Hillel Yaffe Medical Center Quality Assurance Policy

The hospital’s work is based on the fundamental values of humanity, professionalism and efficiency. Introduction: The medical center’s management is adopting a Continuous Quality Improvement policy (CQI) by adopting and implementing a Total Quality Management philosophy (TQM) as a means of imparting an organizational culture designed to create customer satisfaction with health services, nursing and administration (patients, family members, visitors, local residents, recipients and providers of services, medical service employees, and health insurance providers in contact with the medical center and internal customers). The medical center’s administration views quality assurance as a strategic objective of paramount importance. This strategy aims to ensure that the needs of its customers are met, resulting in their full satisfaction with the center’s services.

We are committed to improving and optimizing medical and nursing care, and developing the quality and level of our services for those visiting the center for medical care or for other reasons. We believe that improving the quality of work and management in the organization, at every level, in a manner that will meet the expectations and needs of our customers, to their full satisfaction is of utmost importance.

This document has been drawn up to highlight the administration’s commitment to providing high-quality services and related products, at prices that meet customer expectations and that will be competitive in the healthcare fields for which the hospital is responsible.

The document details hospital policies related to quality assurance, the procedures performed to ensure the quality of services and products, and a statement of intent regarding other actions planned for the next three years.

This document will also serve as a guide and reference for employees and managers at various levels regarding the organization’s expectations, plans and demands.

The hospital’s employees are its greatest asset in implementing its policy of continuous improvement. The way in which each of us carries this out is the key element in the success of this process. The hospital will therefore strive to broaden the knowledge of all employees and managers in their specialist fields, expand interdisciplinary and interdepartmental cooperation, and develop inclusive teamwork that places the customer at the center of the organization.

An important element in creating this process of continuous improvement is data collection and identification of any adverse events (or “near misses”), to learn the reasons for any events and to solve them quickly. We therefore encourage openness between employees and managers, while demonstrating involvement and meeting our obligations. This goal will be achieved by appointing a hospital Risk Management Director.

The hospital exists to provide the highest possible level of health services to its customers. Our customers are therefore a central element in shaping our activities, and they are partners in the organization’s decision-making processes. This goal will be achieved by involving them in decision-making entities such as the Quality Assurance Management Steering Committee, various improvement teams, the different quality assurance bodies, the Complaints Committee, and data-gathering bodies.

External parties and suppliers working with the hospital are part of our organization’s quality assurance system. We will collaborate with them to help them develop the required level of compliance with standards and quality assurance that the hospital demands. In general, the hospital aims to work only with suppliers who comply with ISO 9000 International Quality Standards.

The hospital’s activities will be based on the fundamental values of humanity, professionalism and efficiency.

• The administration’s commitment is a prerequisite for successful implementation processes and the establishment of the quality assurance system, therefore the medical center’s administration undertakes to act in a manner that tangibly demonstrates this commitment. 
• The main strategic objective for the medical center’s employees will be the complete satisfaction of both external and internal customers. 
• Motivation and full involvement of all employees is central to the continuous quality assurance improvement approach, and the management will therefore work to integrate all or most of the employees in the improvement processes, during or after appropriate training. 
• Training employees to act on issues of quality assurance is one of the plan’s basic components on the path to success. The management determines that most of the training activities and guidance will be carried out by medical center employees. 
• The center’s management believes that departments and employees who strive more than others to improve the quality of work at the center deserve to be recognized and rewarded. It is only fitting that such compensation should also be related to broadening their knowledge of quality assurance issues in a manner that will contribute to the development of the employee and/or the service provided by the unit concerned. 
• As part of the quality assurance improvement program, the management has decided to establish organizational systems that will help carry out the above policy. The program’s success is partly conditional on these systems, and other systems will be established gradually as implementation progresses.

