Healthcare Organization Accreditation Standards

1
Healthcare Organization Accreditation Standards
For the 60th Anniversary Celebration of His
Majestys Accession to the Throne
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Part I Organization Management Overview
Measurement, Analysis, Knowledge Management
Part IV Results
Strategic Management
Human Resource Focus
Patient Care Results Patient Focused
Results Financial Results Human Resource
Results Process Effectiveness Results Leadership
Results Health Promotion Results
Leadership
Results
Focus on Patients / Customer
Process Management
Part II Key Hospital Systems
Risk, Safety, Quality Professional
Governance Environment of Care Infection
Control Medical Record System Medication
Management Diagnostic Investigation Disease
Hazard Surveillance Working with
Community Patient Care Processes
Part III Patient Care Processes
Access Entry Patient Assessment Planning Patient
Care Delivery Education Empowerment Continuity
of Care
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I 1.1 Senior Leadership
Senior leaders guide the organization. Senior
leaders communicate with staff and encourage good
performance, ensure quality and safety of care.
b. Communication and Organization Focus
a. Vision and Values
1
Mission, vision, values set, deploy, commit
Communication Empowerment Motivation
1
Focus on action PI, org obj, vision
Environment legal and ethical behavior
2
2
Review Performance measures
Environment for performance improvement,
accomplishment of mission org obj, innovation,
agility, learning, working relationships,
cooperation and integration of services
Practice
3
Strategic Objectives
Good performance, ensure quality safety,
patient focus
Culture of patient safety
4
4
I 1.2 Governance and Social Responsibility
The organization demonstrates its good governance
and its responsibilities to the public, ensures
ethical behavior, and contributes to the health
of key communities.
b. Legal and Ethical Behavior
a. Organizational Governance
Governance system management, fiscal,
transparency, audits, interests
1
Risk adverse impact public concern
Processes Measures Goals
Evaluate performance of leaders
Improve leadership effectiveness
Legal requirement
1
2
Monitor
2
c. Support of Communities and Community Health
Promotes Ethical Behavior
Responds to Breaches
Identifies key communities areas for support
Organization that give value to society
supports and strengthens communities
support community health
5
I 2.1 Strategy Development
The organization establishes its strategy and
strategic objectives to address its challenges
and strengthen its performance.
2.1 Strategy Development
b. Strategic Objectives
Strategic planning process
1
Strategic objectives timetable
1
Participation, key steps planning time
horizon, strategic challenges and
advantages, potential blind spots
Address organizations challenges
2
Address key organizations strategic challenges
and advantages, Respond to the health situation
and needs, Contribute to improvement of the
health outcomes
Data analysis
2
Health problems health care needs SWOT Other
key factors - Safety / error - Collaboration,
competition - Technology change - Health care
economic change - Financial, societal ethical
risk Ability to execute
Health promotion objective
3
Health outcome of patients, families,
communities, staff, Environment conducive to
health
Strong sustainable organization
Strategy Deployment
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I 2.2 Strategy Deployment
The organization converts its strategic
objectives into action and tracks progress to
ensure goal achievement.
Strategic objectives
a. Action Plan Development and Deployment
HR plan
4
Strong sustainable organization
1
Action Plan
Deploy
Modify
3
Resources
Goal achievement
2
Track progress
5
KPI
Reinforce org alignment
covers all key areas and stakeholders
b. Performance Projection Comparison
Performance projections
Compare
Address gap
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I 3.1 Patient / Customer Knowledge
The organization learns its key patient /
customer needs and expectations to ensure the
relevance of its services.
a. Patient / Customer Knowledge
Identify patients / customers, groups, market
segments
Determine groups segments to pursue
1
Use for planning improvement
Requirement expectation Listen learn with
varied methods
2
Service relevant with customer needs
Use to Become more customer- focused, better
satisfy customer needs, identify opportunities
for innovation
3
Customer voice feedback
4
Listening learning methods Keep current with
healthcare service
8
I 3.2 Customer Relationship and Satisfaction
The organization builds relationships with
patients / customers to promote trust,
satisfaction, and cooperation. The organization
determines and uses patient / customer
satisfaction information for improvement.
