The Quality Charter
The Quality Charter
Service Quality Policy
The management of the
We consider ourselves as committed to maximizing and facilitating the medical and nursing treatment quality and the quality of the accommodation and hospitalization services and the quality of the work and management n the organization, on all levels, in order to attain the complete satisfaction of its clients.
The hospital employees are the most important asset in assuring continual improvement. The quality of the performance of each and every one of us constitutes a key component in the success of the process. Consequently, the hospital will work to expand knowledge of its employees and managers in their fields of work, and to develop interdisciplinary and interdepartmental cooperation, and to facilitate comprehensive teamwork which considers the client as central in the organization’s existence.
An important facet in creating a continual process of improvement is data collection and identifying problems in order to investigate the source of the problems and to solve them quickly. Therefore, we will strive to increase openness between the employees and managers, while demonstrating involvement and meeting commitments. The tool for achieving this goal is the risk manager’s institutionalized operation at the hospital.
The hospital exists in order to provide its clients with the highest possible level of of health services. Consequently, our clients are a central factor in the development of our activity and are partners in the decision making processes in the organization. This objective is achieved by their involvement in the decision making bodies. Representatives of our clients, who are represented in the Friends Association, the YAEL Organization and in the Nahariya Hospital Conurbation, participate in management meetings.
External institutions and suppliers that work with the hospital are part of our organization’s quality system. We will work with them cooperatively in order to develop their capability for meeting the standard and quality level required by the hospital. In general, the hospital will aim to work with suppliers that meet the specifications of the ISO 9000 international quality standard.
The hospital’s activity is based on fundamental principles of humanity, professionalism and efficiency.
1. In order to ensure the methods for implementing the quality policy and the continual improvement at our institution, the hospital will implement a quality system based on:
· The management’s clear and unequivocal quality policy.
· Complete implementation of the TQM Total Quality Management approach.
· Managing the quality system based on the international standard for management of quality systems in service organizations (ISO 9000).
· Risk Management
· The Public Inquiries Commission.
2. The Hospital’s Commitment to its Clients
· The hospital was established for and works toward the benefit of the patient, and its clients’ rights are as follows:
To receive treatment in accordance with the hospital’s undertakings based on this charter.
To know the name and position of every employee who treats him.
To receive treatment that is received based on his free will and inclinations and with his complete consent.
The client is entitled to refuse treatment of any kind, and this will not affect his right to continue to receive treatment that he does agree to. In an emergency medical situation or if it is not possible to receive informed consent from the client, or from his guardian or his legal representative, essential medical treatment will be administered without delay, provided that this decision be reached by three doctors, unless the emergency circumstance do not allow for such, and the decision must be make by only the attending physician. (in accordance with the Patient’s Rights Law, 1996).
To receive information regarding the purpose of the treatment, its essence and any of its proceeding, and its inherent risks, in order to formulate his consent. The patient is entitled to receive information regarding treatment alternatives and regarding the implications of refraining from treatment. Based on the patient’s consent, the physician shall convey medical information to the relatives. In a case of medical emergency, the treatment team is allowed to convey information to a close relative, if such is in the best interest of the patient and in any event, the client is entitled not to receive information as per his wishes.
To respect, privacy when receiving treatment and strict confidentiality of the information pertaining to him. The patient is entitled to the presence of another person during the examination and in the case of a helpless minors, examination of sexual organs, loss of consciousness, or psychiatric patients, the examination will be conducted in the presence of a parent, guardian or member fo the medical staff of the same sex as the patients.
To consult with experts outside of the hospital in order to receive a second opinion, without obstacles placed by the organization.
To refuse to participate in a scientific research study. The patient’s informed consent is an imperative condition.
To refuse to be examined by medical students (In any event, the patient shall not be examined by a student unless the patient gives his full consent).
The hospital will enable the hospitalized patients’ relatives to visit them during regular visiting hours. It will make available a suitable and comfortable place for them to visit. The visiting hours will be determined based on the patients’ treatment needs and rest, and the convenience of the visitors. The visiting hours will be publicized in the hospital’s publications.
The hospital staff undertakes to keep medical records on the patient’s condition and to ensure its maintenance based on accepted procedures. This record will be made available to the patient and his physicians only, unless the patient gives instructions otherwise in writing and with sound mind.
· When treatment is administered, the hospital will operate in accordance with:
· State Medical Insurance Law - 1995
· Public Health Ordinance 1940
· Patient’s Rights Law - 1996. The health laws in effect in the State of Israel
· Ministry of Health policies
· Hospital management policy based on this charter. And any undertaking therein, including adherence to ISO 9000 standards.
· Accepted rules of medical and nursing ethics.
· Service Reliability at the Hospital
The hospital management and the staff will ensure that service is provided in accordance with the rule of this charter, in accordance with the quality procedures of ISO 9000 and the general quality management rules.
The hospital management will strive to only use proper equipment and medications, supplied by manufacturers who implement quality plans and who have quality standard certification.
