Mabini General Hospital

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QUALITY ASSURANCE PROGRAM (QAP)

MABINI
GENERAL
HOSPITAL

JIGGER D.R. GILERA, M.D.
QUALITY ASSURANCE COMMITTEE
CHAIRMAN
2011

MISSION
The Mabini General Hospital organization and healthcare professional desire is to provide the highest quality of care with minimal risk to client.

VISION
The Mabini General Hospital aspires to become the nations most comprehensive Quality Assurance Service Provider.

INTRODUCTION
Mabini General Hospital is committed to providing consistent, exceptional health care that is responsive to the patient’s individual needs. As part of this on-going commitment, the hospital delivers health care that is safe, effective, patient-centered, timely, efficient, and equitable. We believe these six aims form the foundation for living our mission to improve the health and well-being of our patients. To be Safe means providing care in a responsible manner in a secure environment To be Effective means providing the very best care that integrates scientific knowledge with clinical expertise and patient values To be Efficient means to avoid waste in the delivery of health care To be Timely means reducing delays for those who give and receive health care To be Equitable means to provide equal care to everyone regardless of gender, ethnicity, or economic status

To be Patient-Centered means providing care that holds the patient above all else and is respectful of, and responsive to, individual patient preferences, needs, and values

QUALITY ASSURANCE PROGRAM

Quality assurance program is the process of ensuring that clients receive the agreed-upon level of care through the setting up of standards, monitoring practices, evaluating practice problems, and resolving practice problems.

Dimensions/Characteristics:
1. Appropriate health services are available and accessible 2. Health care is effective, that is, desired outcomes for clients are obtained 3. Health service is equitable, that is, priority is given to the most needy 4. Health interventions are safe and are based on professional and agency standards 5. Good interpersonal relations are based on nutual respect 6. Presence of proper coordination among different health workers and a working referral system 7. Efficiency and economy in provision of services

THE QUALITY MANAGER

The Quality Manager reports directly to Hospital Administrator and is delegated authority and organizational freedom to identify and evaluate quality problems and to initiate, recommend or provide solutions.

Responsibilities
The Quality Manager is responsible for:
a. Update and distribution control of the Quality Manual as required.
b. Planning to meet customer's quality requirements.
c. Determining inspection points within the system.
d. Approval of quality work instructions.
e. Directing inspection activities.
f. Surveillance of procurement documents.
g. Approval of Suppliers.
h. Maintaining a listing of approved suppliers.
i. Monitoring procedures to assure compliance
j. Reviewing and maintaining Quality Records.
k. Calibration of Measuring and Test Equipment.
1. Approval of disposition of Nonconforming Articles
m. Corrective action coordination

QUALITY ASSURANCE WORK PLAN

The Quality Assurance Program will perform semi-annual and annual medical reviews to assure Internal Quality Assurance Program activities meet standards and are in compliance with State regulations and contractual agreements.

THE MONITORING PROCESS

Monitoring is an essential process for utilization management while determining unique performance awareness, utilization, patterns, and oversight. The Quality Assurance monitoring and review process is an ongoing assessment that will strive to promote continual quality initiatives and improvements. Initial review areas may be revised and/or updated as necessary to reflect quality concerns in our changing health care environment.

THE REVIEW PROCESS...
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