at national level. 'lhree outcomes were expected horn the meeting. Proposed revisions to and comments on thc draft manual on hospital accreditation.
Proposal of a chronogram with follow-up activities on hospital accreditation. Proposed recommendations for specific actions for the promotion of hospital accreditation in countries of the Eastern Mediterranean Region.
Dr Mohamed Mofli was elected Chairman. Dr Mahi Al-Tehewy was elected Rapporteur. The meeting agenda, programme and list of participants are included as Annexes 1, 2 and 3, respectively. Annex 4 is the draft regional accreditation manual. 2.
TECHNICAL PRESENTATIONS
Dr F. Siem-Tjam, Technical OfXicer, Health Service Provision, WHO/HQ, introduced accreditation issues and trends. He discussed the advantages of accreditation and differentiated between licensing, accreditation and certification. Other ongoing initiatives in this field included an accreditation project for countries in South America and Caribbean (1990-1 997) and initiatives in several countries such as India, Malaysia, Philippines, South Africa, Taiwan arid Thailand.
Dr Fariba A1 Darazi, Regional Adviser, Nursing and Allied Health Sciences, WUOEMRO gave a briefing on previous WHO accreditation rncetings (see reports WHOEWCD/007/E/L/ and
WHO-EMAICD/034E/L).
I
illte~cclurltry ~unsuJklion on
accreditation of district health facilities was organized by the Regional Office in Limassol, Cyprus, in Septernbcr 1999. The Cyprus meeting concluded that although the introduction of accreditatinn n f health f s r i l i t i e s is desired in the Region, it is not yet developed in its Member
countries. The meeting emphasized that in order to initiate question and answer programmes to improve care, it is fundamental to take the following into consideration: Leadership commitment. Commitment is needed from the health care leadership to provide the policy support necessary to carry out these initiatives and to be active advocates for their effective implementation. Regulation. To implement accreditation, there have to be specific regulations promulgated in the countries if this system is to be taken seriously by the health facilities and the health care teams. Resources. Allocation of adequate resources, both human and physical, is crucial for the sustainability md institutionalization of QA.
Use of data. Facilitating the use of data in improvements and decision-making is another fnrmiAah1~ challenge. In addition, issues related to data availability, access, quality and
usefulness need to be addressed.
Sustainability. Institutionalization of the QA system is fundamental to the future o f this initiative in the Region. Therefore identifying the right motivating factors and the
WHO-EM/HCD/044/E/L Page 3 rncchanisms for using incentives to encourage QA innovation and proactive involvcmc~~t is crucial for thc QA to sustain itsclf and succccd.
In April 2001 the Regional Office, in collaboration with Health Ministers' Council for Gulf Cooperation Countries, held a consuI~ation on accreditation of district health facilities in Riyadh, Saudi Arabia. Reconmendations of the meeting were as follows: Institutionalize quality improvement and accreditation through crealion of a quality culture by raising awareness, seeking political commitment, preparing a policy document, establishing adequate structures and processes, building partnerships and mobilizing required resources. ,
Establish a critical mass of expertise within countries by integrating quality improvement and accreditation concepts in both basic and in-service training programmes for continuous professional development.
Adapt and implement the regional guidelines for accreditation. Introduce a system of reward to recognize achievements in performance improvement at all levels. Prepare and regularly share with other countries reports on national experiences and models of quality improvement and accreditation for advocacy and networking in the Region. Dr Abdullatif presented an introduction to the regional accreditation programme. The programme has three primary purposes: Strengthen the role of the national health authority through a progressive structured and scientific process for appraisal based on quality care standards that ensure accountability of the national health system policies and strategies.
Develop a system for continuous improvement of services, where facilities play an active role in monitoring m d improving thcir pcrformancc. 6
Prepare all interested public and private facilities for their new role in health system development.
In his presentation, Dr AbduIlatif also discussed three perspectives of accreditation, accountability, educational and recognition.
Dr Novaes, WHO Consultant, presented the concept of hospital accreditation and its application. He emphasized the interdependency of different parts (departments) of the hospital. He also discussed some quaIity initiatives and compared industrial quality with quality of health care. He elaborated many rcasons in response to the question "Why Accreditation". In reviewing the history of accreditation, it was emphasized that the United
States of America invested about 20 years to move from basic to optimum standards and another 7 1 3 years to establish standards by function. A few more ycars wcrc also invested tu
focus on outcomes of clinical practice.
Dr Siern-tiam gave a presentation on the experience of Snuth Africa Me emphasized that in this surveying experience in itself did not necessarily improve hospital performance. However, accreditation (role of facilitator) had positiveIy improved the performance. Dr Noves introduced the draft accreditation manual. He began by defining structure, process, and outcomes and characteristics of standards. He introduced the concepts of leveling in setting standards, and of voluntary, confidential and periodic accreditation. He also compared the idea of' accreditation on a "yes" or "no" basis versus scoring. During discussion about the term "qualitative indicator", Dr Novaes explained that it is evidence of performance rather than indicator. Criteria of surveyors were also discussed, and the link bctween t l ~ c Arab Duard 1 1 liospival ~ accreditation programme was discussed. At a later stage there will be a need to coordinate the efforts between the Arab Board accrediting teaching and training hospitals and the service oriented hospitals of the Eastern Mediterranean Region.
Dr Abdullatif gave a presentation on the accreditation process in countries of the Eastern Mediterranean Region. He proposed ten steps to launch the accreclit~tionprocess at the national level and nine steps at the local (hospital) Ievel. A plan of action for hospital accreditation at the country Ievel was then proposed, specifying the task, purpose, activities and time-frame necded. The revised versions of the steps at national and local levels, a well as plan of action, are presented in Section 6 (Group Work). 3. 3.1
COUNTRY PRESENTATIONS Bahrain
Bahrain currently provides comprehensive heaIth services to the entire population in line with the WHO global objectives of health for all. Most health care services are provided by the Ministry of Health through 21 primary health care centres and clinics, Salmaniya Medical Complex (900 beds), psychiatric hospital (ZVl beds), geriahc hospital and four maternity hospitals (68 beds). Hcalth cnsc i s also providcd by the D a l x a i ~ Defeilce ~ Fulr;c Huai~ilill,wlri~11 is 111arlaged by the Ministry of Defence. The Hospital provides services to a large section of the population. A number of highly specialized services are offered and the Sheikh Mohammed Al-KhaIifa Cardiac Centre provides advanced cardiac care services to a 1
of the population in
Bahrain. According to the Ofice o f Licensure and Registration data, there are currently three private hospitals in Bahrain:
W HO-EMIHC13/044/E/12 Page 5 Bahrain International Hospital. It was inaugurated in 1978 and has 100 beds, including maternity facilities and an in vitro fertilization centre.
American Mission Hospital. Established in 1902, it has a current capacity of 40 beds as wdl as an cxtcnsivc dcntal scrvicc.
Awali Hospital. Established in 193 7, it provides medical, surgical, obstetrics, gynaecology and dental service to employees of the Bahrain National Oil Company and
their families. It has a total capacity of 37 beds.
In addition, a number of other hospitals have been established recently, such as the IbnNafees Medical Complex with 1 1 beds and Gulf Dental Specialty with 10 beds. Several other hqspitals are also being planned. As part of developing health strategy, the Ministry of Health undertook a SWOT analysis (strengthens, weaknesses, opporiunities, threats) with most of the departments of the Ministry of Health, including clinical and non-clinical areas. Strategies for the future will focus on capitalizing on h e strengths while trying to eliminate or reduce the impact of weaknesses. At the same time, strategics will aim at utilizing the available opportunities for the advancement and growth of heaIth services while taking possible threats into consideration in ordcr to rcmnin rcsponsivc.
Strengths Highly qualified staff
Comprehensive range of services Support from top leaders Gond infrastructt~re-advnncerl trchn n l ngy,
good facilities Strong alliances-local, regional and
Opportunities Open political environment Strategic alliances with other organizations Community ~ ~ ( i c i p a t i o n Investment in IT
Acknowledged role of service planning
international Weaknesses Dual role as regulator and provider are oftcn confused
Threats Government control of finance Demographc changes
Lack of integration, communication and coordination Workforce planning Financial systems
Unplamed cxpcctntions
developments
Negative media and unrealistic public Private sector attracting staff
Organizations structure Performance management Centralized decision-making n c r c is only onc programme which addresses training in health and hclspital administration issues, the Diploma for Health Care Management given by Royal College of Surgeons in Ireland in coordination with Ministry of Health Training Directorate. Quality
WHO-EM/HCD/O44/E/L Pngc 6
management is not yet taught as a separate subject, but it is integrated within several courses. There are plans to introduce a Master's Degree i n Health Policy by Arabian Gulf University.
Bahrain is aiming to provide high quality customer services not only in the country but also in the region. Consequently, expectations of service quality finm government organizations are becoming greater. A ministerial resolution (no 1555) was issued in October 1999 to establish a performance improvement cornrnittce in every government organization with primary responsibility for improving quality services and work performance. Since the late 1980s there have been a number of quality assurance and continuous quality improvement activities in SMC and primary health care centres. In April 2002, a Quality Council at Ministry of Health was formulated with the aim to implement sustain and facilitate the quality improvement initiative based on directions derived fiom Ministry of Health mission and strategies. The Ofice of Licensure and Registration in the Ministry of Hcald~ was es~ablislicd i11 1986. It is r h e official regulatory authority for all heaIth professionals and health care organization/agencies in the couniry. In 2001 the American Mission Hospital introduced a quality management programme as part of preparations for the Joint Commission on International Accreditation (JCIR).
Responses to the questionnaire on accreditation activities in Bahrain Name of your accreditation programme Programme name in English Address of the programme: Street, PO Box City, Postcode Country Telephone
I S 0 9001-2000 Bahrain Military Hos~itaI
E. Riffa Kingdom of Bahrain 766 666
Fax Website Name of person to contact for this survey e-mail address ot person Is there any law or directive requiring accreditation in your
Maj. Sumaya Hussain Sumaya-bdf@hotmai 1.corn
No Independent
country? YesMo: Reference, year
How is the programme related to MOWGovernment? managed by, (partially) funded by, formally Recognized by, totally independent of'? What year did Accreditation development begins? What year was the first operational survey visit? Does the programme focus on primary ox secondary or tertiary care? All of these Does it include public and private facilities? Are the accreditation standards available to the public free? If not, at what price can they be purchased? US$
1997 1998
All Yes
No Differ from one company to
Which foreign country most influenced the deve I opment of
another USA, United Kingdom
WIIO-EMIIICD/044/E/L Page 7 . , ,. . .
.. . ..
.
. .. . - . ---. . -
--
-
. -
standards in your country? How m n y rull revisions of the s~andards have been published?
Nil
What year were current standards approved? How many days does a site visit usually last? I low Inany surveyors arc usually in a tcam? .
2 days 3 auditors
Are full reports of surveys available to the public free of charge?
No -
Yest'No If not. at what price can they be purchased? US$ I Iow many survey visits were done i n 1999? How many trained surveyors were available to the programme at the end of 1999? How inany rlew surveyors were trained in 1999? What was the total expenditure of the programme in 1999? US$ What fee is charged to survey a 1 00-bed hospital? US$ Whal is the Accreditation programme's main source of income? Please name any other national Accreditation programmes in your country, will] contact details Plm~p: ad11 any n t h ~ cnmments r you would like to make about
2 1 auditor
Nil -
Within Ihe hospital budget
your programme or this survey
Major challenges in the health system are bridging the gap between the available resources and the increasing demand on health services, and managing the growing population and changing demographic structure, which is characterized by dominance of the young population and a rise in the elderly population. Other challenges include ensuring appropriate human resources, supporting and maintaining improved management practices, developing a proper structure and work process and maintaining the availability of advanced t~~lll~ulugy.
3.2
Egypt
Egypt is a lower middle income country, The economic situation is heavily influenced by the political instability in the region, as well as the need for the country to adapt its economy to the globalization of the world economy. Some 22% of the population is poor. Official unemployment stands at over 10% and is expected to increase to 17% by 2005. Thc Egyptian health care system faces multiple challenges to improve and ensure the health and well-being of the Egyptian people. Primarily, therc is a double burden of illnesses associated with povcrty and lack of education coupled with diseases of lifestyle brought on by economic and demographic transition. High birth ratcs combined with longer life expectancy also increase the pressure on the Egyptian health system.
Egypt has 2139 inpatient providers located in 26 different types of facility. The total llultlbcr uf bc J b ill thest: fdcililirs is 123.67 1 . Eighty-eight percent (88%) of all beds in Egypt are in the public sector, with the Ministry of Health and Population having the largest share of
inpatient beds (57%) in the country. In urban areas, the Ministry has 223 inpatient primary health care centreq cnn~titilting 9.06% o f the total inpatient capacity i n the country.
The Egyptian health care system is facing serious challenges to enhancing the provision of quality services. These challenges may be divided into five areas: customers, prnvikrs, health care organizations, systems and third party payers.
In 1 965 the Ministry of Health and Population established a department for monitoring, follow-up and evaluation. This department has the task of analysing the shortcomings and suggesting solutions. In 1993 this department was approved as a General Directorate at the central level, which is replicated at governorate Icvel as departments. A number of quality assurance projects have been ~rnpiemented, in collaboration with international partners. Quality Assurance Project (QAP): a project cosponsored by the United States Agency on 1993 in collaboration with University Research Company (URC), Bethesda, USA. This project focused on establishing QA capabilities and systems in 5 pilot hospitals: May 15 and Imbaba in greater C-airo, Shark El-Medina in Alexandria, Kantara Garb in Jsmailia, and Kufi ElDawar in Beheira. The main deliverables of that project were a QA hospital manual, QA policies and procedures, clinical guidelines, and the First National Conference on QA in Health Care in September 1995. for International Dcvclop~ileiit(USAID) il11d esrablished
Cost Recovery for Health project (CHIP), Ministry of Health and Population as a continuation of the previous project, the quality function was elaborated in the CRHP with technical assistance by URC, Bethesda. The project expanded the pilot to cover all governorates. In 1991, this USAID project developed the first national clinical guidclines for family planning services in Egypt. This product was adopted by the Ministry of Health and Yopulation. Health teams working in this area were trained in the Regional Centre for Family Planning (RCT) and its 7 satellites covering various regions. Quality Improvement project (Gold Star), Population Sector. Within the POP 111-USAID project, family planning quality standards and indicators were developed, communicated, and monitored. FP units achieving a 98% score in relation to the approved standards are awarded with the Gold Star and incentives for the health Learn. Quality assurancc functions of the Child Survival project, USA'ID-MOHP. Within this project, quality standards and indicators were developed for primary health care services covering the dimensions of the project (EPI, ARI, child spacing and nutrition). The project covered all governorates of Egypt thoughout its lifespan (20 years). Clinical Service Improvement project, Ministry of Social Affairs (MOSA). This USAID project established Reproductive Health and FP centres in all governorates. These centres are based on self-financing mechanisms. Quality standards and indicators of RCT were adapted and communicated to ensure providing high quality service.
WFIO-EM/HCD/044/E/L Page 9
Sporadic: quality initiatives in the Health Insurance Organization (HIO), Curative Care Organization (CCO), and Tcaching I Iospitals Organization. Thcsc initiatives arc implemented in somc hospitals as individual efforts by hospital directors trained by QA. Establishmcnt of the Egyptian Society for Quality Healthcare (ESQua) in 1995. ESQua is a unique entity in the region. The mission of ESQua is to mobilize resources and to
coordinate scattered efforts aiming at improving quality of national health system.
Quality Assurance function of the Healthy MotherlChild Health project (HMHC), MOHP-USAID. This project is a continuation of ihe child survival project. It covers 8 governorates in Upper Egypt. The HMHC developed quality standards, indicators and protocols for child heaIth and safe delivery. Establishing the General Directorate of Quality Improvement and Centres of Excellence (QI/CE), Ministry of Health and Yopulatlon. Abt Associates, through the Health Ketorm Project (HR), supported this initiative. During 1999-2000, QYCE, HR, and the Technical Support Ofice (TSO) of the Ministry of Health and Population developed a pilot accreditation system. The projcct was iillplcil~ciltcdill its pilot phase ill
3 hedlth
centres in Alexandria, then covered 30 more health centres. Efforts are being continued during 2002 to apply a modified tool for hospital accreditation. That tool is still under t~cting nnd modific a t ion. '
Responses to the questionnaire on accreditation activities in Egypt . -
-
-
.
Namc of your accicditatioil ploglanullr
Husyital a ~ c t e d i h l i uptugrar~nrlt: ~l . .
Programme name in English Address of the programme: Street, PO box City, Postcode . Country Telepl~one Fax -. Website Name of person to contact for this survey E-mail address of person Is there any law or directive requiring accreditation in your country? Yes/no; reference, year How is the programme related to MOWgovernment? Managed by, (partially) funded by, formally recognized by, totally independent of?
--
--
Technical Support Ofice, Ministry of Health and Population, Magles El-Shaab
Cairo
-.
W L
A . .
Dr Hanem--Ahdel-A7em --
No - -
Managed by Ministry of Health and Population and funded by international donors --
I 1
i
1
Pngc 10 --
.. .. . .. .
What year did accreditation development begin? -- .
.
What year was .the first operational survey visit? . .. Does the programme focus on primary or secondary or tertiary care? All of these -Does it include pubiic and.private facilities? - .-. -Are the accreditation standards available to the public free
1
All . . .. .
Public .-
1
--
.. .
of charge? Yes/no .If not, at what price- can they be purchased? US$ Which foreign country most influenced the development of standards in your country? -. How many full revisions of the standards have been published? What year were current standards approved? lIow many days does a sitc visit usually last?
I
i
No
No . USA and European Union -.
t Not yet --
One for PHC and none for hospitals
1.10~ many surveyors are usually in a team? Are full reports of surveys available to the public free of charge? Yesinn
--
-
If not, at what price can they be purchased? US$ How many survey-visits were done in 1999? Hnw many trained qi~rveynrq wprp ~ v a i l a h to l ~the
1 No 6
1 3 (30 up to 2002) --
. .
programme at the end of 1999?
.
-
How many new surveyors were trained in 1999? What was the total cxpenditwe of the programme in 1999? US$ What fee is charged to survey a 100-bed . . -- hospital? US$ What is the accreditation prugramme's main source of Income? Please name any other national Accreditation programmes in your country, with coiltact details Please add any other comments you would like to make about your programme or this survey --
I ! !
. .
I
Free Ministry of Health and Population and international donors .
-
-.
The progrnmmc is still in thc pilot
phase
3.3
Jordan
The population of Jordan is 5.4 million (2001). It is considered to be onc of the countries that has accomplished big steps towards primary health care, with an infant mortality rate of 28/1000 live births. Immunization coverage is 96%, 96% and 94% for polio, DPT and measles respectively. The life expectancy rate is 68.6 years and 7 1.1 years for males and females, respectively. I he Minlstry of Health budget is US $ 193 milllon (bYo o o f general governmental budget) and the total per capita health expenditure is US$ 133. Sv~lleof tht: wl=alulcsses in the Jul dizllial 11ciiltl1 sy stcu~UG. f i ~ ~ m l ~dificullics; ial
shortages in health personnel due to immigration; inadequate salaries; more need for human resource development including continuing medical education (CME) and scholarships;
WHO-EM/HCII)/044IEII. Page I I inadequate information systems; weak commitment to quality programmes and absence of an accredilarion sysLem and re-licensure. The following are considered to be the strengths of the Ministry of Healh: emphasis on PHC scrviccs including cnvironrncnt, food, discnscs, ctc.; good mmagcrial Icvcl; good relationship with international health agencies; high level of medical technology; cooperation between governmental and private sectors; good capacity for conducting studies; good number nf universities and institutions for medical, nursing and
studies, i n hoth
private and governmental sectors; and the creation of the higher health council and higher nursing council that will be responsible for the coordination and planning of health in the country.
The Ministry of Health has begun, with the help of some international agencies, to improve its database and information system. A major training programme in PHC is taking place in the country to train all the PWC centre staff on primary health care services (2500 people have been trained to date). In collaboration with WHO and USAID, the Ministry is working on implementation of a CME master plan and accreditation system. A health academy w a s recently established for teaching health administration. ,
Hospitals in Jordan (20001 Scctor Number of hospitals 24 Number of beds
Ministry of Health
3384
RMS JUH JUST Private Total
9
173 1
42
2469 94 10
88
Health personnel in Jordan (2000) Category Physicians Num her
Per 10 000 population
Dentists Pharmacists Registered nurses
10 627 2 869 4 987 7 391)
20.5 5.5
9.6 14.1
Midwives Assistant nurses
1 291 5 638
2.5
10.9
The Ministry, through its directorate of licensure and medical professions, is responsible
for licensing all practising professionals in the country as soon as they are graduated, but no further annual re-licensing is nceded.
Some hospitals have applied for IS0 on a voluntary basis. 'l'hc Ministry o f Health began to implement a quality assurance programme in some of its hospitals in 1993, and serious
efforts have been done since that time. This includes deveIopnlent of protocols and guidelines and establishment of different quality assurance committees. A special Quality Assurance and Monitoring Directorate was created in the ministry, but has come to concentrate on monitoring more than on quality. Some steps are being taken now towards reviving the quality assurance focus. Accreditation of hospitals or other health care organizations is not yet activated. However, sincere efforts are being made, and many different parties, including the Ministry of Health, are interested in creating an accreditation body.
11rastt.1 ' b cl~gret: prugrarnrne
Regarding training in health and hospital administration, Jordan has established a 2-year in Jordan University. To date 65 people have been graduated wlth a master's degree in hospital administration. This programme stopped for few years, but has been opened again. Some private hospitals teach a 4-year bachelor's degree in hospital
administration. Other universities have shod 2 y e a diplomas in hospital administration.
Ln coIlaboration with WHO and Jordan University of Science and Technology, (JUST) a new 2-year diploma in applied administration will hegin in 71)133 Gryduates from this programme will be allowed to continue their study in JUST to obtain their master's degree.
Major challenges in health systems and hospitals include the following: Continued difficult economic situation. Lack of cooperation and integration between different health sectors. Need tor a national health insurance programme. Loss of skilled human resources. Lack of coxnprehensive health information system. Nt-~cl Tur ~url~iriuirlg rnedical education (CJvlE). Need for accreditation and re-licensure. Kuwait
3.4
The health care system i n Kuwait is managed by the Ministry of Public Health, the main provider of health care. The system is including primary health centrm, a e c n n d ~ rc.are ~ hospitals and tertiary care centres and hospitals. The role of private sector, as health care provider, is limited as health care is given to all the population free of any charge at government health care centres and hospitals. The commitment of the government to improving health status of the whole population is evident and is reflected by the achievements in infant mortality rate, maternal mortality rate, crude death rate and still birth rate.
The infant mortality rate has shown a substantial decrease, fiom 11.5/1000 live births to 9.111000 live births fiom 1996 to 2000. The matema1 mortality rate was 9.6 in 2000 (9.6 per
WHO-EMIT-ICD/044/E/L Page 13 100 000 live births). The budget of the Ministry of Public Health was about KD 126 per population capita in 1999-2000. Other strengths of the system include well organized management of the care provided by the Ministry of Public Health, awareness about quality of care, community participation in health programmes, well organized health information sys terns and good r a w or heallh cart: wui~kfvrct: LU pupulaliun ( 1G yhysiciiins, 4 1 nurses pcr 10 000 population at the national level in 2000). Primary health care services me ~ r o v i d e dby 75 primary health care centres, each
covering about 30 000 people. The total population of Kuwait is 2 189 668 (Ministry of Planning, 2000). According to the Mjnistrq. of Public Health statistics (2000), the total number of Ministry hospitals is 15 (6 general hospitals, one in every health region, and 9 specialized hospitals and centres providing tertiary care). The total number of beds in Ministry hospitals is 4575 (bed occupancy rate 67.2%, average length of stay 5.3 days). In the private sector there are 5 private hospitals and 3 hospitals belonging to oil companies. The total number of beds in these 8 hospiials is 5 59 (Ministry of Public Hcalth, 2000). 'I'he other health care organizations are health care centres of Ministry of Social Affairs, Ministry of Interior and Ministry of Defence. However, their share in health care provision at rialiurlal level is r~ol c;u~~~ able p a i will1 illul uC iht: Mirlistly of Public IIcaltll, which is thc illail1
provider of health care at the national level. Interest i n quality assurance i n the hcalth care sector i n Kuwait was formalized i n 1987,
when Quality Assurance Administration was established in the Ministry of Public Health. In 2001 the name and functions of the Quality Assurance Administration were changed to the Accreditation and Quality Assurance Administration (Ministerial order 3 58/200 1). The Accreditaiion and Quality Assurance Administration is the executive body of the Ministry of Public Health responsible for accreditation and quality assurance activities. At the regional level, quality assurance activities include mortality review, medical records review, utilization review, infection control and accreditation preparation activities. The Emergency Services Department in the Ministry of Health is implementing an I S 0 programme. Despite the ongoing activities and initiatives in quality assurance and health care accreditation in the Ministry of Health, the situation in the private sector is still far behind. One hospital is preparing for accreditation by JCIA, others in the private sector are starting
quality assurance activities. The rapid tumuvci- of health care personnel, as most of thcm (89%) are non-Kuwaiti, is an important weakness affecting the implementation of the quality assurance programme. Licensing of the private sector hospitals, health care centres, laboratories and private clinics is under supervision by Health Licensing Administration of the Ministry of Public Health. Licensing of the organizations is given according to their compliance with standards of licensing of different health care organizations and after being assessed by the health licensing administration. Moreover, all private health care organizations are inspected by teams of professionals assigned to inspect the private sector health care organization to check
their compliance with laws of medical practice. During 2000, the total number of inspections was 724 (41 3 for private hospitals, and 3 11 for private clinics). Thc 2000 statistical repuit of
the health licensing administration showed that the total assessment visits (pre-licensing visits to organizations requesting licensing was 141, with 42 for hospitals, 46 for clinics and 53 for other private places). The Kuwait HeaIth Care Accreditation Programme (KHCAP), established by Ministerial Order 358/2001, is totally managed and funded by the Ministry of Public Health. Accreditation development began in 2001, and the first operational survey has not yet started. The programme is focusing on all levels of care, with particular attention to government hospitals. Accreditation standards are still in the drafting stage.
About 40 local surveyors are engaged in a local training programme in 2002. The local surveyors are selected by the Ministry of Public Health hospital administrators. Criteria for sclcction arc; sciliur pusitiu~l;i ~ i l e r r s in ~ the programme; and having the required skills. The training programme for surveyors includes orientation about accreditation, survey process and quality assurance/quality management issues. The training programme ends with a written warnination and oral interview.
Questionnaire on accreditation activities in Kuwait .-
Name of your accreditation programme Programme name in English Address of the programme: Street, PO Box City, Postcode Country Te lcyhonc
Kuwait Health Care Accreditation Programme
Kuwait 9654846871
Fax
Website Name of person to contact for this survey
Is there any law or directive requiring acc~editation in your country? Yes/No:
Reference, year How is the programme related to MOHfGovernment? managed by, (partially) funded by, formally Recognized by, totally independent of? What year did Accredilalion development begins? What year was Ihe first operational survey visit? Does the programme focus on primary or secondary or tertiary cmc?
Ministerial order 35812001 Establishment of Accreditation and Quality Assurance Administration The programme is totally managed and funded by the Ministry of Public Health
200 1 Not yet All; but more on Ministry of Public Ileallh hospitals
All of thcsc
Does it include public and private facilities? Are the accreditation standards available to the public free of charge? Yes/No. If not, at what price can they be purchased? US$ Which foreign country most influenced the development of
Still in drafting
Jninr Colnmission International
W HO-EMIHCDI0441EII, Page 15 stardards in your country? I Iow many full rcvisions of thc standards hnvc bccn .*.-
Accreditation . -- (JCIA) Basic requirements: 2
published? What year were current standards approved? How many days does a site visit usually last? How many surveyors are usually in a team? Are full reports of surveys available to the public free of charge? YestNo - If not, at what price can they be purchased? US$ How many survey visits were done in 1999? How many trained surveyors were available to the programme at thc cnd of 19993
revisionslstandards: drafi Basic requirements 200 1 Not yet Nor yet Not yet
Not yet About 40 local surveyors are trained lo~nlly 2002
How many new surveyors were trained in 1999? What was the total expenditure of the progralnmc in 1999? US$ What fee is charged 10 survey a 100-bed hospital? US$ What is the accreditation programme's main source of income? Please name any other national accreditation programmes in your country, with contact details Please add any other comments you would like to make about ynnr prngr~rnme nr this S I I T V P Y
Survey visits not started yet. Ministry of Public Health One private hospital is preparing for JCIA accreditaQon, emergency department is I S 0 certified. Quality assurance started in Ministry nf Puhlic
Health in 1987,
accreditation for training is managed by KIMS (Kuwait Institute of Medical Specialization)
3 . 5
Morocco
The population of Morocco (2000) is 28 787 000, with 45% in rural areas. The crude birth rate is 22%; crude death rate is 56%; annual population growth rate is 1.6%. Life exprr:tancy at hirth i s t;ll years; infant mnrtality i s 76 6%; mnrtality ~ i n d e r 5 years i s 45.8%;
maternal mortality is 22.8 per 10 000 live births. The health care infrastructure is composed of 2267 health care centres; 3461 consulting rooms (private); 112 public hospitals with 25 000 beds; 192 private clinics with 3862 beds;
and 23 clinics run by insurance organizations, with 1662 beds. Indicators of supply are 1 health care centre per 12 700 population and 1 bed per I000 population. The public sector (2000) has 5812 physicians (46% specialists); 39 pharmacists; 162 dentists and 26 124 nurse agents. The private sector has 6620 physicians (47% specialisrs), 5200 pharmacists and 23 00 dentists. Health care worker to population ratios are as follows: 1 physicid2300 popwlcition
1 pharmacist/7700 population 1 nurse agent/] 000 population.
