Document Name :
Date Created :
25 September 2016
Approved By :
SHELLEY ANN M. MANGAHAS, MD,
MHA, FPAO
OIC Chief of Hospital
Reviewed By :
HEDDAH A. URBIS, MD, FPCP
Chairperson, Quality Assurance Committee
Issued By :
Responsibility of Updating :
TABLE OF CONTENTS
NO.
PARTICULARS
INTRODUCTION
DEFINITION
3.1
Concurrent or On-The-Spot-Review
3.2
Retrospective Review
9.1
General Approaches
9.2
Specific Approaches
10
11
11.1
11.2
12
13
1. INTRODUCTION
Quality assurance is achievable through an ongoing evaluation of patient care which
would assure the hospital that all that was done for the patient was done to justify
diagnosis, treatment and outcome and to pinpoint inadequacies in medical care for
rectification for the future cases.
2. DEFINITION
Quality assurance is defined as all actions taken to establish protect, promote and
improve the quality of health care
3. METHODS OF QUALITY ASSURANCE
Quality assurance in patient care having various methods. They are as follows;
3.1
CONCURRENT OR ON-THE-SPOT-REVIEW
A hospital administrator uses this methods routinely so far as nonclinical aspects
of hospital care are concerned, in the form of daily and periodical administrative
rounds.
(1) As the rounds progresses, the visiting physician should look into the patients
case records, enquire from each patient about his/ her progress, treatment and
diet, peruse nurses report, book and treatment book, and even inspect the
house keeping activities and sanitation of the ward and other aspects
connected with patient care.
(2) The analysis of records immediately after discharge in the ward itself can
prove fruitful in obtaining the final diagnosis from the physician before the
record arrives in the medical record department.
(3) This can assist in providing accuracy of information in the medical record
itself, the most frequently used data source in the hospital.
3.2
RETROSPECTIVE REVIEW
3.2.1
The medical record has to be sequentially filled and a face sheet affixed
to each case record before it is presented to the evaluation committee.
4. EXTERNAL OR INTERNAL QUALITY ASSURANCE
External quality assurance is seen as being concerned with the setting by independent
outside authorities of explicit standards of service over wide areas of health care system.
Internal quality assurance is seen as essentially a local exercise, whereby the activities of
physicians and surgeons are subjected to a confidential review by their peers designed to
improve patient care and encourage professional self-evaluation.
5. PROCESS OF QUALITY ASSURANCE
Help patients and potential patients by improving quality of care.
Assess competence of medical staff, serve as an impetus to keep up to date and
prevent future mistakes.
(3) Bring to notice of hospital administration the deficiencies and in correcting the
causative factors.
(1)
(2)
The process can also help to exercise a regulatory function, restricting procedures. This
cannot but help the medical staff to improve upon their clinical and professional
judgment. By timely verification, it cannot but help provide assurance for future actions
so that better methods could be used.
6. NEED FOR QUALITY IMPROVEMENT
(1)
(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
(2)
(3)
(4)
(5)
Evaluate results of monitoring activities to determine the need for change in practice.
(6)
(7)
(8)
GENERAL APPROACHES
9.1.1
CREDENTIALING
The formal recognition of a person as a professional with technical
competence or of an agency that has met minimum standards of
performance.
Credentialing includes licensure for individuals accreditation for
institution and certification with the features of both licensure and
accreditation.
9.2
SPECIFIC APPROACHES
Specific approaches are implemented voluntary agencies and provider groups
interested in the quality of interactions in their settings. They include,
9.2.1
9.2.2
UTILIZATION REVIEW
The process of utilization review is to assure that if care actually is needed
and that the cost is appropriate.
9.2.3
9.2.4
RISK MANAGEMENT
The goal of risk management is to reduce the liability on the part of the
agency and the no: of grievances brought against the agency.
9.2.5
MALPRACTICE LITIGATION
It is typically results from client dis satisfaction with the provider and with
the content of care provider.
10
11
Patients satisfaction levels as assessed from the satisfaction survey program and the
complaints received from the patients / relatives.
(2)
Complaints received from the doctors about incompetence negligence / or bad behavior
on the part of personnel handling patients.
(3)
(4)
(5)
(2)
(2)
(3)
Someone to provide all the right patient care and medication at the right time
in the right manner as prescribed by the doctors, relieve the pain and suffering
and quickly restore them back to health without any complications or ill
effects.
The nurses monitor the patients condition with efficiency and alertness and
inform them immediately any change requiring the physicians intervention.
(2)
(3)
Nurses take care of the basic needs of the patients provide a safe and
comfortable environment conducive to early healing and nurse them back to
normal health.
(4)
There are no complications / harm to the patients due to any mistakes on the
part of nurses in the performance of above functions.