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LD.1 The hospital has an effective governing body.
LD1.1 There is a governing body that fulfills its main roles for mission and strategy setting as well as performance evaluation and oversight of the hospital processes and outcomes.
Explanation:
The Board of an organization is the group that is above all responsible for making sure that the organization's mission continues to be carried out, and that the organization never strays very far from its true focus. It also, in general has the overall legal accountability for the conduct of the organization.
Developing a governing body system or bylaws with specific responsibilities and procedures has many advantages:
LD.2 A qualified hospital director is responsible for managing the hospital.
LD.2.1 The hospital director is qualified in healthcare management by education, training or experience.
LD.2.2 The hospital director ensures the availability of adequate resources (e.g. human resources, equipment, supplies, and medications).
LD.2.3 The hospital director participates actively in supporting the safety of patients, staff and visitors (e.g.
through leadership safety rounds, and review of reported incidents).
The hospital director (HD) has a legal and moral obligation to improve the quality of patient care. HD is in a prime position to mandate policies and procedures, rules, regulations, and organizational climates. To coordinate the functions of all departments and ensure their proper function, the hospital director must hold a wide set of skills and knowledge including a degree in healthcare administration and experience working in a senior healthcare position.
LD.3 Hospital leaders work collaboratively to develop the hospital's scope of services.
LD.3.1 Hospital leaders identify the scope of services provided by the hospital.
Hospital scope of services is a structural measure that reflects whether a hospital has the resources, facilities, staff, and equipment to provide care for the medical conditions it recognizes to treat or to care for the medical conditions affecting potential patients
LD.4 A structure is in place for the hospital leaders to communicate and collaborate in order to fulfill the hospital's mission and plans.
LD.4.1 Hospital leaders have specific responsibilities as outlined in a current job description.
The Hospital leader's role is to ensure the effective steering, coordination and control of organization business. Hospital leaders shall include the hospital's leaders of different services as well as main departments' heads and senior staff members as determined by the hospital director. To ensure proper and scientific management of the day to day services provided, the hospital leadership group members must have a background in healthcare management as evidenced by education, training, or experience and their responsibilities must be clear in a written approved job description.
LD.5 The hospital administrative work and day-to-day operations are consistent and organized.
LD.5.1 The hospital work is guided by a manual that contains all important hospital-wide guiding administrative policies and principles.
LD.5.2 The contents of the manual are communicated with and made accessible to the hospital staff.
Hospital operations and staff practices should be regulated and organized by sets of policies and procedures and work protocols within the boundaries of laws and professional regulations to maintain and sustain systematic acceptable practices.
These organizational policies and/or procedures is considered administrative in content, may direct a different level of management and reflect the philosophy and objectives of the hospital that affect all departments are called administrative policies and procedures.
These administrative policies and procedures are compiled in a manual. This manual must be accessible to all hospital staff physically (hard copy or electronic) and in a language they can read and understand.
LD.6.1 The hospital has a committee chaired by the hospital director or medical director and includes the heads of clinical departments, to ensure that they work together to coordinate the provision of care.
LD.6.1.1 The committee meet at least three times at the beginning, during and closing of the season.
LD.6.1.2 The committee provides direction and support to all clinical and medical departments within the hospital to ensure the delivery of high-quality patient care.
LD.6.1.3 The committee monitor the performance of medical and clinical department staff and ensures the implementation of policies and procedures.
LD.6.1.4 The committee discuss and takes the necessary decisions regarding medical services (mortality and morbidity review, medication management, blood utilization, OR utilization, infection control) and other relevant services
LD.6.1.5 The committee provides supervision and guidance for the development of standardized crash cart content, storage, distribution and monitoring.
LD.6.1.6 The committee defines the function and composition of the CPR cardiopulmonary Resuscitation Team training requirements and makes sure of the availability of resources for patients/visitors/staff experiencing cardiopulmonary arrest/medical emergencies.
