Healthcare Organization Accreditation Standards

Healthcare Organization Accreditation Standards For the 60th Anniversary Celebration of His Majesty’s Accession to the Throne

Part I Organization Management Overview Measurement, Analysis, & Knowledge Management Part IV Results Strategic Management Human Resource Focus Patient Care Results Patient Focused Results Financial Results Human Resource Results Process Effectiveness Results Leadership Results Health Promotion Results Leadership Results Focus on Patients / Customer Process Management Part II Key Hospital Systems Risk, Safety, & Quality Professional Governance Environment of Care Infection Control Medical Record System Medication Management Diagnostic Investigation Disease & Hazard Surveillance Working with Community Patient Care Processes Part III Patient Care Processes Access & Entry Patient Assessment Planning Patient Care Delivery Education & Empowerment Continuity of Care

I – 1.1 Senior Leadership Senior leaders guide the organization. Senior leaders communicate with staff and encourage good performance, ensure quality and safety of care. b. Communication and Organization Focus a. Vision and Values 1 Mission, vision, values set, deploy, commit 1 Communication Empowerment Motivation Focus on action PI, org obj, vision Environment legal and ethical behavior 2 2 Review Performance measures Environmentfor performance improvement, accomplishment of mission & org obj, innovation, agility, learning, working relationships, cooperation and integration of services Practice 3 Strategic Objectives Good performance, ensure quality & safety, patient focus 4 Culture of patient safety

I – 1.2 Governance and Social Responsibility The organization demonstrates its good governance and its responsibilities to the public, ensures ethical behavior, and contributes to the health of key communities. a. Organizational Governance b. Legal and Ethical Behavior Governance system management, fiscal, transparency, audits, interests 1 Risk adverse impact public concern Processes Measures Goals Evaluate performance of leaders Improve leadership effectiveness Legal requirement 1 2 2 Monitor c. Support of Communities and Community Health Promotes Ethical Behavior Responds to Breaches Identifies key communities & areas for support Organization that give value to society supports and strengthens communities support community health

I – 2.1 Strategy Development The organization establishes its strategy and strategic objectives to address its challenges and strengthen its performance. 2.1 Strategy Development b. Strategic Objectives Strategic planning process 1 Strategic objectives & timetable 1 Participation, key steps & planning time horizon, strategic challenges and advantages, potential blind spots Address organization’s challenges 2 Address key organization’s strategic challenges and advantages, Respond to the health situation and needs, Contribute to improvement of the health outcomes Data analysis 2 Health problems & health care needs SWOT Other key factors - Safety / error - Collaboration, competition - Technology change - Health care & economic change - Financial, societal & ethical risk Ability to execute Health promotion objective 3 Health outcome of patients, families, communities, staff, Environment conducive to health Strong & sustainable organization Strategy Deployment

I – 2.2 Strategy Deployment The organization converts its strategic objectives into action and tracks progress to ensure goal achievement. Strategic objectives a. Action Plan Development and Deployment HR plan 4 Strong & sustainable organization 1 Action Plan Deploy Modify 3 Resources Goal achievement 2 Track progress 5 KPI Reinforce org alignment covers all key areas and stakeholders b. Performance Projection & Comparison Performance projections Address gap Compare

I – 3.1 Patient / Customer Knowledge The organization learns its key patient / customer needs and expectations to ensure the relevance of its services. a. Patient / Customer Knowledge Identify patients / customers, groups, market segments Determine groups & segments to pursue 1 Use for planning & improvement Requirement & expectation Listen & learn with varied methods 2 Service relevant with customer needs Use to Become more customer- focused, better satisfy customer needs, identify opportunities for innovation 3 Customer voice & feedback 4 Listening & learning methods Keep current with healthcare service

I – 3.2 Customer Relationship and Satisfaction The organization builds relationships with patients / customers to promote trust, satisfaction, and cooperation. The organization determines and uses patient / customer satisfaction information for improvement. a. Patient / Customer Relationship Building 1 Build relationships with patients / customers 2 Key access mechanisms seek information, obtain service, and make complaints 3 Manage complaints Aggregate& analyze Keep current 4 b. Patient / Customer Satisfaction Determination Determine satisfation 1 Response to neeeds Trust Satisfaction collboration Performance Improvement Actionable feedback Prompt follow up 2 Keeps approaches current 3