a. Patient / Customer Relationship Building
1
Build relationships with patients / customers
Key access mechanisms seek information, obtain
service, and make complaints
2
3
Manage complaints
Aggregate analyze
Keep current
4
b. Patient / Customer Satisfaction Determination
Determine satisfation
1
Response to neeeds Trust Satisfaction collboration
Performance Improvement
Actionable feedback
Prompt follow up
2
Keeps approaches current
3
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I 3.3 Patients Rights
The organization recognizes and protects the
rights of patients.
b. Patients Right Protection Process
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a. Patients Charter
Organization Staff awareness, prompt response
Basic right in the Constitution Impartial Be
informed Prompt care for emergency Know name of
provider Second opinion Confidentiality Research
participation Guardian
Terminally ill patients Right and dignity legal
requirements belief and culture
1
1
Patient are informed Right responsibility
2
Vulnerable children, disabled individuals, the
elderly
Protection
2
All patient care activities Assault Privacy,
dignity, values Similar care for similar problems
3
4
Seclusion or restraints
5
3
6
Patients right dignity is respected
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I 4.1 Measurement, Analysis and Improvement of
Organizational Performance
The organization measures, analyzes, aligns,
reviews, and improve its performance through the
use of data and information at all levels and in
all parts of the organization.
b. Performance Analysis, Review and Improvement
a. Performance Measurement
data / information / KPI Service, customer,
financial, operation
Analysis review Trend, projection, comparison,
cause effect
1
Select, collects, Aligns, and integrates
Track Daily operation, Overall performance, progre
ss
1
Assess Success, progress, respond to change
Support decision- making innovation
Comparative data Select use
Priority for improvement innovation
2
2
Deploy throughout the organization
Keep performance measurement system current
sensitive to change
Incorporates into the systematic evaluation and
improvement of key processes
3
3
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I 4.2 Management of Information, Information
Technology, and Knowledge Management
The organization ensures the quality and
availability of needed data, information,
software and hardware for staff and patients /
customers. The organizational builds and manages
its knowledge assets to improve organizational
efficiency and effectiveness.
a. Management of Information Resources
c. Data, Information, Knowledge quality
Staff, management, patients / customers,
external agencies
Need
1
Confidentiality
2
Available
Design
Manage
Accuracy Reliability Timeliness Security
Hardware Software Reliable, secure,
user-friendly
Access
2
1
Patient care Management Clinical
audit Performance improve Education research
Facilitate
Available in emergency
3
b. Knowledge Management
Keep current Data information
availability Software hardware
Staff knowledge Patients / customers external
agencies Sharing good / best practices Use in
strategic planning Scientific evidences
4
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I 5.1 Staff Engagement
The organization engages, compensates, and
motivates its staff to achieve organizational and
personal success. Staff and leaders are
developed to achieve good performance.
Multiple Req.
c. Assessment
1
a. Staff Enrichment
Determines key factors
2
2
3
Staff performance management system compensation
, reward, recognition, and incentive
Foster organizational culture cooperation,
communication, and skill sharing communication
with supervisors and managers individual goal
setting, empowerment innovation benefit from
the diverse ideas
Assess Improve
1
Engagement Satisfaction
Org personal success
reinforcement of new knowledge and skills on
the job
Knowledge from departing workers
Development opportunities approaches
Good performance
Knowledge, skill, capability
4
Flexible Innovative Knowledge skill
sharing Good communication information flow
Alignment with org obj Patient focus
Career progression Succession planning
Core Competency Strategic challenge Action
plan Performance improvement Technology Innovation
Ethic
Balance org staff Needs from
staff Needs from management Professional
requirement Quality safety Health
promotion Learning knowledge
asset
Leadership attributes Develop of org
knowledge
3
Evaluate effectiveness
b. Staff and Leader Development
2
1
Leader
Staff
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I 5.2 Staff Environment
The organization manages staff capability and
capacity to accomplish the work of the
organization. The organization maintains a work
environment and a staff support climate that
contribute to the health, safety and security.
a. Staff capability and capacity
Assesses Needs Identify job responsibility Work
assignment
1
c. Staff Health
Recruited, hired, placed, and retain new
staff Evaluate credentials
2
Self action on their health
1
capitalize on the area of greatest expertise
reinforce patient focus meet performance
expectations agility
2
Modeling behavior
Manage organize staff
3
3
Occupational risk
Prepare workforce for changing needs Ensure
continuity
4
TB, HBV, HIV, Sharp Inj, Lab Chemicals, Anesthetic
Gas, Chemotherapeutic Agent
Pre-employment health examination
4
Organization Success
b. Workforce Climate
5
Periodic medical examination
Workplace health, safety, security
1
6
Immunization
Healthy safety
Care of ill or injured staff, exposure to
infectious diseas
Support staff Policies, services, benefits
7
2
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I 6.1 Work Systems Design
The organization determines its area of greatest
expertise and designs its work systems and key
processes to deliver value to patients / other
customers, prepare for potential emergencies, and
achieve organizational success.