Every 6 months, the hospital management will publicize standards related to providing services in terms of appointments, time spent in the emergency room and hospitalization, planning hospitalization and nature of service. In the future, management will make every effort to improve standards set down in this charter.
Hospital publications, including the service quality charter, the comprehensive quality management charter, the work and quality procedures according to ISO 9000, medical procedures, emergency operation procedures, administrative and housekeeping procedures and all reports (financial, organizational and professional) shall be available for public scrutiny (both by publication in general or specific bulletin boards to be posted in all the hospital departments, in the hospital newsletter, and by making them available to anyone who wishes (by request), unless otherwise determined in the civil service regulations, health ministry and IDF procedures, and on condition that no damage to patients or to any other third party will be caused by their being brought to public attention.
· Hospital Services
The hospital undertakes to provide medical services to its clients both in times of peace and in a state of emergency, all year-long, all hours of the day, to any all those who approach, regardless of gender, age, race, ethnicity, citizenship, place of residence or insurance affiliation, based on the accepted payment procedures (or presentation of a financial commitment). In time of peace, the hospital will offer medical services, which it is authorized to provide according to the operating license it is issued by the Ministry of Health.
Additionally, the hospital will be continually on-call to provide unique services during a state of emergency:
On-call for a multi-casualty incident with from ten to 100 casualties.
On-call for the treatment of poison victims (chemical warfare agents, industrial toxins).
On=call for the operation of the hospital in a state of emergency, with an increase in occupancy based on the country’s needs, and providing services under safe conditions.
· Medical and Nursing Treatment
The medical and nursing treatment shall be administered by a professional and skilled team that is constantly updated.
The medical and nursing treatment shall be administered by adopting professional, safe and reliable work methods, which meet accepted professional standards in
The medical treatment will be provided based on recognized clinical guidelines, and clear accepted work processes that are updated from time to time. Moreover, control and supervisory mechanisms will be implemented according to the specifications of the ISO 9000 standard, a comprehensive quality management method and quality committees.
Treatment will be administered using a holistic approach to the patient and while respecting his dignity, privacy and modesty and providing appropriate personal attention. During the course of the treatment, the medical staff will make every effort to make things easier for the patient, to minimize his pain and to improve how he feels.
The medical treatment shall be administered using state-of-the-art technological methods and equipment, which are safe, high quality, inspected and periodically tested to ensure their integrity.
The hospital will employ only licensed doctors, of whom at least one third with specialization recognized by the Israeli Medical Association and the remainder in various stages of their internship.
The hospital will employ only licensed nurses, of whom at least half are RNs and the remainder with specific specialization in the various nursing fields.
The hospital will operate a departmental and institution-wide training system and will run ongoing training programs, both in
The hospital will operate a regular system of clinical dialogues, draw conclusions and critiques of the medical processes, once a month, on a departmental and organizational level.
The hospital will provide the medical and nursing staff with advanced information systems including professional literature, medical and nursing periodicals, and free access to computerized information lines world-wide, in order to offer up-to-date, available information quickly and in real time, which is necessary to ensure the quality of their work.
The hospital will provide its doctors with extensive consultation systems with specialists both from within the hospital and from other institutions in
In cases in which the hospital’s doctors determine that the hospital is not capable of providing the patient with the appropriate treatment, he will be transferred to another medical institution, which has the appropriate measures.
The hospital’s management will encourage medical research in the various fields and help its doctors who are engaged in research at or outside the hospital, in order to facilitate the development of new quality treatment methods and to contribute to the development of knowledge among its doctors.
The hospital will enable its employees to take part in all fields of nursing and medical research.
· Assistance Systems:
Include: social services, dietician services, occupational therapy, physiotherapy, laboratories, institutes and imaging services, psychiatric counseling service and administration and housekeeping.
The assistance systems are based on professional, skilled and up-to-date professionals.
The same principles undertaken by the hospital when providing medical and nursing treatment also apply to the assistance systems.
· Commitment to Improve Services
Availability and Accessibility - The hospital will provide services based on the following description:
*The Emergency Medicine Department will provide medical services all year long, 24 hours a day. The hospital undertakes to accept any person who approaches this department for help. The department will offer diagnostic and treatment services.
*The hospital undertakes to treat those who approach the emergency medicine department, as quickly as possible, and no later than 15 minutes from the time of his admission, and to complete the treatment in 80% of cases within two hours.
*Admission to the hospital shall be executed based solely on a medical decision. The hospital undertakes to admit every person for emergency hospitalization and elective hospitalization according to the hospital’s capability.
* The hospital undertakes to shorten the hospitalization, if so requested by the patient, based on the medical situation of the patient, and to reduce administrative delays to a minimum. 80% of hospitalizations shall not last more than 5 days.
* The hospital shall make every effort to ensure that the availability of the elective hospitalization for observation and surgeries shall be the shortest possible. Hospitalization of observation shall be offered within one week at the latest. Scheduled dates for the surgeries shall not exceed three weeks. The hospitalization date will be determined based on the patient’s convenience.
