Accreditation: consultations for Quality improvement for hospitals

Gutenmed offer consultation to improve Quality of services , preparing for different kinds of accreditation ( JCI, Australian, Canadian, CBAHI and others) until the hospital reaches the highest standard. we offer also our own accreditation. the guidelines presented separately they will now in every instance precede the set of standards for which they apply. we offer The guidelines and standards to follow up for quality improvement . we offer policies and procedures to support theories and practices as demonstrated by research. Policies and procedure must be hospital specific and commensurate with work practices.
we facilitate the genesis of the accreditation process and responded appropriately to the results from the pilot study. Accreditation standards were used as the platform for establishing quality improvement systems throughout The hospital.
we conduct auditing for hospitals and primary healthcare. we train hospital staff to grasp the concept of accreditation. The guidelines now will give an overview of the crucial facets of a department or service to be considered in order to comply with the standards. The expectation is that hospital staff research relevant, current theory and practice and apply the newly acquired knowledge to their unique situation. A quality improvement system demands that the dynamic process of continued applied research underpins all activities.
The authors have endeavored to accommodate the various terms used to describe the range of services across hospitals in Lebanon. Taking into account the varying size and complexity of services offered, certain terms are interchangeable in some instances, example: service versa department; ward versa unit or floor.
It is to be noted the authors have used the terminology policy and procedure with only two references to protocols. This decision was deliberate to clarify and differentiate between all three. In diagrammatical format policies sit above procedures and protocols are invariably subsumed as part of a procedure.
A policy is a non renegotiable in this case, hospital rule, with respect to a specific issue. The rule may be changed but it requires a concomitant policy change approved by a nominated person or body. One policy may apply to many procedures. A procedure is an action that is to occur. It must however, be congruent to its related policy. A protocol is a specific component of a procedure and may take the form of an algorithm.
The introduction of quality improvement activities requires an investment of human resources, time, effort and money. It is absolutely imperative that the commitment to quality improvement activities commences with and is supported by senior management. All levels of staff, irrespective of their roles and responsibilities must be aware of the hospital committee to quality improvement and how it impacts on their day to day work. This frequently requires a cultural shift whereby all employees contribute in a dynamic way towards the implementation of quality improvement and its success.
Auditors recognize the wish for hospitals to achieve accreditation and the desire to demonstrate their level of preparedness. It must be born in mind that the auditors have a limited time in the hospital to complete their work. It is suggested that the auditors, on arrival are given at a list of hospital departments and staff by department and designation to use a reference throughout their visit.
It worth noting that any controversy that involves protracted discussions, reduces the time allocated to a particular department and thus may disadvantage the outcome. Auditors are objective and have a desire to see the hospitals achieve accreditation as a reward for all the hard work and commitment by staff. Therefore, auditor’s will do their utmost to ensure they receive all the information required that allows them to make an informed decision concerning the hospital’s compliance with the standards.
Every opportunity will be given to hospital staff to allow them to demonstrate their hard work and commitment to achieve accreditation. However, this is a two way process and requires cooperation and preparation to facilitate access to required documentation.
we offer visits for preparedness for accreditation
second visit for achieving accreditation

Leave a Reply

Your email address will not be published. Required fields are marked *