Hospital Accreditation in Flanders
Vera De TroyerDominique Vandijck Katleen Valtin
Johan Hellings
Some points before I start:
•
Hospital accreditation cannot be seen split from the
other quality initiatives
•
A framework to embed quality through the whole
organisation
•
Direct link between the inspection model of the
Flemish Government and Accreditation (see next
slides)
•
Indicators must be useful for professionals and
Situation in Flemish department Belgium
An integrated and pro-active approach to work on
Quality and Safety
Situation in Flemish department Belgium
The situation today…
•
59 general hospitals (n = 63) have chosen for
accreditation
•
7 general hospitals accredited
• 2 NIAZ-hospitals: Jessa (Hasselt) and St.-Lucas (Brugge)
• 5 JCI: UZ Leuven (Leuven), AZ Groeninge (Kortrijk), Jan Yperman (Ieper), AZ Sint-Blasius (Dendermonde) en UZA (Antwerpen)
•
52 hospitals in preparation
• 25 hospitals have chosen for Joint Commission International (JCI)
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Situation in Flemish department Belgium
Split between two different kinds of inspection:
• System inspection
= inspection of the implemented quality system:
eg. Process for identification checks patient identity
• Announced (every 4 years)
• Preceeded by a self assessment
→ Accredited hospitals with an ISQua-accredited
organisation by the end of 2017 are exempted
• Inspection of compliancy → For all hospitals
eg. Number of patients with a correct wrist band (2 identifiers)
• Unannounced
• Differentiated → Care paths (2013: surgical care, 2015: medicine services, 2016-2017: cardiology)
Hospital Accreditation - definition
A self-assessment and external peer
assessment process used by health care
organizations to accurately assess their level
of performance in relation to established
standards and to implement ways to
Julia, 83 years old
•
Admission because of hip fracture
•
Antecedents:
•
type II diabetes with insulin injections
•
Lives in a home care facility
Paul, 68 years old
•
A very active grandfather
•
Admission because of a
stroke incident
•
No medical antecedents
•
Allergic to citrus fruits
•
Actual problem:
difficulties with
swallowing
•
Lives together with his
wife
Nutritional aspects of hospital accreditation
Assessment of patients
• Q-mentum (NIAZ): The team accurately and appropriately assesses its clients
• The team assesses the clients physical health → which elements? Medical history, allergies, medication profile, health status, and nutritional status and special dietary needs
• JCI: AOP.1.4 Patients are screened for nutritional status, functional needs, and other special needs and are referred for further assessment and treatment when necessary
Nutritional aspects of hospital accreditation
Assessment of patients → How do we do that?
… Some guidelines or recommendations are provided
For example, the initial nursing assessment form may contain basic criteria for a nutritional screen, such as five or six simple questions with a
numerical score relating to recent decline in food intake, weight loss during the past three months, mobility, and the like. The patient’s total score would then identify a patient at nutritional risk requiring a more in-depth nutritional assessment.
Nutritional aspects of hospital accreditation
Assessment of patients → How do we do that?
… Expectations about qualifications of professionals
In each case, the screening criteria are
developed by qualified individuals able to further assess and, if necessary, to provide any required patient treatment.
For example, screening criteria for nutritional risk may be developed by nurses who will apply the criteria, dietitians who will supply the
recommended dietary intervention, and
Nutritional aspects of hospital accreditation
Nutrition therapy
On initial assessment, patients are screened to identify those patients who may be at nutritional risk. These patients are referred to a
nutritionist for further assessment. When it is determined that a patient is at nutritional risk, a plan for nutrition therapy is developed and
carried out. The patient’s progress is monitored and recorded
in his or her record. Physicians, nurses, the dietetics service, and, when appropriate, the patient’s family, collaborate to plan and to provide nutrition therapy.
1. Patients assessed at nutrition risk receive nutrition therapy.
2. A collaborative process is used to plan, to deliver, and to monitor nutrition therapy.
Nutritional aspects of hospital accreditation
Food choices in hospital
A variety of food choices, appropriate for the patient’s
nutritional status and consistent with his or her clinical
care, is available.
1. A variety of food choices or nutrition, consistent with the patient’s condition, care, and needs, is regularly available.
2. Prior to patients being fed, all inpatients have orders for food in their records.
3. The order is based on the patient’s nutritional status and needs. 4. The distribution of food is timely, and special requests are met. 5. When families provide food, they are educated about the patients’
Nutritional aspects of hospital accreditation
A few questions
• The transport and storage of food?
• Do we have guarantees about the storage and transport before the food comes into the hospital?
• What about the temperature (not to warm or to cold)?
• What about sanitation? Is it clean enough?
• Are there requirements about light, moisture, ventilation?
• Is the storage environment dry enough?
• Who is responsible for nutrition storage in the hospital? In the central kitchen? On the ward? In the patients rooms?
Nutritional aspects of hospital accreditation
Storage and preparation … some requirements
The organization prevents contamination of food, linen, equipment,devices, and supplies.
• Staff and service providers store, prepare and handle food appropriately
• The organization stores and handles linen, supplies, devices, and equipment in a manner than protects them from contamination.
• Staff and service providers use aseptic techniques when preparing, handling, and delivering vaccines, parenterally administered
medications, total parenteral nutrition, and diagnostic media.
• The organization follows national and international safety guidelines on
work restrictions for staff or service providers with transmissible infections.
Nutritional aspects of hospital accreditation
Storage and preparation … some requirements!
The hospital
reduces the risk of infections
associated with
the operations of food services.
Improperly stored and prepared food can cause illnesses,
such as food poisoning or food infections.
1. The hospital stores food and nutrition products using
sanitation, temperature, light, moisture, ventilation, and
security in a manner that reduces the risk of infection.
2. The hospital prepares food and nutrition products using
Nutritional aspects of hospital accreditation
What do want to achieve?
How far do we want to go? Just an inspiring example
• Patients can choose what they want to eat (and at what time)
• Does it fit with the nutritional needs or diet restrictions?
• Patients can eat together with their family
• Patients can choose where and when they want to eat
• Delivery after max. 45 minutes
• Patients eat better and there is less waste
