Česky
QUALITY DEPARTMENT
The direct supervisor is the Director of the Rehabilitation Hospital Beroun, who controls and evaluates the work in the areas of quality management, which is included in the strategic plan and objectives of the hospital. The organisational arrangements for the management of quality and safety of the care provided correspond to the organisational structure of the hospital so as to cover all activities. Staff are familiarised with quality management practices by members of the quality team and their managers.
Quality management activities are organised by the Quality Team:
- Actively participates in the development of internal standards related to quality and safety, the provision of health and nursing care, the development of the organisation's corporate social responsibility and patient protection policies
- Participates in the development of the hospital's strategic objectives in the area of quality and safety
- Carries out monitoring activities related to the quality of medical records, medical and nursing care and the safety of the care and services provided
Quality policy
The Quality Policy supports the Beroun Rehabilitation Hospital:
- Develop strategies to prevent misconduct by healthcare professionals
- Use resources efficiently
- Develop a programme of continuous improvement of patient satisfaction
- To continuously improve the quality and safety management system to strengthen the credibility and to achieve prosperity and stability of the hospital
- Manage critical processes
- Ensure education and training of staff to meet all requirements and set standards
- Ensure collaboration in disease prevention and health promotion
Accreditation
This is a tool for external assessment of quality and safety in the delivery of health services. The Commission assesses how well the health facility is complying with the requirements for improving quality of care and safety. It is an official recognition (verification-guarantee) of the ability to provide health care and services in compliance with quality. It is not about the equipment, but about the quality of the processes. National accreditation is based on the methodological guidance of the Ministry of Health, but is voluntary.
By signing up for accreditation, a healthcare facility commits to improving patient care, providing a safe environment and seeking to minimise potential risks to patients and staff. It is a quality assessment and management tool, which is carried out using the SAK (Joint Accreditation Committee) accreditation standards:
SAK ACCREDITATION STANDARDS:
- Departmental safety objectives
- Patient rights and patient education
- Availability and continuity of care
- Diagnostic care
- Therapeutic care
- Anaesthetic and surgical care
- Ordering, prescribing and administering medicines and drugs
- Hygiene of the hospital environment and anti-epidemic measures
- Management and administration
- Quality and safety management
- Environmental safety
- Information and communication
- Human resources management
An accredited hospital guarantees patient safety and quality of care by continuously monitoring, analyzing and improving quality indicators in all areas of hospital operations. These indicators are included in the hospital's accreditation standards and regulations for all areas of health care management and delivery.
Accreditation is periodically reviewed after 3 years, at which time the hospital must reapply for accreditation.
The Beroun Rehabilitation Hospital has been granted SAK accreditation and external quality certificate according to Act No. 372/2011 Coll. and Decree of the Ministry of Health No. 102/2012 Coll. based on the accreditation survey conducted at the end of 2021.
Departmental security objectives
As part of the admission process, the admitting nurse will attach an identification bracelet to your wrist. It is used to securely identify you, prevent confusion before any diagnostic or therapeutic procedures are performed, and ensure your safety. The wristband is labelled with your name, surname, date of birth and the abbreviation of the ward to which you have been admitted.
1. Safe patient identification
We verify the correctness of the patient's admission by asking for the name, checking the identification bracelet and medical records.
We verify the correctness of an outpatient by asking for the name and date of birth and checking the insurance card (passport, ID card, etc.).
2. Safety in the use of higher risk medicines
Higher-risk medicines (addictive substances, insulins, undiluted heparins concentrated electrolytes - KCL) are stored separately from commonly used medicines. The reason for this is to prevent misadministration or misuse of the drug.
3. Prevention of patient, procedure, party confusion
A uniform procedure is used to ensure that the correct procedure is performed, on the correct patient, in the correct location, including procedures performed outside the operating theatre e.g. puncture. A standardised method is used and patient participation (if medically possible) in the marking of the surgical site is ensured. A safety procedure is also in place and documented immediately prior to the start of surgery to verify the accuracy of the patient, the procedure, the operating field, implants, instruments and anaesthetic devices. The method of verification of implementation and effectiveness is ensured by the hospital's internal audits.
4. Prevention of patient falls
Falls are the most common adverse event of hospitalized patients and the hospital aims to minimize their number. As part of the initial nurse assessment, a fall risk assessment is performed on all inpatients. Patients identified as being at risk of falling are educated about safe exercise and fall prevention.
5. Optimal hand hygiene practices in healthcare delivery
Proper hand hygiene during healthcare delivery reduces the risk of hospital-acquired infections and prevents their spread. Disinfectant dispensers located in wards and outpatient areas are available to staff, patients and all civilians visiting the ward. Use them to protect yourself and your loved ones.
6. Safe communication
The hospital has a uniform procedure for verbal and telephone communication when prescribing medicines, reporting critical examination values. There is also a standard procedure for giving telephone information about a patient's health status to relatives and loved ones of patients.
7. Safe handover of patients
This is ensured by the staff of the Rehabilitation Hospital Beroun, who have the competences set for this activity. A uniform system is established by the hospital's directive.
8. Prevention of pressure ulcers/decubitus ulcers in hospitalized patients
The hospital has set up a system of initial assessment of the risk of developing decubitus, prevention of decubitus in hospitalised patients and the procedure in case decubitus develops. The hospital has set up electronic recording and evaluation of decubitus cases.
