A Self-Assessment Guide for Health Care Organizations - IFC

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Foreword IFC produced this guide because improving standards in health care organizations is important. We believe that patients everywhere, including in developing countries, have a right to receive high quality care in a safe environment. When IFC invests in health care organizations, we stake our reputation on our clients’ commercial performance and their values and standards. We have seen that a commitment to high standards of quality, safety, and ethics makes good business sense. This guide is for health care organizations of all sizes and complexities operating in emerging markets. Raising health care standards is about developing systems to ensure that appropriate care is provided to patients in a safe environment. And health care providers should not only seek to “do the right thing”, but aim to do it well, and to do it right “first time, every time”. I hope that you will find this guide useful in improving quality, ethics, and safety standards in your organization. Guy Ellena Director, IFC Health and Education Department 2 IFC Self-Assessment Guide for Health Care Organizations
Acknowledgements This Guide was developed with support from the Joint Commission International (JCI). We would like to also thank the review panel who were: Name Position Organization Location Dr. Alejandro J. Ayón L. Medical Director Hospital Metropolitano Vivian Pellas Managua, Nicaragua Dr. Francisco Balestrin Vice-President of Board and Coordinator of Information and Quality Committee ANAHP (National Association of Private Hospitals) São Paulo, Brazil Dr. K. S. Bhimwal Medical Director Rockland Hospital New Delhi, India Dr. Sneh Khemka Medical Director BUPA International London, UK Dr. Ajibike Oyewumi Consultant O&G and Head of Quality Improvement Lagoon Hospitals Lagos, Nigeria Dr. Arati Verma Chief, Quality and Training (Medical) Max Healthcare New Delhi, India Dr. Hazem Zagzoug Deputy Chairman Andalusia Hospitals Jeddah, Saudi Arabia This guide was developed as part of IFC’s Health and Education Advisory Services Project (567768). Emmett Moriarty Project Manager IFC Principal Health Sector Specialist IFC Self-Assessment Guide for Health Care Organizations 3
Page 1 and 2: PROMOTING STANDARDS IN THE PRIVATE
Page 3: Contents Foreword 2 Acknowledgement
Page 7 and 8: introduction IFC Self-Assessment Gu
Page 9 and 10: Why are Standards Important Why sho
Page 11 and 12: Leadership Systems Data Where to Be
Page 13 and 14: Preparing for the self-assessment I
Page 15 and 16: Facility Safety and Emergency Manag
Page 17 and 18: The self -assessment template IFC S
Page 19 and 20: Clinical Governance and Leadership
Page 21 and 22: Measurable Element Look for Score O
Page 25 and 26: Standard CGL.6 [Staff recruitment,
Page 27 and 28: Standard EPR.2 [Patient and family
Page 29 and 30: Standard EPR.3 [Informed consent] P
Page 31 and 32: Standard EPR.4 [Ethical management]
Page 33 and 34: Standard EPR.5 [Organ and tissue do
Page 35 and 36: Standard EPR.6 [Reproductive health
Page 37 and 38: Standard EPR.7 [Termination of preg
Page 41 and 42: Quality Measurement and Improvement
Page 43 and 44: Standard QMI.2 [Leaders’ collabor
Page 51 and 52: Standard QMI.4 [Medications use] Me
Page 55 and 56:
Measurable Element Look for Score O
Page 57 and 58:
Patient Safety (PS) Standard PS.1 [
Page 59 and 60:
Standard PS.2 [Effective communicat
Page 61 and 62:
Standard PS.4 [Correct site, proced
Page 63 and 64:
Standard PS.5 [Health care associat
Page 65 and 66:
Facility Safety and Emergency Manag
Page 67 and 68:
Page 69 and 70:
Page 71 and 72:
Page 73 and 74:
Standard FSE.6 [Utilities managemen
Page 75 and 76:
IFC Self-Assessment Guide for Healt
Page 77 and 78:
After the self-assessment Next Step
Page 79 and 80:
Baseline Score Score Score Clinical
Page 81 and 82:
EPR.6 Reproductive health policies
Page 83 and 84:
QMI.4 Medications use 1 Medication
Page 85 and 86:
Baseline Score Score Score Facility
Page 87 and 88:
STEP 5: Develop an Action Plan The
Page 89 and 90:
IFC Self-Assessment Guide for Healt
Page 91 and 92:
Appendices IFC Self-Assessment Guid
Page 93 and 94:
11. Organ donation and transplant T
Page 95 and 96:
Clinical Privileging Committee The
Page 97 and 98:
emergency 1. An unanticipated or su
Page 99 and 100:
privileging The process whereby a s
Page 102:
Contact Information Health and Educ
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