b. Work Process Design
a. Area of Greatest Expertise
Determine areas of greatest expertise
Determines key work processes Health care,
business, support processes
1
1
Design and innovate overall work systems
2
Deliver value to customers, organizational
success
Professionals, patients, customers suppliers,
partners, collaborators
2
Key work process requirements
c. Emergency Readiness
3
Patient safety requirement, scientific
evidence, professional standards, new
technology, organizational knowledge, improved
outcomes, efficiency and effectiveness
Design innovate work processes
Preparedness for disasters or emergencies
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I 6.2 Work Process Management and Improvement
The organization implements, manages, and
improves its key work processes to deliver value
to patients / other customers and achieve
organizational success.
Deliver value to customers, organizational
success
I - 6.1 Work Systems Design
Better performance reduce variability, improve
services outcomes, keep the processes current
a. Work Process Management
2
1
Patient expectation preference
Implements the designed work processes
3
Manage / control
Improve work process
Minimize overall inspection cost, prevent rework
errors
Share to drive learning innovation
Patients, customer, supplier, partner,
collaborator input
KPI, in-process measures
b. Work Process Improvement
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II 1.1 Quality Improvement Overview
There is a concerted and coordinated effort for
quality program at all levels.
Evaluation techniques
1
d. Self-Assessment
a. Leadership Support
Comparison
2
4
Encourage quality culture
3
Self-assessment methods share and learn, group
discussion, writing a port-folio or
self-assessment, clinical tracer, internal
survey or internal audit, presentation for peer
assist, after action review, indicator
monitoring
2
Ensure quality safety of care
1
Policies, goals, priority, expectation
RM/QA/PS/CQI
3
2
Strategic Plan
Quality Structure
Communication problem solving
Team in daily operation Quality
improvement team Team with oversight
function
4
c. Team Work
3
1
Definition of quality
Support monitor
1
2
3
b. Integration and Coordination
4
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II 1.2 Risk, Safety, and Quality Management
System
There is an effective and coordinated hospital
risk, safety, and quality management system,
including integrated approach for patient care
quality improvement.
a. Risk and Safety Management System
1
Coordination between various RM
programs, integration of risk MIS
Evaluate effectiveness
Solutions
Improve
6
5
3
2
Prevention strategy, communicate, make awareness
4
Incident report analysis
Risk identification prioritization
Root cause analysis
1
Improve patient care in targeted clinical
population
Patient care review
Identify population Monitor KPI Improve
2
b. Patient Care Quality
3
4
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II 2.1 Nursing Governance
There is an organized nursing administration
responsible for high quality nursing service to
fulfill the mission of the organization.
Collaboration with organization
committee medication use, infection control,
health promotion, quality and safety
Nursing leadership
1
a. Nursing Administration
4
Ensure adequate and competent nursing staff
2
b. Nursing Practice
3
Patients right, ethic
Key function professional standard
ethic supervision monitor quality
safety nursing process clinical decision
making staff-in-training knowledge
management research
2
Scientific evidences nursing standards
Outcome of nursing care patient safety, relief
from suffering, being informed and learning,
self-care, empowerment and satisfaction
3
1
Use nursing process
Patients health conditions
4
Nursing record
5
Relevant, continuum, enable
Improve
Risk/Safety/Quality Management
6
5
Evaluate
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II 2.2 Medical Staff Governance
There is an organized medical staff organization,
responsible for supporting and oversight of
standard and ethical practice of medical
professional to fulfill the mission of the
organization.