WHO-EMIHCD1044IEIL Pngc 16
Emerging problems are insufficiency and inequity in health financing, and productivity losses and growing ~conornicburden (little recovery of hospital cxpcnses; dcclcpituclt: UP
buildings; lack of equipment; weakness of health care quality).
The health sector strategy for 2000-2004 inclurlcn: der.entralination policy; reform o f public expenses; health system reform; PNAQ (national programme of quality assurance); and creation of a graduate training programme in hospital administration in the Institut National d' Administration Sanitaire (IN AS). The decentralization policy emphasizes the creation of an intermediate level between central and district levels; strengthening of hospital autonomy; decentralization of the planning function; and regional strategic planning of supply, including the participation of the private vector and civil society. HospitaI strategic planning is also included. will be elaborated for developing health care standards, with elaboration of standards for equipment, essential drugs and maternal care. There will also be continuous training and development of national QA experts to strengthen During 2000-2003 a rrlelhudology
national the QA training. During 2003-2006 it is planncd to implement an ac~r~cliialiun
system within the scope of overall health system reform.
3.6
Oman
The population of Oman is 2.3 million, of which 74% are Omanis and 26% are expatriates. The crude death rate is 3.5 per 1000 population; infant mortality rate is 16.2 per 1000 live births; and life expectancy is 72.4 years for males and 75.3 for females. Improved health indicators are having profound effects on the country's current and future health needs in terms of the changing pattern o f disease, from communicable to noncommunicable diseases; and the changing pattern of risk due to social and economic development. Health sector development plans arc concerned with the provision of comprehensive hcalth services, pi-omotillg quality o r health services and improving health status. 'l'he provision of quality health services has allowed for self-reliance and minimized the need for treatment abroad in cases requiring open heart surgery, renal transplantation, cornea transplantation and other major surgeries. A complete canccr unit is cxpccted soon. Caillcer.
cases represent 68% of cases treated abroad. The public sector accounts for 99% of all hospital beds. The Ministry of Health, in previous plans as well as its current plan, has focused on developing and strengthening primary health care and using it as a portal for all other levels of health care. Quality assurance programmes in PHC facilities have been established. It is expected that these will expand to include all levels of health care. Decen~ralization of health care management of key hospitals is now in progress. This has resulted in redistribution of budget and workforce, with morc authority for decision-makers and planners at hospital level. The Ministry of Health has taken several steps to ensure that it rcduces reliance on the expatriate workforce. Basic and post-basic training programmes have been increasing. The
WHO-EMIHCD10441EII. Page 17 Oman Specialized Nursing Institute was established in 2000. The Institute runs post-basic programmes of one-year duration and candidates are awarded diplomas. The programmes currently running are nephrology, midwifery, special care nursing in paediatrics and neonatal nursing. It is expected that more programmes will start in the next year, such as nursing administration m d critical care nursing.
An increasing number of Ornani doctors are graduating from Sultan Qaboos University. The Oman Medical Specialty Board has been set up to oversee specialty training for doctors.
Paramedical programmes are also being run. Oman has 80% Omanis working in the field of laboratory science. There are now a total of 49 hospitals, accounting for 4491 hospital beds, in the Ministry o( Health, plus 3 hospitals in oiher government agencies, with 630 beds total, and 2 private
hospitals with 50 beds. Basic quality assurance programmes are in place, and include continuing education programmes, the development and use of treatment protocols, auditing of different aspects of care, patient referral guidelines and mortality reviews. A basic private sector licensing and regulation system exists under the control of the
private health establishments. Doctors, nurses and paramedical staff are required to pass technical examinations in order to receive a license from the government. Private clinics and hospitals arc also subjcct to liccnsing rcquircmcnts that &c
into considcration infrastructure
and equiprncnt. A ministerial order was issued in 2001 to establish a national Quality Assurance Committee. A quality assurance adviser has been appointed and is in the process of Aevelnpine 9 ~ I I A
lity assilrance department at the Ministry of Health.
While Oman's health system performs well, there is still substantial scope for improvement. Although quality assurance initiatives are under way in most health facilities they are not well coordinated among the facilities and are not institutionalized within the Ministry of Health. There are no nationally recognized external hospital accreditation bodies. The Nursing and Midwifery Council is in the process of setting national standards for education and practice; similarly other professions are in the process o f strengthening professional regulation systems. The strength of Oman is that there is significant political and management support for further improving health services. 3.7 Pakistan The Government of Pakistan is focusing cfforts on making primary hcnlth carc facilities
available to all citizens throughout the country. A nationwide network of health facilities staffed with trained health personnel is providing primary health care services to the clients. Health services in Pakiqtan give high priority to communicable diseases and nutritional deficiency disorders affecting children and women at reproductive age. There are 13 502 public health facilities, with 100 538 beds, available for provision of ambulatory and hospitalized care to the entire population.
The Federal Ministry of Health is mainly responsible for planning and formulation of health policies, containment of communicable diseases, coordination of health functions, drug
WIIO-EM/HCD/044/EIL Pngc 18
control, interprovincial coordination of health services, international relations in the heaIth field 2nd administration of postgraduate medical centres and colleges.
Provincial health departments are responsible for providing health services to the population through teaching hospitals and special institutions and the district heaIth system. The provincial health departments are also responsible for management of federally designed priority health programmes such as the national programme for family planning and primary health care, expanded programme on immunization (EPI) and control. of diarrhoea1 diseases programme, AIDS control programme, malaria control programme and acute respiratory infection (AM) control programme. Pakistan has been undergoing rapid reforms in almost all its sectors during last 3 years.
In Augyst 2000, the government announced a plan to devolve financial and administrative authority to the grass roots level in order to bring government closer to the people and enable thcrn to take l ~ l u l e ~csyur~sibiliiy Tor Lheir heal~h and welfare. The 400-bed Federal Government Servants Hospital was established in 1966. At present 3 1 dispensaries are also working under the administrative controt of FGSH in diffcrcnt scctors
of Islamabad and Rawalpindi. The centre provides medical care to federal government employees and their facilities and serves the general population. The following inpatient and outpatient wards are available in FGHS: medical, surgical, psychiatry, neurology, gynaecology, ophthalmology, ENT, paediatrics, nephrology, emergency, blood bank, X-ray and laboratory. The Pakistan Institute of Medical Science (PIMS) started functioning in fate 1985 with Islamabad hospital, Children's Hospital, MCH centre, Quaid-e-Azam Post Graduate Medical College, College of Medical Technology, College of Nursing and School of Nursing. Islamabad Hospital is one of the major components o f PIMS, with 573 beds and more than 22 specialties of medicine and surgery, intensive care, cardiac care, pathology, radiology, blood bank, angiography, cardiac nuclear laboratory, lithotripsy and physiotherapy units. The wards a-G tquipptd wit11 tllc l a t ~ s ~ l y u i p m and c~~ headed ~ by consultants. More than 2000 employees work in the hospital. The Children's Hospital was established to provide tertiary cme m d act n modcl for
management of childhood illness. Patients from northern areas and different parts of Pakistan are referred to this centre for advanced treatment. The centre trains postgraduate students in paediatrics for DCH. MD and FCPS courses.
The MCH centre, with a 125-bed hospital, was established with the help of the Japan International Cooperation Agency. This is closely connected with the technicaI cooperation project for Safe Motherhood in Pakistan. Patients requiring specialized treatment from all hospitals from Rawalpindi, 'Islamabad, Punjab and North-west Frontier Province are also referred to this centrc. Accreditation in the health care system in Pakistan means certificaiionlregistration of organizations involved in the deIivery of health care, including drugs, equipment and supplies,
WI-TO-EM/HCD1044/EIL Page 19 for the purpose of providing quality health care. An administrative body that ensures provlston of h ~ g h quality health care servlces and U ~ afulfils t the organization's goals, mission
and objectives usually does this task. Tltr G U V G ~ I I I uf I IPakista~ G I ~ ~ has a visioli tu prvvide quality llcalil~ care on an equitable
basis. The Federal Ministry of Health has already laid down a system of accreditation in following areas:
Medical Education: Pakistan Medical and Dental Council Drug Manufacture and Quality Control: in the Pakistan Drug Act of 1996. all manufacturers and importers of drugs are to be licensed and registered Good Manufacturing Practices (GMP): compliance to GMP is to be verified and tested before licensing of manufacturers and importers.
Different accreditation bodies have been proposed for implementation of the abovementioned laws. For example, a Board ot Accreditation has been proposed for the regulation of medical education and training in Pakistan. Similarly, a Medical Inspector may be appointed to grant certificates to all private hospitals clinics and clinical laboratories under the law whicb is being pl-oposcd fur regulativn of thcsc institutions. A medical rnolirusib
(ombudsman) will also be appointed to look into any patient complaints. The irnplementrition process may face certain obstacles that the national coordinator must be well prepared in advance to resolve. Such obstacles include the following:
Lack of trained personnel and other resources Poor governance and management Lack of clear follow up mechanism Absence of necessary legislation for implementation of standards Un-availability of practical and implementablc standards in various areas. 3.8 Saudi Arabia
In November 2001 the Minister of Health formed an ad hoc committee to develop national standards for accreditation of health care facilities in Saudi Arabia. The committee includcs rcprcscntativcs of ninc hcnlth care providers in the country, and is chaircd by thc
Director General of the Quality Assurance Department in the Ministry of Health. Goals of the committee are to:
Establish standards that responds to patient needs and expectations with available resources, for all sectors across the country Develop standards that take into consideration the concept of continuous quality improvement (CQI)
DeveIop training programmes for health care employees in order to implement these standards
Continuc evaluation and assess implcrnenlation process of the standards.
Available sources include the Ministry of Health assessment format for hospitals (200 1); Canadian Council on Health Care Services Accreditation (1 992); JCAHO and JCIA standards for hospitals (2002); Saudi Ararnco medical services organization standards 12002): and WHO standards for district Ministry of Health facilities. The framework used will include the following steps: 1) 2)
St@ with hospitals then polyclinics at a later stage. Focus on dcvclop~rlentu r skuclural slandards with emphasis on issues whch have greatest impact on patient and employee safety.
7)
nmirle upon content after review of different avaiIable rcsourccs.
4)
Draft the structural standards for different services. Kevise the draft by experts in specific services.
5)
6) 7) 3.9
Examine the standards in pilot studies. implement standards for the purpose of accreditation.
Syrian Arab Kepu blic
In 1998 an office for quality assurance was established in the Ministry of Health of the Syrian Arab Republic t o u-aiupt;uylt. u11 QM implementation in Minisuy activities. In ZOUU the first meeting of central quality team convened to develop national quality standards of health care facilities/services in the Syrian Arab Republic. Goals of the central quality teams are a s follows.
Establish standards that responds to patient needs and expectations with available resources, for all health organizations.
Develop, implement and update standards that take in consideration the CQI (TQM) concept. Develop training programmes for health care employees in order to implement these standards.
Evaluate and assess the implementation process of the standards.
WHO-EM/IiCD/044/E/L Page 2 1 In each Ministry of Health directorate, health governorate and hospital, quality teams were establrshcd to sct locaI quality standards for health services (health care and administrative procedures) after undertake training courses in quality system implementation and certain necessary skills (QC tools, problem solving techniques and computer skills). 'lhey e ill fur ri~atiurr,k ~ ~ u w l r c l g ae i d experiences and tu collduct rcscarch on quality issues. In 2001 a special technical committee was formed to study and adapt riieet pt;liodic;ally cu st
accreditation standards after reviewing American standards.
3.10 Tunisia Hospital accreditation has not yet been implemented in Tunisia. However. the Ministry of Health is working to develop the necessary prerequisites. Norms and standards concerning fa~ilities, buildings and human resources (needs and qualifications) were adopted in 1 993, and a nationaI sanitary information system is being developed. Currently there are a number of public and private initiatives to set up mechanisms in order to ensure high quality in health care provision. One private clinic is obtaining IS0 certification.
Averagc life expectancy in the country is 72.1 years (IYYY), N.1 for men and '/4.1 for women. Infant mortality (per 1000 live births) was 262 in 1999 (1386 in 1966); maternal mortality (per 100 000 births) was 69 in 1993 (134 in 1966); and 85.2% of deliveries were assisted by trained pcrsoilllcl in 1998.
Resourccs in Tunisia include 1.8 beds per 1000 population (1 70 health care units divided into 3 levels); 1 basic health care centre per 4000 population; 4200 doctors, 400
dentists and 28 000 paramedical staff. Geographical accessibility of the health care units is satisfactory. Weaknesses in public health care include unequal distribution of resources; incficient use of resources; weak internal organization of health care management; weak medical information system; and limited temporal accessibility (external consultations).
Private health care weaknesses are heavy concentration of private medical services in thc large urban centres, with no regulation concerning the geographical distribution of health care units (except for dialysis centres), and low involvement in national sanitary plans. In the semi-public health care sector, there are hospitals and units belonging to the Ministrics o f Dcfcncc and Interior, clinics for ambulatory care belonging to thc ilatioi~aIsocial
security fund (CNSS) and medical centres belonging to national companies. This sector improves health care accessibility for some categories of the population and participates in the develnpmcnt of health care and in improving n e w technologies.
Almost all the population is covered by a scheme to cover health care expenditures. Total health care expenses have increased significantly much faster than the growth of the GDP. The weaknesses of the system are the multiplicity and heterogeneity of the various schemes, which leads to high health care consumption/waste; inequities between the insured (contributions vs benefits); and low public financing of the private beneficiaries.
WHO-EM/HCT)/044/E/'L Pngc 22
Tunisia gains almost 500 new doctors every year. Qualifications and course of study must h e 9d;lptcd to produce general practitioners and/or family doctors, in relation tu the
needs of the population. Attention must also be given to balancing general practitioners versus specialists. Ongoing medical training is essentialIy through professional organizations with lack of efficient assessment mechanisms to assure cnordinatinn between various sectors. Administrative and regulatory weaknesses include the following: Insufficient norms and standards in the public sector. Lack of price regulation in the private sector. Lack of a nationa1 strategy of continuous quality insurance involving all parties. Centralizing the public management procedures (investments and human resources). In) conclusion, the strengths of the Tunisian health system must be consolidated and reinforced to cope with new challenges: epidemiological transition; reaching a consensus for thc dcvelop~llcnt wf the 11raltll syskm; sysrematic assessment of the development of the health sector; and ensuring a balance between equity, efficiency and quality. 4.
PROPOSED MODEL OF ACCREDITATION
In 195 1, the American College of Surgeons, American College of Physicians, American Hospital Association, and thc American Medical Association c n n p ~ r a t e dto form the Joint Commission on Accreditation of Hospitals to address the need to improve the quality of care in the United States of America. Today it is the primary instrument used by the United States Health Care Financing Administration to approve the transfer of medicine funds to hospitals. Only hospitals that have passed an accreditation process can receive payments. Countries in other WHO regions have also employed this method, such as Egypt and Lebanon (EMR); Brazil and Argentina (AMR); Thailand, Taiwan and Indonesia (SEAR); England, France and Spain (EUK); South Amca (AFK); and Korea (WPR). Accreditation has been defined as a "system of external peer review for determining con~pliancc with a set uf stiir~cliads." I1 is a procedure that evaluates the institutional resources periodically and confidentially, seeking to ensure the quality of care on the basis of previously accepted standards. Standards may be minimal, defining the bottom level or base, or more detailed and demanding, defining various levels of achievement. A hcalth cnrc cstablishncnt
is said to bc "accredited" when the disposition and organization of its resources and activities make up a process which results in medical care of satisfactory quality. Accreditation implies confidence in a hospital by the population. In almnst all cases thiq can he achieved without major investments in infrastructure.
There are three main purposes of accreditation: 1.
Quality improvement: using the accreditation process to bring about changes in practice that will improve the quality of care for patients;
WHO-EM/~ICIl/O44/B/L Page 23 2. Informing decision-making: providing data on the quality of health care that varlous stakeholders, policyrnakers, managers, clinicians and the public, can use to guide their decisions; 3.
Ac~oull~abilily urld regularion: making heallh cart: orgaiizalions accountable to statutory or other agencies, such as professional bodies, government, patient groups and society at large, and regulating heir behaviour to protect the interests of patients and other stakeholders.
Standards are statements of expectation that define the structures, processes, and results that must be firmly established in an organization so that it may provide quality care. For example, standard of structure refers to equipment, physical area, support services, personnel; standard of,process includes admission, nursing procedures, medical procedures, operational manuals, norms, routines, flows; and slundard o f outcomes covers mortality, morbidity, readmissions, complications, infections and client satisfaction (accessibility, information, personnel and facilities.). All these standards require evidence of performance (or qualitative indicators) that are simple, inexpensive and easy to observe by the surveyors.
In the Eastern Mediterranean Region there is often greai diversity of hospitals within the same country. Although there may be prominent public and private medical centres, col~~pat-able tu the ~liust advar~cecl irl iuly olller Regiun, mSmyor Lhese hospitals would nor pass an evaluation review for a minimum level of quality in some services. Currently, as well, many hospitals have a greai variation in quality among their services, independently of their size.
Major reasons for implementing accreditation are as follows:
It stimulates the improvement of care delivered to patients It strengthens community confidence in its hospital It reduces unnecessary costs It increases efficiency It provides credentials for education, internships, and residencies It can protect against lawsuits It facilitates acceptance by and funds from third-party payers The following concepts are important in accreditation methodology:
Accreditation is not the goal; the goal is to improve the quality of each hospital service The emphasis is on the total hospital system (and its processes) Educational progra111nzs arc; r;sscnlial
Standards for accreditation will evolve as the countries' hospital services progress The final verdict of Accreditation is based on a consensus among the surveyors The standards should reflect the average status of hospitals in a country.
WHO-EM/HC D/044/E/L Page 24
In the draft manual of hospital accreditation (Annex 4), standards are organized by increacing 2nd r ~ l a t e ddegrees o f quality performance (or complexity) i n such a way thai to
attain a superior level of quality for a specified hospital service, the standards for inferior levcls must necessarily be satisfied. The standards seek to evaluate, within a single service, aspects of structure, processes and results. through qualitative and dynamic evidence nf performance or indicators thai reflect the quality of services provided. To establish a given level for each item, the evaluation should begin at inferior levels until reaching the level where the requirements are not completely satisfied. Qualitative indicators, or evidence of performance, are described for each standard and designed to ascertain the degree to which measures prescribed by standards are carried out and t h e ~ reffect on patient care. The data collection process for observing qualitative indicators is designed to be as simple as possible. The results should offer information useful to those in decision-making or managerial positions to help them make necessary changes. For countries that do not have suff~~icra valid or reliablt: infurmalion for sratisrical analysis, or where adequate numerical data have not been collected, the indicator for each standard will be determined by qualitative observation using surveyor consensus. In the future, and to the extent that data are collected and analysed, one will be able to develop statistical
interpretations to establish quantitative observation. 'The evidence of performance of standards is not assessed through a checklist. Hnspitsls are unique entities, each with its own tradition, culture, and background. The surveyors will establish a tailor-made model of assessment for each hospital, defining how, when and what will be assessed first, and this flexibility cannot exist in a rigid checklist. Accreditation is still a very subjective type of assessment. For this reason, highly competent surveyors must be selected.
Currently, qualitative indicators poinl to sources where surveyors can seek evidence, or where a hospital can show surveyors that it is, or is not, complying with the staled standard(s). These sources might be documents, interviews, medical reports, patient records, etc. The draft accreditation manual covers all services of a general hospital for treatment of acute cases. It is intended to serve not as a national requirement, but rather as an illustrative guide for national multi-institutional commissions when formulating their own evaluation
tools. Increasingly complex standards, or those that evolve continually, have becn established for each hospital service, from an initial "threshold" to more sophisticated levels. These standards represent the expected level of desired care. practice, or methods defined hy national experts and/or professional associations. In each situation, the initial standard is the required minimum level of quality. No country's hospital hopes to find itself below this level, within a specified period of time, for example. As these initial standards are met, subsequent steps are addressed to reach successive standards. Thus, when the standard for the basic level is met, the next step is to reach the second and then the third levels, progressively. As a hospital is not comprised of independent or isolated services, it is necessary that all its services, from the laundry to the operating room, or to staffing of the intensive care unit, for example, reach at least the basic level standard in order for the hospital to be accredited
WHO-EMlHCD/044/H/IA Page 25 and receive the resulting public recognition for good quality medical care that accreditatio~~ bungs. An isolated servlce is not "accredited." Even if a hospital unit is h l l y equipped and of exceptional quality in some units or services, with sophistication levels at 3 or 4, the institution will continue to be accredited at the first level if other services do not exceed the f i ~ s level. t
This methodology attempts to reinforce the fact that hospital structures and processes are so integrated that poor functioning in one component interferes throughout and i n the final
rcsult. Thus, a hospital "is" or "is not" accredited as a whole, indivisible unit. Distinct levels of accreditation are not established for secondary and tertiary care hospitals. It is commonly observed that hospitals perform complicated clinical procedures, however, the surgical centre, for example, must interrupt its activities for lack of linens.
The methodology proposes that each service or hospital department standard reflects increasing performance of care. This promotes an environment of continuous improvement, because there will always be standards of higher complexity to pursue. Before, during and after an evaluation for accreditation, administrators must gradually develop items to identify and distinguish discrepancies between practices and acceptable standards of qualiry, finding ways to correct or reduce deficiencies. The draft manual of hospital a~creditation recornmcnds thc usc of lcvcls of standards of
accreditation of increasingly complexity. The accreditation process may observe some specific principles. For example, Level 1 should characterize the clients' "safety" (mainly stn~cturc component); Level 2 is more oriented at "safety" m d "organization" of the hospital
(mainly process component); and Level 3 is for "safety", "organization" and "management and quality" (mainly outcome component). Level 1: The demands of this level observe basic quality of care compatible with institutional resources. The services, units or sectors have responsible certified personnel, observe formal safety requirements and have appropriate infrastructure to implement activities within the corresponding rules and regulations. At this level, surveyors should verify the following evidence of performance:
Responsible certified personnel Functional personnel according to service needs Structural and opcrntional conditions according to snfcty rcquircmcnts for hospitnlizcd
and outpatient clients. 1 , e v ~2 l At t h s level, in addition to Level 1 standards, there should be evidence of organizational planning of care in relation to documentation, training, control, and decisions making based on information and the internal audit. Services, units or sectors have documcnted process and procedure manuals that are up-to-date and available, as well as
clinical protocols and basic statistics; continuous education programmes are offered for the improvement of processes, sentinel events and evidence of integration with other hospital services.
WI 10-EM/fICD/044/E/L Page 26
At this level, the surveyors should verify the following evidence of performance:
Up-to-date and available process and procedure manuals QuaIified professionals Groups for process improvement System of critical case assessment to control eventual problems or risks, procedure improvement Patient orientation Continuity of care and case follow up. Level 3: At this level, in addition to Level 2 standards, there should be evidence of institutional policies for continued ~rnprovement in terms of structures, processes, procedures, technol~gy upgrades and outcomes or impacts. The services, units, or sectors have measurement systems for client satisfaction; integration with the institutional quality and productivity programme; evidcllce uf i111pr.uvt.111~1lt cycles; data information systems and indicators that allow service evaluation; and community impact. At this level, the surveyors should verify the following evidence of performance:
Planning and continued improvement systems relating to structure, processes and results; new technologies; refresher courses in clinical care actions and pmcedi~rec Cycles of improvement with systemic impact Information systems based on indicators that allow analysis and comparisons Permanent system of satisfaction of inpatients and outpa~ents. 5.
MAJOR CHALLENGES IN IMPLEMENTING HOSPITAL ACCREDITATION Dr H, Novaes, WHCl Consultant Legal considerations. Executive orders, laws or regulations of the Ministry of Health are important and useful, but should not the paramount factor. In some cases, a change in Hcnlth hlinistcrs can hiildci- iillplr;n~cl~~illiuri or Lht: policy, even if it has just been announced by decree or through regulations, if the new Minister does not consider it a priority to encourage the national process of accreditation for political reasons. Thus, the initiative is delayed until another Minister presses the issue.
Lack of an inter-institutional and independent National Commission on Hospital Accreditation. Such a commission is always the goal to be reached, a l t h o ~ i ~it h is not easy to achieve consensus among the different actors in the public and private health sectors to work together with a common goal, Another threat is the appearance of multiple accreditation entities, competing among each other, and setting different standards, priorities, and fees. This can affect the entire accreditation process negatively, leading to the possibility that if a hospitaI is not accredited by one entity, it may be accredited by another, under different standards. It is essential to have uniformity; therefore there must be a National Commission that applies uniform accreditation standards to be foIlowed by state or provincial entities.
W HO-EMIHC~I0441EIJ~
Page 27
Lack of participation by the insurance sector. The role o f public or private social security and private health insurance is vital for implementation, since the mclusion of accrcditcd hospitals in their list of providers characterizes the inlportance of hospital accreditation as an instrument to ensure quality of care for the clients of these insti iutions. Private insurance companies art: begiru~i~lg LU ural y st: Illis situaiiur~, however, many countries unfortunately do not yet have a process to tie national accreditation to contracts for hospital services.
,
The non-application of minimum standards, as opposed to optimum standards. It is necessary to implement basic standards during the beginning of hospital accreditation development. This seems to be the most rational approach. since no country would be likely to have adequate and sufficient human and financial resources to correct dcficiencies throughout all of its hospitals, whether structural or process-related, using optimum standards. Since the methodology anticipates that each hospital service will have increasingly complex standards, the highest level of standards would be considered ideal or optimal (Level 3). Generally, professional associations, such as medical or nursing associations, always strive to establish optimum standards, although when starting to implement the accreditation process, they convince themselves that it is not possible to begin with very sophisticated levels. Consequently, very few hospitals, in the short term, manage to be in a position to implement optimum standards. Ensuring standards for all hospital services instead of for a few units. Approval of particular units or isolated programmes has been supported by some groups, by those in charge of the programme for prevention and control of hospital infections, or isolated
accreditation of hospital laboratories. A hospital may have a good programme in place to control infections or a good clinical laboratory, but this does not always ensure that other services are in a position to be accredited, even using minimum standards.
Risk of assigning points, or giving a precise value or numerical score to findings. This approach results in probIems because in some cases, the sum total of points may mask areas with deficiencies. Instead of giving a score, the surveyors, by consensus, should agree at the end of the accreditation visit whether the hospital is or is not accredited, or if some time is required to correct deficiencies (partial accreditation). Confusing licensing with accreditation. Some countries, have not yet instituted a national hospital licensing system, or a systcm for initial health permits for construction or renovation, which arc gcllcrnlly issued by muni~iyal authoi-itics and w h i ~ l l al~llost
always deal only with observable structural features (licensing). When a country tries to use accreditation as a tool for licensing, the degree of complexity created renders accreditation impractical,
Ensuring sustainability of a national accreditation programme. Although accreditation may be voluntary on the part of hospitals, these institutions must have some incentive for accepting the accreditation process. In the United States, for example, the vast majority of hospitals survive as a result of patients covered by Medicare, or social security for the elderly. For a hospital to be contracted under Medicare, it must have
WHO-EMIHCD1044IEIL Page 28
prior accreditation from the National Accreditation Commission. Similar incentives for sustainability nf this process will be required in countries of the Eastern Meditcrrancnn
Rcgion. Misperception of the role of surveyors. The accreditation process mlrst always be viewed as an auxiliary and permanent educational activity for hospital staff, never as a bureaucratic inspection or critical audit in search of victims. The basic role of surveyors should always be seen as that of specialized consultants helping the hospital to overcome its managerial or technical difficulties. Assessment teams generally include a physician recognized for hisher skills, a nurse with far-reaching experience in hospitals, and an administrator with a solid background in hospitals. In many countries, most of the hospital admln~strators are physicians, but in the surveyor team they are only "qdministrators," leaving the clinical side to be observed by the physician on the team. 6.
GROUPWORK Overview
6 . 1
On the second day the participants were divided into three groups to review the draft manual. Heterogeneity regarding countries and professionalism was considered in selection and distribution of groups. Each group was respo~lsiblc fur reviewing 14 s l u d a d s un hospital
accreditation. The objective was to discuss a set of standards with emphasis on the technical merit, consistent with current evidence, and its validity and reliabiIity for the Region. Group inputs nn standnda were i n r l ~ ~ d e i n d the draft manual.
