International Patient Safety Goals110.164.68.234/tqm/images/stories/files/Presentation.pdfX Policy...

STANDARD MEASURABLE ELEMENT(S) ENGLISH TYPE OF DOCUMENTATION Responder

IPSG.1 5. Policies and procedures support consistent practice in all situations and locations. (See ME 1 through ME 4 for policy inclusions.) X Policy and Procedure TQM/QST

IPSG.24. Policies and procedures support consistent practice in verifying the accuracy of verbal and telephone communications. (See ME 1 through ME 3 for policy inclusions.)

X Policy and Procedure TQM/QST

IPSG.31. Policies and or procedures are developed to address the identification, location, labeling, and storage of high-alert medications.

X Policy and Procedure คกก.ระบบยา/QST

IPSG.4

4. Policies and procedures are developed that will support uniform processes to ensure the correct site, correct procedure, and correct patient, including medical and dental procedures done in settings other than the operating theatre.

X Policy and Procedure MSO/QST

IPSG.5 3. Policies and or procedures are developed that support continued reduction of health care–associated infections. X Policy and Procedure ICI/QST

IPSG.6 4. Policies and or procedures support continued reduction of risk of patient harm resulting from falls in the organization. X Policy and Procedure NSO/QST

International Patient Safety Goals

STANDARD MEASURABLE ELEMENT(S) ENGLISHTYPE OF

DOCUMENTATION

Responder

ACC.1 5. Policies identify which screening and diagnostic tests are standard before admission. Policy MSO/QST

ACC.1.1

6. Written policies and procedures support the processes for admitting inpatients and registering outpatients. Includes: • Outpatient registration • Admitting inpatients • Admitting emergency patients • Holding patients for observation

Policy and Procedure PST OPD/PST ER/QST

ACC. 1.1.34. Written policies and or procedures support consistent practice [on the process for managing inpatients and outpatients when there is a delay in treatment].

Policy and Procedure MSO/QST

ACC.1.41. The organization has established entry and or transfer criteria for its intensive and specialized services or units, including research and other programs to meet

X Criteria MSO/QST

ACC.2 2. Established criteria or policies determine the appropriateness of transfers within the organization. Criteria or Policies MSO/QST

ACC.2.1 5. The transfer of responsibility from individual to individual of the patient’s care is described in organization policy. Policy MSO/QST

ACC.35. Organization policy guides the process for patients being permitted to leave the organization during the planned course of treatment on an approved pass for a defined period of time.

Policy MSO/QST

ACC.3.2 6. Policy and procedure define when the discharge summary must be completed and in the record. Policy and Procedure คกก.เวชระเบียน/QST

ACC.3.3 5. Clinical records contain the completed summary list per organization policy. Policy MSO /คกก.เวชระเบียน/

QST

ACC.4.4 2. The records of transferred patients contain documentation or other notes as required by the policy of the transferring organization. Policy and Procedure MSO/QST

Access to Care and Continuity of Care


DOCUMENTATION

Responder

PFR.1 5. Policies and procedures guide and support patient and family rights in the organization.

Policy and Procedure MSO/Ethics/QST

PFR.2

1. Policies and procedures are developed to support and to promote patient and family participation in care processes. 2. Policies and procedures address the patient’s right to seek a second opinion without fear of compromise to their care within or outside the organization


PFR.2.3 5. Policies and procedures support consistent practice [on resuscitative practices].


PFR.3 5. Policies and procedures support consistent practice [in the complaint process].

Policy and Procedure ฝ่ายบริหาร/QST

PFR.6 1. The organization has a clearly defined informed consent process described in policies and procedures X Policy and

Procedure MSO/Ethics/QST

PFR.6.4.1 1. The organization has listed those procedures and treatments that require separate consent. X Policy and

Procedure MSO/Ethics/QST

PFR.7 7. Policies and procedures guide the information and decision process [for research].

Policy and Procedure

MSO/Research/Ethics/QST

PFR.111. Policies and procedures guide the procurement and donation process.2. Policies and procedures guide the transplantation process.


.?????

MSO/Ethics/QST

Patient and Family Rights

STANDARD MEASURABLE ELEMENT(S)

ENGLISH

TYPE OF DOCUMEN-

TATION

AOP.1

1. Organization policy and procedure define the assessment information to be obtained for inpatients. 2. Organization policy and procedure define the assessment information to be obtained for outpatients. 3. Organization policy identifies the information to be documented for the assessments.

