A strong and unwavering commitment to safety and quality results in demonstrable benefits, not only for patients but for the organization including less complications and deaths, lower costs, greater efficiency and improved clinical outcomes.
A major component of the Hospital’s Quality Management and Improvement priority will focus on accreditation. In February 2016, an initiative called ‘A.I.M. High for Excellence and Quality’ was launched. The acronym ‘A.I.M.’ stands for Achieving Improved Measurement which epitomizes the requirement of continuous improvement. Under this initiative, the intention is to pursue hospital-wide Accreditation and the credentialing of selected services in furtherance of the overall vision. The Board and Management of the QEH believe that accreditation is the backbone of good governance and the hospital’s transformation into a centre of excellence. We are therefore striving towards:
- Safer environment for patients, visitors and staff
- More efficient service delivery
- Stronger interdisciplinary teams
- Better communication and collaboration with internal and external stakeholders
- Appreciation of the flexible and culturally sensitive approach to increased credibility and accountability with the public, investors, government and funding agencies
- Cost savings from the implementation of efficiency measures and reduction of litigation resulting from medical errors
The Accreditation Programme is being implemented over 12-18 months and is hinged on five pillars – Hospital-wide Accreditation, Baby-Friendly Hospital re-certification, Laboratory Accreditation, Hazard Analysis Critical Control Point (HACCP) Certification to Improve Food Safety and the Code of Practice for Information Security Management (ISO 27001). The attainment of these international designations will serve to improve the quality of healthcare delivered to patients and lead to the strengthening of the operations and management of services.
Perhaps the most profound initiative under A.I.M is the pursuit of hospital-wide accreditation. Following the Board’s approval, management engaged Accreditation Canada International to assist the Hospital in its quest to achieve an accreditation status.
The QEH’s journey to Gold level accreditation began in earnest when a team of surveyors from Accreditation Canada conducted an orientation session and Readiness Assessment from April 4 to 8, 2016. The objectives of the team were to assess and compare the policies and procedures utilized to effectively manage the hospital’s clinical, diagnostic and general operations against Accreditation Canada’s corresponding Qmentum International programme standards; and introduce the Tracer methodology to the hospital. The team’s findings identified the hospital’s strengths and areas for improvement and the QEH was provided with quality improvement plans to be implemented in the short, medium and long term and an outline of the next steps along the journey towards accreditation.
The results from the Readiness Assessment confirmed that the hospital was 66% compliant with international standards and founded the QEH’s progression towards a culture of continuous quality improvement and patient safety.
The formal assessment by Accreditation Canada was conducted in February 2018. The survey involved an independent assessment which compared the QEH’s organizational practices against international standards built around best practices. Assessments were conducted on resource management for increased efficiency, improved quality and patient safety utilizing a number of approaches including review of documentation, audits, focus groups, interviews and tracer studies.
The accreditation survey concluded with debriefing sessions for the QEH’s management team and general staff at which surveyors indicated that the QEH had achieved an average compliance rate of 80 percent across various areas and commended staff for their dedication to patient care and exceptional work ethic.
Baby-Friendly Hospital Initiative
During the previous reporting period, focus was on achieving readiness towards re-certification of the QEH as a Baby-Friendly Hospital under the UNICEF/WHO Breast Feeding Initiative (BFI) for the promotion of breast feeding for lactating mothers.
The recertification process commenced with a peer review assessment to gauge the level of readiness for the QEH’s Baby Friendly Reassessment. This process required the strengthening and operationalization of policies, the training of staff and increased patient education. To facilitate the attainment of the Baby Friendly Hospital Designation, in January 2016, the QEH revised its Breastfeeding Policy. The revised policy was ratified by the Hospital’s Patient Care Committee and subsequently a two page summary of the Breastfeeding Policy was developed and is currently distributed to all staff at orientation. In addition, the QEH Discharge Information Booklet which details and supports lactation to ensure successful breastfeeding at home was developed and disseminated to staff to strengthen the patient education aspect of the discharge planning process.