The hospital’s commitment to its customers

Hospital customer rights – The patient is the person for whom the hospital was founded and for whom it operates. Patients requiring care at the hospital are entitled to:

• Receive care in accordance with the hospital’s commitments, as specified in this declaration. 
• Receive information about staff providing care. Patients are entitled to know the name and position of each person caring for them. 
• Receive the proposed treatment of their own free will, according to their wishes and with their complete consent. The patient may refuse to accept any treatment, and such a refusal will not adversely affect the patient’s right to continue to receive the treatment to which s/he consents, from among the treatments offered by hospital staff. In a medical emergency or if the informed consent of the patient (or a legal guardian responsible for his/her health) cannot be obtained, the necessary medical treatment will be given without delay, provided that such a decision has been taken by three doctors. 
• Be informed about the purpose of treatment, its nature, every stage and procedure, and the risks associated with it, so that s/he can decide whether to provide consent. The patient is entitled to receive information regarding the alternative forms of treatment and the consequences of refraining from treatment. Upon request, the physician will provide medical information to family members. The patient has the right to elect not to receive information. 
• When receiving care, the patient is entitled to respect, privacy and the observance of strict confidentiality on all data concerning him/her. 
• To consult, at his/her own expense, specialists from outside the hospital and to receive an additional medical opinion, with the full cooperation of hospital staff. 
• The hospital must permit visitors to visit hospitalized relatives and friends at set visiting times, and must provide them with an appropriate, comfortable visiting area. Visiting hours will be set with due consideration for patients’ treatment and rest needs and the convenience of visitors, and will be published in the hospital’s publications.  
• The patient is entitled to expect the strictest privacy and confidentiality of medical data relating to him/her. The hospital undertakes to manage medical records of the patient’s condition and to ensure that they are filed in accordance with accepted procedures. These records will be made ​​available only to the patient and the physician, unless a patient of sound mind has instructed otherwise in writing (or by order of a court authorized to give such an order). 
• The patient will only participate in scientific/medical research with his/her full consent, according to the Helsinki Convention and the requirements of the law. The patient is entitled to refuse to participate in any such scientific research. Non-participation in research will in no way be detrimental to the patient or to the care he/she requires.

When providing care, the hospital will abide by the rules, regulations, procedures and ethical instructions which specify our duty towards those entrusted to our care.

Credibility of the hospital service 

• Hospital management and departments will provide services in strict accordance with the rules of this declaration, according to ISO 9000 Quality Assurance Procedures and according to the total quality assurance management approach. 
• Hospital management will ensure the preferred use of only standard equipment and drugs provided by manufacturers operating quality-assurance programs with the highest-quality standard. 
• Every two quarters (six months) hospital management will update the treatment goals regarding appointments, ER waiting times and inpatient stays, hospitalization planning and the nature of its services. Management will make every effort to improve the hospital’s performance, according to the standards determined in this declaration. 
• Hospital publications, including the service quality assurance declaration, total quality management declaration, work procedures and quality assurance according to ISO 9000, medical procedures, emergency operating procedures, the administrative and economic procedures and overall reports (financial, organizational and professional) will be available for public scrutiny, both by posting them on general or designated notice boards in all hospital departments and in the hospital bulletin, and also by making them available to anyone asking for them (on request), unless otherwise stated in the regulations of the Civil Service, Ministry of Health and IDF procedures and the hospital’s procedures, and provided that bringing them to public attention will cause no harm to patients or to any third party.

Hospital services 

• The hospital undertakes to providemedicalservices to its customers both in times of peace and in emergencies, all year round, at all hours of the day, to all those coming to it without discrimination on the grounds of gender, age, race, ethnicity, religion, nationality, place of residence and insurance affiliation, subject to the accepted payment procedures (or on presentation of a financial commitment). 
• For medical emergencies, treatment will be given immediately. 
• In normal, peacetime circumstances the hospital will provide those medical services it is authorized to give under its Health Ministry operating license. 
• The hospital will also be on constant alert to provide special services should an emergency arise, such as: 
  • Preparedness for a mass-casualty incident. 
  • Preparedness to treat victims of toxic substances (chemical agents, industrial toxins). 
  • Preparedness to place the hospital in a state of emergency, by increasing its capacity to answer national requirements.