* The hospital clinics are open to the public at large based on appointment, and the hospital undertakes that the wait shall not exceed two weeks for 80% of the patients.
*Setting appointments for elective surgery and for the outpatient clinics shall be done through the computerized system. Setting appointments will be possible through either telephone or in writing, at the patient’s convenience and subject to medical referral and presentation of a monetary commitment for payment. Notification regarding the appointment will be issued to the patient in writing, orally or by telephone, within 96 hours from the time the medical decision is made
· Hospital Stay and Hospitalization
The hospital undertakes to provide its services in a pleasant, comfortable and safe atmosphere in all areas of the hospital.
The hospital’s buildings and surroundings shall be pleasant, clean, attractive, well-lit in the hours of darkness and marked with appropriate signs.
The waiting areas will be spacious clean and pleasant, facilitating a comfortable wait, with background music. They will also feature cafeterias and games for children.
The hospitalization will be in comfortable and spacious rooms. The hospital will make every effort not to place hospitalized patients in the halls, unless in extreme cases and for a period that does not exceed 12 hours.
The food served will be nutritionally balanced and will be prepared under professional supervision of a dietician, depending on the patient’s illness, without detracting from his option of selected food from the daily menu, based on their personal taste.
The patient will select food from the menu at his bedside, based on his personal taste.
The food will be served in an attractive manner in the department dining room, or will be served at the patient’s bed, based on his condition. The food served will be kosher and the hospital undertakes to adhere to the laws of Kashruth in all of its units.
Information about Service
The clients can receive information about the hospital’s services by telephone from information service at the hospital switchboard or from the various departments during their regular work hours.
The department’ telephone numbers will appear in the internal and external telephone directories, and on hospital correspondence.
The hospital features a automated answering service for setting appointments for elective surgeries and at the outpatient clinics.
The hospital will operate an information service to provide all clients with information. In a state of emergency, the hospital will operate information hotlines for the public and will transfer information to municipal and national hotlines.
The information will be provided to clients, while adhering to the medical confidentiality rules.
The hospital administration undertakes that its employees shall wear appropriate uniforms, identification tags and identify themselves on the telephone by their name and the name of the department. The names of the service providers will appear at their counters and in their offices.
Complaints, clarifications and appeal:
The hospital will operate a public inquiries commission that includes: a senior doctor, a senior nurse, social worker and management representative. The hospital will place a box for inquiries and suggestions in all of the hospital’s departments.
Personal communication with the hospital management will be possible in writing, by telephone or by fax.
Every inquiry made to the ‘public inquiries commission’ will be confirmed within five days of its receipt. At the end of the investigation, the results will be sent to the client. The hospital will make every effort to complete its handling of the complaint within 60 days. In the event that the handling of the inquiry takes time, the client will receive notification of the status of his inquiry, no later than once every 60 days. Conclusions will be drawn on an individual, departments and organizational level as well as on a quality management and/or risk management level.
Continual evaluation of the customer’s needs and expectations
The hospital management will ensure continual investigation of the client’s needs and expectations, through:
*Customer Satisfaction Surveys
*Satisfaction surveys that will be conducted from time to time on various topics throughout the year and their results will be publicized in the hospital’s publications.
*Encouraging ‘User Control”
*Residents of the region through various social organizations.
*The regional authorities, through the Nahariya Hospital Conurbation.
*The various insurance companies through their ‘control centers’.
*The Health Ministry through the ministerial quality assurance mechanisms and their ombudsman.
*Specialization control by the Israeli Medical Association’s scientific council.
Measurement and Control Tools:
The hospital shall operate a reporting and quality control system through:
*The Quality Assurance Division
*Internal and external quality verifications and permanent quality committees, according to ISO 9002 procedures.
* The Chief Nurse’s Report
* Computerized departmental reports
* Hospitalized patient reports, hospital stay reports.
* Admission, discharge and emergency stay reports.
* Follow-up reports, following hospitalizations, surgeries and procedures.
* Drugs, equipment and measures consumption reports.
* Periodic financial statements
* Control and budgeting unit.
* Risks administration.
* External control by a government auditor and the Israel Standards Institute.
· Repair Tools
The hospital will operate a system for locating problems and their repair in real time. It possesses a computerized system which provides alerts regarding the various problems. The following is a list of controlled subjects:
Follow-up of patients’ attendance for hospitalization at clinics and ambulatory units. Identifying patients who did not arrive for their appointment, with the reason for their non-attendance and immediately handing of this issue.
Follow-up of surgeries.
Computerized follow-up of laboratory results, control of results and computerized alerts regarding unusual results.
Daily control of the cleaning, administration and housekeeping inspectors.
Quality Assurance Division’s control based on ISO 9002 standards.
The hospital undertakes to monitor and control the degree it meets the standards and the service standards set down in this charter, and to publicize the results of this follow-up for public knowledge. These data will constitute the basis for improvements.