I – 3.3 Patients’ Rights The organization recognizes and protects the rights of patients. b. Patients’ Right Protection Process ค. ผู้ป่วยที่มีความต้องการเฉพาะ a. Patients Charter Organization Staffawareness, prompt response Basic right in the Constitution Impartial Be informed Prompt care for emergency Know name of provider Second opinion Confidentiality Research participation Guardian Terminally ill patients Right and dignity legal requirements belief and culture 1 1 Patient are informed Right & responsibility 2 Vulnerable children, disabled individuals, the elderly Protection 2 All patient care activities Assault Privacy, dignity, values Similar care for similar problems 3 4 5 Seclusion or restraints 3 6 Patient’s right & dignity is respected

I – 4.1 Measurement, Analysis and Improvement of Organizational Performance The organization measures, analyzes, aligns, reviews, and improve its performance through the use of data and information at all levels and in all parts of the organization. b. Performance Analysis, Review and Improvement a. Performance Measurement data / information / KPI Service, customer, financial, operation Analysis & review Trend, projection, comparison, cause & effect 1 Select, collects, Aligns, and integrates Track Daily operation, Overall performance, progress 1 Assess Success, progress, respond to change Support decision- making & innovation Comparative data Select & use Priority for improvement & innovation 2 2 Deploy throughout the organization Keep performance measurement system current & sensitive to change Incorporates into the systematic evaluation and improvement of key processes 3 3

I – 4.2Management of Information, Information Technology, and Knowledge Management The organization ensures the quality and availability of needed data, information, software and hardware for staff and patients / customers. The organizational builds and manages its knowledge assets to improve organizational efficiency and effectiveness. a. Management of Information Resources c. Data, Information, & Knowledge quality Staff, management, patients / customers, external agencies Need 1 Confidentiality 2 Available Design Manage Accuracy Reliability Timeliness Security Hardware & Software Reliable, secure, user-friendly 2 Access 1 Patient care Management Clinical audit Performance improve Education & research Facilitate Available in emergency 3 b. Knowledge Management Keep current Data & information availability Software & hardware Staff knowledge Patients / customers & external agencies Sharing good / best practices Use in strategic planning Scientific evidences 4

I – 5.1 Staff Engagement The organization engages, compensates, and motivates its staff to achieve organizational and personal success. Staff and leaders are developed to achieve good performance. Multiple Req. c. Assessment 1 a. Staff Enrichment Determines key factors 2 2 3 Staff performance management system compensation, reward, recognition, and incentive Foster organizational culture • cooperation, communication, and skill sharing • communication with supervisors and managers • individual goal setting, empowerment • innovation • benefit from the diverse ideas Assess & Improve 1 Engagement Satisfaction Org & personal success reinforcement of new knowledge and skills on the job Knowledge from departing workers Development opportunities & approaches Good performance Knowledge, skill, capability 4 Flexible Innovative Knowledge & skill sharing Good communication & information flow Alignment with org obj Patient focus Career progression Succession planning Core Competency Strategic challenge Action plan Performance improvement Technology Innovation Ethic Balance: org & staff Needs from staff Needs from management Professional requirement Quality & safety Health promotion Learning & knowledge asset Leadership attributes Develop of org knowledge 3 Evaluate effectiveness b. Staff and Leader Development 2 Leader 1 Staff

I – 5.2 Staff Environment The organization manages staff capability and capacity to accomplish the work of the organization. The organization maintains a work environment and a staff support climate that contribute to the health, safety and security. a. Staff capability and capacity Assesses Needs Identify job responsibility Work assignment 1 c. Staff Health Recruited, hired, placed, and retain new staff Evaluate credentials 2 1 Self action on their health • capitalize on the area of greatest expertise • reinforce patient focus • meet performance expectations • agility 2 Modeling behavior 3 Manage & organize staff 3 Occupational risk Prepare workforce for changing needs Ensure continuity 4 TB, HBV, HIV, Sharp Inj, Lab Chemicals, Anesthetic Gas, Chemotherapeutic Agent Pre-employment health examination 4 Organization Success b. Workforce Climate 5 Periodic medical examination Workplace health, safety, security 1 6 Immunization Healthy & safety Care of ill or injured staff, exposure to infectious diseas 7 Support staff Policies, services, benefits 2