New tasks were assigned for groups on the third day. Group 1 was requested to review the national and local steps of accreditation process. The objective was to determine how to promote the implementation, at the national level, of a process of continuous improvement of the quality of care ihrough wider dissemination of the manual on accreditation and enhance appreciation of the usefulness of accreditation standards. Group 2 reviewed the local steps to determine how to promote the implementation at the local level (health facility Ievel). Group 3 was responsible of reviewing the introduction of the draft manual. The objective was to ensure the feasibility of the methodoIogica1 considerdtion at the national Ievel and the clarity of instructions and procedures. A recommendations committee was also selected to set recomrncndations for both the country representatives and WHO/EMRO. Group prcscntations thcn took placc and group input on tbc llaticrllal a i l C 1 I u ~ a slcps l Tor
launching accreditation programme was included. After the presentations another round of discussion took place regarding the need to build up a mass of expertise in surveying, provision n f inc.entives (national and local) to motivate adoption of the programme and the
value of developing a survey checklist to reduce subjectivity. The group then agreed that ensuring unanimous clarity of the standards would reduce subjectivity and that checklist could be developed at a later stage. The thee groups met again to review and discuss the recommendations proposed by the recommendation committee and their input was included. They also discussed how to promote the implementation of accreditation programrnc and
WHO-EMIHCD/044/E/L Page 29
develop general cooperation agreements between countries and participating organizations, to support lhe inltlatlvcs being undertaken by the participants in their respecrive counrries. 6.2 Preparation for launching hospital accreditation
Currenily, there arc great discrepancies in quality among different services o f the same hospital, independent of the number of beds. Faced with this scenario, the Regional O f i c e is developing, with the collaboration of countries, a hospital accreditation model thnt i s appropriate for the Region and that is flexible enough to allow for adaptations of major differences. The model accreditation guidelines for the Region will cover all services of a general hospital for treatment of acute cases. They are intended to serve as an illustrative guide for national multi-institutional bodies when formulating their own evaluation tools. Many government, semi-private and private health institutions seek a recognized accreditation system in order to cope with the newly emerging competitive environment of health care service delivery. Hospital accreditation processes have recently begun to be implemented in some countries in the Region. Institutionalizing improved quality of care through accreditation requires more than a technical approach; more than the appIicauon of tools and methods. Failure to change ihe behaviour of people and organizational attitudes is the commonest cause of ineffective quality initiatives. Sustained improvements often require a change in attitudc and acquisition of a scnsc of owncrship with rcgnrd to thc quality of services provided by an organization. Many supporting factors are required to integrate accreditation into the structure and h c t i o n of an organization. The challenges in setting and measuring against standards arc mostly technical; the challenges in m ~ k i n gnpprnprist~
changes are social and managerial. Sustainable quality needs a supportive environment of leadership, clarity of purpose and organization, in other words, a strong accreditation programme. Accreditation can be the single most important approach for improving the quality of health care structures. Hospital accreditation is a method of ongoing consensus, rationalization and hospital organization. The first instrument for the explicit and objective technical evaluation of quality was the accreditation manual. The creation of the National Accreditation Body was of great importance. It should be apolitical, multi-representational, and should undertake its work energetically, prudenrly and periodically. This entiry will be responsible for the administration and policy-making of the accreditation system at the country level. It will be responsible for Ihe setting of national standards for accreditation, adopting WHO guidelines for accreditation, identifying and training thc surveyors, conducting md monitoring thc site surveys and making
the decisions rclatcd to the awarding of accreditation and maintaining it. It is essential to have uniformity; therefore, this body should apply uniform accreditation standards to be followed by state: or provincial entities.
In spite of recommendations that the National Accreditation Body be multi-institutional, and include the most prominent and active players in the civic, public and private sectors of the national health sector, the presence of the Ministry of Health is essential, both because of its prestige in our countries, and its capability of transferring resources within the process of national hospital accreditation. The mandate of such a regional entity would be to ensure that
WHO-EM/HCD/044/E/t., Pugc 30
national accreditation systems are competent to: monitor and evaluate adherence to national health system policy and responsiveness to current and futurc chnllcngcs; munitul- r u ~ d
evaluate quality performance of health org,anizations/facilities on various levels; cover managerial and clinical aspects; enhance organizations' learning environment and quality improvement culture; and establish a national framework tn takp fill1 responsibility for the accreditation initiative.
This national ownership is crucial, both to lay the foundation and to maintain. fiom the beginning, a high degree of integrity as well as accountability of the national accreditation system. 6.3
Implementing hospital accreditation in countries of the Region
The following steps are suggested to be followed by countries of the Eastern
I.
Orientation of national authorities within the Ministry of Health and other stockholders on conccpt, methodology, benefits and expected outcomcs of Accreditation by GMRO
and members of consultative meeting. 2.
Launching of the accreditation proccss by establishing an ad hnc national accreditation committee P A C ) by the Ministry of Health.
3.
Presentation of the accreditation manual to the national accreditation committee.
4. 5.
Contact with the country leadership by the national accreditation committee. Review and adaptation of the WHO manual by the national accreditation committee.
6.
First national seminar on hospital accreditation, "Validation of standards and evidence of perfonllalcc (qualirativc irlcli~aturs)".
7.
Identification of available resources and existing ongoing activities on Accreditation and Quality Improvement throughout the country by the ad hoc National Committee
8. 9.
Selection of public and private, Iarge and small hospitals as pilots. National seminar on hospital accreditation, "Presentation of the accreditation process in pilot hospitals" Establishment of a permanent multi-institutional national commission/counci1 representing health care providers, independent or semi government organization, universities, insurance companies andlor community representatives. Reformulation of some standards and indicators based on the pilot study.
10.
1 1.
W H 0-EM/fTCD/044/E/L Page 31 12.
Initial formal surveyor training.
6.4
Hospital accreditation at thc local level At local hospital level the expert group recommended the following steps to implement
the accreditation process: r n n t a c t with hospital a~rthorities
Configuration of the hospital accreditation committee Training staff on concepts of accreditation; presentation of the manual to governing bodies and hospital committees Communication of these standards to those who must use them; Self-evaluation, bascd on proposed standards for services Design of situational profile. Implementation of a plan of action to improve the standards that did not reach the minimum level. Problem solving and process improvement. Solutions to problems can be sought lhrough ~rlu~uial help arid ~uopera~iurl.
Training and monitoring the plan of action Report to the hospital authorities. 6.5 Task
Plan of action for hospital accreditation at the country lcvcl Wcc k Purposc
Activities
Stepsl, 2 and 3
To be established
i.
Meeting with professionals representing national/provincial/1ocal Meeting with groups who applied the accreditation model (if ii. Conceptual and methodological applicable) consolidation of a national Vis~ts country health leadership programme with the (nationaVregional/local) participation of govemorate/province surveyors iii. Constitution of the ad hoc national accreditation commission Presentation of the accreditation manual to national and regional authorities representing the health sectors (public and private)
Step 4
Ad hoc accreditation commission for thc revision of accreditation manual
Estiiblishmcnt of the worhng group in charge of the preparation of the preliminary version of the accreditation manual, m d other
instruments
Step 5 and 6
Working group meetings at the national/provincial lcvcl;
Revision of the first version of the a c c i cditativl~ rlrarluals
preparation for national seminar
pilot appliclion in the field (stateslprovinces): large, small, public and private hospitals Presentation of the results of the accreditation assessment; national meeting
Step 7
National seminar
Step 8
b
Step 9
Immediately after national consullations, permanent project personnel should prepare the formatting, editing, and publication of the document, incIuding all revisions Revision o f legislation and Analysis of currc~it lcgislatiun Tor proposals for the establishment of an the implementation of the national oversight programme at the national accreditation programme, offcring alternatives to the level MinisrryDepartrnent of Health
Consolidation of the pxinciples of the accreditation manual
Step 10
Step 11
Standards for the establishment of governorate/provincial commissions of hospital accreditatinn (if applicable) Elaboration of the curricular model for the preparation of surveyors (nurse, physic~an, and hospital administrator)
Preparation of the criteria that will be set for the establishment of provincial commissions for
hospital accreditation Preparation of course modules to train surveyors; characterizing accreditation procedures as educational instruments to improve hospital management; workshop with andlor international consultants Analysis of economic alternatives for the feasibility of the national hospital accreditation programmes in the capital o f the country or altcrnativc locativl~ a~ecd upon
Step 12
Proposal for the financial sustainability of the national progi-ailu~lcs
Step 13 and 14
i. International workshop to present International seminar, 2 or 3 days, the countries hospital accreditation programme
ii. Presentation to the Minister of Health, or equivalent, on the status of country proposals on hospital accreditation
6.6
Surveyors
The role of surveyors is crucial to the credibility and sustainability of accreditation. The expelt group recvrilll~er~clccl L ~ E hlluwing ; criteria for selection of the sweyors:
Experts in the field (medicine, administration, nursing)
Skills for interpersonal relationships M;lllagcl~lcilt cnperiell~c
Knowledge of standards and methodology Knowledge about quality assessment rnelhods. Surveyors should be trained in the following areas: Visits and teamwork, not inspection Handling of a daily agenda-time management
rn
,
bowledge of standards and indicators Communication skills Handling difficult situations. Skills to describe findings in detail and precise summaries Ethical issues such as confidentiality and others.
7.
RECOMMENDATIONS
To Member States
1.
Conduct an intensive programme awareness-raising campaign, including capacity building, disse-mination of c.onceyts and s ~ ~ k i n cnmmi e trnent, tn promote accreditation
of health care delivery services. 2,
Seriously consider the implementation of the WHOEMRO suggested steps for launching the accreditation programme. A clear national vision, mission, scope, goals and objectives for the programme should be the starting point at the national level. Excrt all possiblc cffort to includc accreditation in strategic national hcalth plans.
3.
4.
Issue regulations necessary to ensure credibility of the national accreditation programme.
5. 6.
Determine the requirements for financing and sustainability of the national accreditation programme and identify necessary financial resources and potential funding sources. Develop national expertise in quality improvement and accreditation.
7.
Share progress and constraints with EMRO and seek relevant support where needcd.
8.
Continuc supporting thc dcvclopmcnt of nccrcditntion programmes i n countries of thc
Region through the joint programme review mission planning exercise. 9.
Prepare an orientation paper on hospital accreditation including its implementation, for discussion at the 2003 Regional Consultative Committee meeting and Fiftieth Session of the Regional Committee for the Eastern Mediterranean.
WHO-EMIHCDI044IEI1, Page 34
10.
Support countries in developing action pIans to launch accreditation programmes. Develop a monitoring tool to follow up and assess progress of Member States in implementing their accrcdilation programmes. In collaboratron with Member States, involve the identified responsible national
11.
12.
officials for the nationaI health care accreditation programme. 13.
Enhance partnership with regional (such as thc GCC) and intcrnalioll.dl urganizations to
expedite implementing accreditation programmes in the Region. 14.
Organize an expert group meeting in November 2003 to address; surveyor training packagc; awareness package; and updating of the manual. Facilitate exchange of information on country initiatives and progress in accreditation progranurles arrlortg countries of rhe Region.
15.
Annex 1
AGENDA
Election of officers Adoption of programme
Briefing on previous WHO accreditation meetings Presentation on the concept of hospital accreditation and its application Country experience in accreditation models
Organizational components of the accreditation model Setting standards for hospital accreditation Inti-oductiun uf a prupused inudcl uf a~crcditation fur countries of the EastcIl~
Mediterranean Region Establishment o f national bodies on hospital accreditation
The process of hospital accreditation Promotion of hospital accreditation and training surveyors Recommendations and follow up actions for the promotion of hospital accreditation in Member States 14.
Policy directions review of WHOlEMRO for accreditation
WHO-EMIHCDI044IEIL Page 36
Annex 2
PROGRAMME Monday, 23 September 2002 08:3&09:00 09:OO-10:15 Registration Opening session Message of Dr Hussein A. Gezairy, WHO Regional Director for the Eastern Mediterranean Introduction of participants and resource persons Election of officers Adoption of agenda and programme Objectives, expected outcome, and methodology of the rneetingmr Ahmed Abdellatif, WHO/GMRO
Briefing on WHO Hospital accreditation policy/Dr F. Siem Tjam, WHOMQ Briefing on previous WHO accreditation rneetings/Dr F. Al-Darazi, WHOIEMRO Plenary session I Discussion Country cxpcricnce in accreditatiur~ ~r~udels'
Presentations and general discussion on the different models on accreditation. Presentation on the concept of hospital accreditation and its applicatinn (Dr Humberto M. Novaes, WHO Consultant)
Tuesday, 24 September 2002 Rapporteur summary: EMR status report on accreditation initiatives Lntroduction of a proposed model of accreditation for EMR Member Statesmr Humberto M. Novaes, WI-IO Con.~ultant
10:30-17130
General discussion Group work: session 1 Studying the organizational components of the accreditation model Setting standards for hospital accreditation
Wednesday, 25 September 2002 08:30-10130 10:3&11:00
Group presentation: session 1 Implementing hospital accreditatiodDr Ahmed Ahdellatif, WHfi/EMRO
11:OO-17:30
Group work: session 2 Establishment of national bodies on hospital accreditation The process of hospital accreditation 'lraining and promotion of hospital accreditation
Wl-~O-EMIHCD/044/E/I. Page 37 Thursday, 26 September 2002
08:3&10:00
09:30-10:30 10:30-16:OO
Group presentations: session 2 Major challenges faced in implementing hospital accreditation Group work: session 3
16:OO-17:OO
Feasibility, suggestions, recommendations and follow up actions for the promotion of hospital accreditation in the Region Recommendations and conclusions Presentation of summary recornmcndations by ihe Rapporteur Approval of the proposed model of accreditation for countries of the Region Presentation of proposals by countries and action steps by countries
General discussion
Closing session
Annex 3
LIST OF PARTICIPANTS
BAHRAIN Major Sumaya Hussain Abclul Rahman Head of Quality Management Bahrain Defence Force Medical Services Riffa Tel: 0973-766 I l l , 766 666100 973-9 629 639 Fax: 0973-766 0 13 E-mail: S UMAYA-bdf@hotmail.com
EGYPT Ur Mahi El-Tehewi Public Health Department College of Medicine Ain Shams University Cairo Tel. No.: (202) 4 170 372 Fax No.: (202) 4 837 888 E-mail: Elbokl@menanet.net Dr Sar~iy Oddalla
Managing Director HeaIth Care International (HCI) Cairo
Tel: +(202) 4 023 763-2 61 8 690 Fax: +(202j 2 6 12 622 E-mail: Sgadalla@hci.com.eg
JORDAN Dr Osama Samawi Director of Education and Training Ministry of Health Amman Tel: 962657 089
Fax: 9 6 2 4 657 084 E-mail: Osama~~i@hotmail.com
WI-10-EMIHCD1044IEIL Page 39 KUWAIT Dr Alaa El Din El-Farargy Head, Quality Assurance Oflficc Al Jahra HeaIth Region Ministry of I Icalth Kuwait Tel: 00 9 6 5 4 893 627 (H); 00 965-4 55 1 OX6 (0) Fax: 00 965-4 570 858
LIBYAN ARAB JAMAWIEUYA Dr AIi El-Mabrouk Ahou-Grain Mjnistry of Health Tripoli Tel: +2 1 8-214 800 200 -3 607 522/1780; (mobile) 4 800 20013 61 1 9 1 9 Fax: +218-203 6 1 1 92014 622 02 1 E-mail: abougrain@hotrnail.com
MOROCCO Dr Abdclnli Bclghiti Alnoui
Head of Hospital Division Direction des hopitaux et des soins ambulatoire Minintty nf Heglth
Rabat Tel: 212 (0) 61 392 616121 237 208 170 Fax: 212 (0) 37 207 38 1 E-mail: belghitialaoui@hotmaiI.com Dr Saida Choujaa Jrondi Director of Hospitals and Ambulatory Services Coordinator of Basic Development Needs Approach Coordinator of the National Programme of Quality Assurance Minisly of Health
Rabat Tel: 212.37.20.81.68 Fax: 2 12.37.20.00.70/37 207 38 1
E-mail: s-irondi@sante.pov,rnaor saidachoujaajrondi@hotmail.com
WHO-EM/HCU/044/E/L Pngc 40
OMAN Mrc F ~ r i d a Salim Al-Abrawi
Nursing Officer Al-Nahda Hospital Ministry of Health Muscat Tel: 009 687 737 51 1 , O O 968 544 255 Fax: 009 687 737 522 E-mail: SAJ?ASSM@OrnanteI.net.orn SAUDI ARABIA
Dr Yazid Al-Ohaly HeaIth c a r e Consultant P.O. Box 28075
Riyadh Tel: +96 614 770 647; +96 655 410 102 (mobile) Fax: +96 614 793 334 E-mail: yohaly@medu.net.sa Dr Mohamed Hassan Mufti Director General Security Forces Hospital Programme Department of Medical Services M~nistry of lnterior Riyadh Tel: 966-14 776 44814480; 96 6 14 558 645 (mobiIe) Fan. 9G6-14 792 451
E-mail: MUFTI-MH@compuserve.com
TUNISIA Dr Noureddine Chemi Director Private Sector Regulation Ministry of Public Health Tunis Tel: (216) 71 561 032/(216)98 304 015 Fax: (216) 71 561 838 E-mail: Noureddine.cherni@ms.tm
WHO-EMIHCDI044IEIL Page 41 OTHER OKGANlZATTONS
Executive Board of the Health Ministers' Council for GCC States Dr Tawfik A.M. Khoja Executive Dil ectur
Riyadh SAIJDI ARABIA Tel: 0096 614 885 262
Fax: 0096 614 885 266 E-mail: sgh@sgh.org.sa OBSERVERS h
SAUDI ARABIA Dr Yasser A1 Obaidi Quality Management Director Security Force HospitaI Kiyadh
Tel: 0096 655 163 485 Fax: 0096 6 14 774 480 Ext. 2187 E-mail: vasci-wb@.11ot~~~ail .con1
SYRIAN ARAB REPUBLIC Dr Rajwa Jbeily
Quality Management Proiect Director Ministry o f Health Damascus Tel: 00 963-1 1-2 2 12 336 Fax: 00 963-1 1-33 1 11 142 WHO SECJWTAIUAT
Dr Mohamed A. Jama, Deputy Regional Director, WHOIEMRO Dr M. Ishaq A1 Khawashky, Special Adviser to Regional Director, WHOIEMRO Dr Ahmcd Abdullatif, Rcgional Adviser, I Icalth Care Delivery, WHO/EMRO
Dr Ferdinand Siem Tjam, Medical Oficer, Health Service Provision, WHOlHQ Dr Mohamed Assai Ardakani, Mcdical Oficer, Primary Health Care, WHOPakistan Dr Humherto M. Novaes, WHO Consultant, WHO/HQ Mrs Deya El Assra, Administrative Assistant, WHOIEMRO
Mrs Nahed Zeid, Secretary, W HO/EMRO
Annex 4
DRAFT MANUAL ON HOSPITAL ACCREDITATION
This manual was adapted by INTECH, Inc.* and especially designed for the WHOEMRO Intercountry workshop and is based on the document "Standards and Indicators for Hospital Accreditation in Latin America," by Drs Flumbertu M. Novaes and Jose M. Paganini, published by P A H W H O , with support of Dr. Hugo Arce and collaborarion from ITAES. Reprnduccd wirh authorization.
All rights rcscrved by WHOEMRO. No part of this manual may be reproduced in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without prior written permission. Entities interested in reproducing or translating all or parts of this manual should request timely authorization from WHOIEMRO, which will givc favourable consideration to such requests. The lcxl used in this publication and the way in which data is represented do not imply judgment about any legal condition in any county, territory, cities or areas cited or about its authorities, nor in relation to the delimitation of its frontiers, by WHOIEh4RO.
The mention of specific commercial elltities or the name of certain commercial products does not imply that WHOiEMRO either approves or recommends them in preference over other analogous ones.
* The Institute for Technical Cooperation in Health, I N E C H , Inc., 12 Pasture Brook Ct., Potomac, MD 20 854, USA, telephone 001-301-6 1CL9620, Fax 001-301-610-9621, E-mail tecsaude@aoi.com (Washington D.C. Metropolitan Area)
INSTRUMEN'CS 'I'HA1' REGULATE: THE QUALITY OF C A W .....................................................
3
4 GENEML CONSIDERATIONS ..................................................................................................... Mt.tlludulugic;al ~ u l ~ s i c l e ~ i l l........................ iu~~s . . . . ............................................................. 4
Interdependence of standards .................................................................................................. 5 .......................................................................................... 5 The hospital coiitext of health care Preliminary instr~rctionr and procedures ................................................................................... 5) Instructions for the use and interpretation of the manual ........................................................... 10
MINIMUM SI'ANIIAWS............................................................................................................
12 Organization of medical care ................................................................................................ 12
.
.
General and support areas .................................................................................................. 23 Building documentation ....................................................................................................... 33 Functional physical slructurr: ................................................................................................ 34 installations ....................................................................................................................... 35 FACULTATIVE, SI'ECJIAI. S'IANIJAKLIS...................................................................................
3'7
APPENDIX: EXAMPLES OF INDICATORS OF THE QUALITY OF MEDICAL CARE. SPECIFIED BY SERVICE OR SPECIALTY. 1-0DE REVIEWED AND ADAPTED '1'0 1'1 1C LOCAL CONDITIONS
OF EACH I IOSPITAL..................................................................................................................
47
BACKGROUND At the beginning of this new century, countries or the WHO Easterr] bledite~~a~tean Region prescnt a great wealth of social and political experiences which, al tliougb facing a cot~text of economic and financial challen~es, show unmistakable signs of a society engaged in a proccss of tra~lsfoin~ation and maturation. In several countries the health sector has been developed over the years with planning and stable political conceptions to orient the invcsiment and development of the health scctor. Tllis took place, however, without a continuaus quality improvement program or an analysis of outcomes related to the quality of ~ C T Y ~ C provided C ~ to improve thc quality of health care. Consequently, the policies appli~rl had nnly p t - t i n l goals and results that did not reorganize or reorder the entire sector, but only some of its cornponetlts. The need to irnprove quality has been an issue in health care for many years. A step foiward, since 2000, compared to other periods, are the improved systcrns and methods that now exist to help health care organizatiot~s itnprove quality. In addition, it has becomc a social imperative that this is carried out because altnost all users, providers, and purchasers are aware that health care services and systems can be contii~uouslyimgroved. Consequently this social imperative has stimulated many countries to embark on llealth care refonn initiatives.
Factors that contribute to this imperative arc: increased patient awareness of their rights as consulners of h e a l ~ hcare, ir~cr-casccl atk~i~iuri lu quality- i 1 1 all i~~dustl-ics bccausc o f thc recognition that quality is the key to long-term success; and a need to control health-care costs. Health care reform can be considered successful only if the quality of care improves as a rcsult of the changes inlroduced by reform. In turn, the spontaneous growth of some of the sub-sectors brought ahout a clear-cut separation between private activity, the public sector, andlor social security systems, fuming provider systems with their own problems which, though independent in their origins, nevertheless exacerbated the cffists of the financial and economic crisis currently amiciing the m i ~ n t r i e v poteiiti~l
The organization and morphology of provider systems sliow the existence of compartments occupied by the professional sub-scctors (physicians, dentists, nurses, etc.), the health care establishments, and the drug market--each organized in accordarlce with the mterests cotnmon to their particular activities and subjected to an u~lreasonable struggle, whose conceptual framework is impacted by the generalized li~nitationc ~ rcsou~.ces. f Many of the current systems lleglected an cvaluntion of the quality of individual and systematic institutional care, giving rise to an unnecessary ~ncreasein costs. Inversely, a trend emerged in the social security systems to lower expenditures regardless of' real coverage needs. There are few health carc 1)n~viJcls who call igllvrt the dcmands to changc thcir irlstitutions and hcahh carc nctworka. Fortunately, health care professionals, by the vely nature of their work and training, generally want to improvc their patie~lts'outcomes and satisfaction. The challenge for health care leaders is to identify and successfully implement systems to harness and promote the desire of professionals to have to improve scrvices and at the same time, meet the demands of consumers and other payers for more ~ntormatlonabout the quallty of l~ealthcare. The result of this equation has been an increase in the overall insufficiency of the syslcm, reflected in increased medical care costs and a reduction in their quality.
Accordingly, the basic need arises to effect substantial and sufficient changes to deal with the detericlration of the quality of the health systems. Analysis of the factors responsible for deterioration of the cfieicncy of the health sector demonstrates that the deficit in planning leads to the existence of hospitals tl~alr~cqucrl~ly lack tile i ~ ~ i ~ l i ~ u ~~ ii ucn l i~ tiu f'ul ~~s yualificatiorl, do not rcspoild to the real necds of thc
population, and provide services that do not satisfy nlini~nutn quality standards.
Page 2
Philosophically, and from a theoretical standpoint. it is impossible to deny the need to implement standards to irnprove the quality of tnedical care. Howevcr, the difficulties tlie various countries are undergoing rrequently lend thcm to postpone s11ch i i c ; ~ i o ~ u11 ~ s the grounds rI~atthcy woirld be neither feasible nor practical. This fallacy should be corrected by demonstrating that an effective means of remedying the deficit described is acting on the quality of care provided by optimizing the cost-benefit ratio. Govenlments, accrediting agencies, insurers, and other parties interested in quality assurance have variously tried to design valid and reliable pcrformai~ce measures to objectively assess clinical competence. Among these are stanrlsrdc nf practice are generic screens for rcvicwing rccords, n systclll Cur reporting adverse occurrences, practice guidelines and critical paths, and indicators of pei-formance. In light of this reality, the utilization of suitable methods, such as hospital accreditation, for reorganization is a valid approach that acts as a guideline, maintaining its effect even in the event of possible modification of thc covzrngc a11J f i r l a ~ ~ ~system. i~ig
In'the Eastern Mediterranean Region, awareness has grown of the special significance of the current stage of development of societies and of the projections of this situation fnr the r r ~ r n i nyears. ~ We are undoubtedly witnessing a period of rapid change, affecting a11 aspects of our lives, and that have dcep repercussions on the hcalth situation and on the resources available for coping with it. It is imperative to undcrstarld this process a ~ l d the consequent adjustmr~~ts in the health sector and in society itself, if the gnaf ~t hy g n v ~ m m e n t to s achieve hcalth for all, with equity, cffcctivcncss. c f f i i i c ~ ~J~ Iy I,parlicipation, ~ is to be attained. The need exists to establish priorities for the develop~nent of health scrvice infrastructures and for special attention to priority problems and groups in accordance wit11 the primary care strategy. In response, in different countries, proposals have been drawn up to transfomi national health syste~tisthrough the developinent of their district health systems and as an operational tactic to accelerate the application of the strategy of care and its essential components.
The development of a new model of health care sllould not be limited simply to a division of labor of government. Rather, it should be a process of fundamental change in the within a decentralized scl~eme technical pruieJurt.s ul'ser-vic~ delivery, in the use of available technologies, in the integration of relevant knowledge, in the ways resources are used, and hi the efforts to ensure social participation. A series of methodnlogies and basic principles based on these elements can be set to facilitate the development of new models of health care. Based on these concepts, EMRO/WI-IO began to cooperate with Mcmber States on the incorporati011 of hospitals in the health services iietwork or district health services, to assure quality and efficient health care <crvir.c< T n this way, the Guidelines for Hospital Accreditation ochicvc the doubIc I - U ~ G uf prcserlting a tlexiblc scheme to facilitate the incorporatiori of hospitals into the network of services, as we11 as to pri~vide guidelines for quality development of services. Analyses ot the Factors for health sector efficiency deterioration demonstrate that lack of planning leads to the existence of institutions that frequei~tly lack the minimum conditions for licensing, and provide services that do not satisfy quality stsandards.
INSTRUNtENTS THAT REGULATE THE QUALITY OF CAKE For the reasons stated above, we propose to act on the provider model, with instruments to regulate and guarantee the quality of care, expecting that his will contribute to improve the overall efficiency of the system and provide a consequent benefit for the population and participating sectors. For this purpose we wrll f ~ r s of t all iucus upon to the tem~inologyFor evaluating public and private hospitals. These procedures
are as follows: I.iccnsing: T11iq prncedure is carried out hy legal health authorities. or other entities in charge for this purpose. 'This is usually done only once, prior to the beginning of operations, and defines the local structural requirement.
Accreditation: Is a fonnal process by which an authorized llealrll body assesses and recognizes rllat a hcalth caw organization meets predetermined standards designated to improve quality of care
Categorization: This procedure refers to the classification of outpatient and hospitalization services according to criteria adopled (complexily, care risks, and the like) that allows the definition of levels, concentration of activities, classification of benefits. These must be feasible in relation to, and the kind, of hospital under study, and cotlform in the future within a local health services network (district health system). Self-assessment programs (peer review): A process where by the perfortrlance of an organization, individuals or groups are evaluated by members of similar qualification internally
There are, however, other kinds of self-evaluatiot~, that are commonly defined wit11 regard to explicit and acceptable performailce criteria, and that are compared with the care provided. Various techniques may be applied in te~msof self-evaluation, such as when the appropriateness o f hospitalization is analyzed before patient admission into the health institution, when the kind of medical or nursing care is considered upoil admission of the patient into the hospital, or after discharge, when the indications for follow-up in the short or long term are evaluated. Other examples of evaluation iilclude referral and counter-referral within the n e ~ w o r k o f services using tracer indicators, clinical sequelae, and ihe satisfaction o f rhe patient and of the family members with the care received. The working tools utilized are epidemiological, sociological, administrative, and clinical, adopted to coordinate the activities, such as hospital infection control, blood transfilsion control, accessibility, use of drugs, pathological anatomy, medical records, etc. l'hese activities represent what is being promoted as "Hospital Epidemiology."
STRATEGY Total or gradual implemetltation of the instrurr~entstnerltioncd sllolild lead to the dcvclopment of a regional or local strategy. Licensing would consequently be the initial step for setting up a hospital. Accreditation will lead to gradual increase in the level of institutional quolit). o f core provided. Self assessment methods are specific: intra-institutional pl-ocedurcs. Implementation of the referral and counter-referral instruments should lead to
organization based on regional or local realities.
The preparation of this manual for the quality of healthcare constitutes an instrument to guide the evaluation of services or hospitals, with previously defined objectives. To prepare the standards, the following criteria were taken into considerations: 1.