Medical care 

• Medical care will be provided by trained staff who receive constant briefings. 
• Medical care will be provided using professional work practices that are safe and reliable and meet criteria that are widely accepted in Israel and elsewhere in the world. 
• Medical care will be provided according to guidelines and clinical criteria (Clinical Guidelines) that are acknowledged, accepted and updated from time to time. 
• Medical care will be provided using advanced technology and equipment that is safe, of a high quality, which is periodically monitored and tested to ensure its integrity. 
• To achieve these aims: 
  • The hospital will only employ qualified personnel (as required by their profession and level of training). At least one third of the doctors will be recognized as specialists by the Israel Medical Association, and the remainder will be in various stages of specialization training. 
  • The hospital will operate training and refresher programs at both the departmental and general organizational level – and will make every effort to ensure that the organization’s doctors are able to undergo additional training in Israel and abroad. 
  • The hospital will operate a system of clinical discussions, appraisal of problems and monitoring of medical processes, at a fixed frequency of once a month, both at the departmental and at the organizational level. 
  • The hospital will provide doctors with advanced professional information including professional literature, medical journals and access to computerized global data lines providing the latest available knowledge, rapidly and in real time, to ensure patient-care quality. 
  • The hospital will allow its physicians to consult with experts in their field, both inside the hospital and in other institutions in Israel and worldwide. Consultation will be available at all hours of the day and the hospital will allow for additional consultation in real time, as necessary. 
  • Recognizing the importance of medical research in order to develop new qualitative treatment methods, and the contribution of research to doctors’ knowledge, the hospital will strive to promote medical research and support doctors participating in research, both within the hospital and outside it. 
  • Medical care will be provided and supervised according to the accepted guidelines of total quality management and according to the requirements of the international ISO 9000 Standard.

Nursing care

• Nursing care will be provided by professional, skilled and fully-briefed staff. 
• Nursing care will be provided using professional, innovative and safe work methods, while maintaining the patient’s dignity and privacy. 
• Care will be given using clear, acknowledged and controlled work procedures which are periodically refreshed and drilled as required. 
• Nursing care will be provided with respect for the “overall” concept of customer needs, not just the specific illness. Treatment will be based on tried and tested methods based on the best nursing practices.
• To achieve this: 
  • The hospital will employ only authorized nurses, at least half of whom will be registered, and some of whom will have expertise and certification in specialized fields and sub​​-specialties of the nursing professions. 
  • The hospital will run a system of training and detailed knowledge updates in the framework of its policy of “Education as a Service” (EAS), both at the departmental level and within the overall institutional framework. Hospital management will enable its caregivers to participate in ongoing training opportunities, both in Israel and abroad. In this framework, the hospital will aim to raise the level of nursing care by sending caregivers to participate in advanced study programs, including academic studies. 
  • The hospital will operate a system of nursing job procedures based on the best current professional knowledge. The hospital will also run nursing quality assurance systems and control and supervision mechanisms under both management and customers. 
  • The hospital will provide nursing care professionals with advanced professional information including professional literature, medical and nursing journals and free access to computerized global data lines rapidly and in real time, providing the latest accessible information necessary in order to ensure the quality of their work. 
  • The hospital will maintain a system of constant discussion and appraisal of problems. 
  • The hospital will encourage and permit its nursing staff to participate in all areas of nursing and medical research. 
  • Nursing care procedures will be based on the principles of total quality assurance management and will be in compliance with international standard quality assurance management systems ISO 9000.