I – 6.1 Work Systems Design The organization determines its area of greatest expertise and designs its work systems and key processes to deliver value to patients / other customers, prepare for potential emergencies, and achieve organizational success. a. Area of Greatest Expertise b. Work Process Design Determine areas of greatest expertise Determines key work processes Health care, business, support processes 1 1 Design and innovate overall work systems 2 Deliver value to customers, organizational success Professionals, patients, customers suppliers, partners, collaborators 2 Key work process requirements c. Emergency Readiness 3 Patient safety requirement, scientific evidence, professional standards, new technology, organizational knowledge, improved outcomes, efficiency and effectiveness Design & innovate work processes Preparedness for disasters or emergencies

I – 6.2 Work Process Management and Improvement The organization implements, manages, and improves its key work processes to deliver value to patients / other customers and achieve organizational success. Deliver value to customers, organizational success I - 6.1 Work Systems Design Better performance reduce variability, improve services & outcomes, keep the processes current a. Work Process Management 2 1 Patient expectation & preference Implements the designed work processes 3 Manage / control Improve work process Minimize overall inspection cost, prevent rework & errors Share to drive learning & innovation KPI, in-process measures Patients, customer, supplier, partner, & collaborator input b. Work Process Improvement

II – 1.1 Quality Improvement Overview There is a concerted and coordinated effort for quality program at all levels. 1 Evaluation techniques d. Self-Assessment a. Leadership Support Comparison 2 4 Encourage quality culture 3 Self-assessment methods share and learn, group discussion, writing a port-folio or self-assessment, clinical tracer, internal survey or internal audit, presentation for peer assist, after action review, indicator monitoring 2 Ensure quality & safety of care 1 Policies, goals, priority, expectation RM/QA/PS/CQI 3 2 Strategic Plan 4 Quality Structure Communication & problem solving Team in daily operation Quality improvement team Team with oversight function c. Team Work 3 1 Definition of quality 1 Support & monitor 2 3 b. Integration and Coordination 4

II – 1.2 Risk, Safety, and Quality Management System There is an effective and coordinated hospital risk, safety, and quality management system, including integrated approach for patient care quality improvement. a. Risk and Safety Management System 1 Coordination between various RM programs, integration of risk MIS Evaluate effectiveness Solutions Improve 6 5 3 2 Prevention strategy, communicate, make awareness 4 Incident report & analysis Risk identification & prioritization Root cause analysis 1 Improve patient care in targeted clinical population Patient care review Identify population MonitorKPI Improve 2 b. Patient Care Quality 3 4

II – 2.1 Nursing Governance There is an organized nursing administration responsible for high quality nursing service to fulfill the mission of the organization. Collaboration with organization committee: medication use, infection control, health promotion, quality and safety 1 Nursing leadership a. Nursing Administration 4 Ensure adequate and competent nursing staff 2 b. Nursing Practice 3 Patient’s right, ethic Key function: professional standard & ethic supervision & monitor quality & safety nursing process clinical decision making staff-in-training knowledge management research 2 Scientific evidences & nursing standards Outcome of nursing care: patient safety, relief from suffering, being informed and learning, self-care, empowerment and satisfaction 3 1 Use nursing process Patient’s health conditions 4 Nursing record 5 Relevant, continuum, enable Improve Risk/Safety/Quality Management 6 5 Evaluate

II – 2.2 Medical Staff Governance There is an organized medical staff organization, responsible for supporting and oversight of standard and ethical practice of medical professional to fulfill the mission of the organization. Ensure the quality of medical services scientific evidence & professional standards, continuous monitoring and improvement, respect to the patient’s rights, professional ethics 3 Give advice, suggestion, and plan with the management 2 4 Communication & problem solving Key functions: credentialing, clinical privileges, CME & knowledge sharing, professional standards and ethics, quality review and improvement, medical record quality, clinical decision making & use of technology, patient care policy, part-time & physician in training High quality medical & health service 5 Organized medical staff at the hospital level 1 Collaboration with organization committee: medication use, infection control, health promotion, quality and safety Agreements and guidelines medical practice, ethical / legal / social issues, quality and safety, competency development, documentation 6 7