The consideration of costjbenetit ratio durlng the evaluation procedures And excessively detailed procedure, which can be too much expensive in relation to the investment required in qualified personnel to carry out every evaluation. In the detectio~ of evidence o f performance in a hospital, the objective should be focusing on the ve~ificatio of ~~ the most representative data of existing conditions. The analysis of this data makes it possible to arrive easily at el'fcctive concIusions. Simplification of the procedure requires outcome indicators (final results) lhat are essentially qualitative, and whose verification does not require prolonged accourlts of events, but the obseivation of certain data, that when preseni, allow us to assume conditio~ls of quality.
2.
3.
4.
The sclectcd indicators (evidence of performance) should be easily verifiable, whenever possible by observation alone (yes or no), avoiding standards whose cvali~ationimplies extensive reviews of documentation.
5.
The standards will provide for evaluation, within a single service, aspects of structure, process, and results (or outcomes), which reflect the benefits of quality.. Alrhough the evaluation of results offers many difficulties, given that the evaluated hospitals do not carry it out themselves, the evidence of performance preferably should allow consideration of structural conditions existing prior to rriedical iutervention, as we1 t as the quality with which the process of care evolves. The range of thc sta~ldards may go from an acceptable level of quality, up to an optimum, which may be present in some hospitals in the Region. The optimum should not be ideal, but thc best that the existing conditions pennit (Level 3 or 4 in the Manual). The different dcgrees of satisfaction of a standard should be correlated among themselves; they should not comespond to d i k r c n t features in parallel hierarchies. The highel degrees of satisfaction irnply fulfillment orlhc lower degrees.
6.
7.
Concerning the hospital of certain standards, it is desirable to cornmcnt as well on some additional concepts:
1.
The services of critical medicine, intensive carc, as well as neonatology, depend substantively on the available technological infrastructure and, in particular, on the concentration of the technology in each theatre of intcnsivc caic. In this case, the different lcvels of satisfaction of the standards reflect. in part, degrees of technoiogical complexity of the service, although some aspects of quality in the process of medical care havc hccn considered, the content is a description of the existing equipment. In some cases, such as tllc resuscit;ttion unit or nornlal newborn care, the features overlap with activities required for thc standards for emersency csre and childbirth care, respectivcly. This
overlapping expresses the "compulsory" and "facultative special services'' aspects of those areas, as we will see further ahead.
2.
The standartis for radiation therapy and rluclear rrledicine are serlsitive to the technological infrastructure; besides Illat we have sought to it~cludeaspects of quality in the process of medical care. Anaesthesiology should be corlsidered a basic and coinpulsoty service; however, in practice anacsthcsiulogq- functions as an undiffcrcntiatcd dcpcndcncy of tIlc surgical s c ~ r i c c .111 soinc countries, nevertheless, both intensive care and responsibility for pnticnt clinical care during surgcly depend on this service. When they function in an undifferentiated marmer within the surgical service, and include responsibility for the care of cardiovascular complications during surgery. that care is ~ h c responsibility of cardiologists and not of anaesthesiologists.
3.
Intcrdepcndcncc of standards
This ~illc contains a set of requirements that arise fsotn the need for tlie hospitals to function as a I~amionious group of services and, in turn, as part of a local rlehvork of integrated hospitals (the district heal111 systcm). To define thcsc it~terdependent needs, it is useful to take into account three organizational concepls: The comprehcnsive development of the difTerent conlporients of a hospital improves organizational eficicncy and avoids dispropodionatc. grr~wthof somc scrvicu unsupporlcd by an adt'quate technical infrastructure in the institution as a whole.
The concept that should define the categorization of hospitals is the risk of medical care, instead and before teci~nologicalcomplexity, so that the institution is prepared to absorb a specific level of risk and refers the cases that excced it.
The district health system approach. as a svstem. leads to considering services as part of the l~ospital when they are really outside its pliysical plant. This happens in spite of different ownership of these services, so that Iocal availability of services is a hospital institution resource, which should be included in the evaluation, as for example, in the case of a hospital purchasing outside laboratory or radiology services.
In general tenns, as it is expressed in the itistructio~lsfor the i~lterpretationof the manual, tlie ~'liorizontal" coherence of the levels of satisfaction of the different standards expresses a primary approximation of interdependent requirements. In addition, the services of critical medicitie, intensive care, and neonatology raise the issue of a set of requirements with respect to available diagnostic media. Surgery, the emergency service, and related services add a set of interdependent requirements that should be taken into account.
The hospital context of health care I.
Scope 0fApplruabzon
This Manual considers each hospital, regardless of its denominatiot~,dedicated to providing medical care. inpatient and outgaticnt. whether public, private, military. or a branch of sociai security, of greater nr lesser complexily, wilh or without profit among its institutional objectives, and open to the entire community in its area of coverage or with admission limited to a sector of it, as a hospital. Following a systemic approach, hospitals fonn par1 of a healrh care service netwol.k, associated geographically, either through a planned organization or as a result of a spontaneous arrangement of existing health care delivery factors. '[his criterion, including all of the service delive~yfacilities in a specific "catchment" area, is called "district health systetns."
Page 6
2.
The Patient crs u Foczis ofHospifu1Care
'I'hc dcvclop~ncr~t uT Qualily Assurdrice programs is a necessity it1 terms of eihcrcncy and an obligatio~lin ethical and moral terms. All hospital institutions, given that their basic mission is to benefit the patient, shouId be concerned with eilsuring continuous improvement with a view to achieving the harmonious integration of the medical, technological, administrative, economic, and care areas and. where applicable, the teaching and research areas as well.
Unlike other industries, in a health institution or hospital the input is the patient, when s h e is ill and what the institution is expected to deliver is hcolth. Conscqucntly, thc conccpt uT "liu~r~iio being" is
fundamental to the existence of these institutions, which can only have true significance wIlet~thcy are conceived to be for and at the service of mankind. It is a patient whose body does not function properly; it is a person who becomes ill, who suffers, who becomes unbalanced, whose capacities, personal development, or societal relationships are weakened. It is that individual who provides the "raison d'ct1.e" to the health entity.
A hospital tnanual acquires true meaning when the criteria for evaluation of the various areas arc determined, us111g as a foundation the concept of the institution as a place for the recovery and treatment of profouild hurnan values. This concept must include the awareiless of all the active participants in the icslur-alioil of heal~hand that tIley are trca~ing human beings; they recogllize that ttlclr iunction is to llelp relieve hlrinan pain, stlffering, and irnbalanccs. 3. Putienl Rights Access to care
Every individual should be glven ~mpart~al access to care without considerir~grace, religion, sex, national origin, or provisions for payment of the care. Respect and Dignity
The patient has the right to receive respectful care at all times and under all circurns~ances,as recognition of hidher personal dignity.
Privacy and Confidentiality The patient has a righi io privacy with respect til hic pprcnn nnrl in the following rights: tn
infnnnatinn, such as i s manifested
The right to refuse to speak to or to see someone, including visitors and persons officially related to rhe hospital, but not involved directly in Ilisnler treatment.
The rights to wear appropriate personal dress, as well as other synbolic or religious objects, whenever they do not interfere with the procedures for diagnosis or treattneiit The right to be examined in installations designed to ensure reasonable visual and auditory isolation. This includes the right to request that a person of the same gender be present during cci-tain parts of a medical exam, or during treannent or procedures done by a professional of the opposite gender. ' l h s includes the right not to remain undressed for tnore time than necessary for carrying out the medical procedure for which s h e was requested to undress.
The rights to expect that every collsultation or mention of hisher case is made discretely and that there are no people that are not directly ii~volved in his treatment prese~~r withoiit his consent. The right to have hislt~errnedical records or files read only by tllose directly involved in hislhcr lrcatment or those who supervise its quality, and by other persons only with hisher prior written aut11o1-ization 01that o f IlisAicr authorizcd lcgal I-cpl-cscutntivc.
The right to expect that all communicatioti and records pertaini~ig to hisllier treatment, including the provision for payment, are treated confidentially. The right to be provided with the isolation and protection considered necessary for hislher personal safety Any other right as defined by local law and regulation.
Personal Safety Thc patietit has the right to expect reasonable security to the extent that thc practices and i~~stallations of the hospital allow.
Identity
The patient has the right to know the identity and the professiorial position of the individuals that are providing h i d l e r services, as well as the right to know which physician or health professional is mainly in charge of his care. The pal-ticipatiotl of a patient in cliriical training programs, or fur the purpose of obtaining information for research, sllould be voluntary. Information
Tbe patient has the right to obtain from the professional responsible for the coordinatio~~ of his/her treatment the complctc updatcd infonnation on hisiher diagnosis (to the extent that it is known), hislher treatment, or any prognosis. That infonnation should be communicated to the patient in such a way that s/he can be expected to understand. W~IEII it is not considered medically advisable to give this information tn t l ~ p p ~ t i ~ thzt ~lt, information ill be made available to an authorized individual.
Communication
The patient has the right to access to people from o ~ ~ t s i d the e I~ospital through visits atid oral and writtell cornrnunication. When the patient does not speak or understand the predominant langlinge of the community, she
should have access to an interpreter. This is of particular importance when such language barriers represent a continuing problem.
Consent Tllc p a ~ i r r has ~ i rhe righr ro be reasol~ably informcd about, and participate In, the decisic~ns related to hislhcr health care. Whenever possible, this should be based on a clear and coilcise explanation of hisher condition and of all the implicit technical procedures, including the possibilities of any risk of death or serious reactions and of proble~iis related to hisher recovery and a satisfactory oulcome. The patient should not be subjected to any procedure without hidher voluntary, competent, and conscious consent, or that of hislher legaIly authorized representative. When there are significant medical alternatives for treatment, the patient should be so informed. The patient has the right to know who is responsible for authorizing and carrying out the procedures or the treatment.
The patient should be kept informed if the hospital is proposing to carry out or to undertake human experimentation or suine other educational or research project that would affect hisher health or triatment. In addition, the patient has the right to refuse to participate ill such activities. Cons~rlta tions
Under request and at hidher own expense, the patient has thc right to consult with other specialists.
Kefusal of Treatment Thc paticnt cnn rcfusc trcatrncnt t o
thc extent pcnnittcd by law. W l ~ c ti ~ h lefusal ~ uf Lrealment by the
patient or hisher legally authorized representative interferes with the provision of adequate treatment, according to professional standards, the relationship with the patient will be tenninated with reasonable prior advance notice. 4.
Rcsponsihililies of the Patients Supply of Information
The patient has the responsibility to provide, according to his best understanding, precise and complete information on hisher current complaints, previous diseases, hospitalizations, drugs, and other matters related to hisker health. The patient has the respoi~sibilityto report any unexpecled change in hisher conditio~lto the respo~~sible professionaI. 'l'he patient is also responsible for reporting whether she understands clearly thc course of action.
Compliance with Instructions The patient is responsible for following the plan of care recomme~ldedby the professional maioly respotlslble tor hw/her care. 1 h ~ can s ~ncludefollow~ngthe ~nstructionsof nurses and other personnel, associated with hisher care in the imple~nentationof the coordinated heaIth plan, carrying out the orders of the responsible professional, and adhering to the regulations atld statutes of the hospital. The patient is responsible for keeping hisnler appointments and, wllcn this is impossible for any reason. For notifying t l ~ c responsible hospital professional. Refi~sal of Treatment
The patient is responsible fnt hislhcr actions if slhe refuses to receive treatment, or if s h e does not follow the instructions of the practitioner.
Page 9
Regulations and Statutes a T the Hospital
'I71e patient is responsible for observing hospital regulatioils and statutes that relate to hisher corc and the behavior ofthe patient. Kespcct and Consideration The patient is responsible for being considerate of the rights of the other patients and IlospiPal and for helping tn r-ontrnl n r l i ~ c . smnkt., ~ anll thp numhttr nf vicitnrc T h e P"tient iq
r~<~nn<ih fnr le
respecting the property of other pcrsons and of the hospital. Preliminary instructions and procedures C o ~ l d i t i o ~ f x r~qzie.~fing f~r uccredidation
To request accreditation, the hospital applying sllould meet all the follouring preliminary
requirements: J1 must be licensed by the appropriate health authority.
It must have been in continuous operation, legally licensed, for at least one year.
-
It rrlust maintain its installations in operation 365 days a year.
It tnust maintain installations, beds, and serviccs continuously available 24 hours a day. It must have its owl1 medical staff that always guarantees contitiuity of the care. I t must ensure that all professionals, perform their specific activities.
who have access to the use of its i~lstallations,arc liccnsed t c ~
RecomaendufionsJi~rproceu'ziresfr~r requesting acureditilution
To request accreditation, the hospital shoirld the national accrediting body in writing and in accordance with the following standards of procedure:
-
It ahould complctc an applicntioll form in which thc prcliininnry rcquirclncnts statcd in thc prcvious
scclion are verified.
It should pay the cost of the evaluation in accordance wit11 the fee stipulated by the evaluating entity.
Before the evaluation, the hospital will rcceive the Accreditdtioti documet~ts that will be to be used for the accreditation. 11)advance, the authorities sIiouId communicate to the public, the pe~sonnel, and the patients, plainly and clearly, that during the times stipulated the surveyors that will carry out the survey will visit the hospital. The public, personnel, and admitted patients should be i~~structed to respond to all tlle rcquests of the surveyors.
Page 10 At the end of the surveying process, the surveyors will report the results of the applicatioil of tile evaluation instr~~iiieiit, and the decision that they will recommend to the accrcditatio~~ body,. In addition, they will advise h e Iluspi~alcurlcerr~ingthe objecdves roward which it should orient ~ t s investments in the imtnediatc future, in accordance with the i~~structiotls for interpretation. r
The ihal opinion will be cotntni~nicatedby thc accreditation body to the authorities of the hnspihl confidentially. The right to make the results of the evaluation public will remain excl~lsively with the hospital. 'rhc I-csults u f t l rvill~riltiu~l ~ car1 LC aypealed bzrore: the highest authority of the accreditation bodq:. which will issue a final opinion that can not be appealed.
Implicit conditions o f qurriif y bejbre upplying for accreditation The methodological characteristics for setting of staildards of quality in developing countries are oriented toward analysis of some indicaturs representative of the evaluated services and not toward describing thc totality of thc conditiorls UE quality r c q t ~ i ~ c d Tlris . clifi~~cr~ct. bzlween lhe exhaustive description and the most representative data, selected in reIation to the cost-benefit ratio of thc evaluation, requires pointing out some elementary requircments not included among the quality indicators, but that should be considered implicitly required conditions in cvery hospital. Among such collditiot~s the following are cited as examples: a
Walls that are peeling or have deteriorated piaster,
Rough surfaces in areas of restricted circulation (operating rooms, sterilization, intensive thcrapy, etc).
Dripping or moisture
011
the ceilings and/or walls, neglected.
Interrupted or restricted water supply during some part of the day.
Building located in a flood-prone area. Deteriorated or old paint on the walls and woodwork. Domestic animals within the building, presence of roaches or rodents.
-
Uniforms of thc staff diity, shabby,
01-
ill disar-ray.
Trash and/or garbage accu~nulated outside the places designated for it. I.ack of installations for the vertical circuIation of stretchers and wheelchairs (ramps, elevators) in hospitals with more than one story.
Tnslructions for the use and interpretation of the manual
These instructions are to establish the criteria by means of which the final result wilt hc determined, based on evidence of performance and taking into account that the set of the data collected should lead to a
concrotc decision on whether the hospital accredited or not. These standards are orienting and are subject lo rcvision by those responsible for the proEram in each country, in accordance with:
'I'he policies within which the evaluation procedure is framed. 'l'he local reality in the health sewlces.
The levels of development of the existing hospitals. 'I'he manual is composed of two groups of standards, complilsory and facultative standards. The standards included in the first group should be considered minimum and compulsory for every hospital. Those included in the second group will depend on the existence or absence of the service in the evaluated ~nst~tution or on the d e c ~ s ~ o of n the regton to include them among the standards.
All the standards are organized on increasing correlated levels of satisfaction; to achieve a higher , level of quaiity. the prcvious levels should have been achieved. To determine the Ievel agreed upon for every standard (Level 1 to Level 3 or 4), ;he evaluation should be initiated at the lower levels and continued up to the level whose requirements are not totally met. For every standard one shouId consider as verified the Ievel whose requirements are met completely; the requirements are indivisible wl~en they refer to more than one quality: if onc of t h c s c is not mct, thc sntisfnction of thc prcvious lcvcl should bc pronounced as achieved.
For every interpretation of the results of the sunfey, in applying the set of compulsory ~~linitnutn standards, the following criteria should be considered:
4 b)
To be accrcditcd, 1l1c hospital should achieve, a1 least, the satisfaction "Level 1" for ull thc starldards.
When onc to three standards of the accreditation requirements are not completely met, because of deficiencies that can be corrected within a year, a provisional certi.ficate of accreditation can be granted li)r that pcriod. The standards have the salnc value and no standards can be waived. The purpose for the different levels of satisfactiorl of the standards is thc promotion of comprehensive developinent of the hospital, leading to the coherence of inter-related service qualily. The levels are for exclusive intenlal use of the evaluating entity and of the authorities of the hospital; they do not have public status. The advice given by the surveyors to the authorities of the hospital should be oriented at the manner of channeling investments to achieve greater "horizontal" coherence in the levels of satisfaction of the different selvices. One should take into account that the levcls rcfcr to satisfaction of requirements for accreditation. A rull c ~ liiicalc r tlr accr t;clilit~iu~~ will bt: gr-ankd fur l ~ v o 01- thrce years; at its rerrninarion it should be renewed. Provisior~al ccrtiticatiorl will be for one year; depending on whether or not deficiencies targeted in the evaluatior~have been overcotne. The hospitals no1 accreditcd should
C)
d)
e)
0
wait at least one year before requesting a new evaluation.
Page 12 g) Successive su~vcys will involve a progressive increase in the levels required. In this regard. the different degrccs of satisfaction serve the purpose of orienting the objectives toward which the I~uspilitlsshould direcr zheir efforrs for i~nprovenlent In Ihu tuture.
MINIMUM STANDARDS Organization of medical care1
I.
Patient cure
Implicit condition: All individuals permitted to provide patient care services independently in the hospital are licensed. Level I : It has a medical directorate that administers the care and assumes respoi~sibilityfor it as
well as for its supervision. Thc continuity is based on the physicians on duty. It has professionals specifically charged wid1 follow-up of the admitted patients. with daily tours of the wards A professioncrl sraffmember manages the nzedicul cure, supervises t11e decision-rnuking concerning diugnosis unJ trealnlent, and assumes .final re~~mnsibilily fijr the medical proccdzires udoyletl The e.stuhli.~-h,~re~~t Iit-rs yly~iciurrs urr r/u+ 2 4 iru~ir,\u thy; (hey ure re.spp~nsiBlefor the cure of [he hosprtolrzed patierits when there are no orher medical personnel in the imslihdion. The responsible physician should be yueslioned ct~ncerning the syslern by which confjn~riv of me~Eicul cure is guuranteed when the phy.si~>iun in charge of euch pnrimt is not present. Request should he made in the ofloe qf personnel for the 1i.l.f of u.s.~ign~dpplsiciuns, with their disfribution by day and houl: in every ruse the regi~tratior~ o f the cerfIJicalionof-the phy,sicians on duy shozrld be verified. h every wing, deparlment, .flool; or secfrjl; there are purl-time profes.~ionulsthat are responsible,for the follow-up ofthe admifredpatients, in addition /o rhe al(vsiciuns on dub in the emer_eenc-vservice and the intensive carp s ~ r v r i l ,T ~ ~rp P prof~rrionrr1.c. ~ ~ icrll . ~ ithe f bed,s daily nnJ zpliude the decisions. The rcsponsihle physician shorlld he uskcd the schedule on which these rounds art. made and adherence fo it should be vervied, checking the medical records. Level 2 : Responsibility for each paricn~is assigned to
a professional in the establishment, through
whom all the indications of the specialists arc channeled. Every parient has a chief clinical physicirm and a resident or a member ~f he permuncnt .sfnfl assigned to hidher; all thle incficutions ofthe specialists are channeled through him. lfthe chiefphysicians ure residents they should have continuous supervisiun, $/hey are on [he reglrlar stu# [hey w i l l be under the
direcrion o f clinical medicine. The responsihIe physician shozrld be questioned on the upplicarion o f [his sj~xfen~, nnci the chiefphysiciuns an ihu dogroo ~Judhercncc t o this standurd in thc daily activifics.
Level 3: The ~nedicalstaff discusses the cases in clinical meetings, held no less frcqucnlly than once a week.
At leasr once per week rhe medical stag in plenary se.uion or by sector: holds a clinical mccring lo Ji.scti~*s the most relevant cases. Thc person responsible ,for the organizalion of'thr! meetings should be , I 1 , ~ . ~ l i / ) n/In r d t h p m n d ~cf operrrtion ond the r e l ~ c t i o no f cases. The clinical rucord,~ o f fhc paticnts
Ed. N.: Standards of each lcvel of satisfaction have a small instructive highlighted for the evaluator and the evaluated. These are evidcncc of performance or qualitative i~ldicators of thc standard (in "italic"). The dctailcd ir\structions shoilld be further developed for the evaluation committees of cach EMR coulitry.
discus.ced in bheji)rtlin.~ shotrid he checked to see whether rhc decisions adopted
af those meetings wwerc
recoi-detlll'
2.
Transfirs or Referrals
Level 1: There are standards conccnling t]lc establishments in the district health systems, olgrcatcr complexity to which the cases that exceed its opelativt: capacity should be transferred. [t has inecharlisms for transfers to establishments of lesser complexity of the cases that have passed the critical stage. The pcltients covered by some,finrrncing entify usua~ly have u list ofservices under contrcrct to which they should be frcmsferred for the purpose 01 specialized didgnostic studies or procedures o f grearer complexify ihan those exisring in the estiiblishment where they are sewed. When this does not occllq the emergency service should have prccise ipldicarfonsconcerning rhc csrabllshmcnrs ro whtch The ca.Tes wirh different needs that cun urisc on a sh@ should be transferred. The physician on duty should be asked about the existence and cclsy accessibilify o f f h e ljst o f reference centers should be ver$ed That list shozrld cdntai~zut least onc more general hospital wiih n c o n a t o l o ~ neuroairgery , traumutolo~y, uphr~mlmology, and inrensive care services. The room physicians have n list of estublishments~forlesser degrees of'risk, loca/ud in ihe hospitals' area oj' influence of' the districr, to which the recovered cases tlrar reside in cszrhtirbanor rural urerrs can be transfirred. Such esiublishmenls mciintcrii?good commu~?ications with the referring estuhlz.shmeni thmu.yh conluu!s among phy.viciun,~ hy tulephmne or r-udio or on-w othur uvailahl~ c~~mmamiculion nzeuns.
Level 2: A means of transport with or without tiit following elements should be available: MedicaI care. Eqizipment fnr r r i t i r ~ rla r e 2nd life ~ n v i n g medirinrq
Incubator for transportation.
It should also huve precise indicafions concerning the rneans of-fransjir oj yatienfs ro other establishrnenrs. One shotrld crl.so ask the physician on dl,@ and v e n h the existence and accessibility of'tl-re list. I/ shotild ulso be ~sccrtuined,by tneuns of'a telephone conszillafiort, whether rlze institutions lisieu' do indeed oRer the services listed. Level 3 : There are written policy and procedul-es for. tI~c initial care and during the transfer for ttie priilcipal serioirs acute illnesses, and also discrimination of rcferral cstabIishments depending on the pd~llulugylu LC 11ai~srcr~.ecl.
The stundards should contain !he initial inclications ~Jdiugnr~sis and treutrneni, appropriate jbrm qftransfep;Jbr at least the folio w ing clinical .syr?u5-ome,s: copnlllications ($pi-cg~auncy and delivery
LLT
rsvell l1.s [he most
,Yerious uctdte resplmrory,fallure: l a ~ n g e asyndrome, l hypertensive pneumofhorm. Serious acute oirculcrtni-y Juilure: acure yarlmonary edetnu, pzrlmonury embolism, seriolls actlte arrh ythmiu, shock. Aczrte suprarenal.fuilur~..
Page 14 ,Seriozrs ucute psychiatric .~yndrome: delii=izimtretnens, acute schiz~~hreniu. m
Acl!le yuPtcreulilis, drgesflve hemorrh~gc, acute ubdomi~lul symptoms.
Trauma Those policies undprucecitrres shoulrl he easily accessible, within the reach of rhe physician on dzrry, and should provide for ihe necessary mefisurus to mmake the initial d~fferenriuldiagnosis o f every case and provide the essential care rhat would make it possible to transfer the patient. Similarly, if should indicate the most desiriihie place to ti-an~fer every iype oj"parholoay. Level 4: There is a mechanism for follo~v-up of the transfers and the quality of the care provided to them should be evaluated. Through the meliicaI management o ~ .social . service a jdlow-ttp of the patients fhaf huve been traPlsferr~ds h o ~ ~ lbe d made. In the same mwner there should he n determination of whether the e.sfublishment to which the patient wns transferred ratfwd or rectified the riiugno.~isand cmwrse o f frearmeni determined by those who ori~imted the rransfir; this shotrld he recorded in the paiient clinical record. The responsible physician and thc sociul service should be questioned and the clinical record.^ rf
the kiisr I 0 iransfers should be observed.
Level 1: In the basic specialties there are office hours available during the day; for the rest, ~ h c waiting timc is no longer than 5 days.
In the schedules of-ofice hozirs there shotrld he ver$cafion o f the spaces reserved for office hozas during the day and which specialties are provideif; in uddi!iun,for the remaining spccialties the anficipu[ed ~zjaiting time for p a f i c ~ t s being sccn for the fist tinrc shorald be detct-tlrir~cr?.
Level 2: It has specialists who have the necessary means to carry out specialized practices and outpatient surgery. There are physicians in the mod importunt specialties in the hospital that have fhe means to cmly out the mostfiegzre~ltly zrssd diugnostic und ihrrapezilzc procedures us well as the s~ipporf infrus~ructtve to corr)~071f c~lttpntientsiirgirnl infunrer?fiuns. The ,fsa.~ibilify o f the most frcquonh/y rsscd p~occdudurcs and
operations should he assessed Level 3: The outpatient department relies on its own secretarial and nursing staff:
It should be t.erij7ic.d in thc ofjlice ojpersonnei ~ n iwith i the nursing direclul-fhar one secretory and one nurse are ussigned 60 Serve exclusively iin outpatient clinics during the time that they ore open. The ~ x c l r ~ ~ i v c nref~r.7 e . r . ~ fn fhc! hnur.c flj'op~rrrtinnI l f ' f h o ~ w t p ~ t i ~ rlinics, nt arttrid~ o f which the pcrsnnnul car1
be assigned to orher ia.~ks. Level 4: The ofice hours are scheduIed on thc basis of guidelines set by the pmfcssionals. Appointments can be made by telephone.
Page 15
The p.~r.vonneluhurged with muking tip the .~claeduI~ has in.strziciionLs OI? Iheji-eqzten~y, dzrrurion, af7d cij.~trihtrtic>n c.fthe c o ~ s ~ ~ l ~ ~ i ! i evslyj r ~ n~ . s~f e i c i ~ lThe i t ~p~i-.sc.innr?l r shozrl~lbe ~PIVSIII>MU OM C ~lh8
tslephomi.
numbers ctvuilablc fbr making the appoint~nenrs and throzrgh whut media [hey ure mude known.
4.
Emergency Service
Level 1: It has a physician on active duty 24 hours a day, fiinctioning with the exclusive use of a site and nurses dedicated to the service, with Radiological, pharmacy, Laboratory and Blood Bank support, Ti) have written standards, protocols, guidelines and posters available for the most prevailing diseases.
The oflice o f personnel shotrlu' he re yuesud 10 provide the lisf of physioiuns a n J nurses assigned to the sector and their distribution to provide udeequute coverage 24 hotirs u day .seven days a week C'onjirmation shonilu' he mhtlrined rg'the record c f f h e regivtratbn oj'all the physiciuns. The s i k designuted for emergency service should not he e~tiiized for other tusk.^ and shoziid hove the elements necessary for &&/ling itx fine tion: stretcher,^, in.strziaent.sfor sutzlres and dr.es.~i~gs, and r frzigsfir emergenuie.~.
Level 2 : It has the following specialties on call: clinical medicine, general surgery, obstetrics and gynecology, and pediatrics. It has a resuscitation unit, sa-ved by personnel of the emergency service. For specialized hospitals relevant specialists should bc availahlc (In call. The list o f professionals with these specicrltiesfir every day ofthe week should be rcqlresred There should be verij?cation thut list exists and is uvailable in fhe sen~ice.Tile resuscifirtion unit is an urea designalert for the resuscitation of patients at imminent risk of dcath; it has the stafand instrtrments to ullo+v !he immediute survival of the patient unlil he cun be moved fo fhe intensive cure service. The resu.soifation zmi! shotrid have appropriutc! drugs c~rrd dispo~uble murerials, a defibrillate< an electrocurdiogruph,, and cm internal paoemuker; it will have, in acldilion la oxygen, camprcssed air and an f~vpirn/nr
Level 3 : Professionals represelitizig at least three of the basic specialties are on active duty 24 hours a
day. There sholild be veri$calion oj'fhe list of'cnrre.~pundingprr$es.vional.vand {heir distriburion and also that they have facilities for thc nighttime rest in rooms thut aru not zrtilized$~r putien1.s. A hernodynamic monitor and u respirator should be available. Level 4: It has professiorlals representing at least bvo additional specialties on call 24 hours a day, with access to the equipment of the corresponding service.
There shollld be verificarion offhe /is/ of corresponding professionals and their $ishibution and ulso /hut there are keysjbr itlie respecfive services in the general key cabinet and that they are acce.~.riblo to the night shiJi. It should be vcr$ed that the telephone ntrmhers recorded ullow rapid contact with the specialisfs on call. Edlrcntionai levels are essenfiai at /his level.