X

X

X



MSO/Med Record Committee/QST

AOP.1.1

3. The minimum content of assessments performed in inpatient settings is defined in policies. 4. The minimum content of assessments performed in outpatient settings is defined in policies.

XX

Policy and Procedure Policy and Procedure


AOP.1.2

1. All inpatients and outpatients have an initial assessment(s) that includes a health history and physical examination consistent with the requirements defined in hospital policy.



AOP.1.3

5. Policies and procedures support consistent practice in all areas [related to identifying patient medical and nursing needs].

Policy and Procedure Xxxxxx

AOP.1.4.1

1. The initial medical assessment is conducted within the first 24 hours of admission as an inpatient or earlier as indicated by the patient’s condition or hospital policy. 2. The initial nursing assessment is conducted within the fist 24 hours of admission as an inpatient or earlier as indicated by the patient’s condition or hospital policy.




NSO/Med Record Committee/QST

AOP.1.8

1. The organization defines criteria, in writing, that identify when additional, specialized, or more in-depth special-needs assessments are performed. Criteria MSO/QST

AOP.2

3. Patients are reassessed at intervals based on their condition and when there has been a significant change in their condition, plan of care, and individual needs or according to organization policies and procedures. 5. For nonacute patients, the organization policy defines the circumstances in which, and the types of patients or patient populations for which, a physician’s assessment may be less than daily and identifies the minimum reassessment interval for these patients.



MSO/QST

MSO/QST

AOP.3 5. Those qualified to conduct patient assessments and reassessments have their responsibilities defined in writing.

Policy and Procedure MSO/QST

Assessment of Patients

STANDARD MEASURABLE ELEMENT(S) ENG-LISH

TYPE OF DOCUMENTATIO

N

Responder

AOP.5.1 3. Written policies and procedures address the handling and disposal of infectious and hazardous materials. X Policy and

Procedure ICC/MSO/QST

AOP.5.41. There is a laboratory equipment management program and it is implemented. Program Lab Patho/

Instrument/QST

AOP.5.5 4. The laboratory has and follows written guidelines for evaluation of all reagents to provide for accuracy and precision of results. guideline Lab Patho/QST

AOP.5.6

1. Procedures guide the ordering of tests. 2. Procedures guide the collection and identification of specimens. 3. Procedures guide the transport, storage, and preservation of specimens. 4. Procedures guide the receipt and tracking of specimens.

Procedure Procedure Procedure Procedure

Lab Patho/QST Lab Patho/QST Lab Patho/QST Lab Patho/QST

AOP.5.9 1. There is a quality control program for the clinical laboratory. Program Lab Patho/QST

AOP.6.2

1. A radiation safety program is in place that addresses potential safety risks and hazards encountered within or outside the department. 3. Written policies and procedures address compliance with applicable standards, laws, and regulations. 4. Written policies and procedures address handling and disposal of infectious and hazardous materials.

X Program

Policy and Procedure Policy and Procedure

Radiology/QST

Radiology/QST

Radiology/ICC/QST

AOP.6.5 1. There is a radiology and diagnostic imaging equipment management program, and it is implemented.. Program Radiology/

Instrument/QST

AOP.6.8 1. There is a quality control program for the radiology and diagnostic imaging services, and it is implemented Program Radiology/

Instrument/QST

Assessment of Patients, continued

STAN DARD MEASURABLE ELEMENT(S) ENGL

ISHTYPE OF

DOCUMENTATION

Responder

COP.1 2. Policies and procedures guide uniform care and reflect relevant laws and regulations. Policy and Pro.. MSO/QST/Medical

Council

COP.2.2 1. Orders are written when required and follow organization policy. Policy MSO/M Record/QST

COP.3.1 1. The care of emergency patients is guided by appropriate policies and procedures. Policy and Pro.. PST ER/MSO/QST

COP.3.2 1. The uniform use of resuscitation services throughout the organization is guided by appropriate policies and procedures. X Policy and Pro.. XXXXXX

COP.3.3 1. The handling, use, and administration of blood and blood products are guided by appropriate policies and procedures. X Policy and Pro.. Blood Bank/MSO/

QST

COP.3.4 2. The care of patients who are on life support is guided by policies and procedures. 1. The care of comatose patients is guided by appropriate policies and procedures. Policy and Pro.. Anesth./Neuro/MSO/

QST

COP.3.51. The care of patients with communicable diseases is guided by appropriate policies and procedures. 2. The care of immune-suppressed patients is guided by appropriate policies and procedures.