Ensure the quality of medical services scientific
evidence professional standards, continuous
monitoring and improvement, respect to the
patients rights, professional ethics
3
Give advice, suggestion, and plan with the
management
2
Communication problem solving
4
High quality medical health service
Key functions credentialing, clinical
privileges, CME knowledge sharing, professional
standards and ethics, quality review and
improvement, medical record quality, clinical
decision making use of technology, patient
care policy, part-time physician in training
5
Organized medical staff at the hospital level
1
Collaboration with organization
committee medication use, infection control,
health promotion, quality and safety
Agreements and guidelines medical practice,
ethical / legal / social issues, quality and
safety, competency development, documentation
6
7
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II 3.1 Physical Environment and Safety
The organizations physical environment
contributes to the safety and well-being of
patients, staff, and visitors. The organization
ensures that all occupants are safe from fire,
hazardous material and waste, or other
emergencies in the facilities.
a. Safety and Security
c. Emergency Management
Facility requirements
1
1
Hazard vulnerability analysis
Facility management, safety security program
2
Inspection to identify risk unsafe practice
Plan -gt Implement
2
3
3
Train
Environment safety management
Training education
5
4
d. Fire Safety
Fire safety plan
1
b. Hazardous material and waste
Safety well-being of patients staff
Education / fire drill
2
Safe processes selecting, handling, storing,
transporting, using, and disposing
Fire protection fire safety system equipment
3
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II 3.2 Equipment and Utility System
The organization ensures that essential
equipment is available for use and functions
properly and ensures continuity of essential
utility services.
b. Utility system
a. Equipment
Utility system management (effective, safe,
reliable) Inventory list, mapping, inspection,
test maintenance, emergency procedures,
cooling tower and water system ventilation
system
1
Equipment management (effective, safe,
reliable) Select / acquire, inventory list,
inspection, test maintenance, education,
emergency procedures
1
Availability of essential equipment
2
Emergency electrical power source maintenance,
testing, and inspection
2
Data monitoring -gt upgrade or replace
3
Data monitoring -gt upgrade or replace
3
Available, safe, reliable system
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II 3.3 Environment for Health Promotion and
Environment Protection
The organization demonstrates its commitment for
the hospital to be a healthy and safe workplace,
to support health promotion activities, and to
protect the environment.
b. Environment Protection
a. Health Promotion
Environment that support social and psychological
health
Efficient water treatment system Capacity, staff,
testing, quality
1
1
Facilities and environment for learning and skill
development
2
Decrease the volume of waste Reuse, reduction,
recycling, avoid
2
3
Access to healthy food product
Use of material and equipment not harmful to
health
4
Garbage disposal system Containers, segregation /
transportation / storage, training, disposal,
audit
3
Healthy and safe workplace, support health
promotion, protect the environment
Protect improve the environment Partnership
with the community, assess and receive feed back
4
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II 4 Infection Prevention and Control
4.3 The organization performs appropriate methods
of surveillance and monitoring to detect and
control infections, and manage nosocomial
outbreak situations.
Minimum infection
4.2 The organization ensures appropriate
practices to prevent nosocomial infection.
4.1 The organizations infection prevention and
control program is appropriately designed,
adequately supported, and well coordinated.
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II 4.1 Infection Prevention and Control Program
The organizations infection prevention and
control program is appropriately designed,
adequately supported, and well coordinated.
b. Management and Resources
a. Program Design
1
IC committee oversight, policy recommendation,
planning, coordination, monitoring evaluation
Scientific knowledge, accepted practice, legal
requirements
3
ICN
2
All areas
4
Minimum infection
Infection prevention control
1
Goals, objectives, strategies, measures
Context Size, service, patients
Integrate with quality safety program
Adequate resources
3
5
Information system
4
2
Coordination
6
Important infections Focus of prevention control
Education
5
Empower families/communities
6
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II 4.2 Infection Prevention
The organization ensures appropriate practices to
prevent nosocomial infection.
Monitor evaluate
Standard Precaution Clean/disinfect/sterilize Infe
ctious waste Hand hygiene
Strategies to reduce infection risk
1
Program design
Building structure, ventilation, hand washing
facilities
Environment control
2
Minimum infection
OR, LR, ICU, laundry, CSSD, kitchen, PT,
postmortem
Working area with unique concerns
Management
3
Minimize risk of certain infection
SSI, VAP, CAUTI, IV infection, BSI, sepsis
4
Blood-borne infected, low immune, resistant
bacteria, emerging infection
Care of complex case
5
Resources
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II 4.3 Surveillance, Monitoring, and Outbreak
Control
The organization performs appropriate methods of
surveillance and monitoring to detect and control
infections, and manage nosocomial outbreak
situations.
