Hospital-Quality Assurance Management Program (H-QAMP) Service

The American Society for Quality (ASQ) defines Quality Assurance (QA) in two ways as follows:

  1. “part of quality management focused on providing confidence that quality requirements will be fulfilled.”; and alternatively,
  2. “all the planned and systematic activities implemented within the quality system that can be demonstrated to provide confidence that a product or service will fulfill requirements for quality.”

From the above two ASQ definitions, QA is focused to provide confidence that all the quality requirements for the services provided are fulfilled for both internal management and “externally to customers, government agencies, regulators, certifiers, and third parties. (ASQ) ” through the planned and systematic activities implemented within the quality system.

QA is an essential part of any service profession. The healthcare industry is no different since it provides professional services whose core output is a service or expertise rather than a manufactured product.

For the field of medical and care-taking treatment of patients in the hospital, the term “quality” can be described as the total of characteristics of the medical services necessary for the realisation of all requirements which lead to optimal patient treatment.

Hospitals focused on QA normally initiate a Quality Improvement Program(QIP), which is a set of focused activities designed to monitor, analyse, and improve the quality of processes in order to improve the healthcare outcomes in the hospital. By gathering and analysing data in key areas, a hospital can effectively implement change.

A QIP is critical because they drive:

  • Improved outcomes for patients
  • Improved efficiency of staff
  • Less waste due to process failures

In a hospital, the Department of Quality Assurance works with QA teams throughout the hospital system to design policies and procedures that promote the best possible patient outcomes. That means ensuring compliance with a multitude of regulations, policies, and laws at the federal, state, and local levels, as well as developing internal strategies to support quality healthcare delivery and the overall health of the community the organisation serves.

RecordsQAEasy Services Consulting focuses on a hospital’s QIP with the hospital’s information system constraints affecting the healthcare quality and safety of patients attending the hospital, in collaboration with the hospital’s Department of Quality Assurance.

Addressing the challenges faced by the hospital’s information system constraints requires the hospital to capture valid and reliable data that can be transformed into useable information to aid in developing change strategies.

In the delivery of safe, high-quality patient care, trained Health Information Management (HIM) / Medical Records Management (MRM) professionals/staff are needed to convert data into meaningful information for decision making.

To demonstrate greater diligence in capturing information that supports more accurate measurement of healthcare quality, such HIM / MRM professionals/staff possess unique knowledge and expertise to enable strong partnerships with clinical and executive teams to advance the quality and safety of patient care delivery.

Existing data from administrative, laboratory, clinical registry and electronic health record (EHR) systems can provide the necessary information to improve patient safety and quality.

Effective HIM /MRM practices enable accurate data assignment by facilitating the aggregation of data from these multiple sources to enable the capture of data once so it can be repurposed many times, analysis, trending of healthcare operations and patient safety, and output of objective data for decision making.

Records&QAEasy Services Consulting Role in QIP of a hospital

Records&QAEasy Services Consulting can advocate for and obtain leadership endorsement to provide support and guidance in the following essential HIM / MRM practices that are to be considered part of quality and safety initiatives in the QIP of a hospital which include:

  • Data Governance involves a group of dedicated individuals that make information management decisions and develop a structure to enforce rules involving technology training and education, auditing, and compliance. It includes an inventory of the organisation’s resources and how they are managed, organised, and controlled, as well as the process for the application of the rules to the applicable information resources in the information inventory;
  • Data Standardisation in creating, utilising, and maintaining a data dictionary that standardises definitions and ensures consistent use, but also facilitates a common understanding of an organisation’s data quality when developing reports and analysing information that affects the use of data for quality and patient safety programs which will assure the end-user that the information used for decision making is consistent and comparable;
  • Data Capture Validation and Maintenance to help create an environment where the integrity and quality of data are preserved;
  • Data Capture, Analysis, And Output from the EHR and other source systems that feed into the enterprise-wide data warehouse that requires critical thinking about healthcare performance expectations to draw informed conclusions from measurement data;
  • Improved Documentation throughout the hospital system supported by Records&QAEasy Services Consulting’s role to work collaboratively with HIM / MRM professionals/staff to monitor the quality of documentation while also working collaboratively with other members of other healthcare teams, to maintain the clinical accuracy and completeness of the data. These efforts will be the key to identifying system and process problems within the realm of patient safety and quality of care; and
  • Records&QAEasy Services Consulting will play the pivotal role of guiding HIM / MRM professionals/staff to provide (i) the expertise to develop any new Performance Measures(s) if they can be feasible, quantifiable, and measurable, (ii) guidance to use and enhancement to existing Performance Measures(s) of the HIM / MRM department, and (iii) guidance to those other performance measures of other hospital departments, with relevant input from the HIM / MRM department.

The objective of this service component is thus to see through the development of a structured development plan and maintenance program by building and/or strengthening your organisation’s and/or HIM / MRM Department’s practices for compliance with and meeting requirements of the following agencies:

  1. The Malaysian Society for Quality in Health (MSQH)  Standards for hospital accreditation(consultancy is available for Malaysia only);
  2. The Joint Commission International (JCI) Standards for hospital accreditation for overall Hospital-wide Standards and/or relevant HIM / MRM and HIMS Standards depending on the specific requirement agreed upon in the Consultancy Proposal(consultancy is available for Malaysia and any other country pursuing JCI accredited status); and
  3. The International Standards Organisation (ISO) and its MS ISO 9001:2008 Standards(consultancy is available for Malaysia and any other country pursuing ISO accredited status)

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