Advisory services & accreditation

Advisory Services

Quality Assessment for Healthcare Facilities
a. Healthcare Quality Assessment for Hospitals:
Quality assessment includes an in-depth examination of the quality practices, framework, and procedures, in order to further interrogate some of the patterns emerging from the rapid assessment and have a closer look at the existing quality structures. The assessment will be based on a Healthcare Quality Toolkit jointly developed with JCI and incorporates “core” international standards.
The assessment can be delivered in one of the following options as described below: Option A: cover 8 standards
Option B: cover 12 standards

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Option A
-International Patient Safety Goals
-Ethics, Patient & Family Rights
-Medication Management & Use
-Quality Improvement & Patient Safety
-Prevention & Control of Infections
-Governance, Leadership & Direction
-Facility Management & Safety
-Human Resources
We recommend this option for facilities that haven’t previously been exposed to external evaluation of quality and patient safety. It provides a balanced overview and prioritize quality improvement plan for the first year in the quality journey. The assessment is typically completed by one specialist.

Option B

In addition to the eight areas listed above the review will cover four additional clinical standards:
-Access to Care & Continuity of Care.
-Anesthesia & Surgical Care.
-Assessment of Patients.
-Care of Patients.
We recommend this option in case the medical facility has been implementing healthcare quality and patient safety standards for at least a few years and/or been previously exposed to external assessments and improvement program. It is typically performed by at least two specialists.
b. Healthcare Quality Assessment for Laboratories:
Assessment for Laboratories is based on Healthcare Laboratory Quality Toolkit aligned with ISO 15189/190 standards. The review will assess compliance of AMG Laboratories to 98 measurable elements in 3 key areas and 27 standards:

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# Key Area Standards
1 Management Requirements • Organization and management responsibility
• Quality management system
• Document control
• Service agreements
• Examination by referral laboratories
• External services and supplies
• Advisory services
• Resolution of complaints
• Identification of non-conformities
• Corrective action
• Preventive action
• Continual improvement
• Control of records
• Evaluation and audits
• Management review
2 Technical Requirements • Personnel
• Accommodation and environmental conditions
• Laboratory equipment, reagents, and consumables
• Reagents and consumables
• Pre-examination processes
• Examination processes
• Ensuring quality of examination results
• Post-examination processes
• Reporting of results
• Release of results
• Laboratory information management
3 Safety Requirements • General considerations
• Hazards
• Emergency preparedness and response
• Fire safety
• Laboratory ergonomics
• Equipment safety
• Safe personal practices
• Personal protective equipment
• Transport of samples and hazardous material
• Waste disposal and house keeping
• Incidents, injuries, accidents, and occupational illnesses
c.Healthcare Quality Assessment for Radiology Centers:

Assessment for Radiology Centers combines the general patient safety assessment as per above with international imaging standards for specific modalities. The scope will be chosen on modalities in use of radiology operations. The international medical imaging quality standards¬ include specific requirements for clinical and phantom images for each modality of radiology services. The standards relate to patient information, diagnostic quality, examination appropriateness, clinical diagnoses, results reporting. They also guide follow-up procedures and data collection. The specific standards that affect quality of patient care in diagnostic imaging include:

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# Key Area Standards
1 MRI • Equipment and maintenance
• Performance
• Environment Safety
• Patient Safety
• Report Structure
2 Ultrasound • Equipment and maintenance
• Performance
• Patient Safety
• Report Structure
3 Mammography • Equipment and maintenance
• Performance
• Record Keeping
4 CT • Equipment and maintenance
• Performance
• Environment Safety
• Patient Safety
• Report Structure
5 Nuclear Medicine • Equipment and maintenance
• Performance
• Environment and Personal Safety
• Patient Safety
• Radiopharmaceuticals
APPROACH The quality assessment process includes the following:

Step 1: Preparation and briefing of the local teams at the assessed hospital/medical facility and sharing of required documentation. This involves organizing the schedule, interview list, and sharing and review of required documentation. We jointly finalize the schedule, interview list, and the documentation required. It’s recommended to assemble a team and assigning a “champion” to head this team will ensure the engagement of staff. The assessment will be optimized if all members contribute their knowledge and skills. The team of internal champions is essential for internalizing the quality and patient safety requirements that we share during the assessment.

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Step 2: On-site assessment We would expect the assessment against the Healthcare Quality Toolkit for Hospital/Laboratory/Radiology Centres to take place over 2-6 days (depending on the number of standards to be covered). The assessor(s) will work closely with your Quality Manager/Team (or similar) going through the Assessment. Activities will include review of documents, interview of managers and front-line staff, inspection of the facilities and observation of activities in the hospital.

Step 3:Feedback, reporting, and support in action plan development. We will provide a verbal report and presentation of preliminary score and key conclusion at the end of the Assessment. This will be followed by a detailed written report and final presentation to the management.
Our team will set up a meeting to present and discuss final results, key conclusions, and recommendations with the management. Together, we will develop a detailed Action Plan for broader improvement of quality and preparation for full assessments. This will include key tasks, allocation of responsibilities, and timeframe for development of policies and procedures and other tasks.

