Policies

Healthcare Quality and Safety Improvement Policy 2012 - 2017

The policy for improving healthcare quality and safety is based on the commitment and values shared by all the professionals of the establishment. It is devised according to the needs and the level of quality expected by patients, their families and more generally by all users and partners, and takes into account the internal and external constraints specific to the establishment.

RESPONSIBILITIES, PROGRAM and ACTION PLANS

The Clinic Management, in collaboration with the Establishment Medical Conference (CME) and the Steering Committee (COPIL), among its responsibilities

the definition of the quality plan objectives to be achieved in a permanent search for healthcare quality and safety
the development of action plans to improve healthcare quality and safety by sector of activity in the context of management reviews
to ensure the development of quality procedures and the monitoring of their progress (certification by the Haute Autorité de Santé (HAS)…)
exploitation of new assessment methods and the new tools of the Haute Autorité de Santé's certification procedure
the definitions of everyone's missions in terms of quality, by formalizing and applying controlled quality documents, as well as by participating in bodies and working groups
to define, as part of the Professional Practice Assessment (EPP), the improvement actions to be undertaken to achieve the set objectives
to ensure, for the sake of efficiency, that the necessary human, material and financial resources are implemented to achieve the objectives
to develop a culture of quality and safety of care among health professionals in a continuous commitment for patient satisfaction
to ensure the application of healthcare quality and safety by means of our quality management system

INSTITUTIONAL POLICY AND PROJECT

This policy, based on the permanent development of our structure and the strong empowerment of our staff and practitioners, is an integral part of the establishment plan.

The establishment project within the framework of the strategic orientations, the Multi-year Contracts of Objectives and Means (CPOM), as well as the certification by the Haute Autorité de Santé made it possible to:

have a global vision of the organization, management, and running of the various sectors of activity, as well as to clearly set the objectives of the establishment, reflecting a strategy that makes it possible to adapt to technical, regulatory and social changes, and even to anticipate them in a "competitive" environment
meet the requirements of the certification reference system of the Haute Autorité de Santé, in particular of chapter I "Management of the establishment" of the manual:
- strategic management (part 1)
- resource management (part 2)
- healthcare quality and safety management (part 3)

and to bring together professionals around a shared vision for the development of the establishment.

The establishment plan is broken down into its various components, which are the medical project, the care project, the social project, the information system, etc ... and takes into account their financial implications. Through the rules and priorities that it determines, it is the guarantor of the quality and safety of the healthcare provided to patients.

In addition to the establishment plan, the healthcare quality and safety policy is now obliged to take into account :

the HPST (Hospital, Patient, Healthcare and Territory) law, reforming the hospital and pertaining to patients, healthcare and healthcare access. This law includes these main measures: regional health organization (PRS), governance of hospitals, access to healthcare, prevention and public health (national plans) ...
the health context in its entirety: CPOM, HAS certification and Contrat de Bon Usage (best practice for the use of pharmaceutical products)
mandatory national indicators
activity-based pricing and its implications

EVALUATIONS, AUDITS et SATISFACTION

The hospital management accords our evaluation system a prominent place in our organization.

Patient tracer assessment: Patient tracer is methodology developed by the HAS to improve healthcare quality. The deployment of this assessment method in the establishment contributes to the development of a culture of quality and safety for healthcare professionals, by:

taking into account the patient's experience
bringing together the professionals of the team that took care of the patient throughout his or her treatment.
promoting exchanges and communication between the healthcare team and the patient

Its pedagogical approach, without judgment or search for responsibilities, pleases healthcare professionals and therefore ensures a long-term use of the method.

The CME contributes to the development of the strategy for deploying this method in the establishment, integrated into the policy for improving healthcare quality and safety.

The other bodies are consulted, and in particular the CRU which gives an opinion, in particular on the choice of specialties to be favored in the selection of patient tracer profiles, in function of elements such as results of satisfaction surveys, undesirable events, complaints. and claims.

Information is provided through the establishment's website for patients and their entourage, as well as in the online accounts of staff and practitioners.