In order to consider ihut the liiborafwyfortns purr ofthe evuluoled establishment, regard1es.s clftvho has rille to [he eqzriptnenf, it should be locuted in the same building or ut szrch a ~ i i s t u n ~ thuf x bhe trip fhere unu' buck on foot takes less than 30 mintrtes. There is cl formal relationship hefiveen Ihe iuhorulory and ihe esmblishmeni.
The laboratory tests listed in the Anriexes are only indicative for the regions.
Page 16 Level 1: a) It can process, without delegating to another laboratory, the analyses listed in Annex A, and it has a technician and/or biochemist on active duty 24 hours a day. The service should comply with thc basil; labur a i u y ~ pr ucudures u11 s a k ~ y
Without delegating means that all phases of a determination are carried out within the laboratory itself. Tliere should be verificatiori of the existence of the necessary reagents and their expiratinn date?, n i d there should be an evaluation of their consumption through the respective purchase invoices or other available documents; the consumption should coincide reasonably with the billing statistics in the financial entities. There should be verification of the list of technicians and/or biochemists on caII as well as the effectiveness of the comlnunication sy3tcm wl~icllsl~ouid pcr~nit thc arrival uf thc I-cspo~tsilslc pt;r s u i ~ al ~ t ~ t .
laboratory in less than 30 minutes. b) Hemothcrapy service is available nearby, from which it obtains blood within a period of not more than one hour, and i t meets the standards of communicable disease control. There is a forn~alrclationship between the service and the estabIis1iment. It has plasma expanders on hand. The service sllould comply with the basic laboratoly procedures on safety.
The distance behveen the nearby service and the evaluated establishment dlould make it possible have blood it) less than an hour by the usual means of cominunication. It should have the mcans for carrying out the compulsory irnmunohematologic tests:
Group and Rh factor in the receiver. Group and Rh factor in the blood donor. Compatibility tests. Level 2: It can process without delegating to another laboratory, disk antibiotic sensitivity tests and biochemical identification of pathological microorganisms. The individual responsible for the service controls the operational quality of the detcnllinations through thc supcrvisiol~of tllc pmccd~rrcsuscd and the contiiluous instruction of d ~ personnel e in his charge.
There should be verification of the existcncc of antibiotic sensitivity disks and of reports done previously arid also of the existence of an incubator for cultures, different cultire media, and adequate glassware. 'The individual responsible for tlie service and the personnel should be questioned about the measures adopted to control ~ h c quality of the laboratory services. There should be verification that guidelines on biocliemical procedures are available and that personnel meetings are helrl tn C l i ~ ~ l lthem; w the frequency with which the responsible individual personally supervises the steps of the detenninlt'Ions should be ascertained. Level 3: It can process, without delegating to anotller laboratory, blood gases and quantifative
antibiotic sensitivity tests. It has technicians and/or biochemists 011 activc duly 24 hours a day. The control of the operatiotial quality of the laboratory services is the responsibility of the individual responsible for the service and is carried out through running control samples periodically. There should be verification of the presence of the technician andlor biochemist on active duty, as well as the list of the night shift provided for each day, There should be verification of the availability of facilities for their nighttime rest in rooms that arc not utilizcd for thc hospitalization of patients. Thc existence of pII meter equipment for p 0 2 and pCOz, with usable electrodes and available charges of gas
should be verified. The responsible individual should be questioned on the frequency with which he carries out the controls with samples, the origin of tliose samples, which determinations are verified and where the results are tabulated. ' l h e records o f the coi~trols done In the three last months should be observed.
J,evcl 4: It can procoss without delegating to allother laboratory the analyscs listcd in Annex adhcres to an external program of qualily control.
B.It
'I here should be verification of the existence of a manual well counter or an automated scilltillation counter, co~~tainers for radioisotopes, and also a bunker for their storage. There sho~lldhe a comparison, usirig 1 1 1 purct~ase ~ invoices for radioisotopes, of consumption with rhe pmduclion st;lristics. Evidence oPa liccnsc to use radioactive material, issued by the competent authority in thc jurisdiction that corresponds to thc establishment, d~ould be requested. The certificate of registration in the program for quality control should be seen. The responsible individual should be questioned on the frequency with which samples are received, on determinations, and on communication of the observations. There should be verification of copies of the records of the results from the last three months. Annex A:
Serum arnylase test and compIcte urine analysis Bacterioscopy (tuberculosis) Basic coagulogram Cholesterol Creatiliirie Prepnaricy test Acid phos~hatase and alkaIine phospliatase Gram, Giemsa staining Blood glucose Bblood group ( h n O nnd Rh) Complete blood picture Blood Film for Malaria Complete urine analysis Complete stool analysls Total protein Coornbs test Occult blood in feces Clotting time and bleeding time Prolhi-ombin time Triglycerides Uremia
Sedirnentatioll rate Qualitative VURL Others
Annex B: Australia antigen (Au antigen) Carcino-embiyonic antigen (CEA) Antist]-eptolysin 0 Calcemia Creatine phospl~oki~iase (CPK)
Estriol Ferrernia Follicle-stimulating hormone (FSH) Lactic dehydrogeilase Latex Luteinizing hormone (LH) Prolactin
C-reactive protein 'I'hyroxin (T4) * Tri-iod~th~ronin ('1.3) c
Thyrotropin (TSII)
Blood urea
Blood culture Pop smear Frustdr, s p r ~ i fari~iger~ i~
Tumor mark Others 6.
Diagnostic lmcrging2
Included under this title are the followil~g procedures: Kadiology: conventional, linear tomography, by digital subtraction of images, mammography, computerized axial tomography (CAT), etc.
-
Ultmsonogmphy: mono-and bidimcnsional s o ~ ~ o g ~ a p sluclics l ~ y , Lllrui~gh Doppler effects, etc.
Nuclear medicine: fixed-head scintiscan (gamma chamber) or mobile-head (linear) scinliscan. Photon-emission computerized tomography and positron-etoission computerized tomography. Others: magtietic resonance imaging (MRI), thermography,
Level 1: The unit is cerliliod in accordance with tile requirements of the health physics service of the coiresponditig jurisdictio~~. It has fixed equipment, from at least 100 mA, with a Pottcr Bucky device without serialograph. Basic radiological system (RRS) recommended by WHO. A radiologist is not necessary. The certificate of qualification, issued by the health physics service or the crrrcspanding jurisdictional authority, shoulcl bc rcqucstcd; it should be cl;hilbitcd in a visible y l a ~ c Fixed . crl~~iprrre~i~ is that which is not movahlc hut i s left in place, once installed (study table, generator, support for X-ray tubes, etc.). It should have a Pottcr Rucky device.
Level 2: It can do contrast radiological studies via radioscopy. The studies are interpreted by specialized physiciaris who excl~ange opinions with the attellding physicians. A radiologist is necessary. It has equipment wit11 greater than 200 mA, with scrialo~rrlphand radioscopy scrccn, or with an image iiltensifier and closed-circuit television. The service has, at least, a site for the shldies, space for
Editors' note: These standards were established as exarriples arid do nut try to establish reference standards about spccific techllology. Each EMIC country shou1d nlnkc its respective adaptations.
Page 19
preparation and dressing of the patients, a site for developing, and a site--with negatoscope and file snace--where the repoi-ts are prepared. Kequest should be made in the oflice of personnel for the history of specific training of the individual responsible for the service. There should be verification in several reports of the constancy of the signature of the specialist. The physicians of the establishtne~ltshould be asked if they exchange opi~lions with the specialist frequently. if there is a forrnal or inFormaI rnccl~anisrn(forurn) for that cxchangc, and if t l ~ c pllysiciatis gatlicr frcqucntly in thc scrvicc in crrdcr tu vicw tllc studics.
Level 3 : It fiinctions a fill1 24 hours a day, with a radiological tedmician and a radiologist on duty. It has poi-table radiological equipment for studies in the wards or operating rooms. It has the personnel and auxiliary equipment necessary for carrying out invasive procedures under fluoroscopic or sonographic control. It has a gamma chamber and CT or MRI. The specialists in the service are involved in the indication of the diagnostic medium most appropriate for each case.
In the office of personnel thc lisi of technicians and physicians should be verified, with their hourly schedules and the rotation of the shifis. Thcrt; should be verification in the records of the service of the existence of reports coverii~g the hours hctweci~10:00 p.m. and 6:00 a.m. The existence should be verified of at least one portable radiological dev~ce, with IAcilit~es tor inoving it to carry out studies in both patients' rooms and in operating rooms. It should havc suflicient resolving power to do intra-operational cholangiographies. In the service there are the pcrsonncl (suppofi nurse on call) and ihe necessary equipment (glass cabinet with instruments, drugs and disposable materials, garments for sterile prcltection, dressing cart) to cawy out invasive studies ut~det fliro~.oscopicor sonographic control, such as cndoscopies, aspiration punctures, and biopsy punctures. The assigned persotlnel have the training to transform the site into an aseptic environment. The personnel of the service sI~ouldbe questioned about the frequency with which these pmcedi~resare carried out and the steps that should be carried out in order to accomplish them. Procedures for intravascular or hernodynamic catheterization are excluded. The specialists in the service are consulted, in tours of wards and forums, on the diagnostic medium most appropriate for each case and arc subsequently involved in the intcrprctation of the different studies. The specialists in the service and the ward physicians should be questioned about this mode of operation with the aim of establishing whether an integrated concept of diagnosis through images and free exchange between this service and the attending phvsicians exist. 7.
Care at Birth
Inchided In chis caregory IS she set oJ".servrces desrgnated ,for the care oJ-pregnant women and children and, in partiozrlu~the aspeurs relafed lo [he moment o f birth. The diferent componenfs of the urea are z~nfledby health and j%nctionul fuclor.~, aifhowgh they ure nor especially concenlraied wirhin rhe physical plun f .
Level 1: It has an obstetrical nurse (midwife) 011 duty and an obstetrician and a pediatrician, who are on call. ?'he births are attended in a differentiated delivery room. The hospital is committed to the natio~lal and/or globaI promotion health programs. These include but are not limited to Baby Fricndly Hospitals and
Expanded Program on Immunization. The emergency unit should be asked for the list of professionals available cach day of the week and the means of communication through which they can be called. There should be verification that by these means the professional can be located in less than one hour. Thcre should be verification in tlie office of personnel of the record of specialized training of each professional. I1 has a site designated exclusively as i? delively room; it will have a dclive~y table or chair, adequate illumination, n u r s i ~ ~silppnrt, g in.;tririn~nt~, drugs and disposable materials in glass cabinets and cupboards, and also a11 adjoining washroom.
Page 20
The care provided by the health staff for mothers and infants rneets global criteria of Baby Friendly Hospitals and Expanded Program on Immunization. Level 2: It has obstetricians on duty and an anesthetist and pediatricians on call and thcre is an exclusive site for receptio~~ and resuscitation of the neonate, with the necessary elements to assist a highrisk pregnancy, with pse and perinatal monitorina. It guarantees adequate minimum care for the neonate and its mother up to their transfer to a center of greater cotnplexity. There should be verification in the office of personncl of the list of professionab assigned, the dish ibu~iullol. ilieir hours, their assignments on rotation, and rhe records of their previous specialized training. The site devoted to the rcccplion of the newborn is air-conditioned at the proper temperature, is contiguous to the delivery ruom, and is provided with hot water 24 hours a day; the newborn can be bathed if it is necussary. It has a blood bank facility, laryngoscope, a baby scale oxygen, an aspirator, and comprcssed air; it has an incubator for transport. If necessary, the mother can be transferred rapidly to a neighboring operating room, (see standards for thc surgical area). Level 3 : It has a trained pediatrician i n neonatology or neonatologist on oall. It possesses u scctor
designated ior the care of the pathological newborn, clearly differentiated from the section for normal newborn, which can resohe the principal respiratory syndromes of the newborn, including the need for mechanical respiratory assistance.
The different environments of the area for care of the pathological newborn constitute a differentiated futlctional unit, located in an area with restricted circulation. This sectiorl has its own nursing station. It possesses all the equipment necessary for: resuscitation. blood exchange. drainage of the pneumothorax, channeling of umbilical artery, and central venous pressure. It has equipment for light therapy, neonatal mechanical respirators, transcutaneous oxygen motlitor, oximeter, continuous positive pressure equipmei~t,and a pump for negative aspiration. The medical team holds weekly forums and reports, upon rcqucst, t o thc pnrcnb on tl~c evolution of cach casc.
8.
,Sz~rgicuI Area
Level 1: It is in an area of restricted circulation, diflerentiated and exclusively designated for this purpose. It has, at the very least, a support site for washing, nurses, Bnd final gowning of the surgical team. 'There are standards for preparation and/or ~naintenance of the operatirig rooms and the necessary materials are available. There are surgical and anesthetic protocols for cach operation. There i s a standardized
proccdurc: for cleaning operating rootns between operations.
The urea ofrestricred circtrluiiopl is sepurnredfiom the resr by n door that is kept closed, with signs prohibifing entry. 7'he sectionjofbr hand-washing by the surgicnl tecrm has n jinicer und dispenser.^ qf'sonp andor aniiseptics that permit [heir munagemenf withour zrtilizariopl ofthe hands. Personnel (hat come,fionz orher areas of the establishment are nor admifred to this support seclion without having chunged their clothes and put on the proper clolhinn for the surgical area. The nurse shozrld be asked for the ins~rdclions with the stanilards for preparation andor rnuinlenunce of operating rooms; rherc! should be verficution of' the existence of clean glassJIusksfor this pzirpose, formaliri, alcohol, and every other item indicatrd in the instrucfions. in u namp[e of 20 clinical records, luken+om !he service recod book, nfpcrtiends operated on dziring rhc last rhrcc months, the prcscnec ojfthc surgical and amcsthciic operutivu rccord~' i n 100?4 ofthc
cu.~esshozild he coi$rmed. opernfion.
The operating rooms are clccrned wirh wafer arld detergent ufier each
Level 2: Ir. has two operating rooms and there is at all tiines at least one person designated exclusively for the surgical area.
The per.ronnel assigned exclusively ro the surgiccil area is a member oj' the nur.cing s t a f - u ~ x sees i lo the arrungemcnt ofthe in.sbrument.~ and cllher surpiccrl ibern.~: sihe controls the receipl und Ji~putch of ~he.se mut~ricrls wlren ~ h e v are sent for w ushing aud sler il izalion; s/he con/rols /he disposal ufihe rqfilse oncl .solid wastes otltside o j -the surgical aren; during hi.~/'laer shiji sihe does not perform any func lion plot reluted to ihe area; s/lze i s responsible f i r the udl7erence to the stundurds of usepsis, both in operuting roonzs ccnd in tire ~LJjuirmirz~ MI-cu t-verr ~ , wir/z r-cJpecl lu thr:p / z y ~ i ~ i u f i ~ .
Level 3 : The surgical area is coordiriated by a professional. It has a site designated for rccovcry frorn anesthesia. The dressing room for the staff has a differentiated access. There are facilities for intraoperational radiological diagnosis. The intra-operational monitoring of paticnts at increased risk is carried out by medical specialists.
Szpervisicln ofthe work of the nlirsi~lg person~1~1 Scheduling the tours qf duty and u'istrihurion offhe operuling rooms. C,'ontrolling lhe udherence to the .sfundardsji)r the prevention r,finfeclio?zs.
Delel-n~incliiuno-f ~ k eneeds .for provision qf items fur surgica! ~Ei,~posu hle mat uriub, antiseptic, and vurio us swpplies).
zisc
(instrurnent~iri2tn1,drzig,,
The size o f the sife.for recovery porn anesthesia should be related to the uvailohle operuiing rooms, u rote of one bed,for eve1.y nvo operating rooms; if cun be divided into ctihicles. Tht. ~rneslhetis~s control the recovery qf the pnrients a l r ~ a d y operated on and iprdicate the moment oJfran,$er lo Ihe appropriate scrlgicc m tkc kospital. The nursingpomor~;?cl shotrld bc askcd on t l z t fidf;IIr?te~zt o f thilr . W ~ L L I I - C ~ ~ ZPutietlt CJI~. truff;c ZJnot crossed with that of the surgeons, anearheiists, and instrumeni nzirses. There is a /mn.@r areu 6hut prevents the entry to the surgical area of stretchers and personnel from !he rooms for hospitcdized puti~'111~; uccess to the dressing room is differentinfed and one can enter,potn the exlerior oj-the szirgicul area or,f^rjm the Irun~Ikrarea. There shozild be vel-iJicaiiona] [he exrsrence of mdiologicul eqzriprnendfor inrru-operutiond diugraosis, which should be in operable condition and have personnel, adeqtlately protected ficjm rudiufion, avuiluble io oper(~(e it. The names of profi.ssioplals that perfbrtned intraoperational monitoring o f palients with increased curdiulogy risk should be copied .from fhe opera1in.q room book and tiwir special~zutionin curdiology shmukd be ver$ed in the office pfpsrsonnd ar
Level 4: The operating rooms are differentiated and equipped by specialty. There is an operating room for t h c exclusive use of the emc~gcncy scrvicc.
The irzdiviclual responsible for the disfributiopl of the operaring rooms in fhe surgical area shnzdld be asked and ihe ,speciul/iesfor which they are dcsignclred should be ascerlained. i f should be determined whether they hove .specific eqtd@menrfor every special@, such as a pumpjbr extra-corporeal circulurion in the roomJi)r cup'lliovusct~lar sut-gev, u microscope in that for neurosurgery, an ortl~opedic srreicher i u [hat Jbr traumatoln~~. In the szirgical service book the appropriateness oj'the cases operated o n with respect to the de,rignurion oj'every operaling room should he evalz(rrted Thc e m e r p n r y . v r r v i r ~ ip~rnting rililm r n n be annexed !(I thu! .service and thus sepnrotedfiom the surgioal service; in this case, it sl?ozrld ul Ierlst meet thc requiremer?ts of Le1:el.s I and 2.
Page 22
Level 1 : The anesthetists respond to the demands of the surgeons. 'l'hoy prepare the anesthetic protocol. It has a lisr of anesthetists on call, organized for every day of the week. Pre-anesthetic visits should be carried out.
in the surgical service there is a list of anesthetists with their respective means of communication. There should be verification of the existence of the list in the surgical service and also that the named professional is available at the time of the evaluation. The pre-anesthetic visits should be verified in a samplc o f clinical rccol-ds. 111 a randurn saiiiplc or20 cli~iicalrt-cuids ulpatielils uperaled on during the last thrcc months, there should be verification of the existence of an anesthetic protocol in 100%. Level 2: It has a service of anesthesiology, under the direction of a responsible irldividual that coordiliates the shifts arid ancsthctists on call. There should be verification of the specialized training of the individual rcsponsible and the ancsthctists on duty, in thc o 6 c c o f pcrsonncl. Thc scltcduiing of the shifts and l l ~ c a c l l r ~ ~ u lu ~ ~L ~t ~: L
schedule on the day of the evaluation should be observed. The orders for supplies and drugs placed by the individual responsible for the servicc d~iiing the previous month should be reviewed.
I.cvcl 3: The shifts are covered by on-duty anesthetists and medical residents in the specialty (who act as auxiliaries) or auxiliary technicians. In addition to the specialists, it has residents in the specialty w l ~ o scse the preparation ond sanitatioli
of the instruments as welt as the induction of onesthcsia. In the places where there are courses for auxiliary technicians in anesthesiology, one can allow their inclusion in the evaluation under the functions mentioned for the residents.
T , P V P ~ I - rt has written standards for precautions for the control of infectiarls and part time
responsible nurse (infection control officer).
The responsible physician and thc individual r~~vpnnsible fur nursing shordd be gzaestioneci on the 01wriflen standards l o r injection control. 1here should he ver~icatiun oj the ueces.sibi1ity of these standards and the physicinns, nursing personnel, and cleaning sf@ shozrld be usked whriher ~ h t y have received some special instruction on this szibjecr within the establishment. The siandards cun he oflcial, fium a scientific publication, or prepared in-house u ~ l dendorsed by the hospiral uttfhorities. Appeming among their contents should be recommend~rions concerning szrch stlbjecfs ar.: hand-washing, antiseptics and disinfectants, hospital hygiene, isoiafion precautions, universul yrccutrtions with blood and bodyjli~ids, dressing o f wounds, and care o f intra-vascular and urinary catheters and [hose,for respiratory uvuilobrlzfy slipport m d obstelric procedtrres.
Level 2: Records are kept of the ilicidence of hospital infections or prevalence studies are co~lducted
at least once a year. The authoriries should be questioned on ihc type of fbllolv-up performed the evilcrin ,for c/ass~~cution, the n~erhodused .for informnfion collecfion, and the person wsponsible jbr the data p r o ~ ~ ~ s , snnd i v g n n n b ~ w s ,Thp ~ w i ~ t i n writtppl g rppovrs on I ~ .stwJier O corvi~lJ C V / / .PJ?II?IJC~h i ' ~ ( ' Q P I P P ~ P C I . The records of incide?loe shoerW conrain information on the number oj-cases defecieu' in n spucrfiu period, the mode q f infccliun, und the r~lu~ion.ship wit11 the ntrmber of hospitulizc~fiuns.The studies qf~prevulcnce
shozrld contuin he number rfexisting iqfictudparicnts in one duy in rclaiion ro rlle tnrd number udnlirred the di,cirihubiortpcr room, and the mccrpls hy dhcit rvhich the iyfcctior?~ v u diupaosed. s
Level 3: It has at least one person, a nurse or other professional, responsible for infection control, who applies active epidemiological surveillance methods. The azithorities should he quesbioned ahour: their level of'prufes,siond !ruining, junctions that they JulJill (in cddition lo lhcrl o f infection cunli=olJ,their decision-muking power Ubrrnul and reao, and rush that they usucrlly carry otrt. The person responsible shozlld he questioned ahour the ejiur thui hisiher uctivities huve, the artenlion /hut s/he receive.^ from hisher stiperiors itz response to the pmblems .xihe presents, and the general scheme uf work folluweJ. Previously wriiten reports shozrld be checked Level 4: It has on infection control committee and a program for prevention and control o f hospital
infection that is revised annually.
The ~zrihoriliesshould he quesldnned on the cnrnposition of' the committee, who perfbrr~ls the coordinrrfion or funciions m the secrcturiat, ihe linkage with the highest atithority qf the establishment, and the freqtiency with which meetings are held. The proceedings or records of the meetings held during the last six months and the subjects treated should he observed The program,fur epidemiological suweiilaplce, if there is such, to which the cotnmirteck objecrives are adapted, shotlid be reguesteii. There shottld be evrrlz~ofion uf the coniponentx of the progrurn: I-ecords qf infections, identificnfion qfthc p r e ~ ~ u l stmins, ~nt stcmdnrds of antibiotic theriipy, conrinziin,q instrucliopt.~io personnel, and surveillunce of cleaning procedures and invasive techniques fbr dingnosis and trelrtinent. The program for epidem ioIo,qiccrl ,
yurvcillancu uppcarv in the annual rcport of thc cstablishrncr?t.
General and support areas 11.
Food h'ervice Level 1: It has a list of diets categorized by disease, prepared by a dietician or nutritionist. Not Iess
than 50% of a samplc o f patients rates thc food as satisfactoiy.
The plrysiciun re.sponsible .for the arcas qf hospitulizubion shozild hc asked on the system by which the diets (Ire prescribed there should be ~erificationthat professional has a list of-stundurddiets fop- ihe principui pulhologies and that these are detcriled with their n~rtrient composition, their dietetic pre.scription.s, und their dnily menus. The list shotlld contain diets at least .for: gasfro-dziodennl ~ l l c e ~ : diuheles, posf-choli-.cy.sleciomy,und renal failure, as well as a soft diet. A dietician should be responsible J#r their original prep~rulion.The individzlzlul r~,-t..\po~zr.ih~t.j$~r ihu kilchen shmllld he u.cked IO verl_ty thnt ht? has /he same diets m the i-e.spo~~.sihle physici~~n. There should be verrJiuoiiunof lhe relutionship beiwccn the rnenzisfor !he day and the d~flerent dieleiic indiuu~ions, in u representufive rundom su?nple of not less fhan 20 yatienls. In the same saniple, there .shozlI~ihe queslioning as 10 whe~her/he pmvided fi~filodwus satisfactory or not. Patictits should he itrte~.vicrvcd wlruz c l z e c k i ~ z out. ~
Level 2: It has a dietitian for the organiz,ation of the service, the prescription of personalized diets, and daily visits to patients. It has an area for the preparation of milk formulas with specific standards (if it is rncdically indicated).
It shozrld be a,scertained in the oflice ofpersonnel wheiher it has one or more dr'eaitiuns or? ibs s t r j ' thur.follo14,a rclguiar schedule. In n rcp~*cscntutivc rar~dorrz ~awzplc c! f 'tao,fuwcr than 20 patict?t.~, it thotrl J bc ascertained whether they were visired by a dicririun &ring their hospiralizarion. The kitchen service relies on the services of'u dietitinn who is chcrrged with plcrnning the provirions ofcrppropricrrejbod mnteriul, the ul-pnizrrtion of !he foodJor errch ')cry, and the supervision of thc qztaiiw ujpthejbod that is prescnrcd tu the
Page 24 putients. The same sun?ple (If~uiienis shozrlu' be usked abo~rtthe yz~ulilyo f the food received. in he ureu qf peifiafric Izo,spifalizuiion,there is u special .rile where mwri~k,f;llrmtt/us are prepurefi; ir hus specific .rlunclurds f rile drfferenr filrmrlkus, m langziage undersrurrdnble by ~mn.~peciulized fur rlie IIIULIU U /prepuruCiol~ o personnel. Level 3: There is a tnedical servicc of ni~tritionthat intervenes in the < i i p ~ r v i ~ i of o n the feeding of the nutritionally compromised patients. It has the capability of effecting parenteral and enterrtI feeding with a feeding pump. 2'irt: r ~ i ~ j - i e r ~ uf ce u nurritiun service shozrid he ver!ficd m the medical orguniziifinnul chnrt qf the irts~~lilufion. The members o f f h a t service should he usked about the tasks thut they be assigned specifjcalty. Among the patients udmittcd durirg the evaiuulion, all the cuses in which there wus iintervenfion by rile nutrition service should have their clinr'cui recurds reviewed and ir should he derermined whether rhe .service has had a delemining inflrlence in ihe nzi6ritiun oflhe paiient during the ho.rpilulizatir~n or whether he inter-co~?sultaliun was devoted solely io e~iapathog~nic conaider~tionsi n 6he ouse. There should be ver$catlaon ofthe existence of uppr-opriute equipment for enferalfeedirzg. The individt~al respmnsibie for fhe senlice should he 4ue.~tioned ahnwt t h r~ r ~ c ~ vrn,r.rl c in ~ h c s e Idrqls dirring the throe l u s t months; ii should be ascertained in ihe respeclive clinical records whether she service inlervcned in the pre.curiptio~,&.ruge, and supervision of-the nuti-itiunul scheme provided
12.
Laundry
This standard upplies lo the establishment S own services, whether locaied within the physjcalpluni of the establishment or not, us well ox to contrlicted service.^ Level 1: The laundering process and changing of clothirlg is standardized. l h e personnel of the service shouId be asked about the standards applied to the laundering of soiled hospital linen. The texl of those standards should be checked to verify that they are accessible to the personnel. Compliance wit11 them should be observed during the laundry process and changing of clothing. Level 2: Thcrc is a special separate system for the treatment o r contaminated clothes, and sufficient provisiorl to su~gcries. The standards require that linens co~lta~nir~atcd with blood or pote~ltlallyIiigh-risk secretions be transferred separately in polyethylene bags. The personnel should bc interrogated about this and adherence to the standards during the laundering should be observed,
Level 3 : Soiled linens are removed daily throughout the year and clean ones are provided daily. A random sarnple of no fewer than I0 patients that present open drains of various types and/or abilul-mal 01 p i l t l ~ u l u ~ i ~ sci~t-liur~s al s11i)ulcl be qucslioned about their sarisfactiorl with rcspcct to the daily changing of the bed linen. The individual respntlsible for the service should be questioned about the periodicity of the removal and delivery of linens to the wards; the supervisors of nursing should be asked about the adherence to the periodicity scheduled. It should be verified that there is an adequatc supply of surgical clothing, and n o surgical procedures should be postponed for lack of clothing.
13.
Cleaning
Level 1: Alt the floors are washed a1 lcast once a day, with soap, detergent. Dly sweepirlg is prohibited.
A random sample qf'l U patients shotild be que.srioned on the fieqzrency of [he j/floo~+ wusbring snd the mefhocls trsed. The personnel of [he service should be a,sked uhozit the husic in,ctrzictions thcit they have received wi!h regurd to the cleaning of the j'luars. Level 2: It has an individual responsible for the cleaning and the procedures are standardized, il~~ludillg iilutructio~isfur- tllc usc of disinfccta~~ts. Thtrc arc standards for t l ~ cspccific trcotmcnt of potentially polluting elements andlor excreta (hepatitis B, AIDS, salmonellas, etc.).
There should be verificution in the ojice ofper,\*-sonnel.of the existence ofthe,function and who is in churw. The exislence of'wriiien standurds ofproceJzlre .should be verified as should their eusy uvuilubiiiry to tJae personnel that ulilize them. The existence ojthose standards should be verlfificd and it shollld be uonJirrned lhul they ure within reach oj'rhe personnel that z~tilizethem. The personnel of the service should be ~ P ? ~ ~ Y ? - o ~ Y ~ u YU L .~ S~OC~
with
t o their crypliccrfion.
