ACHS Hospital Accreditation PART II Combined Endoscopy Unit

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Presentation transcript:

ACHS Hospital Accreditation PART II Combined Endoscopy Unit Ms Cecilia YEUNG WM, CEU & SUR, CMC 24-6-2010

ACESS TO CEU

Access prioritized Appointment booking waiting time and case loading SOPD DATA 2010.xls

Patient safety Pre-procedure preparation checklist Pre & intra & post-procedure assessment Correct patient identification Informed consent policy Time out/ sign out policy Checklist and assessment form Evaluation of endoscopic complication Complication report

Discharge Discharge advice note Hotline and pathway of post procedure management Call back alert Education for carer on post procedure management

Infection Control Airflow & Workflow of environment floor plan Disinfection & sterilization policy and working group Tracking system : equipment and accessories Training and audit on reprocessing 5 S policy

Follow up after ACHS Clinical Support Compliance audit on patient identification biopsy taking Compliance audit on clinical documentation Review safety checklist and Compliance audit on safety proceduce * Patient satisfaction survey on provide information and post-procedure management* Support Introduction of image capturing system Introduction of CGRS booking system Corporate Renovation on reprocessing room Review report tracking system Review transportation system