Patient and Family Rights (PFR) : Hakpasiendankeluarga

Patient and Family Rights (PFR)
Hak Pasien dan Keluarga
6th Edition | Effective 1 July 2017

KFSH&RC provides the highest
level of specialized healthcare in
an integrated education and
research setting.
It is important to have a culture of :
Quality
Patient safety
Continuous Improvement
JCIA accreditation is designed to create that culture.

Objectives
Re-akreditasi JCI
 JCI mempersyaratkan re akreditasi setiap 3 tahun

 Setiap tahun akan ada kunjungan untuk menilai kelangsungan proses
peningkatan mutu
 Setiap reakreditasi diharapkan ada peningkatan mutu yang
berkesinambungan
RS YANG SUDAH JCI HARUS:
 Continous quality Improvement

 Monitoring dan evaluasi terus menerus untuk menilai implementasi standar
 Capacity building dan Pendidikan Kedokteran Berkesinambungan bagi staff medis
untuk
meningkatkan kemampuan seluruh staf
Hak Pasien dan Keluarga
terkait komplain, konflik, dan perbedaan pendapat
Standar GLD 6 – GLD 6.2
2008 JCIA Survey visit findings
6
Documentation
 H&P form (Admission Notes) use.
 Procedural Sedation Assessment form

completion (Endoscopy).
 Pain documentation.
 D4 Chronic Patients Weekly Assessment.

Documentation
 Authentication of telephone orders.
 PRN order for Restraint.
 Inconsistency in ASA score documented for

the same patient.
 Renewed orders completion (e.g. cont

fentanyl)
Documentation
 Consultants co-signature on Residents

entries as hospital policy states
 Date documentation in the progress notes
 Significant Medical Record Documentation

issues: Timeliness, Eligibility, Completeness
Practice & Documentation
 ASA Score of III accepted for procedural

sedation in Outpatient w/o explanation
 Inconsistency in the location of documenting

site marking (tooth) in dental clinic
 Patient discharged from post anesthesia unit

w/o physician order
Standards Changes
Quality Management is currently

working with concerned departments
and staff to implement the required
policies & processes for the standards
changes
At least 5 Clinical
Measures
should be chosen from
(International Library of International
Measures) Library of Measures
 Heart Failure (HF)

 Stroke (STK)
 Children’s Asthma Care (CAC)
 Hospital-Based Inpatient Psychiatric Services (HBIPS)
 Perinatal Care (PC)
 Pneumonia (PN)
 Surgical Care Improvement Project (SCIP)
 Venous Thromboembolism (VTE)
 Acute Myocardial infarction (AMI)
 Nursing Sensitive care (NSC)
Standards Changes
(International Patient Safety Goals (IPSG))
 IPSG – stay the same but more emphasis on monitoring

1. Identify Patients Correctly
2. Improve Effective Communication
3. Improve the Safety of High-Alert Medications (IPP list)
4. Ensure Correct Site , Correct- Procedure , Correct –
Patient Surgery
5. Reduce the Risk of Health Care Associated Infections
6. Reduce the risk of patient harm resulting from falls
(High Alert Medication Policy)
(High Alert Medication Policy)
Standards Changes
Standards Changes
(Patient and Family Rights – PFR)
 Patient’s right to seek a second opinion without fear
 Consent is obtained in a language the patient can

understand
 Process to respond to patient’s request for additional

information on the practitioner
 The organization obtains informed consent from live

donors
Standards Changes
Standards Changes
(Patient and Family Rights – PFR)
 Patient’s right to seek a second opinion without fear
 Consent is obtained in a language the patient can

understand
 Process to respond to patient’s request for

additional information on the practitioner
 The organization obtains informed consent from

live donors
Standards Changes
(Access to Care and Continuity of
Care – ACC)
 Patients with emergent, needs are given priority for