LD.6.1.7 The committee ensures the development and implementation of policies that govern the review of tissues removed during surgeries and develops methods that guarantee that they are in place.
LD.6.1.8 The committee provides oversight on formulary management addition and deletions, the medication management plan including drug recall, off-label use, medication error and adverse drug reaction.
LD.6.1.9 The committee reviews all sentinel events occurrence variances, medication errors, root cause analysis (RCA) and improvement projects monitoring and implementation.
LD.6.1.10 Hospital leaders support the training and awareness programs related to policies, procedures, committee recommendations and improvement plans.
LD.6.1.11 The committee sets rules and guidelines for governing the eligibility requirements for credentialing and privileging of medical and clinical staff allowed to practice during season.
LD.6.1.12 The committee provides oversight of the infection prevention and control program, reviews the hospital infection prevention and control policies, and procedures during the season and makes recommendations for action plans.
LD.6.1.13 The committee approves all new medications, products, equipment, materials and required supplies needs to deliver safe and high-quality services.
LD.6.2 The committee has terms of reference that define:
LD.6.2.1 Committee functions.
LD.6.2.2 Chairperson and members with their titles.
LD.6.2.3 Quorum.
LD.6.2.4 How often the committee is expected to meet during the season.
LD.6.2.5 Mechanism for disagreement resolution including when to resort for voting and members that are not allowed to vote.
LD.6.2.6 Distribution of the minutes to the executive management.
Participation is a corner stone of the concept of quality management, and team work is an essential aspect of participation. Therefore, collaboration among hospital leaders and staff through hospital-wide committees and task forces to plan, decide, and monitor clinical and non-clinical services is essential for improving services. Those committees are expected to support using research and best practices to solve challenges and improve patient care services. Hospital Committees are regular standing multidisciplinary groups that deemed necessary by hospital administration in formulating policies, coordinating and monitoring hospital-wide activities that are considered critical in the delivery of quality health care services.
Committees assist the governing board by bringing reports and recommendations for the board action. They only final decisions a committee may make are those for which the full board has granted authority to the committee.
"As health systems grow larger, more boards are delegating certain decisions to committees," according to The American Hospital Association's Center for Healthcare Governance. Thus, it's critical for committees to keep the full board informed to avoid becoming a "board within a board."
According to the size of the hospital and diversity of services provided, each function can be discussed in one separate committee or multiple functions can be under one committee. Most committees with one function responsibility work well with five to seven members. Committees that have broader responsibilities and functions may be a bit larger and include more stakeholders.
LD.7 Hospital leaders work collaboratively to ensure the provision of safe and quality care.
LD.7.1 Hospital leaders work collaboratively to solve challenges, conflicts, and problems affecting patient care.
Participation is a corner stone of the concept of quality management, and team work is an essential aspect of participation. Therefore, collaboration among hospital leaders and staff through hospital-wide committees and task forces to plan, decide, and monitor clinical and non-clinical services is essential for improving services. Those committees are expected to support using research and best practices to solve challenges and improve patient care services.
LD.8 Hospital leaders work collaboratively to develop the hospital's strategic plan.
LD.8.1 Goals and objectives are translated into operational plans with defined projects, clearly delineated responsibilities, and time frames.
LD.8.2 Resources required for executing the operational plans are properly allocated.
LD.8.3 Operational plans are implemented and closely monitored for progress toward achieving the goals and objectives.
LD.8.3.1 Key performance indicators are developed for each operational plan.
LD.8.3.2 Key performance indicators are reviewed regularly and corrective actions are taken when required.
Achieving organization's mission requires generating short and long-term objectives. Strategic planning is the process of developing organizational objectives, strategies and tactics to achieve the mission of the organization. Strategic plans often mean a change in organizational structure or a move toward change. Change can be a difficult process and requires time, therefore, it is important for leaders to get employees on board with the change and decision-making processes. Hospital leaders are to ensure all planning activities (departmental plans) of the organization are in line with the strategic plan. Operational plans should reflect hospital performance in achieving its strategic goals and accomplishing its mission.