Program design, management, resources
Infection prevention
Use monitored information Plan, detect epidemics,
education, evaluate improve program, response
to individual patient problems
a. Surveillance and Monitoring
4
Minimum infection
Active ongoing prospective surveillance
1
Monitor of other serious NI
2
b. Outbreak Control
Monitor antibiotic utilization and susceptibility
3
1
Identify outbreak
Detect and respond to new and resistant
microorganism
5
2
Investigate control
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II 5.1 Record Management System
The organization establishes an efficient medical
record management system to serve the needs of
all parties.
a. Planning and Design
b. Security and Confidentiality
Protection From loss, physical destruction,
tampering and unauthorized access or use
Determine purpose of medical record Communication,
continuity of care, quality assessment
1
1
Policies on security confidentiality
2
2
Need assessment providers, management,
individuals, external agencies
Education
3
System design
4
Patient to access data
3
Policies guidelines Record, correct, receive
order, code, store, access, destroy
Implement
4
Quality patient care information
5
Code index
Evaluate improve
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II 5.2 Patient Medical Record
Every patient has a sufficiently detailed medical
record for the purpose of communication,
continuity of care, education, research,
evaluation, and medico-legal requirement.
1
2
Sufficient information to -identify the
patient -support the diagnosis -justify
the treatment -know the course and results
of treatment -promote continuity of care
-give correct coding -use for medico-legal
purpose -assess quality of patient care
Review medical record Completeness, accuracy, and
timely completion
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II 6.1 Medication Planning, Management, and
Storage
The organization ensures safety, appropriateness
and effectiveness of medication management system
and availability of high quality medication.
a. Planning and Management
b. Medication Storage
3
Procurement Formulary drugs, drug shortage,
urgently need drug
1
2
Hospital formulary Limit choice, safety measures
for new drugs non-formulary drugs
Proper safe store Adequate, quality and
stability, ready-to-use
4
4
1
Lower the risks Identify, design processes
Multi- disciplinary team Direction support
efficient system
Essential emergency drug Control, replace
Returned drug
2
Safe drug dispense when pharmacy is closed
3
ME/ADE prevention
5
Appropriate response to ME/ADE
High quality drug available
Drug use
Training
6
Evaluate improve
7
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II 6.2 Medication Use
The organization ensures safety, accuracy,
appropriateness and effectiveness in the
prescribing and administration of the medication.
a. Ordering and Transcribing
b. Preparing, Dispensing and Administering
10
5
Drug Reconcile Admit, transfer, discharge
????????????????
4
Patient information
1
Provide to patient care unit
1
Review order Appropriateness, safety
Order Clear, appropriate
Drug information
Verify
2
7
2
Prepare
Administer
4
9
Transcribe / communicate Accurate, standardized
ME/ADE prevention policies
Patients/families Active partners, education
3
Label
3
???????? ??????
8
Provide to patient
Review
5
7
Physical environment Clean, adequate space
lighting, no distraction
Adverse drug reaction / medication error
Notify
6
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II 7.1 Diagnostic Investigation and Related
Services General Requirements
The diagnostic investigation services provide
accurate and reliable diagnostic information with
minimum hazards to patient and staff.
a. Planning, Resources, and Management
b. Service Provision
2
Competent staff
Space environment
Direct examination to patient Assess, prepare,
inform
3
1
1
Equipment Maintenance calibration
4
Plan
Referral laboratories Evaluate, select, and
monitor
Interpret
5
Equipment, supplies, reagents Select, procure,
inventory
Document
2
6
Communicate
Communication with users
7
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II 7.2 a. Medical Laboratory / Clinical
Pathology
The examination processes and quality management
system of the medical laboratory ensure reliable
and accurate results.
2
Quality Management System Problem / OFI
identification, error records incident reports,
KPI monitoring, corrective / preventive actions,
pre-analytic and post-analytic variables
monitoring, document controls, patient safety
goals, appraisal of the QM program effectiveness
1
Proficiency Test
verify
Examination Appropriate standard test methods
that are validated
Input Reagent, equipment, analytical instruments
5
Reliable accurate results
Planning, resources, management
Sample after exam Store for repeat exam, safely
dispose
7
4
Specimen Collect, handling, identify, packaging,
label, preserve, requisition, transport, storage,
evaluate
6
Report Confidentiality, critical level, retrieval
of reported result copies
Quality control
3
33
II 7.2 b. Blood Bank
The organization complies with the Standard of
Blood Transfusion and Blood Banking issued by the
National Blood Service, Thai Red Cross Society.
