Step 1:

Obtaining leadership commitment To adopt quality management and implement a sustainable Prevention and Control of Infection (PCI) program providing excellent patient care requires effective leadership. The latter is a key to the success of the quality journey inside the organization. In particular, the integration of all quality management and improvement activities throughout the organization results in improved patient outcomes.

Step 2:

Conduct a ‘needs assessment’ To identify performance gaps from the assessment results, we help your managers prioritize the recommendations and develop work plans based on your organization's environment.

Step 3:

Building an infrastructure for a quality system  - Environment of care that provides patient, employee and visitor safety

• - Medical records
• - Procedure manuals
• - Scopes of care and service
•  - Utilization management system
• - Risk management system
• - Credentialing system for medical staff

Step 4:

Creating and empowering a structure to oversee the quality process Defining administrative structures and management processes institutionalizing the PI process establishing quality councils, department quality committees and PI teams

Step 5:

Training staff on the fundamentals of Accreditation process

• A: Getting ready for Hospital Accreditation

This Orientation course? Is designed for health care professionals who will lead the process of preparing the hospital for accreditation The Course is based on the content of the Joint Commission International Accreditation Standards for Hospitals that cover the following areas: Access to Care and Continuity of Care, Care of Patients, Patient and Family Rights, Patient and Family Education, Assessment of Patients, Governance, Leadership, and Direction and Management of Information, Facility Management and Safety, Prevention and Control of Infections and, Staff Qualifications and Education Participants will have the opportunity to demonstrate how each set of the standards will apply to their respective areas. Learning Objectives At the conclusion of this course, participants will be able to

 

1. 1. Guide the efficient and effective management of a health care organization.
2. 2. Guide the organization and delivery of patient care services, and efforts to improve the quality and efficiency of those services.  
3. 3. Review the important functions of a health care organization.  
4. 4. Become aware of those standards that all organizations must meet to be „JCI‟ accredited. 
5. 5. Review the compliance expectations of standards and the additional requirements found in associated intent statements.  
6. 6. Become aware of the relationship of the JCI standards for hospitals to "JCI‟ U.S. standards and other quality evaluation and award program standards and criteria.  
7.  7. Become aware of the accreditation policies and procedures and the accreditation process.  
8. 8. Become familiar with the terminology used in the accreditation process.



• B. Additional tailored courses can be developed to train staff on:

   
  1. 1. Introducing the concept of outcomes management  
  2. 2. Acquainting staff with evidence-based medicine as an approach to clinical improvement  
  3. 3. Explaining and reviewing standards with various units of the healthcare facility  
  4. 4. Providing specialized training -as needed- to improve performance

Notes:   1. The above mentioned courses can be modified to suit different types of healthcare organizations.   2. In case the organization is not planning to use "JCI" standards, QAHM can tailor the program according to the national standards the organization is intending to use.  

Step 6:

Providing support to the medical information system, Including medical records, to enable the facility to conduct the necessary quality reviews

Step 7:

Ongoing Monitoring QAHM assigns a team of consultants who will provide ongoing assistance, monitor progress, and help the leaders of the organization monitor quality and observe the impact on patient outcomes.

Step 8:

 Mock surveys Three accreditation survey experts, including a physician, nurse and an administrator, assess your organization's readiness for an actual accreditation survey. This kind of survey is usually conducted before the actual survey to assess the degree of readiness of the facility and make recommendations for implementation prior to the survey