Level 3: The infection control committee at~d/oran epidemiologist participate actively in the and supervision of the cleaning standards.
Their participrrlinn sholrld be ver~Fedihruuglt the questioning o f the personnel.
la1 o f
itle stur~dards and tlzro~rgh the
I.cvcl 1: lt possesses a site where the preparation and sterilization of all the materials of the institution are carried out. It has at least an autoclave and a stove or an oven. 'l'here are wr~tten standards of procedures. Biological coritrols are carried out in accordance with to local standards. The ritp ~ h n r ~hcl l ~in i ( 1 ~ 7o r ~I u $J'YP.S/~-~C~ r'irc~~lr~tiori IY~I nncI h o u ~ rr171ni~rv . .s h v l v ~{ ~ m. r i r:rdphoorrJc,fr~,-
the deposil o f he slerilized murerial It has an uzrtocluve and a gas or eleuiric s t o ~ ~ or e ovepz; fb?c airrigIttness of the closzng in !he uu~aclave.~ and the lemperuttdre in the stoves or ovens slioull be checked LS~f;~ilizcrtiun should be ver$ed by u recoguized means. The written srundclrds, which shu~rl~i be uvuilable in rh~per.wnnt.l, ~hurrld be u l ~ s e r v e d
Level 2: The area of the service has four sections: Reception and manual washing Preparation and processing of materials. Sterilization and storage. Dispensing of material.
It has its own or contracted services for sterilization of thelmo-sensitive material. The sectors ure CtiJfirenfiafed un~1 sepurated by doors or cou~rtev~c; co~lainztniculion to [he ozrtsidc 01 the service $)r delivery and rcceptiun cfrnateriuls is uo~?diicted thrc~~igh u tvin~iowor over o coufiter The srerilizarion qf therwo-scnsiti~winulericll j . ~dmne by a recognized sleri/iznlion qf ihermn-sensibive muteric~l; it b own or contracted. The hospital is re~.por~ssible fbr the qlialiry o f the process, which means shut it cclwics ozrt periodic conjrols qf tlac pi-occssed mnierials. Level 3: The personr-iel havt spccific training.
Page 26
There .choztld he vul-ijkulion in the qfice ?fper.~onnelefthe recording of the trait?ing histories; each stafmcmber shozllu' huve u curlificclte us a sterilizution technician or huve received n,fi)rmrrl cozirse within tlrc hospital.
Level 4: It has mechanical ventilation equipped with high-eiliciency filters. TIie washi~lg and disinfection of equip~nentis carried out by automatic equip~~lent. The filters should he c n n t i n i i n ~ ~ s l ~ monitored for bacterial containination. Qualified personnel should operatc this equipment.
The churacteristics of the filters (of the 99.99 Qpe) sltuuld be verified with the maintenance stafl The cvtktct~ cr o f auiurnuti~. wudiirig eilu ipmen f should UISO Be v e r l p d .
Level 1: It has a pharmacy wit11 its ow11 site and a refrigerator for the conservation of drugs. It is administered by the director of the establishment who provides drugs to the inpatients on a restricted schedule and controls the stock.
The refrigerafor should be connected lo the alternu/ive system o f electric energy. The .~ys/em for controlling rhc stock shoul$ be observed in order to ver~fi,for at least I0 drugLs, the corre,spc~ndence hetween the stock lisrcd ufid rhc actlrnI stock Level 2: There are n o r m of pre-surgical and vademecum antibiotic prophylaxis, which are being actualized for use of the establishment. Level 3: It has personnel on duty 24 hours a day, phannacists and/or technicians, for tile care u f inpatients atid outpatients.
There shozrld be ver$cafiou in the ofice ofpersonnel qf the list ofprojessionals and fechniciuns, the distribution of schedtrles, and the scheduling ofthe rotuting shijts. Levcl 4: It has o pharmacy survcillancc committee.
The pharmucy aand therapeuric committee should be composed oj-the individziul responsiblefbr the pharmacy. baureriologist,~, and head of clinical departments. The prided stclndurds should bc observed and the knowledge {hut the ward physicians have of' them should he verified. The pur~*huxes of drugs are programmed an (he bnsis ofrhe munerul.
Therc should be prior verificlirion in the ofice of personnel of the total nzlmber o f projissional nurses, and nursing szppori workers tho[ the e.~lublishmsnt has, along with the procedz~res for rhc selection o j this stajf.
Level 1: The individual responsibIe for the service is a qualified nurse. The vital signs oFthe patients ~rlmitted should br recorded an needed based on the patient's condition in the clinical record. Tlle nurse/bed
ratio is adapted to local standards.
There should be verification in the office of personnel of the I-ecordof the diploma of the individual responsible for the servrce, granted by a recognized public or private institution. The vital statistics include pulse, temperature, respiration rate, and arterial pressure and the periodicity of eight hours should not apply in areas with critical patients or tllase with different specific indicatioils; the recordiilg of the cotltrols
Page 27
should be inade on lists beside the beds or on the nursing sheets in the clinical records. The nurseibed ratio will pmerge from the general number per shi R. Level 2: The individual responsible for the service and all of the supervisors are rcgislcred nurscs. All personr~elwith less than one year's service have received specific in service training. There are written standards in all the offices.
'There shouId be verification in the office of personnel uf the record of h e diploma of the iiidividual recpnnsihle and of more than half of the supervisors. The list of personnel added to the staff in the last year sllould be requested and consulted coilcerning the training received within the eslablishment; the instruction can have been provided by the authorities of tlie service for a period of not less than 15 days or through an i~lternal course combining theory and practice. Level 3: There is a department of nursing that is charged with the selection, training, number, and management of all nursing personnel as well as setting policies and procedures for nursing care.
The entire nursing stqff is adn~inis f ratively under u central depurtment. The s fa f nssigncd permunen~iyto a specialized sector (surgical service, sterilizutinn, etc.) i s lechnically under the individual re.sponsihle fbr [hut sector, but u d ? ~ l i n i s ~ n v eunder l y the nursing utrthoriiy Thc individiiul responsibie,for thc u'~'purf~ncnt reports Lii~octly to urzu qfbhc. d i ~ ~ c t u rld,hn x , Lc in
r h c ~ ~ .rgf'nll g c ~ thr trrhnir/rl rrrvic~.r
17
Clinical Recur&
Level 1: It possesses clinical records or all persons being cared for in the hospital, both outpatients and inpatients. The clinical record is legible; it is signed by the treating physician; and it has a closing (epicrisis, summary, or discharge diagnosis). There are known and widely used standards for the preparation of medic31 rprnrrlc Mnre th:ln Xn% nf a wmple of inpatient medical records s h o ~ ~be l d foutid to be updated to the day preceding the evaluation. It has Medical Records Supervision.
There are one or more sites where the clinical records aru,filed, and fhese are nor utilized for any other adminrsiralive or heaIth cure achvrfy. The recordirig oj clinical record.^ is organized by do ubie entry: in numeriuul order and ulphnbeticctl order: The retrieval of the clivlical records can be carried oert bused on the nzrrnher ipl~iicuiinghe order of' the initiation of the record or By rhu surname o n d f l ~ ~nume s t oj-theyuiient, itnd~ffrentiated, regc~rdless of the way in which t11e records are ordered ulz rhe shelves (by rerminal digit, numerical ordec or alphube~icnl
or&!?. First of all, the highest medical aatthority in Ihe csfabIishrneni shozild be asked with respect fu rhe ,foliow ing: Whether clinical record^. arc preplrred,for ail cases. a
The difirent pluces where they are $led, lhc adminis~ufive wrechanisms,for opening clinical reuoPzl.s und their deIi\)ery to rhe prof~ssionnls, on their orders.
Especially, the clinicai r~cordsof- hospitalizntiuns, oziparienr clinic,^ emergency services, and principal services.
Page 28
Ir should be verjficd fljat a safizple qf' 20 medicul re curd.^ sselecred .fronz the most recent hospiralizatiom recorded in ihe book ~ f ' ~ ~ i ~ s c h u w e r gsigned ~ ' s ure legihlu, and have szri?~muries. The medicclI cruthority should be asked on the existence of,stundm+ds, the mnnner in which hey were dis.~eminated, the method o f instrztcting the prufessiunal personnel and confiu't:ntiuli~of paticntk igljbrmation. There shozrld he verificution rhar there arc! acce,s.siblcl copie.r o f r h ~ ~ f ~ l n i l ~ t rin r Jtho s physiciu~s' rest ureas, nursing offices, efc. Severul professio~alsshould be asked or2 their knowledge qf the stundimis. There shozdd be v e r i f i c u f i of adherence fo the standurds in the same sample ofclinical recorull. that is described below
A sample should Be tuken that is represenfarive o f the inputienl areas except those with critical putients, selecied rundomly, nnd corrfuining not less than 20 clinicul records, in flre establishmen/s of more than 20 be&. There should be verijicution that, in nt least 80% rf rhe clinical recordr* reviewed. the evolution oj'lhe worhng day prior to thaf of the evalziaiion was recorded The same procedure should be f;lllowed with the clinical records in ihe archives. TAP ~ P nre
strmrfarcis, cJissominutod a?ad known, on the prupar-ation of clirliuul r.ccc~r-d~. Mure Thai? to
80% of sumple of' cli~icalrecords of'admilled parienls art. upduted to rhe day prior evrrltiution.
fhuf oj' the
Level 2 : I here IS a ullrque clinical record that covers both outpatient and itipatient care. Tht~+e is a Committee of Medical Records auditing
There should he verrfzmtinn in t h ~ r#/iniectIr6)curds Ilf the ozrtpniicnt clinic .fbr rhaf duy clf tlie existence o f records of previous hospifalizu~ions, as ,veil as verification, in the same sample of cclinicul records mentioned for Level I , of the existence of records of outplrtienl care. A zinique clinical record is tinderstood ro mean the concentrntion of' all the medicul data on one individ~ialpatient if1 Ihe some EIIVC~O~G,
jik,U I ~ u r i t a i r ~ e r .
The movement of the clinicui records is recorded and there is u jbdlow-zdp of'the route. All movements o f f h e clinical records are recorded in nofebuoks, car& or lists [hut show the dure o f rernnvf~l, I ~ nt-lrne P qf /he responsible person, the service, ut7d the dute of'return. I f the cli~lioal records should be tran.$erredfiom one service to unothel; provision i s made for a report of the change o f route to be scnt to [he archives. Level 3: There arc pcrsonncl dcsignatcd cxc1usiv~;lyrui lllis purpose and there is access to
the
archives 24 hours a day.
The archives ui-e served by personnel designated exclttsively for thix purpose. If during their scheduled shifs, the staff members carry oul other relu~ed iasks (such as sfatisticZs,olher records, shifts, erc.), they should LIP considered exclushe if they are a!w~yv uvaidclblefor meeting flze needs uf the archives. There is a provision j5r service in the archives 24 hotrrs a duy, which cun be verijied on the li,rt of ihe schedules of the personnel responsible for tile wrvirr 18. Siuf is1ics
Level 1: it keeps statistical records of at least tlie followi~lg data:
'
Medical records shor~ld include physician and nursi~~g admission and progress notes as well as otlier mcmbcrs ofrncdical tearrl, laburatory results, pathology and r:~diulogy reports and discharge summaries.
Page 79
Outpatients and emergency visit^,
Surgical and clinical discharges.
Births (deliveries, cesarean sections, vaccination at birth if applicable). Average stay.
Deaths. The chief of the s~uSfhu,sJitll uu~horiv to observe the strrtislicul r~cords and [he service provided during the lust caiendur- yeor The datu mentioned shozild be found robula~eu' andprocc.ssed ut leus1 lhrue rnunihs prior to the month in which the evalzration is cond~rctud, alihol4gh they may nor have been prt!piired for inIern~lpuhlicufi~n. The .stcrtistical dutu has b e e commu~licaled ~ lvirh health arlfhurities and concerned pcrrlie.~, a s applicuhle.
Level 2: There is a person specifically devoted to this work, althougl~ not exclusively.
The recording, tabulation, and processing of xduristioai indicators am curried our by 11 person especiiilly [ruined or assigned to /his tusk, ulthough hu/she mcly, in addition, pecforin othel; different nctivities. The medicul ut~lhorityqf rhe es/ablish~ne~lf should be usked about his interpretufion and observcltion ofrhe datcr and the service provided dzaing the lust ccilendor yeal: Level 3: The inpatients are classified by one of the followitlg classifications: WHO classification with two or thrce digits. B y principal synd~.ome for clinical inpatictlts, attd by anatotnical syste~n for sur~ical patients.
By precise clinical diagnosis and by the code of the operation. Level 4: lhere i s a department of statistics with technicians who issue a tnonthly publication of the information and periodic meetings are held for its discussion. l'he srari.srics depmtmcnt should includt', besides stuiistics, the archives o f clinical records and the office oj'admissions and iiischarges. The monthly publicutions issued dziring the inst y e w which should cwer at least tap to three months before the month o f the evalucriion, should be requested. The chief of lhe statistics department and the chiefi of the principal sewices shoerid be questioned on (he dute of llze Iust meeting hcldfor thc prarposc of d i . ~ c u . ~ ~ tlgc ir~ published g iplformation und on thc pcriuiJiciiy ~ r ~ i f~vhich h
these meetinfix occur; Iltcy should be held at luust every [hive months. 19.
Hospital Governing Body
II includes the azrthorities, committee.s individzru1.s or grotps, that set /he policies oj-!he ins!iltrlion and mnlrol their implementntinn, as oppliurble. Level I : The establishmer~tis headed by a director. TI-le director is present at least six hours on workdays and manages the programming of activities.
Page 30
The registration of signatures, in the case that the director does this, should be verified and sevural unranked staff mco~bersshould be questioned about the presence of thc director in the establishmcnt, as wc1l as his active pa~.riciparion in daily decision-making. Level 2: The director has had specific training in health services administralion. The institution has a Director (Chief Executive Officer), a Clinical Director (M.D.) and a Chief Adniini~trntive. The principaI decisions are comn~unicatedin writing. There is a Manual of Operational procedures and standards. The hospital has an annual budget and a is an annual budgat balance.
c o l ~ t i ~ l u~r~u~lituririg ui~~ of expenses. There
It should be verified in the office of Personnel that there is docunlentalion attesting to the training of persons as admitlistrative specialists. The budget for the last hvo fiscal years qhnl~ldhe nnalyred and budgetary execution compared. An evaluation of the balance sheet for the last fiscal year should be undertaken. The memoranda and commtmication issued by the medical and administrative management should be requested. It should be verified that periodic meetings of heads u f departments andlor serviccs have been held.
Level 3 : The instittdion also has a medical/technical committee's and a technicalladministrative council. As an important elcment of advisory assistance to the director/clinical director and chief adrn~nistrativeoflicer, audited ailnual financial sbtenlents should be prepared by a reputable coinpany or an authorized public agency. It qhnrtfd h~ confirmed that periodic meetings of the technical, medical, and ndministrntivc cuuncils are held (see proceedings). 'The fi~iaticialstatements from the last two fiscal years should be evaluated. Confirmarion should be obtained of the audit conducted by a public accoimting firm.
Level 4: ' l h e tnstitution has a governing body (board of trustees, as applicable) which is the highest
authority for the hospital and is responsible for formulating and establishing general policies; defining and approving the institution's operational, administrative, and financial plans; verifying compliance and following-up the results of their execution. 111 addition, it is charged with setting priorities. apprnving tlir? programs for services, atld other functions to be defined in accordance with the nature of the institution (public, private, governmental, non-governmental, academic, etc.). There should be a general executive division and an internal auditing service under the board of directors. AniluaI finailcia1 statemei~ts sliouId be pepared and an annuat report should be published together with un uuditor's rcport.
Ir should be confirmed that meetings of the board of directors are held in accordai~cewith lhe bytaws of the institution. There should be verification of the follow-up and execution by the operational scctor of the resolutions of the board of directors. Intcrnal audit reports should be analyzed. The annual report should be evaluated and observations made by external auditors on the annual financiat state~netlts for the last two fiscal years should be studied. The concept of depreciation of physical and operational infrastructure should be analyzed in the annual balance sheet.
Level 1: I here is a trained ~ndividualresponsible for the administration. There is a record of thc certifications of the professional personnel. It has updated a manual of adlninistrative procedures, (including operational routines, procedures and standards). There is a persvnnel office with files on all staff members that include certifications of training.
The estuhli.shlrnen has ~r leust one rruinedperson thcrt is responsiblefor.
Page 3 1 lhc ncqursition, distributiopr, und control qfrhe supplies and durahlu mcrrericrl resoztrces
The recorci.s, liq irziiu~ior~ of property, and cnnrrol of' the humun re,l-ources. The adminis~utionof the jnancial resources, billing and puyn~eprls lo pruvider.~,und generul btr dgetary consroL At least the prujessionul personnel hove lheir professional certificatzopls recorded by thnt adminisfration. which is evidenced in n veview oj'the files o f the pr~fi.s,sionalsthat are listed on the signs, especiully rhose on duw. The uilmini.strative prooedz~msund rhe routine actions are collected in a manunl /hat records the mcrin slcps in euch circziir. Thmf compendium shotlld conloin ut least rhe procedures reiuted to the junctiom menliuned ubove. TJzcm arc .files in the oflce designafed for this pztrpose on a i l projessionul lrnd nonprofessiunul peysonnel, in which are $led the cerlgficarions of ti-uining courses taken R~fi7r.e hiring or during servi~>e. d representative random sample vf)les eqldal~s10% o f rhe number of'employees birt nor l u exceed dU$les fiom difirent services and I~iercrrchiciil levels shozild he selected, hnsed on the list of regtrlar stuff,' unnd {he respeclive files studied Level 2 : The individual responsible for the administrative area s l ~ o u l ~ be l a professional. Thcrc
should be an administrative and financial structure with all the necessary services for an effective management.
2 1.
Occupational SuJety and Health Level 1: A health card for each e~nployee sliould be available. liere is a pi-ogratn for health safety of
the per~nn~ie in l a r r n r r l n n r e with the l n w ~ in Fnrre
i11
the r n ~ i n t r yInfcwrntinn i< mndc Tor- cnrc in case< n f
occupational accidents at~d necessary equipmetlts should be available.
F~r[fillment uf this requiremeni should be verified in a sample oj'the files of 40 employees Ji-om diJkrenf sectors and deparllnenls. In lhe dzrerent dresslng rooms for ille personnel, Ihe avmlubll~tyof .sholvurs with hot und cold wuter should be ver$fied The chief o f persunnel shozrld be questioned on lhe procedzizrre throtrgh whiclz occuplrtional accidenis are reported und ireated; the exi,rlenuu in purliculur oj' apt inszit-once cun6rucl to cover this shozrld be veriJied The per.~nnnelthat reporled aucid'en~.~ in [he kusl six months should he qztesfioned on the sutisfirction with the C U ~ Preceived. S/uJf rne~nhers~.vurkinglvilh radiation shozlld he monitored wilh per.runul dosinreters. Level 2: There is a manual of procedures nvoilnble in which mnteriol pertinent to the rislcs defined in
the standards of the count~y is described.
In the nursing ojflces andphysicicrns'con@rence room and on bulletin boards, iplslrarctions s h o ~ l d be posied concerning [he risks qf'contaci with [he di.~easesmenrioned and rhe precautions that should be udopted. Level 3 : The person~lelis classified by risk group and, for each group, prnrrisiorl is lnadc for the
corresponding preventive programs. Clothing is provided for the personnel, along with its decontaminatioti and laundering and the provision of bio-safety materials. Y Y I P enlire slajj is clrssvied by risk grozp, uaocording to their speci/ic tcrsks and the degree
rg'
exposzrre. On the bmsis qf tl~is projile uj'risks preventive progrunls are prepared for elrctricul uccidunts, explosions, hepatifis 8,tubo.culosis, and other i ~ l f e c r i o ipafhologies. !~ The head o f ~ d e ~ ~ a ~ mshotri~i ~ent,s I'M
qtiesiioned on the conrent of these prevenrivc progrurns und thr)se who ore mspmnsibIe in~plemenlcition.
j ~ r [heir
Rolh rhe provision of work cl0rhe.r and z,nij'ormsJor rhe personnel und fheir J~contaminationand iuundering are the responsibiliry ofthe esiublishment lhrougb? its own or a conlruuled seri~ice. The heud of depnrtmenls should he guesfioned with respect to thi.c r r . ~shnulcl drffbrrnt ~ w p l r y j ~ e that s trtilizo ,180r.k cloihes or ~mlforms;there should be verificution in parfictalar that the replacemen( o f soiled clolhes occzirs on a firnely basis.
Level I : It has emergency exils that are accessible and clearly marked and an evacnation plan, with training of the staff. It has a system for preventioi~ and extinguishing n f firm In.lhe compuny ofthu maintenance sfujfall the emergency exifs shutild be visited, versfying {Plat (hey are ciecrrly murked and [hut, in the places fhat the public traverses, [here are visible arrows lhat point tu w~xru'rirc erltergurrcy mils. Ii is recummended rhar rhe doors open to the outsrde. ' Ihe sfuD has received specitic insfrucliun on the system fur evacuating the instill1ation.r in case r f a general alrrrm; there ure a1.r.o instruction.^ exhibited in a visible place on how io proceed in t11le.s~ cases. Lcvcl 2: It has a program for disaster situations in accordance with the risk, approvcd by the appropriate authority. sh~uld be mude for oaher cnru~trophes (quch us eeartltquukes and flood$. The programs for emergencies and catirsrrophes .vhoulil he upprovcd by In
accordunce tvirh ilrc risks
iill e i d ~ I ~~ U C Z ~ J ~ (prepurilfiur1 ?II
the $re departments or civil dejeme or olher cornpeten/ uu!horifies. Level 3 : It has security and maintena~lce personnel on duty 24 bours a day.
There shouid be verification in the oflice ~Jpersvnnelof &hestoff assigned, [lie disrrihulion of schoduics, and the duty r u t a i i o ~ s assigxcd. j.If'thc service b uo~rh.uctsd, t1~r.e ter-rrrs qf tlic uvrrfriruf ~ h u u l d be reviewed und it should be crscertcrined whether it provides czd~q'yuute coverage 24 hours a duy. Level 4: It has a general alarm device allti is integrated into the civiI defense program
from
Through some acoustic or 1trrninuzr.s mechanism the existence o f a generul ulurm can he perceived any pliice in the eslabli.shmenf. The pnjnphleis and technical spcc~ficationsof the insfulled device
hn111d h~ r r q i ~ p s t ~ c nnd l there .~hoitlCIhe ver$c~lfion that tho dovice fifirnctioras. Thc gci?cral adcfirrm mechanism should be integrated into the civil dtfinse program of the local commtrni& a.v milch for attention to the damage to the e . s f ~ ~ h l i ~ ~ cls hm for e n the ~ reception ofthe victims ofthe disaster
Level 1: It has activities that are organized in such a manner as to ensurc the quality of medical care.
The responsible parties should he asked us to the frequency, nnture, and organization o f evaluation sessions or meetings. The list of cases .schedudedfor discz4ssiopr at the next meeting should be exumined, as .rlaozlld f he ctrrrcnt selecrion oJ'topics to be uddressed dziring {hefollowing three months and the rcspeclive speaker^. The health ream sizoulu' he usked concernzng their participcltion in and iw~pressionolJ'ilzese evaluation .F~?S.F~OPIS and whether thcy aye carried out with multi-disciplinary criteria.
Page 3 3
Level 2: It carries out activities intended to evaluate the quality of care. The quality of professiot~al performance within the establishment is ensured by: Periodic updating of the curriculum vitae and the recording of certificates of specialized training.
Entry by selection on the basis of background. Bucklfrulind checks should cover both professiunulx who ure r~gzrlur staflmembers und those who work i~ the hospitcrl on nn occn.sinna1 bnrir and rholrlrl hc qnplirnhlc ro rrl! hrnlth pm~ferrionnls. There should be verflcation in the ofice ofperson~lelof.files o f a representative random sample o f 10% the
ntrmher q j -professionais, but not exceeding 40 professionals. The ,files should contain prqfessioncrl background information up to the preceding yeat; as well us copies qf the respective certlficicatcs qf specildized rruiningJi)r rhe ucriviry rhur rhe prufessional performs.
Level 3 : It has coin~nitteeson quality assurance, infections, drugs, and other matters. Surveys are conducted to evaluate satisfaction of users and contit~uous cycle of improvement. Such commitrecs shozfld he interdisuiplinury and shozrld inclzlde the par~icipution uf~various services. They should have dtlfined objectives and an unnzrui program oj'adivities, und they should record thc work that is ur~iicr-takstz itt p~vcccclirrg.~ (71- I - ~ ~ O I - LTheirJ~. ~ ~ e c o ~ r r r ~ r e~ ~h zu d~ ar ~ p l id~ ~~ i i~ r~ ~ '~ tu t ithe y /tiu/z~TgCtrierrt
oj'rhe hospital and ail decisions arising ozrt of those reco~nmen~Jution.s should be communicated to ail the services. The responsible parties should he asked with regurd to the srinwys curried out, their objectives, the questions asked, and the manner in which the sample wa.q selected. 7'he report of results and unuIyLsi.s the lutesf survey should bc requesled and exumined. Level 4: It has a hospital epidemiology service and outreach approach to the community hcalth problemq, with qpecia li7ed p r o f e s c i r ~ n n l santi n r e w n r r l i pvngratn a irnerl at 121ity ;tnprnvement.
rv-
Building documentation
Level 1: It possesses updated plans in accordance with the building site and structurc. 11' there is a r~~linln w m rvir~ t h plnns ~ m ~ i s he t npprnved by the appropriate authoriqr
Level 2: It has updated plans for tllc installation of water, gas, electricity, and sewers.
Explanofion for LevuIs 1 unnd 2: 11)dutecd plans ure those that corrcspond~faithfirllyto the actiral status o f the bzrilding strzrcture ar the time o f the evalurrtion. These should be availuble at the cstublishmcnr as required by fhe szrrveyo~ Level 3: It possesses plans of the existing services and installations, approved by the appropriate authority.
7hc corresponding approvfll should appear in the re.sppective plum or in certijicales on {,J$ciul lctterheud. Level 4: It, possesses a dytiarnic, t n a s t e r a r c h i ~ c r : t r ~ p r~ l l~ n fnr r n n c t r ~ r c t i o n ~rnder way or tn be carried
out
Page 34
The muster plan .should be availuble in the es!uhli.vhtnent us reyzlired hy the surveyor; it shouid he wrirren und clearly specrh the pztrposcs ulong with the means lo uchieve [hem. There should be ver;rticution e~pccicrlly ofclre degree u/'k.nuwltidgc uf I ~ L plun . possessed by rhe direelor und rhe chiefs of'the services. Functional physical structure 25.
Access
Fur all the levels one should observe the safe@ condirions and thc protection f i r n the weather provided to ihe palzents that arrive at the ~nsiittrtion in afl arnbiilancc or other vehicle.
Level 1: It possesses facilities where transported patients can enter and leave vehicles under safe conditions and with adequate protection, with apprn~rintephycir.;l l harriers. The stnbulatory sen~isos should have access suitable a ~ safe ~ d for disabled. Transported patients should not enter or leave vehicles on roads with high levels of veliicular traffic. When This does occur, rhe walkway should have a sheltered area for vehicular parking tor protection over
the walkway.
Level 2: It possesses differentiated cntrarlces for vehicles and pedestriaris. Outpatients access the building by an entry different from that, which is clcsignated as the entrance for transported patients. Level 3: It possesses an exclusive vehicular entrance for the emergency service, with adequate signs.
The area for thc parking and maneuvering of service or upp ply vehiclec nnrl thnw nf thr public and/or the slaff should not overlap that for vehicles that a11-iveat the access area for the etnergency service.
Level 4: It has personnel exclusively for the cor~trol of the entrances and for directing the public 24 hours a day.
Ail [he entrances designuied for zrse by the public 24 hourcs a dcry have personnei dzily trained b o direct the trafic properly. These personnel do plot carry out a1z.y orher {vpe of work dttring the period it is assigned to thatfunction. Therc should be veriJicu!ion in the perso~zneiofJicce oflhe scheduling qf tours of duw to cover this function cind #f!he presence ofpersonnel in the designaled uccesses nights and holiclays.
Level 1: It has a divisio~~ of areas as follows: general, technical, semi-restricted, and restricted. There are easily understood signs in the passageways (in all the areas).
There should be vcrlfication rhnt the signs permit users enferingjbr rhe f i ~ ~ s time l to access the sectors cxperiencing the grentesr use (emergency room.s, conszrlting rooms, services for diagnosis llnd tre.utr~re~zt, hatlw; etc.) rsifhozlt ~zeedir~g tu ask.
Level 2: Adequate circulatory independence is maintained between the public and technical areas in the services that care for patients. There should be verification that the areas dedicated to the care of patients in critical condition arc found in areas with general technical and/or specific technical circulation, with selective control of acccss.
There should be special verification that there is no inteimixing of general traflic in the intensive care and surgical areas.
1,evcl 3; It provides for facility of movcrnctlt in a11 the areas for patients.