LD.9 Hospital leaders work collaboratively to plan for staffing needs, recruitment, and selection.
LD.9.1 Hospital leaders work together to develop a hospital-wide staffing plan.
LD.9.2 The staffing plan defines the total number and categories of staff required by all departments and their qualifications.
LD.9.3 The staffing plan ensures the services provided by staff meet the health care needs of the patients.
Leadership group function includes a variety of activities, and key among them is deciding what staffing needs they have and whether to use independent contractors or hire employees to fill these needs, recruiting and training the best employees, ensuring they are high performers, and ensuring the personnel and management practices conform to various regulations. Investment of people requires an equally significant approach to manage it. Having a strategic plan for the hospital staffing needs and decisions allows you to organize and account for demands in personnel while keeping organizational goals and vision in the forefront.
LD.10 The hospital has a process for delegation of function and authority.
LD.10.1 There is a policy and procedure that guides the process for delegation of function and authority between two qualified peers.
LD.10.2 The process of delegation is consistent with other relevant hospital policies.
A manager alone cannot perform all the tasks assigned to him. In order to meet the targets, the manager should delegate authority. Delegation of authority means division of authority and powers downwards to the subordinate. Delegation is about entrusting someone else to do parts of your job. Delegation of authority can be defined as subdivision and sub-allocation of powers to the subordinates in order to achieve effective results. Authority can be defined as the power and right of a person to use and allocate the resources efficiently, to take decisions and to give orders so as to achieve the organizational objectives. Authority must be well- defined. All people who have the authority should know what is the scope of their authority is and they shouldn't mis utilize it. Authority is the right to give commands, orders and get the things done. The top-level management has greatest authority. Authority always flows from top to bottom. It explains how a superior gets work done from his subordinate by clearly explaining what is expected of him and how he should go about it. Authority should be accompanied with an equal amount of responsibility. Delegating the authority to someone else doesn't imply escaping from accountability. Accountability still rest with the person having the utmost authority.
LD.11 Hospital leaders ensure effective and efficient internal and external communication.
LD.11.1 The hospital implements a policy that outlines the process, including roles and responsibilities, for communication between the different departments, both vertical and horizontal.
LD.11.2 Hospital-wide policies are properly communicated to all relevant staff.
LD.11.3 The hospital utilizes one or more of professional communication tools (e.g., intranet, bulletin boards, reports, newsletters and website).
LD.11.4 The hospital implements a policy that outlines the process, roles and responsibilities for handling all incoming requests from other hospitals and external organizations.
LD.11.5 The response to the incoming requests is timely and informative.
To coordinate and integrate patient care, the leaders develop a culture that emphasizes cooperation and communication. The leaders develop formal (for example, standing committees, departmental meetings, joint teams) and informal (for example, newsletters, posters) methods for promoting communication among services, and individual staff members. Coordination of clinical services comes from an understanding of each department's mission and services of each department and collaboration in developing common policies and procedures. Throughout all phases of care, patient needs are matched with appropriate resources in and, when necessary, outside the organization. This is usually accomplished by using established criteria or policies that determine the acceptance of requests from outside organization. Incoming requests may include: medical reports, sick leaves confirmation, patient transfer, medical consultations, among others.
LD.12 Initiation of a new process or changing of an existing one is systematic and consistent throughout the hospital.
LD.12.1 Hospital leaders ensure that the initiation of a new process or the changing of an existing one is always based on evidence, research, and best practices.
LD.12.2 Hospital leaders assess new or modified processes for risk and safety issues.
LD.12.3 Hospital leaders regularly evaluate new or modified processes through process and outcome indicators to ensure optimal performance.
LD.12.4 Hospital leaders ensure the provision of staff training on new or modified processes.
Proper coordination and communication are required whenever change happen to processes or work regulations or a new process is planned to be implemented. Systematic approach or methodology must be identified to be followed in these two situations. The approach should include identification of internal and external process customers and their needs, risk assessment, be evidence based, piloting, and regular evaluation after full implementation. Changes must be communicated to all staff after adequate coordination with all units and staff that have input in the process.
