Compliance with CPGs-related

accreditation standards(ACI & CBAHI – 2016/2017)

Dr. Yasser S. AmerQuality Management Department

Medical-City Wide CPGs Steering CommitteeResearch Chair for Evidence-Based Health Care & Knowledge Translation

With gratitude Compiled by Mohammed Hussein, Accreditation Unit

Current Practice

Best Practice

Clinical Care Gap

PROVISION OF CARE18. Clinical practice guidelines, pathways, and protocols are developed or adopted to guide priority care services (CBAHI Ref. PC. 18)

18.1 .The hospital implements the national CPGs, pathways, and protocols that are consistent with current EB practice.

18.2 .CPGs, pathways, and protocols are updated at least every two years and as required with emphasis on the most common diagnosis.

18.3 .CPGs, pathways, and protocols are documented in the patient’s medical record.

CPGs standards in All Accreditation Chapters(PCC-15, ICU-13, Cancer-14, DEM-15, MED/PED-13, OBSGYNE-16, PSYCH-16, OR-27, REHAB-14)The team bases its services on (the latest) research, EB-CPGs, and best practice information to improve quality of its services.

CPGs’ Sub-standardsEvidence Standard/ sub-standard

• CPG Steering/ dept. committees.

• Adapt/ adopt from int’l CPGs

• Access: printed/ e- (offline/online/eSiHi)

• ICity: Academic digital library

The team has access to EB-CPGs for _________ services.

(AC-Gold)

CPGs’ Sub-standardsEvidence Standard/ sub-standard

• Policy• AGREE II Instrument

(QA) is a main part of the ADAPTE methods.

The team follows a standardized process to select EB-CPGs for _________ services.

(AC-Platinum)

CPGs’ Sub-standardsEvidence Standard/ sub-standard

• Policy: (same) AGREE: Domains #3 (methods), #5 (App).

• (Different) (Cochrane)SR/ Evidence synthesis of several specific CPGs?

The team has a detailed process to select between conflicting EBCPGs, multiple Rs, or the app of > CPG for clients with comorbidities. (AC-Diamond)

CPGs’ Sub-standardsEvidence Standard/ sub-standard

• Disease-specific (Adapted CPG)

The team’s assessment process is based on EB CPGs.

(AC-Diamond)

CPGs’ Sub-standardsEvidence Standard/ sub-standard

• Or other CPG implementation tools (?)

• Detect/ justify variation in practice + link to clinical outcomes.

The team has care pathways for the common diagnoses that it manages .

(AC-Diamond)

CPGs’ Sub-standardsEvidence Standard/ sub-standard

• Access: 1. Printed: NSG, Drs.2. Electronic:(offline-PC, online-ICity, eSiHi-PowerPlans/Forms).

The team has access to EB CPGs at the point of care.

(AC-Platinum)

CPGs’ Sub-standardsEvidence Standard/ sub-standard

• Access: 1. Printed: NSG, Drs.2. Electronic:(offline-PC, online-ICity, eSiHi-PowerPlans/Forms).

The team has uses CPGs (& CPs that are based on CPGs) to standardize the delivery of ____care services.

(AC-Platinum)

CPGs’ Sub-standardsEvidence Standard/ sub-standard

• Adapted CPG: section for update/ review.

• *2-5 years.• CPG dept.

committee

The team regularly* reviews its CPGs to verify they are up-to-date and reflect current research and best practice info. High priority(AC-Platinum)

CPGs’ Sub-standardsEvidence Standard/ sub-standard

• Clinical audit, case reviews, clinical rounds & discussions.

The team’s CPG review process includes seeking input from team members about CPG applicability & ease of use .(AC-Platinum)

CPGs’ Sub-standards (Non-CPG!)Evidence Standard/ sub-standard

• IRB Policy• IRB Approvals for all

research activities available.

The team’s research activities for ____ services meet applicable research and ethics protocols and standards. High priority(AC-Diamond)

CPGs’ Sub-standardsEvidence Standard/ sub-standard

• Conferences papers.• Full-text publications.• Saudi specialized

Assn's endorsement.• Special collaboration/

communication (?Ext. review)

The team shares research, CPGs and benchmark info with its partners & other similar organizations. Team’s mandate/scope. High priority(AC-Diamond)

INFECTION PREVENTION & CONTROL(CBAHI Ref. IPC 39-43) * Area for improvement

• 13.2. The hospital implements EB interventions to prevent VAP*.• 13.13. The hospital implements EB interventions to prevent SSI. Two adapted CPGs by SURG SAP (ASHP-13) & NSG SSIP (NICE-11), HW-QIP.• 13.14. The hospital implements EB interventions to prevent

CAUTI*. • 13.15. The hospital implements EB interventions to prevent

CLABSI. Adapted CPG by NSG (CDC-11, INA-11)• 13.16. The hospital implements EB interventions to reduce the

burden of epidemiologically significant organism (MDROs)*

EMERGENCY STANDARDS•9.8. The team uses EB protocols to select diagnostic

imaging services for pediatric clients (DEM/RADIOLOGY)*.•11.7. The team uses EB care protocols when providing

emergency department services to clients.

CRITICAL CARE • 7.5. ROP The team identifies medical and surgical clients at risk of

VTE (DVT & PE) and provides appropriate thromboprophylaxis.Adapted CPG by ICU VTEP (ACCP-12), HWPP, HW-QIP, … OBGYNE section for pregnant women (obstetric) not CS*!*MED VTE (T) CPG (ACCP-16) in progress9.5. There are EB criteria for intubation, weaning off ventilator & extubation.9.6. The team follows a protocol when conducting a daily interruption in sedation ICU CPG in progress.

QMD Priority topics:-Process for Effective identification, assessment & intervention for patients with:-•Risk of Pressure ulcers.•Risk of falling.•Prevent catheter & tubing misconnections.