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Step 4: Progress review session. Our team will conduct a virtual progress review session 6-9 after the initial assessment to discuss the achieved results, implementation challenges and how to address them.

DELIVERABLES

The preliminary results of the Assessment will be communicated with your team at the end of the assessment week to allow you to ask questions and provide immediate feedback.
The main deliverable will be a structured and evidence-based written report (a summary report and a scoring table) assessing chosen facilities against each of the core international standards. Specifically, it will identify any significant gaps and priority areas to include in the facility’s Quality Improvement Plan.
The report will be provided in draft prior to finalization. Our team will set-up a debrief meeting to present and discuss final results, key conclusions, and recommendations with the management. We can also deliver three virtual sessions to support the healthcare facility’s team with the implementation of recommendations. The sessions will cover the following:
- How to Structure Quality Improvement Plan Effectively?
- How to Measure Quality Assurance/Improvement?
- A progress review session ~6-9 months after the initial assessment
We observed that medical facilities that implement quality improvement work as a ‘do-it-yourself’ exercise may not be able to resolve all issues with equal effectiveness, and certain results take longer to achieve. Our experience also shows that external guidance and advise from experienced practitioners help to overcome the delays, and progress reviews help to manage and implement the improvement plans well.
The deliverable from the Hospital Design Layout Review will be a Summary Review Report that shall specify concern areas and remedial suggestions. It will also include indicative conceptual layouts of suggestions that will be shared to get a clarity on preferred option whenever possible. The reports will be provided in draft prior to finalization. Our team can organize a video conference to present and discuss final results, key conclusions, and recommendations with the healthcare facility management.

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APPROACH Our approach is to work in a way which is visible and interactive with your staff to ensure knowledge transfer and enable the healthcare facility to bridge existing priority gaps. Under implementation support, we propose to work closely with the healthcare facility team through conducting a number of training/coaching sessions over an agreed period of time (i.e. 12-18 months), according to the needs based on the results of the assessment. In order to transfer knowledge and support with improving compliance with relevant quality and safety standards. The support can be instrumental in case the healthcare facility would like to pursue international accreditation for some of its operations.
Healthcare Quality Advisory implementation support can be a combination of:
i. practical working sessions aimed to help with interpretation of requirements of standards to specifics in operations;
ii. delivering training on topics where gaps of knowledge is observed;
iii. advisory support to improve policies and procedures and;
iv. progress review sessions with ourspecialists to discuss practical solutions to challenges to address implementation challenges to drive the desired change in performance.

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APPROACH The review will cover the following issues:
1. Understanding the Service-Mix and Speciality-Mix of the facility and check its alignment with Facility-Mix and Bed-Mix.
2. Review of design of clinical services, patient facilities, back-of-the-house, administrative and support departments in terms of:
• Comprehensive planning
• Departmental sizes
• Departmental Adjacencies
3. Assessment of flow with respect to:
• Accessibility & Access Control for specific and different hospital functions
• Streamlined Horizontal & Vertical Circulation:
- Accident & Emergency
- Diagnostic & Clinical departments
- Out-patient & Visitors
- In-patient & Staff
- Material supply, Food & Services
- Bio-Medical Waste Management
- Engineering Services & Parking
4. Review of internal layouts of departments with respect to:
• Appropriate zoning
• Adequacy of concept in relation to equipment & functional furniture stack
• Equipment rigging path
5. Phasing of the hospital project (if any):
• Greenfield, cold, warm or operational
6. High-level review of MEP
Please note that the following element are NOT included the scope of the review:
• Equipment planning & adequacy (i.e. Kitchen, Laundry, CSSD)
• MEP detail design (like load calculation)/ space provisions/ compliance with prevalent
• Firefighting norms

DELIVERABLES/ OUTCOMES

The main deliverable of the module will be interactive training/coaching sessions and provided materials for staff. The scope of implementation support and mix of training and coaching workshops will be agreed upon with the AMG, depending on the gaps and critical areas identified through the quality assessments or selected by management of the company.
Hospital Design Layout Review
The Hospital Design Layout Review aims to identify potential infrastructure challenges and provide recommendations on how to prevent/address these challenges in the most cost-effective manner. The review shall be done in context of:
• Infection Control
• Evidence-based design
• Patient & Staff Safety & Rights
• Efficient Hospital & Clinical Operations
• Facilities mandated by regulatory bodies will be reviewed in context with the national guidelines

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VALUE ADDED This proposed approach has several important advantages for you:
• Provide you with a transparent overview of where you stand in implementation of good quality and patient safety practices across the organization.
• Identify any potential urgent issues or areas of clinical risk management exposure.
• Support development of an evidence-based Quality Improvement Plan with clear objectives for your team.
• Identify Quality Champions and transfer of knowledge and skills to your staff.
Throughout the process, we focus on providing solutions rather than highlighting any shortcomings. We use our experience of working in emerging markets to develop practical and cost-effective solutions in this regard. In the medium/ longer term, adoption of such standards will help the healthcare facility in several ways – not only to develop/enhance corporate processes, but also to minimize clinical risk, efficiently utilize resources