Thcrc should be vcritication that at all levels stretchers and wheelchairs can circulate arid that ~ h c r e arc railings on all stairs and in the baths for the public. Level 4: There is circulatory independence between technical and public areas in the entire
establishment. There should he ve~+ification of- the circuluiory dqferentiation in all its categories fhrough a tozrr through the entire estahii.shmeplt, and especially oj'the total independence of the general traffic @ow the rest of the categories. Installations
Level 1: It meets standards of safety filr patients, personnel, and the public. It posscsscs alternative systems of illumination and power supply, if applicable, for the critical areas. Thp rnntrnl n f thr r i ~ r f ~ i rvfyl ~ lt p r n r.hr)~~i,J h p rfivtrih~~tp with d /I rvntr-(11h r ~ l r r fIi I ~ FJ P I . I I I ~ ( I h<~(lrds / (11.
boards on the floors There sshnufd he verflaiirion (,She existence of enzergencv illuplaznuiinn of Ihu crilical areas and the emergency The opemtion rfsuch alternutive systems should be verified ut the time o j inspection. Level 2: Tt possesses alternative systems of energy generation for the critical areas. 'The electric circirits of the critical areas and the emergency exits should have a n alter~iative solirce n f energy generation (electricity-generating group) whose adequate operation shollld be verified during the evaluation. 12cvel 3: Ii has syslcrns tu ellsure uninterrupted lighting and generatioti of energy for ~ l i c nornlal operation of the hcalth establishment.
There should be verijicution qf the existence efu central electricul ene era tor; a l o n ~ ~virh specialized technicaI personncl, ( ~ n that d its mechuni.sm.s workferlly a1 {he time of'fhe evuliiafion. That device should he connected to [he central b o n d and will huvc u central kcy,for tmnsferring the energy source.
Level 1: Thcy confonn to municipal, provincial, national andlor WHO standards. It has drinking water service and a system for the elimination of excreta. It has a special system for safe waste disposal. Inquiry sholrld be made into the background of ihe .srundur~isio which these servi~>es udhere, whether they ure filed in rhe csf~blishmenr or were required previo usiy lhy the local inspection ~ t r r l ~ o r i t ~ ~ . The i4~otev tnnks shvladd havn povmancplt covers. Both the drinking >vatcar ~tnd thc final disposal o f tlzc wastewuter are provided by apublic nehvork; when the latter does not provide drinking wute); rhe quuntily ofstort.dpo!ahie wuler shotlld he verified. Throtigh questioning ofthe nlaintenclncc stufl,' the exislence (!fa blind hozi.sehold well m7d od'~v~tier well witla pump should be ruled out. Wastes arc di.sposed through a
Page 36 special "dirty" dischcrrge point, equipped with resistant plusric bags within rigid-wulled conicrincr.~ ru uvoid pzmcfirring o f f h epers:romzel rhul bundle them. 1,evel 2: There is preventive maintenance of all sanitary installations. The high-risk solid wastes are identified and receive differentiated treatment.
At leust every three months [he rnuinfcnance staf ver$es the correct operufion c?fallfuucets, toilets, water hculing systems (ofvarirm~ Qpes), and discharge pointsfor inspeclion oj~wuste wuter Contlrminarcd solid wastes posing u high risk--except food-are stored in resistant hags that ure lubeled or of a dqJtrenriuruii colur and handled wirh gloves; [hey are not mhed wirh the common solid wustes; there .~hould be verification of compliance with this requirement widh .service personnel. Sc~firymeasures should followed in dealing with contaminated sharps Level 3: It has its own specialized technical perso~irlelor a service contract for this purpose. It has a specific area for storage and disposal of solid wastes and these are collected twice a day. Yltc ,rzuirrterzurlct: sef vict! Jur f l j e ~ auruus is (he rt'~.yu~.i~ibilir~'y of .s]~t'ciuItzL'd dechnical personnel (sanifnry engineers, iuhor sujhty engineers, or the equivcilenb), who are either employees or are sldpplied thro~cgh conlract with n specialized company. There is u specific site exclusively for storage u f [he solid wastes thur are re~iovedthmugh u door dus@ta.teil for this purpose only. Yivice a ddy t h wastes ~ nre collected and are deposited at this site, which is washed once a day, ufier the fi~filaulcollection by lhe public service.
Level I : All rooms meet standards for comfort in accordance with the needs in the Region. In the duyrime [hey will huve nutzrrul lighting. In the geographical areas where the averuge winrei. temperature exceeds 13 degrees Centigrade, heating will be optional The rooms should huve heating rhrough dc vices that do nul consrrme oxygen from the environment and discharge combustimn guses outsic/e (central heating giis healer with ct~ntrdledflarn~. rrir rrrntiitinning, q~rrrrh ~ l ~ c t rh ic c n t ~ sut r in rhu wall) Level 2: All the bathrooms have hot and cold water available 24 hours a day.
The bathrooms are szpplied with hol and cold water: at lemt in Ihe washroom and the shower A sample o f 10 patients +om diferent secfors should he que.stioned about the existence [ f h o l water OI nll hours. This reqztir-enten! depends o o n the clima~ological charucterisiies ofrhe region.
Level 3 ; There is a private bath in all moms, in accordance with the requirements established by the office of sanitary erigineering in the Region. Every room, regardless of- fhe number 01-beds, has cr balh to which there is acce.r.s thrrjzrgh ctn inierior door ofthe room.
Page 37
FACULTATIVE SPECIAL STANDARDS~ 30. Critical Care
Included in [his catcgoly are the services clesignufed for the care qf pcifre~rtsaf risk death.
irnrninenf
Level I: It has at1 intensive care unit (ICU) provided with the csscnti;ll technological resources and ~ R
iS t s own personnel cnntinuo~isly.
It is a service for patients for whom total or partial recovery is possible and who require constant, continuous medicaI and nursing care for their survival. It should have medical and nursing sraff, assigned w~th exclus~venessm such a way that coverage IS of the same ~ntensrty24 hours a day. It should have the following:
Stock of drugs and disposable materials. Oscilloscope monitors.
Syncl~ron~zcr-deii brillator. Transitory internal pacemaker.
Cart for endotracheal intubatiotl. Electrocardiographs. respirator. Volumetric mechai~ical Equipment for trnchidial or thorncic puncture.
Equiprrlent fix nasogastric, vcsical, or venous catheterization. Laboratory for clinical analysis, hernotherapy and radiology services, on call 24 hours a day.
Oxygen; central compressed air and aspiration.
Alternative source of eIectric power.
3
Note: Thc facultative or noncompulsory standards apply both to diagnostic and trcatmcnt scwices that rcquirc invcstmcnt i n cquipmcnt that i s
tochnulugically lligllly cu111plt;nCi~~L~usivr; calr;, ~ ~ ~ u ~ m l o l u g y ,
nuclear medicine, radiation therapy, and rehabilitation) and to support services whose presence contributes substantially to the improvcmcnt of the quality of the niedical care, although frequently not Eorcseen in tlic hospital organizations that arc thc object of this manual. I11 the case of the services meiitioned in the first group, a set of requirements with rcspcct to their
equipment are e~tablishod;these nre only to serve as
g~iidelines and arc subject to the specific standards in effect in the particnlar EMR country Wherl services arc not supplied by the establishme~~t, but havc bccn contracted, thc institution should assume responsibility for the hlfiIlment of these standards on thc parly of those services.
Page 38 Central nursing monitoring s t a t i o ~ .
Ava~lability ofcentral or departmental sterilization facility
The individual respoi~siblefor the unit makes a circuit of the beds with the physician on duty in the 11nit and m ~ i n t a i n s daily exc hangc
ith the ward physicians. ?'he possible participunts in thosc: i n t c r c l ~ a n ~ c s
should be questioned.
Levcl 2: It has a completely equipped 1CU, supplementcd with a unit for intermediate care. The intermediate care unit is designated for patients that require constant, continuing nursing care that cannot be provided under general hospitalization. It should have equipment similar to the ICU treated in 1,eve1 1 ahnve T l i ~ ni~rcing prrsonnel should be exclusive but the medical personlie1 can bc ICU or ward physicians that follow the intcnnediate care unit patients; tllis will only be rcquired in the establishments that have completeIy provisioned intensive care. The ICU provided with complete techriological resources should have the following: Equipment similar to that mentioned as the basic resources for the ICU, concentrated so that it is available for each patient at all times (see Annex A).
Qualified trained medical and nursing pel.sonne1, assigned with exclusiveness, 24 hours a day. Laboratory for clinical analysis, blood bank, and radiology service, with personnel available and on duly 24 hours a day.
The medical slaff of both units meets in a forum at least once per month and the physicians responsible for the sector participate weekly in the ward foiums for the purpose of fnllnw-irp amnng different levels of intensity of care. During the previous year the nurses in the unit have received specific training courses. A~iucx A. B y u i p l r l ~ r ~irlbLr l , UIIIGI~LS, UILI I I ~ ~ I I ~ I supplies I ~ U I ~
for one cornplerely provisioned ICU:
Stock of drugs and disposable materials that would cover the needs of care for 24 hours. Synchronized-defibriIlator: one for evcry two beds. External transitory pacemaker available with two cable catheters: one for every four beds. Resuscitation cart wit11 equipment for cornplete endo~rachealintubation and drugs necessary for treating cardiopulmonary arrest: oile for every bed. Mechanical respirator with volumetric positive pressure: one for every four beds.
.
Complete equipment for nasogastric, vesical, and venous catheterization. Complete equipment for rachidial, thoracic, and abdominal puncture. Equipment for peritoneal dialysis.
Portable suction for drainage: one for each bed.
Oxygen. compressed air, and central aspiration with individual outlets for every bed.
included in [his caregory are rlae sewices und inslullcrrions designaiedjbr the care of the norrnul newborn firNj und pathologicul newborn (PY, us well as the neonutal intensive cure unit (;yICu ,for nrlvhrwn with r r r i o ~ ~ rlinirnl r rrnd r~~rgicrrl s~~nrJrnrner
Level 1: It has an exclusive site designated for the medical care of the newborn. 'The site should be suitcd to rcccive the NN, in a location next to the delivery room. It should be air-conditioned at the proper temperature; it i s providcd w i ~ h hot water 24 l~ours a day and the newborn can be bathed if necessary. It has a laryngoscope, balance, oxygen, aspirator, and colnpressed air. It has a poitable incubator for transferring the child lo an appropriate environment. if there are clinical complications. The physicians that receive thc NN form part oCthc pediatrics senrice of the hospital and are linked to the NICU through forums and cace Ibllow-ups. TIle possible speakers at these exchanges should be asked.
Level 2: It has a sector designated for the care of the PN, clcarly differentiated from the NN, that can resolve the principal cli~~ical syndromes of the ilcwborn. Thc Jiffcrent environtnents of the area for care of the PN constitute a differentiated fui~ctionalunit, located in an area of restricted circulation. It cw rcceive children born in the same or transfers from nearby facility. The medical and nursing personnel are assigned excIusively to this sector; there sIlould be verit'ication in the office of personnel of thu scheduling of the staff 2 4 hours A
day seven days a wcck. It
possesses co~rlpleteequipment for: resuscitation, exsanguine transfusion, pneumothorax drainage, and canalizatioti of the umbilical aflery. It has equipment for light therapy, neonatal rnechallical respirators, transcutarieous oxygen monitors, an oximeter, and continuous positive pressure. The unite should have qualifed ~leorlatologistresporisible for Ihc service makes rounds daily with the phys~c~a~l, ot the service on duty. 'I'he nursing personnel have receivcd spccific courses of instruction during the last year, presented by the physicians in the seivice. Level 3: It has a NICIJ, diKerentiated and organized semi-autoi~oinously,that acts as a referral service for the health facilities of the area. Thc NICU cullst i t ~ ~ t c all s iis>i>~il~i~ ctu : ~r~ple will1 s ~r~eclical illlrl riursi~~g persorlilel and apprc~priatc support and its own adrnirlistratiori of supplies and equipment. It has a reception area, a waiting room, a nursing station, sites for the incubators, isolation areas, rest area for physicians, rest area for the mothers, storage area for supplies arid equipment, etc. Thc NICU should have tbe following:
-
Equipmcnt available according to Aiinex A. Provision of highly trained lncdicol and nurvillg pcrsonncl, assigncd with cxclusivc~lcss 21 huurs d
day. A laboratory for clinical analysis, a blood bank, and a radiology service avaiIable 24 llours a day with personnel on duty within the Iiospital. Equipment for lirc saving emergency and postoperative intervention.
The medical stal'r meets in a weekly forum and the individual responsible for the NICU tnakes rounds daily. The nursing personnel receive classes of instruction and trainirig on a regular basis at least UILCr it 1 t 1 ~ t l ~ l l .
Annex A: Miniinurn equipment for a NlCU. Stock of suitable drugs and disposable material for 24 hours. Convelltional incubators. Transcutaneous oxygen monitor: one for evcry five beds. Pulse oximeter: one for every five bcds.
Equipment for resuscitation, exsnnguinotransfiision, central Vellous pressure, canalization of the utnbilica! artery, pneurnothorax drainage: two of each in the area.
-
Oscillometric tetlsiometer: one for every five incubators. Electrocardiograph with pcdintric clcctrodcs: orlc in thc nrca.
Apnca monitor: one for every three incubators.
Optic fiber transilluminator: one in the area. Oscilloscope-defibrillator: one in the area. Neonatal rcspirator: one for every five beds.
Equipment for continuous positive pressure: one for every four incubators. Continuous perfusion pumps: one for every three incubators. lJumpfor negattve asplrat~on: one
for every three respirators.
Gas mixer: one for every six incubators. Humidifying heaters: one for every three incubators.
Level 1; It has an exclusive site designated for this purpose that meets the stai~dards for hemothcrapy service. The service is under the direction of a physician specialized in hemotherapy. The hemotherapy servicc is the technical udmini.sil-dive entity re.~punsihle fur lrunsfusions, with ihe elements provided by the blood bunk, including preliminary immunohemutologic study. The hernolheropy service i.s responsible for the blood rlral it provides so that if shotridperiodically verify rhlrr the conzponents that ii receives porn the blood bank meet the srandurd.~in ejjecf for cornmtrnicable discu~e prevenlion. Those stundrrrd.~ dictule lhni it? every fr~~a.sfii.sio~a unit the fullo+ving serologic tests should he carried out:
Page 41
Syphilis (VDHL).
Brlrcellnsis (Httddle.~on k test)
Detection ofHIVuntibodiies. There aho uld hc ver.rJicutiorz in the ajict. O ~ ~ ~ ' ~ * . P O I ? o fI ?tC l~ ?~ I?isf~ry of S/ICC~U~
ized trairr irzg of the
responsible plrysicinn. The re.yponsible individttul per,so~zailystpervises the ~rnils received from b l ~ eblood hank; [his should be conjirmed by qzrestionivlg its personnel and observing the signutilre on the receipbs jbr tht~l ~ srntlnfh. t The bugs ure stored in a rejrigei-utor with !he sections labeled by blood groirp. The service extracts blood to supply (he bank. ,
Level 2: It has technical ur medical hernotherapeutic personnel on duty 24 hours a day,
There should be ver$cution in fhe ofice of personnel o f tfrc list o f techrqical or ntedicui personnel the scheduling o f their rotation. Barh the technical personnel assigned [(I the sei-vice, with their hours und she physician huve some specific irnining There sholrld be inquiry inlo tlae fieqlrency wirh which they ~neer with rhe individuui re,~ponsihle f i r the service in order ro uddress op~ruaronnl prublcms arid whether they have rnet within the lust fhree rnmntl~s. Level 3: It has a blood bank that has all the followii~g characteristics:
It is directed by a specialized professional. It has a reg~sler or blood donors.
It has standardized its procedures for processi~ig and storing blood. It is a reference center for other establishrnenk. Makes periodical evaluaiions to adverse reactions.
The blood batik is the technical administrative entity responsible for the following functions: St~tdy, clinical examination, selection, classificatioll of donors, and extraction of blood.
Classification and control of the blood and its componcnls. a
Divisio~ of ~ whole blood in order to separate components. Conservation of the components for their provision on demand.
+
Provision of raw n~aterials to the blood derivative pIants.
It shozlld he cerrfit.0 bv the cor~.esponding healrh a~ithori!v and the certificate should he e-rl~ihi~ed in a visible place. There .shoztld he verficci~ion in the ?flee ofpersonnel thal the individml responsible has been awarded /he yrojessional degree cf Irenzorhernpy spuci~~lis~. There slroirld bc observation .of riie register qf blood ~fonors us well as 1he cli!7ical li.vls in lvhich ihe healdl dutu ,for {heir adnrission us ~1onor.v
Page 42 ure recorded, in accmrdcrnce with Iu~islotionit? gfect. The inunuul ofproueJzlzll-e,rf u r the service should he observed to verifi thur it is accessible and the personnel shozrld he quc.sliopaed with regclrd (0the instrtrction r.t.ct.iv~Jcvi~hr e ~ p c c lru thuxt. pt-uccdures. Ar Iuusr every rhret. rnrlfl1la.l. rneelzngs are heW lo au'd~*t's~. operational matters. The respor~sibleindividual should he u.vked Jbr the lisl of estublishnzc~lfs that are
supplied by rhe bank or lhe surne fime that they provide ~lonutedblood; the $ 1 ~ . o f receipts +om the e,srablishrnents to which blood was shipped u'zrring the lusl (hree monihs shmuId be checked
33.
Nuclear Medicine
Nufiurrul jur iv~~t.rnuriunui) srunllurds for rudio~rcllve prorecrion sholdid be followed. There should he cornpliuvlce wir h nationul srandurdsji~r rudivuctive pro!ection.
Level 1: It has the infrastructure necessary for the various in vivo diagnostic applications of radioisotopes, in the form of radioactive tracers, aud those therapeutic applications derived from them. It is under the direction of a medical prol'cssional, a specialist in nuclear medicine. The specialists arc ccltificd by thc c u ~ u p c t c ~ jurisdi~tiu~~iil lt ituillur ily, allcf
ll~r rcspcc~ivt: LLI lificatcs should be exllibited it1
a visible place. It has a linear scintillograph, a PI-operlycalibrated activity meter, ar~d a rnallual well-type detector, The radioactive tracers should be kept in a storage area that meets the standards presented by the competent authority. Every piece of equip~nent for measurement should be in an exclusive site. 1,evel 2: Has a spccial irnil of Nuclear Medicine. Thc rcsponsiblc individunl is assistcd by onc or morc tcchnicinns that hnvc spccific ti-aining in thc
management of the equipment and the hai~dli~ig of the radioactive material, acquired either by special courses or by in-service instruction. It may or may not have a linear scintillograph. It lias a dctcctor for lneasurernents in vivo and the gamma chamber should have a computer processor of iinages and measurements. Every piece ormeasurmg equipment should be in an exclusive site. Level 3 : It has more than one professional specialist in nuclear rnedicinc and their functions include health care, teaching, and research. The responsible individual is assisted by one or mow: professional chemists, biochemists, physicists, or pharmacists, authorized to handle radioisotopes. It has a portable monitor and i t may or may not have a whole-body scintillograph. It has a rooin for radioactive decontamination; it has facililics fur the processing of photosensitive films. It develops undergraduate and graduate teaching activities as well as programs for applied research, based on activities of the service. It may have plloton-emission or positron-emission co~nputerized t~m~graphy.
34.
Radiulion Therapy
jtirisdiction, with regard to insfuiicrtions,for healtl~radiation physics and nuclear energy. There are two types ofservices: teIe(herapy and brachyrherapy Brachytherupy by itself does not constitute a service of radiation ther~py. It can he ineitrded at U ~ J ofthe J t h e e levels withotit implying chunges in the level o f f h e requirements; $this tecltniqzie is nitiii,-ed, thc corrc.sponding uuthoi-izalions must f irsl be obfuine~i. Inclzrded a s the under (he term brochythcrapy are rrearrncnts lvirlr infused or implanred rcldioisorope.c, s z ~ h placement of'needles or tubes ofr4adium226, cesium 132 (cancer o f rhe uterine curvix), therapczitic dose.c cg' iodinu 13 1 (thyroid cancer), ipztrucnvitur,v solutions (neopkrstic efftr.cion.r;), or int~r.stitialirnp1unt.c o f iridium I92 @reast cancer) or other.?.
Page 43 Level 1: It has equipment for cobalt therapy with or without eqi~ipment for contact radiation tl~erapy {hat comply with radiation protection programme. It should be under the direction of a specialized physician and have therapeutic protocols for each pathology.
It shoirld be uilder the direction of a physician specialized in radiation therapy, who should be ourtificd by the corresponding authority for control of radiation; the certificntcs s h o ~ ~ l bc d cxhibitcd in
visible place. It cornplies with the legal provisions for protection of the eulirt: starf froin cxposure to radiation. The corresporlding documentation should be observed. In the personnel ofice the certificate of the radiotherapy specialist should be verified. The compendium of therapeutic protocols should be observed and the spec~alist should be questioned with respect to their etfectrve appl~catton. It should have speclallzed technicians and access to the advice of a physicistrphysician for calibration of the equipment, clinical dosimetry, and treatment planning. Level 2; it has a linear accelerator of up to 5 MeV, without the capacity for the utilizatisn of electrons. It has a simulator/localizer. It is involved in colIaborative gmups Tor licatment of cancer. 'I'he linear accclcrator is a device that produces X-rays by the impact of a bcam of previously accelerated elcclrims 011 a special anode. The high-performance apparatus permits the therapeutic utilization of both the electron beam and the X-rays. The simulator/localizer is a low-power radiological device with the same geometry as that for radiation therapy that p e r m i t d y means of radiological plates with or without the assista~~ce of an image intensifier-location of the voIumes to bc irradiated and simuIation of the treatment fields, making it possible to delimit with precision the field to be irradiatcd. The professional or professio~~als iu the service participate in colIaborative groups providing a comprehensive approach to cancer invnlving nilcnln~ist, r.h~inntl~ernpict<, wrgenrir, ~ r l r lrtinir*innr, hr.l(.~nging either to the same institution or to other establishtnents. The equiptnetlt should bc calibralcd by the physicistlphysician.
Level 3: It has a linear accelerator of more thau 5 MeV that can einit X-rays or electrons, at the discretion of the therapist. I t allows computed doslnretry of Ihe treatments. Computed dosimetry makes it possible to calculate exactly the radiation dose to deliver; through thc calculation of thc effective beam. penumbra areas. and isodose curves. it reduces the risk of irradiatinn of healthy tissues; this infomation is presented in a graph and is the basis of the simulator--locator.
Level 1: It has specialized personnel that provide treatments for primary rehabilitation in general hospitalization and/or intensive therapy, as required by thc medical staff of each service. The specialized person~lelcotlsist of pt~ysioiherapyur physical therapists whose certification should be confirmed in the ofice of personnel, who rriay or may not be on the staff. They provide treatments of physiotherapy in aculc cases. respiratory physiotherapy and ~~eurological Level 2: It has a specialized service that treats outpatient's and has the necessary minimirm installations. The service is ulldcr the supervision of a qualified person in rehabilitation. The service is also made up of speecl~and hearing specialists and occupational therapists. The installatic~nsconsist of, at the very least: a consulting room, room for occupational therapy with sufficient equipment for practicing the activities of daily life arid a gymnasium for cardiovascular, neurologica1, and orthopedic rehabilitation. The equipment in the gyinnasium should i ~ ~ c l u d pnrnllcl c burs, u wall mirror, a ramp and s~airs,a stationary bicycIe, mats and pulleys; it sl~ouldalso have a Bier oven, short wave, infrared, and ultraviolet rays in the physiotherapy section.
Page 44 Level 3: It has a cornprchcnsive rehabilitation set-vice, equipped to develop the grcatcst part of the treatments of the specialty, on an outpatient basis and for inpatients. It is under the direction of a physician spccinlizcd in rchabilitatin~~, with support fioin v t h c ~spe~iiihics. l'llc~ris a ~~iecl~ar~isrn Tor fl~llow-up of h e treated patients.
A comprehensive service should provide the following treatments: physiotherapy: short wave, Bier oven, ultrasound, infrared, and ultravic~let rays, electrotherapy, iontophoresis, cervical traction kinesitherapy: massages, mobilization, muscular reeducation, therapeutic exercises, respiratory and cardiac rehabilitation treatment of amputations, malformations, congeriital and acquired ncurupathies It should he undcr the direction of a medical physiotherapist or someone in a related specialty, with oitier suppurling spccialiscs (neurologist, trautna~ologisl, olorhinolaryngologist, etc.) and auxiliary professionals (kinesiologists, speech and hearing specialists, occupalional therapists, psychotherapists). The professionals in the service maintain an exchange with the rest of the services and participate in the forums. They enter their therapeutic programs in the clinical records. After the conclusion of thc treatment, the patients are given appointments at regular intei-vals that are establidied for each pathology so that the evolution of their condition can be evalcrated. The individual responsible for that t'ullow-up should be questioned about the mechanism by which it is carried out and its implementation shvuld be evaluated.
36.
Promotive Fenlth Services
Level 1: The care provided by the hospital includes activities related to risk reduction. These include but are not limited to Smoking Cessation, Obesity Reduction, Premarital Exa~nil~atioil and Genetic Counseling. The l~ospitalhas active n~nokingcessation clinic, obesity reduction c l i ~ ~ ipremarital c. examination and genetic counseling activities.
Level 3: The hospital has an active role in Cornm~mity Developmellt
The hospital are illvolved in active programs concerned with community developtnent like health education program (inside and/or outside the hospital), community based medical research and Healthy City program.
3 7.
Social Service
Level I ;
It has at least one social service professional and an area adapted for the development of that person's work.
Therc should be verification in the ofice of personnel of the record of training it1 a recognized public or private institution. Verify the existence of a site firlfilling the privacy requirements and time available for interviews and meetings, for purposes of discretion and intimacy. Level 2; '1'l.lere are writler~ siarillai-ds and pulicies arid procedures ~11alshuuld be reviewed periodically.
Thcl-e should be a rcvicw o f the existing standui-ds, their availability, the date of the last updatirig, and the knowledge that the members of the service h a l e about thetn. -1'lle files of ttie socioeconomic repons on the patients and the record of the tasks that are carried out should be observed.
Level 3: '[he service is integrated with other health care professionals There should be verification of their participation in forums and meetings and of the records of their activities in I0 clinical records provided by the appropriatc scrvice. No fewer than two individuals responsible for services should be questioned on the frequency with which the social service intervenes.
Level 4: It dcvelops extramural activities, such as making house calls and community contacts, fostering institutional relations, aild identifying groups at risk. There shouId be verification in the records of the service of': a file on community resources, reports o[house calls, a file of tiotes and reports, etc. The existence of social statistics on the area of influence of the establishment, transfers to other institutions, contacts with organizatiotis for the public good for the purpose of uhtaining betiefits for patients, and related matters sliould be observed. 38. Lihrury h 1 1 1 of 1
Level 1: There are updated publications concerning the four basic and emergency care in thc textbook or manuals.
It has treatises or manuals, plthlisl>ed in ~ h nalivc c languagc not over five years previously, that cover at least: clinical medicine, surgery, gyneecology, obstetrics, pediatrics, and emergencies. The texts are availabIe in the oflice of the management or in a physicians' rcst room and can be consulted only within the establishment.
Level 2: It is under the dilrction of personnel that control entry and egress. The incorporatioll of material is not programmed. It has subscriptions to some scientific joun~als. It has texts on others
spectalties. The personnel assigned are administrative and carry out other duties, in addition to those specifically for the lihrary. The incorpnratintl nf hihlingraphii: material i s dnnp at t h e rpqlwst of the meclical staff or as a result of uncvaluated donations (a11 the material that it is doi~atedis incorporated). There are subscriptiotis to at least two scientif c jourtlals. There are publication about hospital and health system administration and others health services
Level 3: It has exclusive personnel. There is a program for incorporation of bibliographic material. It functions at least six hours pcr day and has international indexes.
The personnel is assigned exclusively to t l ~ e libraiy. The program defirtes the publications to be incorporated and those that should be dropped. The inteniational indexes are current at least up to the previous year. Through an annual mechanism of consultation wit11 the heads of the services, the p~~blications that need to be acquired arc spccificd cach ycor and, on thr; basis of tllcsc rcqticsts, thc
bibliographic budget for the fiscal year is prepared. Level 4: There is a ca~nmittee of professionals that prepares the annual bibliographic program. 'l'he individual who is in charge of the library artd has specialized library training is a member. The library has access to inte~mational bibliographic data banks aod electronic database. It is desirable that it issues its own publication.
Page 46
The libraly committee prepares
an annual program, for the purpose of:
Incorporating bibliographic material.
Reportirig to the profkssional corps on the availability of materials. Dropping the obsolete or unserviceable material. Preparing the budget of the section.
There is a photocopier available for the library during its hours of operation. It has a cornputer with programs for filing and a connection with international databases. The library's publication will be considered relevant when it is publisl~cd o n a rcgulai- ~ c h c d u l c is , cxchangcrlblc with othcls tl1a1alt: silr~ilar,
and reflects the health care and research activities of the establishment.
Appendix
EXAMPLES OF INDICATORS OF THE QUALITY OF MEDICAL CARE, SPECIFIED BY SERVICE OR SPECIALTY, TO BE REVIEWED AND ADAPTED TO THE LOCAI, CONnITIONS OF EACH IIOSPITAL Selected by Ilumbcrto M. Novaes, M.D., Ph.D, President, INTECH, Inc, Washington, D.C
INDICATORS IN TECHNICAL OR AD&IINISTKATIVE AREAS Admissions
Yromptness ot adrniss~on procedures. .
Accuracy in data collectior~ (for example: personal data, social security, address, etc.) Accuracy of nledical records and i11the
account number assigned in privatc hospitals.
Fulfilltnent of the requirement of obtaining the patient's consent. Patient complaints. Medical Records
Prottiptness in the collection and reporting of data. Lostlmisplaced records. Accuracy of coding. Promptness and accuracy of transcription services.
Satisfaction of the physician.
Compliance with the procedures fur handling requests for confidcirtial infoimation. Prolnptncss in tilling requesrs for old records.