Policy and Pro.. ICC/MED/MSO/QST

COP.3.6 1. The care of patients on dialysis is guided by appropriate policies and procedures. Policy and Pro.. Nephro/MED/QST

COP.3.7 1. The use of restraint is guided by appropriate policies and procedures. Policy and Pro.. Ethic/MSO/NSO/QST

COP.3.8

1. The care of frail, dependent elderly patients is guided by appropriate policies and procedures. 3. The care of young, dependent children is guided by appropriate policies and procedures. 5. Patient populations at risk for abuse are identified, and their care is guided by appropriate policies and procedures.

Policy and Pro.. Ethic/NSO/MSO/QST

COP.3.9 1. The care of patients receiving chemotherapy or other high-risk medications is guided by appropriate policies and procedures. Policy and Pro.. Chemotherapy/MED/

MSO/QST

COP.6 2. Patients in pain receive care according to pain management guidelines.

Guideline Anesth/SURG/MSO/QST

Care of Patients

STANDARD MEASURABLE ELEMENT(S) ENGLISH


N Responder

ASC.3

1. Appropriate policies and procedures, addressing at least elements a) through f) found in the intent statement, guide the care of patients undergoing moderate and deep sedation. 3. There is a pre-sedation assessment performed that is consistent with organization policy to evaluate risk and appropriateness of the sedation for the patient. 6. Established criteria are developed and documented for the recovery and discharge from sedation.


Policy

Criteria

Anesthesiology/MSO/QST

ASC.5.3

1. Policy and procedure address the minimum frequency and type of monitoring during anesthesia and are uniform for similar patients receiving similar anesthesia wherever anesthesia is provided. 2. Physiological status is monitored according to policy and procedure during anesthesia administration.

Policy


Anesthesiology/MSO/QST

ASC.6 1. Patients are monitored according to policy during the postanesthesia recovery period.

X Policy Anesthesiology/MSO/QST

Anesthesia and Surgical Care

STANDARD MEASURABLE ELEMENT(S) ENGLISH TYPE OF DOCUMENTATION Responder

MMU.1 1. There is a plan or policy or other document that identifies how medication use is organized and managed throughout the organization. X Plan or Policy Pharmacy/Drug

Committee/MSO/QST

MMU.2 1. There is a list of medications stocked in the organization or readily available from outside sources.

List Pharmacy/Drug Committee/MSO/QST

MMU.3 5. Organization policy defines how medications brought in by the patient are identified and stored. Policy Pharmacy/Drug

Committee/MSO/QST

MMU.3.1

1. Organization policy defines how appropriate nutrition products are stored. 2. Organization policy defines how radioactive, investigational, and similar medications are stored. 3. Organization policy defines how sample medications are stored and controlled.

Policy

Policy

Policy

Pharmacy/Nutrition/MSO/QST Pharmacy/

Radiology/MSO/QST Pharmacy/Drug

Committee/MSO/QST

MMU.3.3

3. Policies and procedures address the destruction of medications known to be expired or outdated. 2. Policies and procedures address any use of medications known to be expired or outdated.



Pharmacy/Drug Committee/MSO/QST


MMU.4

1. Policies and procedures guide the safe prescribing, ordering, and transcribing of medications in the organization. 2. Policies and procedures address actions related to illegible prescriptions and orders.

X

X





MMU.73. The organization has a policy that identifies those adverse effects that are to be recorded in the patient’s record and those that must be reported to the organization.

Policy Drug Committee/RMC/M Record/QST

MMU.7.1 1. A medication error and near miss are defined through a collaborative process. X Document

Pharmacy/Drug Committee/RMC/

QST

Medication Management and Use


DOCUMENTATION

Responder

QPS.1 1. The organization’s leadership participates in developing the plan for the quality improvement and patient safety program.. X Plan/Program TQM/QST

QPS.2.11. On an annual basis, clinical leaders determine at least five priority areas on which to focus the use of guidelines, clinical pathways, and or clinical protocols.

