A yardstick against which the quality of health care rendered by accredited health care providers can be measured

2. A yardstick against which the quality of health care rendered by accredited health care providers can be measured • Contains accreditation standards that evaluate processes and outcomes of health care • Represents a significant change from the current standards that govern only inputs to health care

4. Element of a Performance Area

5. INDICATORS • These are tools to monitor conformance to standards with respect to specific criterion. • Performance indicators of these 79 standards have been developed by PhilHealth for your guidance.

6. Benchbook Core Indicators • Characteristics that should be present for a hospital to function as a facility providing care, treatment and diagnosis in a manner that is safe and efficient for the patients and its staff. • Non-negotiable, absence of any of them may mean no accreditation (Linden workshop 2007)

7. For Core indicators • 1 = 0% compliance • 4 = 100% compliance

10. Review document – medical records • Interview staff including doctors • Interview patient to validate • Observe patient care processes and structure

13. Examples

16. Standard 2: Physical access to the organization and its services is facilitated and is appropriate to patients' needs.

17. Evidence: • Entrance and exit signs. Check ER, OPD, wards, ICUs, OR, imaging and laboratory • Entrances and exits are accessible and free from any obstruction

18. Standard 1: Each patient's physical, psychological and social status is assessed.

19. Evidence: • Patient chart from wards AND ER • NOTE: comprehensive history includes present illness, review of systems, past medical, family and personal history

20. Standard 2: Appropriate professionals perform coordinated and sequenced patient assessment to reduce waste and unnecessary repetition.

21. Progress Notes Evidence: • Patient chart from medical records • Note: The progress notes should be done regularly and documented in the patient chart either as separate 'progress notes' sheets or side notes in the doctor's order sheets. • Progress notes format in: • Subjective • Objective • Assessment • Plan PROGRESS NOTES

22. Standard 3: Assessments are performed regularly and are determined by patient's evolving response to care.

23. Evidence: • Patient chart from medical records (surgery patients) • Note: Look for pre-operative anesthetic evaluation in the patient chart. Pre-operative assessment should be done for patients requiring more than local anesthesia. PRE-ANESTHESIA EVALUATION FORM

24. Standard 5: Drugs are administered in a standardized and systematic manner in the provider organization.

25. Evidence: • Patient chart from the medical records • For the timeliness of drug administration, check the hospital policy. If hospital does not have policy, frequency of drug administration in the chart should be checked and validate it thru patient interview

26. Standards 2.5.5: Drugs are administered in a standardized and systematic manner in the provider organization.

27. Evidence: • Randomly check the licenses of doctors, nurses and pharmacists if they are updated

28. Standard 1: The discharge plan is part of the patient's care plan and is documented in the patient chart

29. Evidence: • Patient chart from medical records, look at the discharge orders. It should contain all of the following: 1. May go home order 2. Home medications (if applicable) 3. Follow up visits/schedule 4. Home care/advise

33. Evidence Document Review Policies and procedures on credentialing and privileging of staff

36. Standard5.1.1 Relevant, accurate, quantitative and qualitative data are collected and used in a timely and efficient manner for delivery of patient care and management of services.

37. Evidence • Policies and Procedures on record storage, safekeeping and maintenance, retention and disposal. For out-patients: records should be kept for 10 years after last consultation or visit

38. Standard5.2.1. Clinical records are readily accessible to facilitate patient care, are kept confidential and safe, and comply with all relevant statutory requirements and codes of practice

39. Evidence • Document • Policies and procedures on records management for the entire hospital to maintain privacy, accuracy, and prevent loss and destruction • Observation • Observe nurses in the wards and records personnel on how they protect patient chart against loss, tampering, and unauthorized use

41. 5 Sub-areas (Goals) • Standards • Criteria • Indicators 25 core indicators

42. SAFE PRACTICE AND ENVIRONMENT

44. Refers to injuries caused by medical management (and not necessarily the disease process) that either caused death, prolonged hospitalization or produced a disability during the time of confinement or by the time of discharge.

46. Incidences

50. Health Care Waste Management Manual Department of Health