Availability and accessibility 

• The hospital will provide round-the-clock services, every day of the year. 
• The hospital’s emergency room will be open and provide medical services constantly, 24 hours a day and all year round. The hospital undertakes to admit any person arriving at the emergency room, whether he/she has been referred by another medical entity or not. The emergency room will provide diagnostic services, emergency care and urgent treatment. 
• The hospital is committed to begin treating anyone arriving at ER as quickly as possible, and no later than 15 minutes after their admission. We guarantee that in 80% of cases, treatment will be completed within two hours of being admitted to the emergency room. 
• Decisions on inpatient admissions will be based on medical reasons, and on medical reasons alone. 
• The hospital undertakes to shorten hospitalization time to the minimum time required for the patient’s medical condition, and to reduce to the absolute minimum administrative delays or delays arising from waiting for examinations and clarifications. 80% of patients will not be hospitalized for more than five days. Twice a year, the hospital will publish data on the length of hospital stays.  
• The hospital undertakes to admit anyone needing urgent hospitalization. On the other hand, elective hospitalizations will only be admitted when the hospital schedule permits. 
• The hospital will make every effort to ensure that elective hospitalization for diagnosis and surgery will be available within the shortest possible time. Hospitalization for diagnosis will take place at the most within a week. Waiting times for 80% of surgical operations will not exceed three months. From time to time, the hospital will publish the average waiting times for each type of operation. Both inpatient and outpatient procedures will be planned in advance in consultation with the patients, and with their consent. 
• The hospital clinics are open to the general public by appointment. The hospital will make every effort to ensure that waiting times for appointments at clinics do not exceed 14 days for 80% of patients. 
• All ambulatory services will be provided depending on the patient and the urgency of treatment required; the hospital will make every effort to ensure that the waiting time does not exceed the above, that the service is provided as far as possible at a time that is convenient for the patient, and under the appropriate conditions. 
• The hospital will make every effort to allow appointments to be made via every possible channel, including personal contact, by phone or in writing, at the patient’s convenience. For non-urgent treatment that does not require hospitalization, the patient will present a medical referral and/or appointment referral from a hospital physician, and a medical insurance payment commitment or actual payment.

Stays and hospitalization 

• The hospital undertakes to provide its services in a pleasant, comfortable and safe environment, in every part of ​​the hospital. 
• The hospital buildings and surroundings will be pleasant, clean, neat and well kept, well-lit at night, and marked with appropriate signs in three languages.
• The waiting areas will be spacious, clean and comfortable, providing comfortable conditions in which to wait, with background music and the opportunity to watch TV and read newspapers. The hospital will also contain a cafeteria and children’s play areas. 
• Hospitalization will be in comfortable and spacious rooms containing no more than four beds. The hospital will make every effort not to place patients in beds in the corridors, except in extreme cases and if there is no alternative. 
• The hospital undertakes to provide each patient with an optional telephone and personal television set, subject to the accepted terms of payment. 
• Food will be served attractively to patients. Patients who are fit enough will receive their meals in the departmental dining rooms, and the others in their beds. 
• Patients will choose all or most of their meals from a daily menu placed next to their bed. 
• The food served will be prepared under the supervision of a professional dietitian and will be nutritionally well-balanced while being individually adapted to each patient in a way that will not adversely affect his/her medical condition. Patients who need special foods will also be provided with a variety, and be able to choose between several types of menus and/or courses. 
• The food served will be kosher, and the hospital will ensure that all its units follow kosher dietary laws. 
• The hospital will provide hospitalized patients with laundry in sufficient amounts, as needed and in accordance with the patient’s condition. 
• The hospital will ensure that the toilets used by patients and their visitors are kept clean. 
• Immediate response to the call of the patient is a priority, even if it is necessary to stop doing something else in order to respond. This does not include situations where the response and/or termination of another action endangers the health of the patient (or another patient) or violates his/her privacy.

Information about the service 

• Customers are entitled to receive telephone information about the hospital and/or hospitalized patients (unless it is restricted for reasons related to laws, regulations or other limitations). The information will be provided in response to requests to the hospital switchboard, or directly to the department. ER and departments will provide information at all hours of the day and night. Information from the outpatient services and administration will be provided during normal working hours. 
• The phone numbers of the various services will be published in the national telephone directories, in the hospital’s internal phone directory, and on the letterhead of the hospital and the various services included in it. 
• The hospital is working to establish a computerized voice response in the near future. 
• The hospital will operate a call center providing information to all callers, including various inquiries. In an emergency, the hospital will operate public information centers and provide information to municipal information centers nationwide. 
• Information will be provided to those contacting the hospital in accordance with medical confidentiality regulations.
• As part of its provision of information, the hospital recognizes the right to know the identity of those providing the service. The hospital therefore requires its employees to wear appropriate uniforms, carry clear identification badges, and to identify themselves when answering the phone by stating their name and the name of the department in which they work. The names of service providers will be prominently displayed at the place where the service is provided (on the office door and/or work table or similar place).