Priority Areas TQM/QST

QPS.5 2. The organization has an internal data validation process that includes a) through f) in the intent statement Process TQM/QST

QPS.6 1. The hospital leaders have established a definition of a sentinel event that at least includes a) through d) found in the intent statement. X Policy Definition RM/TQM/QST

QPS.81. The organization establishes a definition of a near miss.

X Policy Definition RM/TQM/QST

QPS.11 1. The organization’s leaders adopt a risk management framework to include a) through f) in the intent. Framework RM/TQM/QST

Quality Improvement and Patient Safety



N

Responder

PCI.5 5. The program is guided by appropriate policies and procedures [to reduce risks of health care–associated infections]. X Policy and

Procedure ICC/MSO/QST

PCI.6 4. The organization assesses these risks [of the infection prevention and reduction program] at least annually, and the assessment is documented. Risk Assessment ICC/MSO/QST

PCI.71. The organization has identified those processes associated with infection risk. 3. The organization identifies which risks require policies and or procedures, staff education, practice changes, and other activities to support risk reduction.

ProcessesPolicy and Procedure

ICC/MSO/QSTICC/MSO/QST

PCI.7.1.1

1. There is a policy and procedure consistent with national laws and regulations and professional standards in place that identifies the process for managing expired supplies. 2. When single-use devices and materials are reused, the policy includes items a) through e) in the intent statement.

X


Policy

ICC/ENV/QST

PCI.7.3 3. The disposal of sharps and needles is consistent with infection prevention and control polices of the organization. Policy ICC/QST

PCI.8

1. Patients with known or suspected contagious diseases are isolated in accordance with organization policy and recommended guidelines. 2. Policies and procedures address the separation of patients with communicable diseases from patients and staff who are at greater risk due to immunosuppression or other reasons. 3. Policies and procedures address how to manage patients with airborne infections for short periods of time when negative pressure rooms are not available.

Policy



ICC/MED/QST

ICC/MED/QST

ICC/MED/QST

PCI.9 5. The organization has adopted hand-hygiene guidelines from an authoritative source.

Guideline ICC/QST

PCI.11 1. The organization develops an infection prevention and control program that includes all staff and other professionals and patients and families. X Program ICC/MSO/QST

Prevention and Control of Infections


TYPE OF DOCUMEN

TATION Responder

GLD.1

1. The organization’s governance structure is described in written documents, and those responsible for governance and managing are identified by title or name. 2. Governance responsibilities and accountabilities are described in the documents. 3. The documents describe how the performance of the governing entity and managers will be evaluated and any related criteria.

X Document

Document Document

ฝ่ายบริหาร

ฝ่ายบริหาร/HRCฝ่ายบริหาร/HRC

GLD.1.2 2. When approval authority is delegated, it is defined in governance polices and procedures.


ฝ่ายบริหาร/HRC

GLD.3.2 1. Organization plans describe the care and services to be provided. Plan ฝ่ายแผน????

GLD.3.3 2. The organization has a written description of the nature and scope of services provided through contractual agreements. X Document ฝ่ายบริหาร

GLD.5.1

2. The departmental or service documents describe the current and planned services provided by each department or service. 3. Each department’s or service’s policies and procedures guide the provision of identified services. 4. Each department’s or service’s policies and procedures address the staff knowledge and skills needed to assess and meet patient needs.

Document

Policy and ProcedurePolicy and Procedure

แต่ละกลุ่มงานจัดทําร่วมกับHRC/MSO

GLD.5.3 1. The director develops criteria related to the needed education, skills, knowledge, and experience of the department’s professional staff. Criteria แต่ละกลุ่มงานจัดทําร่วม

กับHRC /MSO

GLD.5.4 1. The director has established a documented orientation program for department staff.

Program แต่ละกลุ่มงานจัดทําร่วมกับHRC /MSO

GLD.6 2. The leaders establish a framework for the organization’s ethical management. Framework Ethic/MSO/NSO/QST

GLD.6.1 3. The organization provides clear admission, transfer, and discharge policies. Policy MSO/QST

Governance, Leadership, and Direction


TYPE OF DOCUMENT

ATION Responder

FMS.2

1. There are written plans that address the risk areas a) though f) in the intent statement. a) Safety and security (Also see FMS.4 ME 1 through ME 4) b) Hazardous materials (Also see FMS.5 ME 2 through ME 7) c) Emergencies (Also see FMS.6, ME 1) d) Fire Safety (Also see FMS.7.1 ME 1 through ME 5) e) Medical equipment (Also see FMS.8 MEs 1 through ME 3 and FMS.8.1 ME 1 and ME 2) f ) Utility systems (Also see FMS.9.1, ME 3)

X Plans Instrument/ENV/ฝ่ายบริหาร/QST

FMS.4.1

1. The organization has a documented, current, accurate inspection of its physical facilities. 2. The organization has a plan to reduce evident risks based on the inspection.