assessment and treatment.
 The clinical records of outpatients receiving continuing
care contain a summary of all significant diagnoses,
drug allergies…etc
 Follow-up process for patients who leave against
medical advice.
 Planning to meet the patients’ transportation needs.
 Medication reconciliation upon admission.
 The planned care is documented in the record in
the form of measurable progress (goals) & updated
based on assessment
 The care planned is reviewed and verified by the

responsible physician.
 The post-surgical plan is documented by the
responsible surgeon or verified by the responsible
surgeon
 The plans of care are documented within 24 hours

of surgery.
 The anesthesiologist are identified in the patient’s

anesthesia record.
Standards Changes
(Staff Qualification and Education-SQE)
 Each medical staff member provides only those

services that have been permitted by the
organization.
 Have a uniform process (defined by organization

policy for ongoing professional practice evaluation &
(at least) annual review on quality & safety of
services
Standards Changes
(Staff Qualification and Education-SQE)
 Uses comparative data such as benchmarking to

literature-based medicine.
 Use conclusions of in-depth analysis of known

complications as applicable.
 Feedback to staff.
Your role as a Quality Director
Reinforce the following to department members:

 Patient Safety.
 Safety reporting (SRS).
 Applying Infection Control Measures.
 Promote the Just culture.

Documentation :
(Not documented, Not completely done !!)
 Identify documentation compliance issues in your
area (i.e. insufficient computers, training..etc ) and
work with Chairman for solutions.
 Review tracer reports & Quarterly documentation

reports. Discuss results with the concerned staff.
Medical Staff files, Ensure that :
 Staff privileges are up to date
 Saudi Commission registration completed
 Life Support certification is completed
 Fire training completed

Reference: Joint Commission
 Evaluations International Accreditation Hospital
Survey Process Guide
Page 67
Departmental education on :
 New JCIA standards
 Hospital policies related to physicians.

Quality Management Educational Role
 Help directors to provide JCIA visit update in

departments’ meetings.
 Provide Educational material for directors.
 Prepare Readiness Tips.

Thank You

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Patient and Family Rights (PFR)

Hak Pasien dan Keluarga

6th Edition | Effective 1 July 2017

JCIA accreditation is designed to create that culture.

 JCI mempersyaratkan re akreditasi setiap 3 tahun

RS YANG SUDAH JCI HARUS:

 Continous quality Improvement

 H&P form (Admission Notes) use.

 Procedural Sedation Assessment form

 D4 Chronic Patients Weekly Assessment.

 Authentication of telephone orders.

 PRN order for Restraint.

 Inconsistency in ASA score documented for

 Renewed orders completion (e.g. cont

 Consultants co-signature on Residents

 Date documentation in the progress notes

 Significant Medical Record Documentation

Practice & Documentation

 ASA Score of III accepted for procedural

 Inconsistency in the location of documenting

 Patient discharged from post anesthesia unit

Quality Management is currently

 Heart Failure (HF)

 IPSG – stay the same but more emphasis on monitoring

 Consent is obtained in a language the patient can

 Process to respond to patient’s request for additional

 The organization obtains informed consent from live

 Consent is obtained in a language the patient can

 Process to respond to patient’s request for

 The organization obtains informed consent from

 Patients with emergent, needs are given priority for

 The care planned is reviewed and verified by the

 The plans of care are documented within 24 hours

 The anesthesiologist are identified in the patient’s

 Each medical staff member provides only those

 Have a uniform process (defined by organization

 Uses comparative data such as benchmarking to

 Use conclusions of in-depth analysis of known

Reinforce the following to department members:

 Promote the Just culture.

 Review tracer reports & Quarterly documentation

Medical Staff files, Ensure that :

 Staff privileges are up to date

 Saudi Commission registration completed

 Life Support certification is completed

 Fire training completed

 New JCIA standards

 Hospital policies related to physicians.

 Help directors to provide JCIA visit update in

 Provide Educational material for directors.

 Prepare Readiness Tips.

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