A document as a credible tool 06/11/2012. Pilot Scheme of Hospital Accreditation

Transcription

1 Setting-up a Document in Caritas Medical Centre & beyond: where bottom-up and top-down meet Ms. Jenny Chan Advanced Practice Nurse ccw658@ha.g.hk 29 th ISQua Conference Oct 2012, Geneva 1 2 Pilot Scheme of Hospital Accreditation In 2010, Document control is identified as one of key area f improvement. 3 4 Pilot Scheme of Hospital Accreditation Recommendations on Document during gap analysis: Establish a framewk f policy development, and develop policy and wkflow structure with staff engagement Set up a mechanism on launching, distribution and implementation of new and reviewed policies Ensure adherence and compliance with policies Review policies on a regular-basis 5 A document as a credible tool Contempary Current issues Latest evidence Ethical Professional guidelines Codes of practice Codes of ethics Quality Lawful Legislation Ordinance Staff as Followers Achievable Wkable Territy wide practice Reality check Patient feedback Staff feedback Imptant References 6 1

2 Objective 1: Policy Framewk A Wking Group with members from various HA hospitals, including CMC, was fmed to deliberate on the document control framewk at HA level in KWC Document KWC Management Objective 2: Develop document control structure in Kowloon West Cluster PMH KWC Document Steering Membership: HR, Finance. Hospital Administration, Quality & Risk, Document control subject officers from all KWC Hospitals CMC YCH KWH KCH OLMH WTSH Hospital Document Hospital Document Hospital Document Hospital Document Hospital Document Hospital Document Hospital Document Management Management Management Management Management Management Management 9 10 KWC Document KWC Management KWC cluster based system KWC Document Steering KWC Policy Paper on Management of Documents Standardization of: 1. Document Tiers and Types: 3 Tiers, 5 Types 2. Document Template 3. Document Identifier (Numbering System) 4. Approving Bodies (Organization Chart, Scope of Authity & Codes) Document control system in individual hospitals Local Document & Document Officers Adopt KWC Policy on Document Management + Local Hospital Guidelines on coding Generate & maintain Document Master List (DML) 11 Objective 3: Standardize the document and the process on document control 12 2

3 Standardization of document control Documents addressed f control include both clinical and administrative-related documents Criteria f selecting documents f control include those related to processes of : (1) high volume (2) high risk (3) high cost Standardization on Document Tiers and Types TIER 1: DO WHAT? Policy Documents TIER 2: WHO & HOW? Procedures Protocols Wk Instructions Guidelines TIER 3: DO IT & LEAVE TRAILS FOR AUDIT Recds & completed fms Minutes of meetings 13 Document PYRAMID: document proliferates as one moves down 14 Header Footer Document Template Name of institution Subject Metadata on front page Version (latest) Document number Auth Custodian Approved by Approval date Distribution Document No. Issue Date Review Date Approved by Page Effective date This printed copy may not be the most updated version. 15 Please refer to the electronic version f confirmation if in doubt. of Document Identifying: Numbering System Cluster / Hospital Version number 1.0, 2.0 A serial number from 001 to 999 accding to the tempal der of promulgation Code of custodian body Type of document: PO=Policy, PD=Procedure, PC=Protocol, WI=Wk Instruction, GL=Guidelines Standard code of 3 letters e.g. KWM f Kowloon West Management List of standard codes 26 alphabets + & Standardized within hospital 16 Hierarchy of Approving Bodies Hierarchy of Approving Bodies Approving Bodies Cluster/Hospital s Individual s Alignment & Consistency Review of Organization Charts & lines of authity Review of function and TOR Define scope of approval authity limit to top 3 levels of committees 17 LEVEL 1 LEVEL 2 LEVEL 3 Code COM Code COM Code COM KWC Manage Com CEC Cluster Clinical Ethics Com REC Cluster Clinical Research & Ethics Com DCC Cluster Document Steering DUG Cluster Drug Use Review Com ABS Cluster Antibiotic Sub-com ISP Cluster Infmation Security & Privacy Com CSC Clinical Systems Codinating Com ITC Cluster Infmation Technology Com KWM ITS IT Services Com SWM Cluster SOP WL / WT Management Task Fce CTC Cluster Technology WEB Cluster Web Editial Board OSC Cluster OSH Codinating Com ICG Infection Team Codination Group 18 3

4 Document Life Cycle NEED IDENTIFIED Document Life Cycle and Process (7) ARCHIVE DESTRUCTION (6) Document REVISION NO Contents OK? (1) DRAFT document YES (5) Document REVIEW (2) Consultation & APPROVAL (3) DISTRIBUTION (4) AUDIT STAFF 19 F every step of the life cycle, there should be (a) Responsible staff (b) System in place 20 Going electronic: e-dms Objective 4: Pilot: the document control system through electronic platfm Document Management System (e-dms) e-document Management System 1. A filing system 2. Automated life cycle control 3. Document binding and auto alert 4. Data as trails f audits of the process Top down approach Strategies of launching document control Top-down and Bottom-up Approach Adopt cpate policy at the level of the Hospital Authity (HA) framewk of policy Standardization of document f control Pilot in hospital setting Review process on regular basis at the levels of both HA and local hospitals

5 Involvement of different stakeholders in the process Involve all disciplines Document Seminar and Training f staff Document Training Evaluation Collect feedback on e-dms from pilot users Suppt f the frontlines on document review Hotline f enquiry and clarification Interview the by department to listen their concerns and the difficulties during implementation website f releasing up-to-date infmation on document control Suppt f the frontlines on pilot of e- DMS Seminar briefing session Hands-on training User guide On-Site Suppt f Document Migration Troubleshooting system f e-dms problem Local Suppt Team triage, manage and refer the problem to Head Office IT Challenges New concept to frontline staff Getting the buy-in from the frontlines Need time to incpate and adapt Get consensuses from management level befe implementation Key message Document control should involve the top down approach Bottom up approach is often employed in building the document tree What is our next step? e DMS helps in automation of life cycle, but it needs a command from staff on starting up the cycles of the process A culture to be embedded in leaders and staff need times

6 A Wking Group with members from various HA hospitals, including CMC, was fmed to deliberate on the document control framewk at HA level What is our next step? KWC Document Steering Experience sharing with hospitals in other clusters Thank you very much A Document Steering was set up in CMC KWC Staff Engagement As an pilot, CMC join the cpate project of e-dms