General policies Quality system, safety
Donor selection Qualification, risk assessment,
provide information
Preparation of blood component Whole blood, pack
red cell, plasma, platelet
Blood transfusion
Blood collection Prevent contamination, Collect
blood, quantity, temperature, donor care
Blood testing ABO, Rh, other Ab, disease markers
Transfusion reaction monitoring
Response
34
II 7.2 c. Radiology and Other Medical Imaging
Services
The radiology and other medical imaging services
provide quality pictures, reliable and accurate
results, with minimal hazards to patient and
staff.
6
Quality management system QC in equipment
preventive maintenance, patient physician
needs, risk prevention and monitoring, annual
review of the quality management program
Facility equipment Comply with standard, be
examined approved
Radiation safety measures Monitor exposure,
hazard signs, disposal of radiation material
waste
2
1
Planning, resources, management
4
Indication communication Professional
guidelines scientific evidences
Imaging study Position, exposure, label
3
Reliable accurate results
Interpretation, consultation, review
Perform by qualified staff
5
6
Quality management system QC in radiograph
technology, review incident OFI, staff
performance evaluation
35
b. Surveillance Data Collection and Analysis
1
3
4
Analyze compare
Interpret with epidemiology
Surveillance CD, NCD, other health hazards
Collect store
Lab
5
2
Clinician
Monitor situations trends
6
Quality of data Updated, complete, accurate,
timely, comparable
Plan prevention control
Project trend
7
c. Response to epidemics of disease and health
hazard
Set up SRRT
1
Resources authority
6
Communication channel 24 hr
4
Response plan, ensure preparedness
2
7
Investigate
Case investigation
5
Preventive control measures
3
8
Warning message
a. Management and Resources
Disease health hazard
d. Information Dissemination and Alert
Policy plan
1/2
Report Current situations, to authorities,
relevant agencies mass media
Overseeing system Policy measures, plan
co-ordinate, monitor, evaluate and improve
3
Personnel / resources
4/5
Education
6
36
II 8. Disease and Health Hazard Surveillance
The organization ensures the efficient
surveillance for detecting abnormal occurrence of
diseases and health hazards, and the prompt
investigation to control further spreading.
37
II 9.1 Health Promotion for the Community
The healthcare team, in collaboration with the
communities, provides health promotion program to
meet the need of the communities it serves.
Define the communities
1
2
Plan and design health promotion services with
the communities Healthy, risky, illed
Assess needs capabilities
Collect data
Identify key target groups
Health care Support Facilitate learning Health
skill development Guide public policy Networking
3
Collaborate with other providers and organizations
Carry out health promotion program
Evaluate improve
4
38
II 9.2 Community Empowerment
The healthcare team works with the communities to
support the development of the communities
capacities to improve its own health and
well-being.
Collaboration with the communities
Participation of the communities Network
partnership
Promote the ability of population groups to solve
their key problems
Promote individual behavior and life skills
1
3
4
Advocating healthy public policy Binding
engagement, information exchange
Promote physical environment conducive for
health Physical chemical contamination, natural
resources, recreation
2
Promote social support services and social
climate conducive for health
5
6
Healthy community, well-being of community
39
PART III PATIENT CARE PROCESSES
III - 1 Access Entry
III - 4 Patient Care Delivery
III - 6 Continuity of Care
III - 3.1 Planning of Care
III - 2 Patient Assessment
III - 5 Education Empowerment
III - 3.2 Discharge Planning
40
III 1. Access Entry
The healthcare team ensures access to essential
services with minimal barrier, ensures that an
entry process is timely, meets patient problems /
needs, is coordinated and supported by suitable
and effective systems and environment.
Refer Initial care, explain, find services
Priority for emergency need
Access, reduce barrier Physical, language,
cultural
2
3
4
Entry to intensive services Established criteria
Determine capability
Initial assessment
Prompt response
1
Entry to general services
Inform Conditions, proposed care, expected
results cost
Education empowerment
Timely, appropriate, effective entry
5
Consent
41
III 2. Patient Assessment
All patients have their healthcare needs and
problems identified accurately in a comprehensive
and appropriate manner.