LD.13 The hospital has a policy for controlling the development and maintenance of policies and procedures for key functions and processes.
LD.13.1 Policies are developed, approved, revised and terminated by authorized individuals.
LD.13.2 Policies are dated and are current.
LD.13.3 Policies are revised according to a defined revision due date (every 2-3 years or when required).
LD.13.4 Policies are communicated to staff and are always accessible.
The hospital has to agree on a system to provide definitions of working documents used in delivery and support of care and to set guidelines for developing the hospital policies and procedures' approval, distribution, review, revision, termination and to provide the formats or frameworks used in administrative and patient care policies and procedures.
LD.14 Hospital leaders ensure the overseeing of contracts for clinical and administrative services.
LD.14.1 Policies and procedures are in place to ensure the quality and safety of all contracted services.
LD.14.2 Policies and procedures indicate how to track and monitor all contracted services for quality and safety within the hospital premises and off-site.
LD.14.3 Hospital leaders ensure that the contracts clearly state the services to be provided by the contracted entity.
LD.14.4 Hospital leaders ensure that contracted services and providers both meet applicable laws and regulations.
LD.14.5 Hospital leaders ensure the services provided are consistent with the hospital's quality and safety standards.
LD.14.6 The process for contract oversight is documented.
Outsourcing involves contracting out of a business process or service to another party for different reasons including the willingness to focusing on the core business, cost saving, or reducing operational burden. Technology advancement has made outsourcing more common as professional expertise are made available and accessible to be contracted from anywhere in the world. The purpose of outsourcing should not jeopardize the quality of contracted services or patient and staff safety. Hospital leaders should ensure the selection of best contractors and continue monitoring the services they provide to ensure that they are consistent with the hospital quality and safety standards. Currently, outsourcing takes many forms. Organizations hire service providers to handle distinct business processes or whole operations. The most common forms of outsourcing in hospitals are information technology, housekeeping, catering, security, waste disposal, some laboratory tests, and bio-med and general maintenance.
LD.15 Hospital leaders ensure there is a system for the safe management of medical supplies and devices.
LD.15.1 Hospital leaders and relevant heads of departments identify all medical supplies and devices that are essential for the provision of safe, quality care.
LD.15.2 Medical supplies and devices are stored safely and in accordance with the manufacturer's recommendations.
LD.15.3 Medical supplies and devices are protected against theft, damage, contamination, or deterioration.
LD.15.4 Hospital leaders respond to any adverse effects resulting from the use of medical supplies and devices through prompt investigation and the use of recurrence prevention measures.
LD.15.5 Hospital leaders ensure the reporting of adverse effects resulting from the use of medical supplies and devices to the relevant regulatory authorities.
LD.15.6 The hospital has a process for safe segregation and disposal of expired, damaged, or contaminated medical supplies and devices.
LD.15.7 The hospital has a process to retrieve dispensed supplies and devices when recalled or discontinued by the manufacturer or relevant regulatory authorities for safety reasons.
Hospital services must ensure patient safety and proper utilization of the available resources by imposing safe management of medical supplies and devices. The safe management of supplies and devices begins with the proper selection of qualified suppliers and protection of supplies from damage and theft and deterioration. It also includes responding and reporting of adverse effect resulting from use of devices, as well as protecting staff and patient when those devices are damaged or contaminated.
LD.16 Hospital leaders work collaboratively to optimize the flow of patients.
LD.16.1 Customers' needs and feedback are addressed when designing a new process (e.g., a new procedure or a new practice guideline) or changing an existing one.
LD.16.2 Hospital leaders implement strategies to maximize the efficiency of the flow of patients.
Optimizing patient flow means moving patients smoothly through acute care settings. This is part of proper utilization of resources which include optimizing the flow of patients in different hospital department (such as operation rooms, emergency department, and clinics) and between the hospital and other acute care settings. This includes minimizing patient and staff waiting time and cancelling of scheduled services. Hospital leaders' efforts in this regard must include evaluating patient flow, testing changes for improvement, and measuring results.
