Hospital Strategic Objective: Full Compliance with Quality and Performance Standards (Local and International)

Hospital Strategic Objective: Full Compliance with Quality and Performance Standards (Local and International)

A 3-Year Design and Development Plan

 

Reynaldo O. Joson, MD, MHA, MHPEd, MSc Surg

November 1, 2012

Introduction:

ROJoson: I believe having a full compliance with established quality and performance standards is one of the steadfast strategic objectives all hospitals should have to achieve performance excellence.

Quality services,  societal responsibilities, and performance excellence are part of the core expectations, values and concepts of Baldrige Health Care Criteria for Performance Excellence.

 

Concept of Full Compliance with Quality and Performance Standards (Local and International)

Standards

In general, standards refer to a set of rules, norms, convention or requirements for ensuring quality or performance.

ISO/IEC Guide 2:1996, definition 3.2 defines a standard as:

A document established by consensus and approved by a recognized body that provides for common and repeated use, rules, guidelines or characteristics for activities or their results, aimed at the achievement of the optimum degree of order in a given context’.

Quality and Performance Standards

Quality and performance standards refer to standards on quality and performance, required or agreed levels of quality or attainment of requirements.

In a hospital setting in the Philippines, as of 2012, I believe the following local and international documented sets of standards should guide all hospitals in achieving a high level of quality and performance:

  • Baldrige Health Care Criteria for Performance Excellence / Philippine Quality Award Criteria for Performance Excellence
  • ISO Quality Management System
  • PhilHealth Benchbook (including PH statutory and regulatory requirements)
  • Joint International Commission, Accreditation Canada International (either one or both)
  • Investors in People

 

  • Baldrige Health Care Criteria for Performance Excellence / Philippine Quality Award Criteria for Performance Excellence
    • Designed to help provide hospitals with an integrated approach to organizational performance that results in
      • Delivery of ever-improving value to customers and stakeholders, contributing to organizational sustainability
      • Improvement of overall organizational effectiveness and capabilities
      • organizational and personal learning
      • ISO Quality Management System
        • The ISO 9000 family of standards is related to quality management systems and designed to help organizations ensure that they meet the needs of customers and other stakeholders  while meeting statutory and regulatory requirements related to the product.
        • PhilHealth Benchbook (including PH statutory and regulatory requirements)
          • Designed to encourage Philippine hospitals improve on their quality management system and to improve quality and safe patient care
          • Joint International Commission, Accreditation Canada International (either one or both)
            • Designed to improve quality and safe patient care
            • Designed to assess and improve organization performance based on internationally agreed standards and stimulating continuous improvement to achieve optimum outcomes on healthcare
            • Investors in People
              • Designed to transform business performance through people

 

Full Compliance with Quality and Performance Standards (Local and International)

This refers to 100% compliance or conformance to the following local and international sets of standards useful for hospitals:

  • Baldrige Health Care Criteria for Performance Excellence / Philippine Quality Award Criteria for Performance Excellence
  • ISO Quality Management System
  • PhilHealth Benchbook (including PH statutory and regulatory requirements)
  • Joint International Commission, Accreditation Canada International (either one or both)
  • Investors in People

Why full compliance to established local and international quality and performance standards?

ROJoson: I believe having a full compliance with abovementioned established local and international quality and performance standards is one of the steadfast strategic objectives all Philippine hospitals should have to achieve performance excellence.

Value of Quality and Performance Standards (Note: at the moment, just go for PQA and PhilHealth Benchbook accreditation):

  1. Stimulate continuous improvement in service and patient care processes and outcomes.
  2. Improve management of health care services particularly on patient safety.
  3. Provide staff education on better or best practices.
  4. Increase efficiency / reduce cost.
  5. Improve organization performance.
  6. Promote recognition for excellence.
  7. Strengthen public and community confidence.

Full Compliance with Quality and Performance Standards (Local and International) as a Hospital Strategic Objective

Goals:

To develop a well-defined integrated system in which all the requirements of the following local and international quality and performance standards are complied with.

  • Baldrige Health Care Criteria for Performance Excellence / Philippine Quality Award Criteria for Performance Excellence
  • ISO Quality Management System
  • PhilHealth Benchbook (including PH statutory and regulatory requirements)
  • Joint International Commission, Accreditation Canada International (either one or both)
  • Investors in People

Key success indicators:

There is a well-defined integrated system in which all the requirements of the following local and international quality and performance standards are complied with.

Philippine Quality Award:

Year 1: Recognition for Commitment in Quality Management

Year 2: Recognition for Proficiency in Quality Management

Year 3: Recognition for Master in Quality Management even Philippine Quality Award for Performance Excellence

Objectives:

  1. To formulate a master design and development plan on establishing and developing a well-defined integrated system in which all the requirements of the following local and international quality and performance standards are complied with.
  2. To deploy the approved master design and development plan across and at all levels in the hospital.
  3. To evaluate and continually improve the master design and development plan  to ensure sustainable achievement of full compliance to the standards.

Critical Success Factors:

  1. Presence of a master design and development plan (MDDP) on establishing and developing a well-defined integrated system in which all the requirements of the following local and international quality and performance standards are complied with.
    1. Presence of a document containing the MDDP approved by top management
    2. b.      Presence of an integrated checklists on all the requirements of the standards
    3. Presence of deployment of the approved MDPP.
      1. Presence of a deployment plan – leadership, managership, communication and education with needed infrastructure
      2. Evidence of effective deployment across and at all levels in the hospital
      3. 3. Presence of monitoring, evaluation, and continual improvement plan on the implementation of the MDDP.
        1. Presence of a monitoring, evaluation and continual improvement plan
        2. Evidence of effective implementation of the monitoring and continual improvement plan

 

 

 

 Expected Outputs:

See Goal and Objectives

See Key Success Indicator and Critical Success Factors

Integration with the other strategic objectives

Expected Impact:

Performance excellence for the hospital

Improved hospital performance, practices, capabilities, and results

Evaluation:

Based on goals and objectives / key success indicator and critical success factors and expected outputs and impact

Based on PQA assessment methods:

PROCESS

Approach – master design and development plan

Deployment – across and all levels

Learning – evaluation and new learnings and innovations

Integration – integration with the other strategic objectives

RESULTS

Level – level of achievement (PQA)

Trend – increasing level of PQA and PhilHealth recognition over 3 years)

Comparison – best compared with other hospitals (local, regional, national, international)

Integration- integration with the other strategic objectives

Action Plan (Draft and Sample):

Y1 Y2 Y3 Remarkswith persons-in-charge
Planning
Master Design and Development Plan November 17, 2012
Presence of an integrated checklists of all the agreed standards
Approved by Top Management November 24, 2012
Deployment
Communication December 2012
Education and reinforcement on Education  –  January to June, 2013 Reinforcement – January to June, 2014 Reinforcement – January to June, 2015
Baldrige /PQA
ISO
PhilHealth Benchbook
PH regulatory and statutory requirements
JCI / ACI
Investors in People
Monitoring All year round All year round All year round
Evaluation and Continual Improvement August August August
Application for PQA
Application for PhilHealth Benchbook

Budget:  Mainly on the educational activities (to be integrated with the other strategic objectives action plans

Task Team Compliance to Quality and Performance Standards

Members:

Chairperson of the Board of Directors

President

Senior Management

or Executive Committee

or Management Committee

Situational Analysis – Baseline

NO master design and development plan

NO integration

NO training

Challenges:

Buy-in of staff

Strategies for Implementation

Leadership

Managership

Communication

Education

To be continuously refined – 12nov1

 

 

 

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