Every 4 months, the patient tracers performed over the past period are presented in the management review. An annual report is produced at the last Management Review of the year. The organization implemented for this method is evaluated during this same meeting. The CME, the CSSI and the CRU are involved therein.

Practice Audits : a system to audit practices is in place within the establishment. These audits are:.

matrixes related to the procedures, instructions and treatment protocols of the quality system
made available to users in the professional area of the establishment's website, and to be downloaded before each use as part of documentary control
defined by sector of activity (theme, frequency, number, threshold of acceptability)
returned during each management review
revalidated annually as part of the annual revalidation

The frequency of their performance can be increased, if necessary, in the event of a non-compliant result during a previous audit.

Patient satisfaction: the evaluation of patient satisfaction is part of an ongoing process of evaluating the quality of the services offered to patients.

The measurement of patient satisfaction makes it possible to make the patient a co-actor in his care, by giving him a voice on his feelings. It allows us to implement improvement actions as close as possible to patient expectations.

The management has tools to measure the level of patient satisfaction:

the E-satis survey: in accordance with the decree of May 3, 2016 *, our establishment is committed to the national initiative to measure the satisfaction of hospitalized patients E-satis, co-piloted by the Haute Autorité de Santé (HAS) and the Ministry of Health.
satisfaction questionnaires: given to all patients during their stay, their analysis is communicated in the management review, in the CRU and is available on the establishment's website for both patients and healthcare professionals
"patient-tracer" evaluations (during the interview with the patient): actions for improvement resulting from "patient-tracer" evaluations are monitored during management reviews

* Order of May 3, 2016 setting the list of mandatory indicators for improving the quality and safety of care and the conditions for making certain results available to the public by the health establishment

BODIES / COMMITTEES

The quality of healthcare concerns all health professionals and, in order to lead a common reflection on certain themes, many bodies integrating all professional categories are in place within our establishment.

SUSTAINABLE DEVELOPMENT

The policy of improving healthcare quality and safety by taking into account this new dimension must be at the origin of an awareness of the concept of sustainable development based on its three axes: social, economic and environmental. The challenge does not lie so much in the formulation of stated commitments, as in their translation and reality at the operational level, in an individual and collective search for the sustainability of the establishment.

The etablissement participated in the Baromètre Développement 2016.

QUALITY SYSTEM

The establishment's quality system is integrated into the overall quality approach of Etablissements Sainte Marguerite, under the responsibility of a Director / Quality Manager, delegated by the Director General, assisted in his duties by a Coordinator and Quality Assistants.

This quality approach is based on risk prevention and the evaluation of professional practices.

The quality methods and tools resulting from the ISO 9001 standard are applied to all of the establishment's business sectors: Management Review / Quality Action Plan, documentary system, monitoring of indicators and evaluation of professional practices.

MANAGEMENT BY QUALITY

In March 2018, in view of the elements mentioned in the V2014 Certification report, the HAS granted the certification and invited the establishment to continue its process of improving quality.

This document defines the strategic guidelines for improving the quality and safety of care. This policy, an integral part of the establishment plan, is presented during the first CME of the year and updated every year with regard to the results obtained, the CRU report and changes in the general internal and external context. The policy for improving the quality and safety of care is communicated on the establishment's website:

to all healthcare professions in their online accounts
to patients, their entourage and other users in the “Quality and risk management” section

Healthcare Risk Management Policy 2012 - 2017

The risk management policy is based on the commitment and values shared by all the professionals of the establishment. It is devised according to the needs and the level of safety expected by patients, their families and more generally by all users and partners, taking into account the internal and external constraints specific to the establishment.

Inseparable from the policy of improving the quality and safety of care, it operates in perfect harmony and in accordance with the latter. It relies, among other things, on the quality system in force and the tools provided by the latter.