Document

Plan

ฝ่ายบริหาร/QST

ฝ่ายบริหาร/ENV/QST

FMS.5 1. The organization identifies hazardous materials and waste and has a current list of all such materials within the organization. List ฝ่ายบริหาร/ENV/QST

FMS.7.2 5. Inspection, testing, and maintenance of equipment and systems are documented.

Documented Inspections

ฝ่ายบริหาร/Instrument/QST

FMS.7.3 1. The organization has developed a policy and or procedure to eliminate or to limit smoking.

Policy and Procedure ฝ่ายบริหาร/ENV/QST

FMS.8.2 2. Policy or procedure addresses any use of any product or equipment under recall. Policy ????????

Facility Management and Safety


TYPE OF DOCUMENTA

TION Responder

SQE.6 1. There is a written plan for staffing the organization. Plan ???? HRC/QST

SQE.8.4

4. There is a policy on the provision of staff vaccinations and immunizations.

5. There is a policy on the evaluation, counseling, and follow-up of staff exposed to infectious diseases that is coordinated with the infection prevention and control program.

Policy

Policy

HRC/ICC/QST

HRC/ICC/QST

SQE.9.1 1. There is a process described in policy for the review of each medical staff member’s credential file at uniform intervals at least once every three years. X Policy HRC/QST

SQE.101. The organization uses a standardized process that is documented in official organization policy for granting privileges to each medical staff member to provide services on initial appointment and on reappointment.

X Policy .??????

SQE.112. The ongoing professional practice evaluation and annual review of each medical staff member are accomplished by a uniform process that is defined by organization policy.

X Policy HRC/MSO/QST

SQE.12 1. The organization has a standardized procedure to gather the credentials of each nursing staff member. Procedure HRC/NSO

SQE.15 1. The organization has a standardized procedure to gather the credentials of each health professional staff member. Procedure HRC

Staff Qualifications and Education

STANDARD MEASURABLE ELEMENT(S) ENG

LISHTYPE OF

DOC. Responder

MCI.7 1. Policy establishes those health care practitioners who have access to the patient’s record(s). Policy M Record/

MSO/QST

MCI.10

1. There is a written policy for addressing the privacy and confidentiality of information that is based on and consistent with laws and regulations.2. The policy defines the extent to which patients have access to their health information and the process to gain access when permitted.

Policy

Policy

M Record/MSO/QST/

Med Council

MCI.11

1. The organization has a written policy for addressing information security, including data integrity, that is based on or consistent with law or regulation. 2. The policy includes levels of security for each category of data and information identified.

Policy

Policy

MIS/M Record/QST

MIS/M Record/QST

MCI.12 1. The organization has a policy on retaining patient clinical records and other data and information. Policy

MIS/M Record/MSO/

QST

MCI.18

1. There is a written policy or protocol that defines the requirements for developing and maintaining policies and procedures including at least items a) through h) in the intent, and it is implemented. 2. There is a written protocol that outlines how policies and procedures that originated outside the organization will be controlled, and it is implemented. 3. There is a written policy or protocol that defines retention of obsolete policies and procedures for at least the time required by laws and regulations, while ensuring that they will not be mistakenly used, and it is implemented. 4. There is a written policy or protocol that outlines how all policies and procedures in circulation will be identified and tracked, and it is implemented.

X

X

X

X

Policy

Protocol

Policy or protocol

Policy or Protocol

TQM/QST

TQM/QST

TQM/QST

TQM/QST

MCI.19.2

1. Those authorized to make entries in the patient clinical record are identified in organization policy. 2. The format and location of entries are determined by organization policy.

5. Those authorized to have access to the patient clinical record are identified in organization policy.

6. There is a process to ensure that only authorized individuals have access to the patient clinical record.

Policy Policy

Policy

Policy

M Record/QSTM Record/MSO/QSTM Record/MSO/QST

M Record/QST

Management of Communication and Information

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