In August 2017, assessors from the Pan American Health Organization (PAHO) visited the QEH and identified major and minor non-conformances and the QEH was granted three months with which to address the non-conformances found. Having successfully done so, on November 10, 2017, The Queen Elizabeth Hospital was officially recertified as a Baby Friendly Hospital.
Hazard Analysis and Critical Control Point (HACCP) certification is an internationally recognized management system for reducing the risk of safety hazards in foods and focuses on ensuring food products are safe to eat. In 2016, the Food and Nutrition and Food Stores Departments pursued and successfully obtained HACCP.
The certification process began with a HACCP Good Hygiene Practices (GHP’s) and Pre-Requisite Programme (PRP’s) Gap Audit to identify areas in the food services system which required strengthening. This initial step established a benchmark position in respect to the QEH’s food safety performance through the conduct of an independent evaluation of the kitchen facility, its immediate environs and the way it handled aspects of food safety in its daily operations. This one (1) day assessment was completed on the 7th January 2016 by HACCP consultants C&G International Inc. After completion of the gap audit an action plan was developed to determine the basis of the work programme for reaching HACCP Certification. Subsequently, a HACCP oversight committee and a HACCP team were established and given responsibilities for the implementation of the Food Services HACCP Management System and the day-to-day planning and implementation of findings related to the gap audit respectively.
The certification process required structural changes, the purchase and installation of new equipment, as well as the strengthening and operationalization of policies and standard operating procedures. The structural changes were completed during the period July to November 2016 and equipment was sourced and installed. On completion of the Main Kitchen and Food Stores Department’s refurbishment, staff were trained in compliance with the revised and improved HACCP policies and procedures compiled by the HACCP Team.
On the 14th December 2016 and the 10th and 11th January 2017 certification audits were conducted by a representative from Société Générale de Surveillance (SGS) which identified major and minor non-conformances. An additional half-day audit was conducted on the 14th March 2016 and it was determined that having addressed the non-conformances previously identified, the Food Services Department of the QEH was recommended for HACCP certification and on the 12 May 2017, the QEH was officially designated a HACCP accredited hospital.
HACCP certification is contingent on yearly surveillance audits to ensure adherence to HACCP standards. The Food Services Department participated in its first surveillance audit in January 2018 and received its HACCP certificate in February 2018. Maintaining the HACCP certification is dependent on ensuring adherence to the policies and procedures it was built upon; and this will continue to be monitored by the supervisory staff, the HACCP Team and Oversight Committee.
The journey towards Laboratory Accreditation commenced over 2 years ago with support from President’s Emergency Plan for AIDS Relief (PEPFAR)/Centers for Disease Control and Prevention (CDC) and the African Field Epidemiology Network (AFENT) which provided financial and technical support. During the 2016-2017 Financial Year, the Laboratory Department was awarded an accreditation certificate by the Accreditation Council of Jamaica National Agency for Accreditation (JANAAC) in the Medical Testing/Examination Field for a selected number of tests.
ISO 27001 Information Security Management Systems
It is against the background of championing and developing ICT as a core business function and a service delivery platform for the modernization of the organization, that the Board is pursuing the ISO 27001 International Code of Practice for information security management. ISO 27001 Information Security Management Systems certification provides strong information security measurement, based on the principles of confidentiality, integrity and availability. To be specific, ISO 27001 can help The Queen Elizabeth Hospital:
- Identify security risks and put controls into place to reduce or mitigate them
- Ensure compliance with relevant laws, regulations, and contractual agreements
- Reduce potential vulnerabilities to the organisation and lower the probability of a successful breach
- Improve information security awareness
- Demonstrate compliance and earn the confidence of clients
- Gain a competitive advantage
- Build a culture of security within the hospital
- Allow for the secure exchange of information