RESPONSIBILITIES, PROGRAM and ACTION PLANS

The Clinic Management, in collaboration with the Establishment Medical Conference (CME) and the Steering Committee (COPIL), is, after revewing existing healthcare safety, responsible for:

the appointment of a Healthcare Risk Management Coordinator (CGRAS)
the definition of an action program for the management of healthcare risks
the definition, adaptation and setting up of the structures for the management, coordination and treatment of risks
these structures will be in charge of drafting reassessed action plans as necessary. Actions with deadlines, those responsible for their implementation, monitoring and performance indicators.
the development of a culture of healthcare safety and associated management practices
the monitoring of the implementation of the action program and evaluate the results

All actions aimed at:

Risks directly associated with healthcare (organization and coordination of care, medical procedures, hygiene, use of a health product, information management, etc.),
Risks associated with so-called support activities without which healthcare could not be properly implemented (staff numbers and skill management, equipment and its maintenance, purchasing and logistics, IT systems, etc.)
Risks related to hospital life and the environment (safety of people and property, etc.).

ESTABLISHMENT POLICY AND PROJECT

have a global vision of the organization, management, and running of the various sectors of activity, as well as to clearly set the objectives of the establishment, reflecting a strategy that makes it possible to adapt to technical, regulatory and social changes, and even to anticipate them in a "competitive" environment
meet the requirements of the certification reference system of the Haute Autorité de Santé, in particular of chapter I "Management of the establishment" of the manual:
- strategic management (part 1)
- resource management (part 2)
- healthcare quality and safety management (part 3)

and to bring together professionals around a shared vision for the development of the establishment.

In addition to the establishment plan, the healthcare quality and safety policy is now obliged to take into account :

the HPST (Hospital, Patient, Healthcare and Territory) law, reforming the hospital and pertaining to patients, healthcare and healthcare access. This law includes these main measures: regional health organization (PRS), governance of hospitals, access to healthcare, prevention and public health (national plans) ...
Decree No. 2010-1408 of 12 November 2010 relating to the fight against undesirable events in healthcare establishments that requires that the policy to combat undesirable events is adopted by the director of the establishment, in consultation with the Establishment Medical Conference (CME) (art. R6111-2 CSP) and that its implementation is assured by a “healthcare risk coordinator” (art. R6111-4 CSP).
the health context in its entirety: CPOM, HAS certification and Contrat de Bon Usage (best practice for the use of pharmaceutical products)
mandatory indicators: indicators of the results of activities in the fight against nosocomial (hospital acquired) infections and indicators for improving healthcare quality and safety
activity-based pricing and its implications
Decree No. 2016-1151 of 24 August 2016 relating to the reporting of undesirable healthcare events
Instruction No. SG / HFDS / 2016/340 of 4 November 2016 relating to security measures in health establishments

structures for the management coordination and treatment of risk

In accordance with decree number 2010-1408 of November 12, 2010, a coordinator for the management of healthcare associated risks has been appointed. He is in charge of the Vigilance and Risk Management Committee (COVIGERIS), a transversal body of the Sainte Marguerite establishments .

In accordance with statutory and internal regulations, COVIGERIS:

Develops a comprehensive and coordinated risk management program which - through its internal regulations, its action program and action plans - includes the objectives to be achieved and the actions to be carried out in terms of prevention and control of risks, awareness, information, training and program evaluation.
Coordinates the various regulatory health vigilances established in each establishment.

The COVIGERIS through the CGRAS is notably required to perform the following missions:

Contribute through its methodological expertise to the definition of the establishment's strategic orientations in terms of healthcare quality and safetyand to the development of the action program for healthcare quality and safety,
Identify and ensure the dissemination of methodological expertise relating to the prevention, identification, analysis, recovery and reduction of adverse healthcare events,
Participate in the identification of risks a priori in collaboration with the various experts for the definition of the action program and its monitoring indicators,
Contribute to the organization and development of the collection of internal data related to healthcare safety,
Ensure the analysis of adverse events in relation to that of complaints and claims, with the business sectors,
Ensure the implementation of the action program in collaboration with the various experts, key people and the project managers identified in the program,
Coordinate scientific and regulatory monitoring.