Complaints, inquiries and appeals 

• The hospital will encourage customers to express their views on hospital services and suggest improvements. 
• The hospital will operate a “Public Complaints Committee” headed by a senior doctor, nurse, social workers and a manager and customer representatives. The committee will provide a body for the referral and investigation of consumer complaints. 
• The hospital will provide complaint and suggestion boxes in all departments, clinics, services and administrative services. 
• Free access to address the management of the medical center will be permitted via all channels, including letters, telephone, fax, personal meetings etc. as required. 
• Unless it has been responded to immediately, a letter or other request (written or oral) will be acknowledged within three days and transferred to the committee or another responsible body for treatment. At the end of clarification and/or treatment of the complaint, the investigation results and information about the way it has been dealt with will be reported to the applicant. If the treatment of a complaint is very prolonged, the applicant will receive an interim report after 60 days at the most, and an additional advisory after each further 60 days until the completion of the investigation and/or treatment. 
• A process of analysis and appraisal of problems will be carried out for each complaint and groups of complaints, according to types of complaint determined by management and/or the committee. Any conclusions will encompass all aspects of the entity being examined and implications for the department and for the entire medical center. Organizational aspects and aspects of risk management will be considered.

Constant review of customer needs and expectations 

• Hospital management will ensure the constant examination of customers’ needs and expectations in order to provide the highest professional level of services and quality required. This will be done by the following means: Feedback questionnaires, which patients will be asked to fill out once their care has finished. 
• Satisfaction surveys initiated by management or quality systems, to be conducted every six months, whose results will be published in the hospital’s publications. 
• Encouraging user monitoring: 
  • Local residents through various social organizations. 
  • Local authorities. 
  • Insurers, through their control centers. 
  • Ministry of Health, through the ministry’s quality assurance mechanisms and Public Complaints Commissioner.
  • Monitoring of specialization by the Scientific Council of the Israel Medical Association. 
• Encouraging those receiving hospital services to suggest improvements by placing suggestion boxes in all departments of the hospital. 
• Involving the customers in various improvement teams at the hospital, both at the overall organizational level and in the departments.
• Various improvement committees of the Friends of the Hospital, the Municipal Association and ad hoc committees of the institution’s customers.

Below are details of the various entities and their guiding principles: 

• Quality Council
• Policy Committee 
• Survey Unit 
• Monitoring and threshold testing 
• Service quality assurance declaration, quality assurance wardens and quality assurance departments. 
• Training unit 
• Public complaints officer 
• Internal auditor

Issues requiring early intervention are usually the most pressing. However, in order to create broad awareness of quality assurance issues throughout the medical center from the earliest stages of implementation, management has decided to choose a combination of subjects at the departmental, divisional, disciplinary and interdisciplinary level. The first issues to be addressed will be:

• Emergency room treatment, with an emphasis on the provision of orderly services and on waiting times. 
• The maternity emergency room and department, with a focus on hotel services and follow-up procedures. 
• Blood-bank services, ordering and provision of blood transfusions for patients. 
• Accidents during hospitalization, with an emphasis on drug dispensing. 
• Collection from the health funds, with an emphasis on differential hospitalization billing procedures. 
• Procedures for reviewing and approving suppliers

A project at a level of complexity of the type being considered requires an aggressive and effective marketing system. This system covers two main areas: 

• Internal marketing 
• External marketing

Main points of the policy

To ensure the ways in which the quality assurance policy is implemented and constant improvements in our institution, the hospital will operate a quality assurance system based on:

A. The management’s clear and unequivocal quality assurance policy.

B. Implementation of Total Quality Management (TQM) and Continuous Quality Improvement (CQI).

C. Managing a quality assurance system based on the requirements of the international standard of quality assurance management systems for service organizations (Series of Standards ISO 9002, Implementation Guidelines ISO 9004, and any derived from these in the future).

D. Risk Management.

E. Incorporation of elements of Outcome Management and efforts to achieve recognition according to the principles to be formulated by professional and scientific bodies responsible for this (accreditation).