Implement
Collaborate coordinate Analyze, Integrate
Reassess
a. Patients Assessment
1
5
3
Initial assessment History, PE, perception,
psychological, social, and economic factors
2
Identify urgent or important care needs
Patient Age, health problems, urgent, education,
service
Care plan
1
Clinical practice guidelines
Record
4
Diagnosis
b. Diagnostic Investigation
c. Diagnosis
Explain
Safe environment
6
Investigation
1
Review
Evaluate reliability
Resources Technology, staff, equipment
2
4
Manage with abnormal results
Communicate
3
42
III 3.1 Planning of Care
The healthcare team ensures a coordinated patient
care plan with goals developed in response to
health problems / needs of the patient.
Patient need assessment
2
Integration coordination professionals,
departments, services
5
Goals, Service to be provided
1
Patient care plan Holistic, appropriate
Implement
Evidence or guidelines
3
Coordinate communicate
6
Monitor
Patients / families participation
4
Revise
7
Inform patients / families
43
III 3.2 Discharge Planning
Discharge planning process enables self care of
patients and ensures that patients ongoing needs
after discharge are met.
1
2
Involvement Physicians, nurses, other
professionals, patients families
Determine guidelines, indication, and key target
conditions
Assess need for D/C plan
3
Patient / families are able and have confident
for self care
Assess need after discharge
Discharge plan
Implement Integrate with patient care plan, use
empowerment concept
Update
4
5
6
Evaluate
Improve
44
III - 4.1 General Care Delivery
The healthcare team ensures that care is
delivered in a timely, safe, and appropriate
manner according to professional standards.
Keep patients safe from accidents, injuries, or
infection
Appropriate delineation of clinical responsibility
3
1
Deal with complications, crisis, emergency safely
and appropriately
Timely, safe, appropriate care, complied with
professional standards
Current accepted practice
4
Holistic care
5
Environment conducive to quality care
2
Exchange information and coordinate to ensure
continuity of care
6
Monitor evaluate
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III - 4.2 Care of High-Risk Patients and
Provision of High-Risk Services
The healthcare team ensures that care of
high-risk patients and high-risk services is
delivered in a timely, safe, and appropriate
manner according to professional standards.
Identify high-risk patients services
Train
Practice
Policies procedures
2
1
Timely, safe, appropriate care for high-risk
patients
Response
High-risk procedures Facility, equipment,
assistance staff
Monitor
3
Change of care plan
4
Rapid response to clinical instability or
deterioration Assessment, stabilization,
communication, education, transfer
5
6
monitor analyze trend of complication or
adverse event
Improve care process
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III - 5. Information and Empowerment for Patients
/ Families
The healthcare team provides patients and
families with information on their health
condition and planned activities to empower them,
encourages them to carry out their
responsibilities, and to facilitate integration
of health promotion in all patient pathways.
2
1
Evaluate Perception, understanding, ability to
implement
Provide information, facilitates learning
Plan learning activities
Assess
Patients / families be able to take care their
health
Emotional support counseling
problem need emotion psychology capability re
adiness
3
Self-management strategies
Follow-up
4
5
Skill training
6
Evaluate
Improve
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III - 6 Continuity of Care
The healthcare team collaborates and co-ordinates
for effective follow-up and continuity of care.
3
Appointment
Communicate patient information
1
Assistant consultation
Patients receive continuity of care response to
needs
2
Collaborate coordinate
Follow-up care
Integrate health promotion
4
Review medical record
5
Improve, plan
Monitor
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PART IV ORGANIZATION PERFORMANCE RESULTS
The organization demonstrates good performance
and improvement in key area, i.e. health care
results, patient and other customer-focused
results, financial results, human resource
results, process effectiveness results,
leadership results, and health promotion results.
Outcome, process, safety, functional status
IV - 1 Patient Care Results
IV - 4 Human Resource Results
Engagement, satisfaction, development,
capability, staff level, workforce climate
IV - 6 Leadership Results
IV - 2 Patient / Customer- Focused Results
IV - 3 Financial Results
Strategy accomplishment, ethic, governance,
fiscal accountability, legal compliance,
community support
Satisfaction, dissatisfaction, perceived value,
retention, positive referral, building
relationship
IV - 5 Process Effectiveness Results
work systems, preparedness for disasters or
emergencies, key work processes
IV - 7 Health Promotion Results
Staff, client, community