Accuracy in census rcports Percentage of qualitative evaluations of clinical histories,
Outpatient Care Capacity for patient survcillancc with monitors.
Patient incidents.
Page 48 Accuracy of tile patient appointment system. Compliance with criteria for discharge.
Compliance with infection control procedures, Patient complaints.
Physician complaints. Patient waiting time of more than '.x" hours. Admission of paticnts for obse~ vation d u ing ~ thc light.
Number of first consultations versus emergency consultatiot~s. Emcrgency Precision in the follow-up o f cases with abnormal test results. Patient satisfaction. Compliance with docurnentation requirements. Relevance of instructions to the patient upon discharge.
Patient incidents, other than errors in medications. Mortality in thc first 24 hours. Cornpliai~ce with infection control procedures and safety measures.
Relevance of patient management. Length of time bctwccn admission and evaluation by the nurse. Physicinn satisfnction with thc scrvicc facilities.
Lesions from contaminated needles. Compliance with protocnls for paticnt management.
Unsuccessful attempts at cardiopulmonary resuscitation. Patients that wait Inore than "x" hours. Re-admissions due to inadequate/unnecessary treatment. Claims due to professional incompetence.
Page 49
Other Indicators for Outpatients and Emergency Patients Inability to locate medical record.
Staffing. Recording of date, hour, and signature for all admissions. Hi,utory of nllcrgii;~ not doculncntcd.
Clinical-administrative cvent not documented. Lncident occurring in the clinic. Complications of phlebototny. Complications of treatment. Dead1 of a patient within less that1 24 hours after the visit to the clinic.
Diagnosis at variance with electrocardiogram, X-ray, or other test.
Error or adverse reaction in the administration of drugs. Anaphylaxis.
Transfer of emergency case to another facility. Adverse reaction or emergency in special arca of operative carc.
Transfer and death to Emergency Room during first 4 hours after admission. X-ray interpretation in Emergency Room at variance with reading by the Radiology service.
Failure to interview of patient with expressed suicidal manifestations. Lack of response to therapy.
Hospitalization within 48 hours after visit to Emergency Room. Illegible handwriting.
Inappropriatelinadequate docuinuntatiot~of immunization. Inappropriate handling (diagnosis/treatment) of patient with venereal disease. I~iadecluaie Cullow-up or inappropriare referral.
Inappropriate delay in seeing patient with acute diseaselsiti~ation.
Page 50
List of probIe~ns too brief or incomplete. Error in endovenous medication.
Failure to follow up on anomalous values in laboratory or x-ray results. Laboratory/radiology questions: Incorrect data provided. Requested test not performed. Specimen lost or poorly labclcd.
111correct study requested.
Inadequate preparation for procedure. Physician/place not listcd in request form.
Prolonged delay in reporting of test results, with adverse effects. Loboratorvlradiolonv support: Laboi-atorya-ray results not recorded. Yrolonged delay in report~ng, with adversely effects for care of patient. Diagnostic procedure tlut perforn~cd.
Diagnosis or specimen lost. Neonate under 6 weeks of age not evaluated by pediatricians.
Consent for invasive procedure not obtained. Lack of doc~~mentntion of instructions for the patient, or inadcquutc or incorrect documcntntion.
Organ deterioration or failure:
Cardiopulmonary arrcst prior to admission to Emergency Room; cardiop111monary resuscitatioil successfi~l.
I
Cnrdi~pulm~llary a m s t occurrcd prior to admission to Cmci-gcncy Room;; cal-diupul~nona~y
resuscitation unsuccessfi~l. Cardiopulmonary arrest in Emergency Room; cardiopulmonary res~lscilatinnsuccessful.
Cardiopulmonaly arrest. in Emergency Room; cardiopulmonary resuscitation unsuccessful.
Page 5 1 Patient dead on arrival at hospital.
Cornplaint ol' patierit or family, Admittirig Room. Complaint of patient or family, Emergency Koom. Injury to patient during the diagnosis/treatrnent. lnstrrlction~given to in Emergency Koom n o t available or1 chart.
Departure of patient without being seen or against mcJical advice. 'I'reatment denied. Discharge of patient without docurnetitation of instructions. Patient stay in clinic or as o~ltpatient longcr Lhan 4 hours. Patient stay in Emergency Room longer than four hours. Patient seen in Emergency Room with complicatioris from outpatient care. Diagnosis by "process o f clirnination" after two visits to the clinic.
Work-related injuries. Indication of or attempt at suicide.
Failure to take statement in casc of suspccted sexual abuse. Failure to take statement or folIow up in case of suspected spouse or child abuse. n e l a y nf mnre than
hO minutes to see physician.
LJnplanlled admission to clinic or oi~tpatient center. IJnplanned admission to hospital by patient seen in clinic less than 48 hours earlier. Unplanned readmission to clinic or outpatient center.
Unplanned readmission for the same pi+obleinwithin less than 48 or 72 hours. Failure to record vital signs at every visit.
Waiting time longer than 2 hours. Illfcctcd woulld 1-csultil1g fcutu it
p~uccllurt;.
Page 52 Nursing
Accurate evaluation of'patients. Compliaiice with requirements for documentation.
Early recognition of sytnptoms that may alter the patient's situation. Satisfaction of patienuphysician. Errors in medication. Cullrpl i a l ~ t c will1 PI VLL)LUIS
liw patie111 ~~laoagernent.
Patient inciderits. Nurses' interventions relevant to patient's condition.
Compliance with infection control procedures and safety measures. Punct~ialityin the administration of drugs. Other K v e n t ~ in NlrrqingiS~~ppnrt
Procedure or dierapy ca~~celed due to inadequate preparation of the patient. Appearance of bedsore or eschar. Nosocornial infection. Improper disposal of needles.
Improper preparation or administration of intravenous drugs. Nursing report incomplete. Illco~rcct t l n l ~ si cy ~t i u l ~ of physiciali'~ dir z ~ l i u l ~ s .
Insufficient nursillg staff to care for patient needs. Lack of documcntcd evaluation by a graduate nurse < 24 hours. Lack of equipment or equipment in poor conditioo.
Diagnostic procedure or rest performance without authorizatiou by physician. FXCPSS~VP d ~ l fnr ~ y ~p~rim~nlr~clilt
Failure of graduate nurse to notify physician of important changes in patier-it's condition.
Program~nedtreatment or procedure not pei'formed:
Vital signs ordered more than cvcry four timcs. Change of dressing. Laboratory test (for example, blood, urine). rluid i n t d k c / r > ~ ~ not i ~ x rccordcd. ~t
Daily weight. Ut~plannedremoval of at1 invasive tube. Use of restraint resulting in loss of circulation in a limb or other injury to paticnt.
Injury to a visitor. Nursing Services in the Emergency Room Cardiac vital signs taken at least every I5 minutes unless otherwise indicated.
Yhys~c~an s orders not checked.
Error in medication. Administrative nursing problern or event. Obstetrical Nursing
Delay in communicating complications ro the pl~ysician. Inadequate monitoring of the delivery room.
Inadequate monitoring of the patient.
Birth in waiting room outside Delivery Room. Operating Room
'rime elapsed between cases.
Co~npliance with irlfectiim control procedures and safety measures. Patient incidents. 'I'irne elapsed between scheduled hour for a surgical procedure and actual ttme of the ~ntei-uention.
Misplacen~el-tlof'the results of preoperative tests at the time of a surgical intervention.
Page 54 Appropriate ad~nirlistratio~l of drugs. Lomplrance with docuinentat~on requirements. Death in the operating room. Correlation between a single surgical team and irlfection of surgical incision.
Postoperative Recovery Room Compliance with criteria for patieilt discharge. Fat icnt illciclellh.
Compliance with documentation requirements. Compliance with infection control and safety procedures.
Physician satisfaction. Errors in medication. Apprnpriate evaluntinn n f patient<
Social Sewices Promptness in responding to requests for services.
Appropriate evaluation of patients. Patiendphysician satisfaction. Appropriateness of post-discharge arrangements. Cornplia~lce with documentation requirements. Mcasur cr11c11t of goals.
Complaints from family members. Co~nplaints froin referral sources. Delayed receipt of referrals.
Delays in patient visits. R e ferrsll~i~ladeq~rnte/i~nnece<~a y
Referrals lost.
Page 55 Other Indicators related to Social Work
Failure to recognize a psychiatric disorder. Inadequate plan for patient discharge. Lack of plan for paticnt discharge. Repeated abuse of spouse or child
Pharmacy Dispensing errors: transcription of prescription, interpretation of the prescription, dispensing (quantity and type of drug dispensed). N ~ i i n h n ~f rr l r i ~ g x that
~ P P A tn hp r e p r k n g p i l
( ~ P R S I I ~d P rS lig
ql~nlity nssul-mce tip to the time of use).
Written iliformatiot~provided to patient on drug therapy cotnpliance and risks associated with the diug. Existence of a drug therapy profilc and ubjcctivr: for its use with information provided about the existence of drug sui-veillancc.
Number of drugs in the Basic Table out of stock for 7 days (indicates availability of adequate supply to ensure therapy). Number of doses not administered to hospitalized patients and reason therefore (measures co~nplial~ce with drug therapy).
Medical prescript inn health care).
it1
stnck pcr p~tienf arlmittsrl ( p r n p h a q i 7 p ~c l n i g ~ d r n i n i ~ t r a t i cas u ~ 3 part of
Number o f prescriptiot~s/numberof prescriptions per patient (measures extent of poIyphan1lacy). Number of drugs included in the Basic Tablehumber of drugs in Basic Table used hy hospital (measures rational prescription practices). Use of nanproprietary name of drug in the prescription (indicates rational prescription practices).
Existence of a Colnmittee on Pharmacy and Treatment and availability of professionals to serve on it (indicates involvelnent of pllysician and nurse In the process ot drug stlpply and ratlonal use). Some exarnpIes of Drugs; Potential Indicators and Indicators of Results
Drug type
Adverse reaction Loss of blood Kenal def?cicncy Allergic reaction High costs
Anticoagulants Aminoglycos~des Penicillin Cephalosporin
Page 56 Laboratory
Protnptness in responding to requests. Test results doubtful. Adequate collection of specimens.
Results of Gram staining vs. final reports from culture. Compliance with infection control and safety procedures. Vcrlipuncturc pcrformcd r t n n ~ c c s s a r i l ~ .
Patient incidents.
Compliance with standards for preparation of specimens for special tcsts. Pro~nptness of reports. Waiting time for outpatients. Accuracy of reports on test results.
Specimens lost.
Patientlphysician satisfaction. Radiology Service Allergic/adverse reactions. Proportion of films damagedlrepeatedlrqiected. Procedure adequately explained to patient. Waiting timc for outpaticnts.
Protnptness in responding to requests. Promplncss of reports.
Films lost/misplaced. Con-ipliance with infection control and safety procedures. Importance of patient's return to repeal a procedure. Quality of X-rays taken in the operating room.
Page 57
Rcqucsts for versus tests performed. Compliance with documentation requirements.
Periodic control of technical parameters reIati11g to ccluipment.
Co~~trol of radiation dosage. C u i l l p c t c ~ ~of c t staff.
Patient incidents. Patient/physician satisfaction. Other Laboratory Indicators, Radiology, Hemutherapy Aspiration during upper gastrointestinal series. Failure to cornpIy with radiation safety requiretnents. Cardiac or respiratory arrest.
Reaction to contrast (requiring intervention). Units of blood destroyed. Emergency distribution of uncrossed blood.
Evidence of thrombosis followirlg a procedure. Excessive waiting time for Ilospitalized patients or outpatients. Extrnvnr;ution o f contrast.
Failure to identify potentially dangerous specimens. Improper collection of sample (tube, anticoagulant, etc.). Hematoma at ill-iection site requiring intervention. Improper IabeIiilg of specimen. Inadequate preparation of patient for procedure.
Specimen presented inappropriate for procedure requcstcd. Inaccurate interpl-ctation of the results of the tests or the procedure. Inadequate examination prior to X-ray.
Page 58
Inadequate preparation of the large intestine for fluor/radiology studies. Inordinate wartmg per~od for the result. Failure to comply with hospital policy 011 infectious diseases.
InsuGcicnt supply of reagents. Invalid patient results transmitted by laboratory. Failure to comply with first aid instructions. Myocardial infarr;t)r;cr cl~uvas~ulicl irc;~iclcuL duf i ~ a ~procedure g or w i ~ h i n 48 hours thereafter.
Irnpropcr ad~ninistration of radioisotopes. Film misfiled. Multiple examinations or vague history.
Failure to perfonn Iaboratory tests requested. Patient injury or accident. Failure to coinply with poIicy for patient treatmentlsupport. Patient punctured more than twice for a btood test.
Perforation during barium enema. Pneumothorax after invasive procedure.
Portable filrn defective. Headache after myelogrnm (requiring intervention). Itcpctition of n PI-occdu~r: bccausc of illadcquatc ~csults.
Action not taken on the basis of information reported.
Seizure within less than 24 hours after a procedure. Transfi~sion of a single unit of blood.
Failure to label tubes. Examination perfnrrned without authori7ation.
Failure to report information that would have an adverse effect on patient care.
Page 59
Incorrect examination perfonl~ed on a patient. It~correct study ordered.
X-ray results not found in the record. Nudear Medicine S e w i c e Compliance with ity ~ o n t r o proccdurcu. l
Promptness in responding to requests. Waiting time for outpatients. Patient incidcnts. Compliance with infection control and safety procedures. Qualitv of films to be used for diagnosis.
Examinations repeated. Cclnipltance with procedures for disposal ot expired ~sotopes.
Requests for versus rests performed.
Promptness of reports. Patientlphysician satislaction.
EIectroencephalography Service Promptness i n responding to requests.
Requests for versus tests performed.
Patient incidents.
Quality of electroencephalogram. Time required producing reports. Physician satisfaction with the services.
Hernodialysis Patient incidents.
Co~npliailce with protocols Tor patient management.
Page 60
Compliance with infection control and safety procedurcs. Compl~ance with documentatton requirements.
Patient/physician satisfaction. Respiratory Therapy Compliance with the protocols for patient rnanngemcnt. Patient incidents. Trcatmc~lts misscd.
Discrepancy between request and treatment given.
Promptness in responding to requests.
Quality of mauagetnent of critical procedures. Recognition of changes in paticnt's situation requiring change in therapy. Patient/physician $atisfactinn
Compliance with infection control and safety procedures.
Compliance with documenration requirements.
Complications during care. Waiting time for outpatients.
Patient refusal of treatment. Coronary Carc/Intensiue Care Unit l'aticnt inzidcnts.
Patient complaints. Physician cotnplaints.
Death rates. Rate of infections acquired in the unit. Medical errnrs
Successfui attempts at cardiopulmonary resuscitation.
External transfer of patients. IJndacutnented adtninistration of drugs.
Narcotics lost/rnisplaced. Special Care Units K ~ l t : v a ~ ~palizlll ~c t.vdludlivlls.
Patient incidents. Cornpiiance with infection control and safety procedures. Recognitiorl of sytnptoills that need to be reported to physician. Compliance with docunlentatiot~requirements. Apprnpriateneqs of emergency treaiincnt.
Comparison of regular requests with treatment administered. Coinpliance with protocols for patient ~t~anagemetlt. Treatment compficatians,
Patientlphysician satisfaction.
HOIHC Care Services Suitability of the services provided. Rcqucsts for vcrsus trcatmcnt providcd.
l1atient/fanily satisfaction. Promptness in respouding to requests for service. Patient incidents. Documentation of measurable treatment targets.
Readmissio~l to the hospital. Compliance with infection control and safety procedures.
Uocl~mentat~on of mstructlons given to patlent. Achievement of tl.eatment targets.
Page 62
Central Supply Ireins our of stock.
Interruptions in sterilization processes. Storage errors.
Physician complaints. Personnel complaints. Positivc culturcs from stcrilizcrs.
Accounting Office Accuracy in the billing process.
Number of charges from digerent sections. Failure to include delayed charges. Rate of re-billing.
Promptness in billing (time elapsed between patient discharge and billing). Yatlent complamts. Housekeeping
Time taken to clean patient rooms. Cleaning inspections.
Compliance with infection control and safety procedures. Ni~mbcr of timcs rcpcnt clcaning is rcqiiircd.
Time elapsed between request and performance of semices. Patient satisfaction. Compliance with state health standards. Employee accidents. Food and Nutrition Patients receiving inadequate diet.
Page 63
Proinptness in responding to requests.
Correct tray contents. Patient incidents. Amount of food wasted. Curr~plia~lct: wilt1 i11re~tiu11 cur~lrol ar~d ~al'c~ py ru~~du~cs.
Accuracy of nutritional evaluations. Patient satisfaction.
INDICATORS RY MEDICAL SPECIALTY Anesthesia Appmprinte ~~1er.tinn nf anecthecin
Docurl~eiltationof pre-and post-operative visits. Compliance with docun~enta~ion requirements.
Promptness of pre-and past-operative visits. ']'ranma induced by anesthesia.
Deaths during periopcrative pcriod.
Cornpliailce with infection control and safety procedures. Availability of cmcrgcncy ti-cat~ncnt.
Delays in surgical intervention caused by anesthesiologist.
Delays of more than "x" minutes before start of a surgical intervention. Clainls of professional incompetence. Cancellation of scheduled surgery. Oiher Specific Clinical Indicators Related to Anesthesia
Mo~tality within a given period of time following anesthesia. la~lure of patlent to recover horn general anesthesia within a given pcriod oftiinc. Illjury to the brain or spinal nicdulla within a given period of time following anesthesia.
Development of peripheral neurological deficiency within a given period of time following anestl~esia. Fulminant pulmonary edema within a given period of time fu1lowing anesthesia. Odor~tological injury during anesthesia. Unscheduled admission to the hospital within a given period of time following all outpatient procedure that required anesthesia. llnscheduled admission to the i~ltensive care unit within a given period of time following administration of anesthesia. Aspiration of gastric content$ with development of radiological results typical of aspiration p~eulnonitisrelated to anesthesia. Cardlac arrest innporally related to anesthesia. Clinically apparent acute myocardial infarction temporally related to anesthesia. Development of headache after dural perforation related to anesthesia.
Failure, poor operation, or disconnection of equipment. Failure of intubation. lnju~y to thc tmchcn.
Deficient local anesthesia requiring general anesthesia.
Failure to recover from general anesthesia within a given period of time. Mortality related to anesthesia. Ocular injury during anesthesia Onset of malignant hypet-thennia.
Prolonged labor secondary to epidural anesthesia. Yrolonged recovery (-/Z hours) atter general anesthesia.
Pulmonary aspiration. Reintubation in the Recovery Room. Repeated cannulatiotl. Repeated epidural anesthesia.
Page 65 liespiratoiy arrest related to anesthesia.
Risk Factors in Anesthetic Care Age
Sex Ilcight
Weight Oorlsiderations related to pregnancy, including time of gestation. Physical state, as deiinud in thr: guidelines of the Society ofAt~esthesiologists. Diagnosis prior to ancsthcsia.
Type of surgical procedure. Duration of surgical intervention. General Surgery
Repetition of any procedure during the same admission. Postoperative atelectasis. Injury from cautcrizalion. Postoperative throinbosis of a vena prohnda. Perforated appendix.
Return to thc operating mom due to injury occurring after surgery. Postoperative thromboemholis~n. Postoperative infection of the urinary tract.
Hematoma of the iucisioi~. Infection of the incision. Same-Day Surgery 1\11
cancellations.
Cancellation due to cmergency.
Page 66 Cancellation at requcst of patient. Caocellatlon due to Illness of staft. Cancellation due to illness of paticnt. Postoperative infection.
Unscheduled admission for the night. Others
Dis~ha~g agai1lsl c 11lc~Iica1 advice.
Reaction to drugs or transfusion. Incident in Operating Roorn. Postoperative compIications. Invasive diagnostic procedure repeated during the same admission. IJnplanned remnval nr repair nf n o r m a l hnrly part rlurint: surgery (~uithout consent).
Appropriate usc of hernoculture sensitivity in treatment of bactcrial sepsis. Serious errors in administratioil of dmgs resultirlg in death or significant morbidity. Dcvelopmetlt of complications associated with substandard methods of administration and ~no~litorirlg specific drugs.
Development of infections related to the use of intravascular devices in special care units.
Development of pneuinonia in patients treated in special care units, Wol.sening of bedsores (decubitus olccrs or eschars).
Development of infections in wounds afier clean or cIean-contaminated surgical procedures. Unscheduled admission to hospital after outpatient surgery or specitic procedures.
Unscheduled readmission to hospital shortly after a surgical intervention performed in the hospital, Unscheduled adtnissioil to Ilospital shnnly attcr a surgical intervention clr specific outpatient procedures performed outside the hospitai.
Prornplncss in perfaiming antibiotic prophvlaxis during specific surgical procedures. Amputation of "diabetic foot" {indicates poor follow-up at priinary care level).
Page 67
Irladeqilate utilization o t'antibiogratn in treatment of bacterial sepsis. Major errors in medicalion resulting in death or serious morbidity.
Dcath of patients with specific triedical conditions during hospitaiization or within 30 days after admission if the death occurs in the insliiution to which the patient was transfen-ed. Death of patients after specific surgical procedures during hospitalization or within 30 thirty Jays qfter admission if the denill occurs in t h e institution to tuhich t l ~ c patient was transferred.
Death of patients treated in the hospital for injuries occurring immediately prior to treatment when the death occurs within 30 days aficr the injury or during hospitalization required because of the injury.
Postoperative hematoma.
Injury following tracheal intu bation. Ora WRfaxiUofaciaYDcntal
Slow healing.
Skin loss. Unforeseen procedure for airway. Unscheduled discharge. Internal Medicine
ACLI~C myocardial infarct in patients under 50 years of age. Discharge against medical advice. In-hospital incident. Injury of organ or body part during invasive procedure.
Non-identifiable pain that did not exist on admission. Rc~lal failurexreatinine elevated above level at admission. It~vasivc diagnostic procedure repeated
during the same adniission.
Page 68 Pediatrics
Congenital problems of the newborn. Fever of unknown origin.
Newborn requiring oxygen for more than 24 hours after birth.
Newborn requiring parenteral antibiotics.
Neonatal seizi~re.
Neonatal sepsis. Ncwborn w it11 significarlt anomalies, Injury to newborn. Patient discharged withnnt written Phototherapy due to bilirubinemia. n i ~ i p t i e n inctr~~r.tinns t
Parenteral versus oral hydration. Readmission to hospital within 72 hours after discharge.
Suspected sexual molestation or abuse. Transfer to special care unit aftcr 24 hours. Untbreseen/anomalous diagnostic results after discharge of patient. Pucunio~iiac u ~ l s c q u c to ~ ~diarrheal t syllcl~ul~lt. (illcli~aks p v u ~Cvll~w-LIP a l prirnary carc level).
Clinical Indicators in Obstetrical Care
Induction of delivery based on clinical indications other than diabetes, pi.ematu1-e rupture or membranes, pregnancy-related hypertension, geslatioi~ to term, retarded intrauterine growth, cardiac disease, isoimmunization, dcath of the fetus, or chorioamnionitis with or without cesarean section. Primary cesarean section because of lack of progress, Successful or failed vaginal delivery after cesarean section. Delivery by repeated pIanned cesarean section of newborns weighing less disease of the hyalinc membrane. tl~all 2500
grams or wit11
Induced dclivciy of o newborn weighing less than 2500 grams or with disease of the hyaline membrane.
In-hospital treatment with aritibiotics starting 24 hours or more after vaginal delivery to tenn. Excessive loss of maternal blood, except because of ruptured or early placenta, as indicated by need fnr t r a n q f ~ ~ r i n n n f red cells, hematncrit Ievel nf less illan 22 or hernoglobill under 7, or a drop of inore than I I in licinatocrit or more than 3.5 in hemoglobin.
Maternal stay of morc than 5 days rollowing vaginal delivery or more than 7 days following cesarean section. Readmission of the mother within 14 days after delivery. Death of the mother 42 days afier delivery.
Death during in-hospital delivery of a fetus weighit~g 500 grams or more. Peririatal death of a newborn weighing 500 grams or more. Death of a newborn weighing between 750 to 999 grams in a hospital wit11 a neonatal intensive care
unit (NICU). Delivery oTa newborn weighing less than I800 grams in a hospital without at1 NICU. Transfer of a newborn to the NICU at another hospital. Full term newborn admitted to a n UCIN.
Diag~iosis of mass aspiration syndroinc. Diagnosis of trautnatis~n during birth.
Full-tcrm newborn with clinically apparent sudden convulsions prior to discharge from hospital.
Number of abortions in Emel-getlcy Koo~n(information on origin and residence of the patient for comparison with community family planning programs). Other Obstetrical Events Injury to the bladder during cesarean section.
Blood loss of more thai 1000 cc. Maternal cardiac/respiratorv arrest.
Cesarcan section procedure lasting longer than 30 mitiutes.
Page 70 Delivery assisted by a pcrsnn without obstetrical credentials. Dclivu~ y uT vcry prerrlarure rirwborn in insrirudorl wilhout a neonatal iiltenslve care unit.
Appearance of cl inically apparent seizures before discharge fom hospital. Diagnosis of meconium aspiration syndrome in the newborn ward. Diagnosis of specific types of birth trauma. Discharge against medical advice. Emergency hysterectomy after delivary.
Fetal monitor not available during delivery.
Injury caused by forceps. Fourth-degree laceration or extension of episiotomy. 1Iematocrit level lower than 28 percent.
Disease of the hyaline membrane after repeated elective cesarean section. Induction for reasons other than those specified, with and without subsequent cesarean section DeXh during in-hospital delivery except In the case of extreme premature birth or signiticant birth
defects. 1nj11ryto organ or body part.
Transfusion of red blood cells during or after delivc~yexcept in the case of abruptio placer-ita or placenta previa. Intrauterine fetal death (less than 20 weeksidelivery in waiting room outside Delivery Room). Maternal diabetes controlled with illsulin
Delivery with high forceps. Neonatal death. Neonatal death of high-risk newborns in institl~tions with intensive neonatal care unit. Neonatal sepsis. Newborn weighing less than 2000 grams. Newborn weighing less than 2500 grams.
Newborn weighing more than 4500 grams. Perinatal mortality except in the case of oxtreme premature delivery.
Hemorrhage following deliveiy. Infection following delivery. Prccipitation of dclivcry.
Preeclampsia. Premature delivety after repeated elective cesarean section.
Primary cesarean section (check whether the following criteria are included in the record:)
Placenta previa Deficient cephalopclvic ratio
Lack of progrcss Fetal compromise
Active herpes Rrccch prcscntation
Preeclainpsia Stillbirth h4ntcmal dcotll
Apgar score of 6 or lower at 5 minutcs 4
Proloi~ged maternal stay based on indications from vaginal delivery or cesarean section. Kate of vaginal or cesarean deliveries attempted or performed. Rcsuscilation of filI1-term ncwhum with intubation. Scalp pH of less than 7.2. Ma,jor birth trauma (fracture, birth palsy, ccphalohematuma).
APG.4R: Evaluatiun of Ihc physical statc of t h e n c w h o r ~aftcr ~ delivery, stating numerical values for: heartbeat, respiratory stress, muscle totle, irritability reflexes, and ski11 color.
Page 72 Stillbirth (at more than 20 weeks). StlIIblrth (at more than 24 weeks or 500 grams). Surgical cotnplications as indicated in postoperative report. Nan-premature newborn admitted to a neonatal intensive care unit. Non-premature newborn with seizure prior to discharge from hospital.
Unscheduled return to OperatindDel ivery Room. UIISL~IGJUICJ (~ar~sf iu e~ neonatal . intensive care unjt.
Complications involving incision
Urology Ad~nission due to scrotal pain within two weeks after vasectomy.
Hospitali7atiiln r111et r , i n f ~ r t i o n of the urinary cystoscopy.
tract
o r hemorrhage within bvo wccks a f t e ~
Reaction to endovenous coiltrast requiritig hospitalization. Postoperative renal hemorrhage. Postoperative scrotal heinato~na.
Unscbcduled return to Operating Room. Postoperative infection of thc urinary tract.
Orthopedics Gangrene. Defective union or failure of fracture to mend. Infection of wound. RehablILtatlon
Patient incidents, Compliance wit11 documerltation requircments.
ReIevance of patient evalu;ltions.
Page 73
Attaimnent of specific targets.
Mcahurefnent of treatment targets. Request for versus treatnlellts pcrrormed. Promptiless in responding to requests for services.
C u ~ r ~ p l i i iwill1 ~ i ~ ~~IIGLLIUII ~: CUII~I-ul and safety pruccdurcs. Patient/physician satisfaction. Waiting period for patients. Delayed visits. Relevance of the treatmcnt program. 0cc11pa tinnal Medicine
Any referral of patient for admission (unscheduled). Injury rcw lting from treatment (splint, plaster cast).
Unscheduled retun) to the clinic within 24 hours with the same complaint. Infection of wound.
Dermatology Treatment for skin cancer not complctcd within 6 weeks. Postopcrativc cornplicutions.
Reaction t o local anesthesia. Request for same-day coiisultation not attended to within 24 hours. Second-degree bum caused hy phototherapy.
Psychiatry F~rapp
In-hospital incident. Injury associated with use of restraints. Error in medication.
Page 74
Failure of staff to comply with hospital policy regarding means used o f restrain patients. 111di~atiu11 uTi)~ alwrrlpL . at suicide while patient is hospitalized.
Unexpected reaction to drugs. Unscheduled transfer to another I~nspitalfor intensive care.
Alcoholism Rchabilitn tiun Service Treatment failure. Treatment-related injury.