And this, in consultation with:

The person responsible for the general coordination of nursing, medico-technical and rehabilitation care,
The commission for relations with users and the quality of care (CRUQPC),
The operational hygiene team (EOH) specialized in the infectious field, equipped with specialized personnel,
The network of correspondents woncerned with regulatory vigilance,
Those responsible for medication quality and sterilization,
The establishment's quality-safety management team, staffed with personnel specialized in the field of healthcare quality-safety, also equipped with the skills to address non-medical risks (risks related to the structure),
Any network of medical and paramedical referents set up within the services as needed,
The occupational health service,
The doctor in charge of the medical information department (DIM),

IMPLEMENTATION

Organize Risk Management

Consists of promoting a safety policy and safety culture, defining responsibilities in order to have an impact on practices and, on a technical level, identifying risks, analyzing them and then reducing them.

Ensure that the management of risks associated with care is efficient in each of the group's establishments and coordinate it.

The action plans drawn up must specify common actions and actions specific to each establishment.as each establishment has its own circimstances. In addition, the plans will never be frozen in time, because both the healthcare system and our society evolve constantly.

Risk management aims to reduce risks through prevention and protection mechanisms. It involves the identification, analysis, prioritization and treatment of risks through the implementation of action plans. The priorities are consistent with the institution's strategy and its risky activities.

Information relating to risks is collected, organized and processed.

Arrangements are in place to identify and analyze risks a priori. This presumptive identification of risks makes it possible to manage foreseeable risks before the occurrence of adverse events.

Arrangements are in place to identify and analyze risks a posteriori. This post-event identification concerns accidents (obvious risk) and catastrophes (if several patients are affected), adverse events, precursors of accidents, near accidents and sentinel events which testify to the existence of the risk.

The results of risk analyzes make it possible to rank the risks and deal with them.

The management of a possible crisis is planned.

Establish the official list of the various persons in charge and actors of risk management.

This list will be distributed to all the authorities of the various establishments and to all healthcare professionals.

Coordinate and standardize these policies by defining and adopting common tools.

Reconcile or even harmonize risk management procedures

in order to improve the consistency and performance of the system
in order to facilitate understanding and increase the compliance of the personnel concerned.

Write and validate quality documents and good practice recommendations concerning risk management.

Organize healthcare vigilance

The purpose of the health vigilance system is to improve healthcare security by understanding the risks, which makes it possible to avoid their recurrence in this or other establishments. Event reporting, event analysis, alert management and product traceability are all necessary for this vigilance. Regulatory health vigilance applies to healthcare products and even cosmetics.

Ensure that health vigilance is operational and coordinate it.
Define the perimeter of vigilance to be supervised.

This perimeter may be extended in function of the evolution of practices, regulatory texts and professional recommendations.

Establish the official list of the various managers and actors involved in vigilance. This list will be distributed to all the healthcare professionals and other interested parties in the various establishments.
Ensure that in each establishment a health vigilance and blood transfusion safety policy is in place.
Coordinate and standardize these policies by defining and adopting common tools.
Reconcile, or even harmonize, vigilance procedures in order to improve the consistency and performance of each vigilance and to facilitate understanding and increase the support of the personnel concerned.
Write and validate quality documents as well as good practice recommendations pertaining to vigilance.
Ensure inter-disciplinary exchanges of information between the various professionals involved in each establishment
Improve the collection, content, circulation and transversality of information.
Develop and strengthen communication internally (avoiding the loss of information) and externally (between establishments, ensuring technical, regulatory and methodological exchanges).
Ensure that professionals are informed and trained at defined intervals.
Participate in the continuing education of health professionals.
Evaluate healthcare vigilance activities and blood transfusion safety.
Participate in the definition, in collaboration with the relevant professionals, of the methods and indicators enabling the analysis, evaluation and monitoring of healthcare vigilance and blood transfusion safety.

In particular, through an assessment of alerts and declarations, follow-ups, related incidents and any other indicator that it may be necessary to monitor.

Each year the COVIGERIS prepares an annual activity report and an action program.