Accreditation at Poriya

Accreditation Coordinator, Mrs. Malka Amar Madmon

The Baruch Padeh Poriya Medical Center The First Government Medical Center
Awarded an International Standards
Seal of Approval for Quality and Safety
 

In June 2013, the Hospital was awarded the JCI Organization's International Standards Seal of Approval for Quality and Safety after two and half years of demanding and intensive work. This is how it began: 

The Director of the Medical Center - A visionary and instigator who decided to plunge into the freezing water and to be the pioneer of the process amongst the Government hospitals. 

JCI- An international organization that has set its sights on raising the level of quality and safety at medical facilities throughout the world. The objective of the Organization is to continually and lastingly improve the quality and safety of treatment of the patient in the international community. The Organization has been in existence for more than 75 years and is the largest accreditation organization for health care institutions in the USA. 

The Accreditation Process- Is implemented by means of a manuscript of standards consisting of 14 chapters, 300 standards and some 1,300 measurable elements. Each chapter, each standard and each element is measurable and garners points and the total points constitute the grade for obtaining the standards seal of approval.

Passing Grade; 90% and over!!! 

The process was kicked off at a festive launch evening at Kfar Hittim, where we tasted of the best the place has to offer and we listened to the fascinating, hilarious and distressing lecture given by the Director of the Carmel Hospital, shortly before their summation inspection. 

We set off on our quest after a JCI run workshop, the selection of 13 work teams - the majority of which were made up of employees of the Medical Center, who voluntarily joined in the process, and making contact with our team of consultants acting on behalf of the Organization. 

Our Medical Center was the pioneer and the leader from amongst the Government hospitals who participated in the process, in all the advisory tests and inspections carried out by the JCI Organization. 

December 2010- The first advisory inspection - which we passed with considerable organizational success, but with a great deal of work to follow. The kick off slogan we coined was: "Soon we will go far" . 

Over the two and half years, hundreds of meetings were held with team leaders, hospital committees, the hospital management team and departmental team meetings. Some 60 new procedures were drawn up, existing procedures were revamped, training sheets for all the departments were updated, department data sheets were drawn up, booklets relating to patients' rights were produced, a pocket manual on the subject of accreditation was published, posters about the hospital's vision and personal hygiene were printed and distributed and working documents were drawn up for use by personnel throughout the hospital. Dozens of documents were translated into 3 languages. 

October 2011 - The second advisory inspection, after which the continuation slogan was coined: " Almost officially happy" . 

July 2012 - A dry run inspection, which determined conclusively that the preparations are bearing fruit and that the Hospital is ready, willing and able to undergo the summation inspection. Throughout the process, many knowledge inspections were conducted at the Medical Center. 

The Director of the Medical Center, his Deputy, the Nursing Director and the Deputy Administration Director carried out inspections on a daily basis in all departments, questioned doctors, nurses, ancillary personnel, housekeeping staff, para medical personnel, administrative personnel, etc.

Nurses in charge of wards carried out initiated inspections in their wards and mutually executed inspections of other wards. 

Inspections - Over the 3 months prior to the summation inspection, inspection were held every day, in all shifts, carried out by senior teams at the Medical Center. 

The Summation Inspection - Was conducted from June 16 to June 20 for 5 days, with 3 inspectors, taking up 120 hours of checking, inspecting and control. 

On the 12th of Tammuz - June 20, we were informed that the Medical Center passed the inspection with flying colors and an announcement was blared out: 


The first Government Medical Center - is awarded the International Standards 

Seal of Approval for Quality and Safety 

ACC Team - Accessibility and Continuation Handling 

Leaders: Dr. Eran Tal Or - Director of the Emergency Room; Ms. Anat Moyal, Nurse in Charge of the Emergency Room 

The team deals in generating criteria for hospitalization, ways to transfer information amongst the various departments at the Hospital, defining a structured and uniform process for discharging the patient. 

PFR Team - Rights pertaining to the patients and to his family members 

Leaders: Dr. Amitai Oberman - Director of the Geriatric Ward; Adv. Shulamit Blank - in charge of public inquiries and responsible for the rights of the patients. 

