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(1)

Hospital Accreditation in Flanders

Vera De Troyer

Dominique Vandijck Katleen Valtin

Johan Hellings

(2)

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

(3)

An integrated and pro-active approach to work on

Quality and Safety

(4)

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)

(5)

S

Y

S

T

E

M

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)

(6)

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

(7)

Julia, 83 years old

Admission because of hip fracture

Antecedents:

type II diabetes with insulin injections

Lives in a home care facility

(8)

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

(9)

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

(10)

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.

(11)

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

(12)

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.

(13)

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’

(14)
(15)
(16)

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?

(17)

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.

(18)

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

(19)

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

(20)

Nutritional aspects of hospital accreditation

Successful Discharge of patients

Returning to Julia and Paul

As

arrangements for discharge

may

take some time, the assessment

process and planning process are

initiated as soon as possible after

admission.

(21)

Don’t forget the other challenges for you

There are also other standards that apply to you

How do we guarantee that all care givers have the

appropriate skills and education?

Do you have a job description? Do you know it? How do

you/they evaluate how well you fulfill your job

responsibilities

Do you know the strategic goals of your organisation?

How does your work fit into these goals?

What is the policy about hand hygiene?

(22)

Some points to conclude

Nutrition is one of human basic needs and extremely

important when people get ill (and/or in the prevention

of diseases)

Accreditation is a hospitalwide phenomenon! Not only

the quality department is in charge!

If we want to deliver good care, we have to work together

with all professionals

Also the dietician is in charge for the quality of care!

Please… don’t be a solo player…

(23)

Success!

Vera De Troyer

[email protected]

References

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