Putting Patients First
The mission of DHCC’s Healthcare Quality Department is to identify, evaluate and implement best practices to improve patient safety and quality of care. The focus of quality improvement is patient-centered healthcare. Responsibilities of the Quality Improvement Department include the following:
- Ensuring that DHCC’s clinical standards are implemented by healthcare organizations
- Ensuring that healthcare organizations have the appropriate mechanisms for monitoring, evaluating and improving the quality of healthcare provided
- Assisting HCOs in DHCC to improve when quality expectations are not being met
- Assuring that quality of care and patient safety in DHCC are sustained over time
DHCC’s commitment to the highest quality of healthcare and patient safety is the foundation for a globally acknowledged center of excellence in healthcare.
Hospital Accreditation Surveys
Accreditation is a process in which an entity, separate and distinct from the HCO, usually non-governmental, assesses the HCO to determine if it meets a set of standards and requirements designed to improve the quality of care. Accreditation provides a visible commitment by an HCO to improve the quality of patient care, ensure a safe environment and continually work to reduce risks to patients and staff. Accreditation has gained worldwide attention as an effective quality evaluation and management tool.
The Joint Commission International (JCI) was appointed by DHCC to accredit hospitals operating within DHCC. This selection demonstrates the commitment by DHCC to provide safe and high-quality care. All hospitals operating within DHCC are required to obtain accreditation by JCI within 2 years and then every 3 years afterward.
Outpatient Clinic Quality Standards Sections
To ensure high-quality care and patient safety, each HCO in DHCC is required to commit to DHCC’s clinical quality standards that are grouped into the following 10 sections:
- Environment of Care
- Leadership and Governance
- Staff Qualifications, Education and Training
- Access and Continuum of Care
- Patient Assessment and Care
- Patient and Family Rights
- Patient and Family Education
- Performance Measurement and Quality Improvement
- Infection Prevention and Control
- Health Information Management
Outpatient Clinic Assessment Surveys
The assessment survey process serves as a tool for improvement and relicensing. The assessment process ensures that HCOs meet core healthcare quality standards. Assessment surveys are conducted by CPQ at 6 months of operation and again at 18 months of operation. The surveys are repeated every 2 years for the duration of the facility’s operation within DHCC.
Communicable Diseases Reporting
The surveillance of infectious diseases effectively prevents the spread of suspected or confirmed diseases into the greater community. The collection of International Classification of Disease (ICD) coding, which provides statistical information locally, nationally, and internationally, is important in the management, control, analysis and prevention of disease cases and related outbreaks. It is necessary and important to take immediate measures to ensure disease prevention and disease communicability through early detection reporting within DHCC facilities. All healthcare facilities within DHCC must comply with the disease notification and reporting process.
Performance Measurement
Quality can be defined, measured and improved. Performance measurement is a strategy to improve quality and patient safety. HCPs “manage what they measure,” therefore, each HCO in DHCC must participate in performance measurement and performance improvement activities.
Performance measurement of HCOs is achieved through the following mechanisms:
- Monitoring compliance to quality standards
- Monitoring communicable diseases
- Monitoring sentinel events
- Developing and implementing clinical indicators
- Conducting patient satisfaction surveys
Performance Improvement
Performance improvement of HCOs is achieved through the following mechanisms:
- Developing and conducting educational activities and workshops to support patient safety initiatives and ensure compliance to challenging standards
- Providing HCOs with survey recommendations and following up with implementation of the recommendations
- Analyzing and trending data from communicable diseases reporting
- Providing assistance with root cause analysis and action plans when required, for example, when sentinel events are reported
- Analyzing and trending data from clinical indicators reporting
- Analyzing patient satisfaction surveys and providing recommendations based on the findings
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