The team deals with the definition of the patient's rights and the implementation thereof in day to day treatment and training hospital personnel on the subject. 

AOP Team - Assessing the Patient 

Leaders: Dr. Yegena Shai - Director of the Hematology Unit; Ms. Mona Peretz - Nurse in Charge of the Dialysis Unit; Ms. Maxine Cohen - Nurse in Charge of the Oncology Ward. 

The team deals with creating uniform profiles for assessing the patient and designing safety plans for the X-Ray and laboratory staff. 

COP Team - Treatment of the Patient 

Leaders: Dr. Said Abuzid - Deputy Director of the Pediatric Ward; Ms. Shlomit Shmilowitz - Coordinator of Quality in Nursing. 

The team deals in setting uniform procedures for treatment of the patient, formulating uniform treatment programs, involving a nutritionist at all stages of the treatment. 

ASC Team - Surgery and Anesthesia 

Leaders: Dr. Shalom Lidzi - in Charge of the Operating Room; Ms. Haya Mari - Deputy Nurse in Charge of the Orthopedic Ward 

The team deals in setting indexes for monitor pre-anesthesia patients and the monitoring process during surgery. 

PFE Team - Instructing the Patient and his Family Members 

Leaders: Ms. Dina Granot - Nurse in Charge of the Cardiology Ward; Mr. Isam Mansur - Nursing Administration. 

The team deals with the formulation of a formal and uniform training process that enables the patient and his family members to participate in the training process. 

QPS Team - Improving the Quality and the Safety of the Treatment 

Leaders: Dr. Anat Segal - Senior Physician at the Statistical Management Unit and at the Pre Surgery Respiration Unit; Ms. Ilana Assa'el - Nurse in Charge of the B Internal Ward. 

The team deals with setting indexes for monitoring quality, data processing and information, formulating a plan that enables the preservation of the safety and quality of the treatment. 

PCI Team - Preventing Infection 

Leaders: Dr. Subach Subach - the Director of B Internal Ward; Ms. Kozita Labai - Nursing E pidemiological Supervisor. 

The Team deals in formulating an overall plan to prevent infection, conducting inspections, monitoring high risk for infection treatments and educating the staff to prevent infections. 

GLD Team - Management and Leadership 

Leaders - Dr. Yuri Perlitz - Director of the High Risk Maternity Unit; Noa Sela - Assistant to the Hospital Director 

The team deals in organizing the Hospital's goals, the Hospital's vision, organizing and executing directives, administration, organization and leadership, including formulating a department and unit level work plan. 

FMS Team - Managing the Hospital's Facilities and the Safety Thereof 

Leaders: Eng. Ron ben Dan - Hospital Engineer; Ms. Bella Monostrasky - Coordinator of nursing emergencies; Dr. Kroani Milad - Director of the Trauma Unit. 

The team deals with designing a structured plan to prevent physical dangers in the hospital buildings, building structure control to prevent accidents involving visitors and patients, planning the gearing up for emergencies and training Hospital staff on subjects of safety and security. 

SQE Team - Employee Training

Leaders: Mr. Nachum Sivan - Deputy Director of Administration and Ms. Talia Livnat - Coordinator of on the job training in nursing. 

The team deals with defining the training needs of the staff, team development, training new employees and periodic evaluation of the Hospital personnel. 

MCI Team - Communications and Information Management

Leaders: Mr. Daniel Zohar - Director of Information Systems and Computerization; Ms. Miri Tal - Nurse in Charge of the Delivery Room; Ms. Liat Finian - Director of the Medical Information Recording Dept. 

The Team deals with record managing planning, the incorporation and the use of information, protecting the confidentiality of medical and other information and improving ways of communicating between the organization and the community. 

MMU Team - Medicinal Management and Treatment 

Leader: Ms. Julia Bartal - Deputy Director of Nursing The team deals with the re-organization of the medicinal treatment process, drawing up an updated procedure on the topic and improving the infrastructure in the various departments.