LD.17 Each clinical and administrative department is directed by a qualified individual.
LD.17.1 Each department has an assigned department head.
LD.17.2 Qualifications, experience and training of the appointed department head match the services provided by the department.
The departments' heads are the key individuals to put hospital plans in action. Effective leadership of departments is therefore of critical importance. Appropriate qualifications matching the scope of the department's services are essential and one of the quality foundations.
LD.18 The department head develops and maintains the mission of the department and its scope of services.
LD.18.1 The department head provides a written scope of services provided by the department that is consistent with the hospital's scope of services.
LD.18.2 The department head ensures coordination and integration of services within the department and with other departments.
A Mission Statement defines the department's purpose and primary objectives. Its prime function is to define the key measure or measures of the department's success and its prime audience is the leadership team and stockholders. Mission statements are the starting points of the department's planning and goal setting process. They focus attention and assure that internal and external stakeholders understand what the department is attempting to accomplish. The departments' heads also determine the scope and intensity of the various services to be provided by the departments directly or indirectly. Scope of services helps the head to make sure that policies and procedures and staff competencies are consistent with their scope of service and aspects of care. Departments that lack the ability to coordinate and integrate plans and services act like a body without a head. Though employees have the ability and skill sets necessary to carry out directives, their work needs guidance. Coordination and integration start at the executive level and carries down to the workers at the front line of all departments.
LD.19 The department head ensures the work of the department is guided by a clear set of departmental policies and procedures.
LD.19.1 The department head develops and maintains a manual for all relevant departmental policies and procedures.
LD.19.2 The department head collaborates with other department heads to develop multidisciplinary policies and procedures.
LD.19.3 The department head ensures and oversees the communication of policies and procedures to relevant staff and their implementation.
The department head is directly responsible for planning, organizing, executing, and controlling of services in the department. Organizing department services includes developing departmental policies and procedures and communicating them to staff. Well-written policies and procedures allow employees to clearly understand their roles and responsibilities within predefined limits. Basically, policies and procedures allow management to guide operations without constant management intervention.
LD.20 The department head ensures sufficient resources and staffing are available for the delivery of safe and quality service.
LD.20.1 The department head defines and requests the resources required by the department for a safe and quality service (e.g., space, equipment, supplies, staffing and other resources).
LD.20.2 The department head provides a written departmental staffing plan that defines the number, type and qualifications required for each position to fulfill the department's responsibilities.
LD.20.3 The department head defines the qualifications (education, training, experience, license, and any other relevant certification) required by all categories of staff in the department.
LD.20.4 The department head ensures the provision of orientation, training and continuing education for the staff working in the department.
LD.20.5 The department head monitors the performance of the staff.
The department head is directly responsible for planning, organizing, executing, and controlling of services in the department. Department heads are responsible for ensuring the availability of the required manpower and other resources to execute department plans and enforce the implementation of hospital-wide and departmental policies. His responsibility about the manpower resources starts with determining number of staffs required and their qualifications, selection, orientation, training, and monitoring of their performance.
LD.21 The department head ensures performance measurement and improvement of the outcomes of the department.
LD.21.1 Performance measurement and improvement are consistent with the hospital-wide quality improvement, patient safety and risk management plans.
LD.21.2 Performance measurement and improvement are based on the important processes and priorities of the department.
LD.21.3 The department head selects and monitors the appropriate performance indicators
LD.21.4 Performance measurement and improvement involve regular data collection, analysis and appropriate improvement actions/projects.
LD.21.5 Results of performance measurement and improvement are reported to the hospital leadership at the end of the season (e.g., the quality improvement committee) and shared with staff, departments, and committees as applicable.
Department outcome measurement is one of the most important activities that department head has to do. There are several compelling reasons to measure outcomes:
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Last update: 01 October 2024
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