II – 3.1Physical Environment and Safety The organization’s physical environment contributes to the safety and well-being of patients, staff, and visitors. The organization ensures that all occupants are safe from fire, hazardous material and waste, or other emergencies in the facilities. a. Safety and Security c. Emergency Management 1 Facility requirements 1 Hazard vulnerability analysis 2 Facility management, safety & securityprogram Inspection to identify risk & unsafe practice Plan -> Implement 3 2 3 Train Environment safety management Training & education 5 4 d. Fire Safety Fire safety plan 1 b. Hazardous material and waste Safety & well-being of patients & staff Education / fire drill 2 Safe processes: selecting, handling, storing, transporting, using, and disposing Fire protection & fire safety system & equipment 3

II – 3.2 Equipment and Utility System The organization ensures that essential equipment is available for use and functions properly and ensures continuity of essential utility services. b. Utility system a. Equipment Utility system management (effective, safe, & reliable) Inventory list, mapping, inspection, test & maintenance, emergency procedures, cooling tower and water system; ventilation system 1 Equipment management (effective, safe, & reliable) Select / acquire, inventory list, inspection, test & maintenance, education, emergency procedures 1 Availability of essential equipment 2 Emergency electrical power source maintenance, testing, and inspection 2 Data monitoring -> upgrade or replace 3 3 Data monitoring -> upgrade or replace Available, safe, & reliable system

II – 3.3 Environment for Health Promotion and Environment Protection The organization demonstrates its commitment for the hospital to be a healthy and safe workplace, to support health promotion activities, and to protect the environment. a. Health Promotion b. Environment Protection Environment that support social and psychological health Efficient water treatment system Capacity, staff, testing, quality 1 1 Facilities and environment for learning and skill development 2 Decrease the volume of waste Reuse, reduction, recycling, & avoid 2 3 Access to healthy food & product Use of material and equipment not harmful to health 4 Garbage disposal system Containers, segregation / transportation / storage, training, disposal, audit 3 Healthy and safe workplace, support health promotion, protect the environment Protect & improve the environment Partnership with the community, assess and receive feed back 4

II – 4 Infection Prevention and Control 4.3 The organization performs appropriate methods of surveillance and monitoring to detect and control infections, and manage nosocomial outbreak situations. Minimum infection 4.2 The organization ensures appropriate practices to prevent nosocomial infection. 4.1 The organization’s infection prevention and control program is appropriately designed, adequately supported, and well coordinated.

II – 4.1 Infection Prevention and Control Program The organization’s infection prevention and control program is appropriately designed, adequately supported, and well coordinated. b. Management and Resources a. Program Design 1 IC committee oversight, policy & recommendation, planning, coordination, monitoring & evaluation Scientific knowledge, accepted practice, legal requirements 3 ICN 2 All areas 4 Minimum infection Infection prevention & control 1 Goals, objectives, strategies, measures Context Size, service, patients Integrate with quality& safety program Adequate resources 3 5 Information system 4 2 6 Coordination Important infections Focus of prevention & control Education 5 Empower families/communities 6

II – 4.2 Infection Prevention The organization ensures appropriate practices to prevent nosocomial infection. Monitor & evaluate Standard Precaution Clean/disinfect/sterilize Infectious waste Hand hygiene Strategies to reduce infection risk 1 Program design Building structure, ventilation, hand washing facilities Environment control 2 Minimum infection Working area with unique concerns OR, LR, ICU, laundry, CSSD, kitchen, PT, postmortem Management 3 Minimize risk of certain infection SSI, VAP, CAUTI, IV infection, BSI, sepsis 4 Blood-borne infected, low immune, resistant bacteria, & emerging infection Care of complex case 5 Resources

II – 4.3Surveillance, Monitoring, and Outbreak Control The organization performs appropriate methods of surveillance and monitoring to detect and control infections, and manage nosocomial outbreak situations. Program design, management, & resources Infection prevention Use monitored information Plan, detect epidemics, education, evaluate & improve program, response to individual patient problems 4 a. Surveillance and Monitoring Minimum infection Active ongoing prospective surveillance 1 Monitor of other serious NI 2 b. Outbreak Control Monitor antibiotic utilization and susceptibility 3 1 Identify outbreak Detect and respond to new and resistant microorganism 5 2 Investigate & control

II – 5.1 Record Management System The organization establishes an efficient medical record management system to serve the needs of all parties. a. Planning and Design b. Security and Confidentiality Protection From loss, physical destruction, tampering and unauthorized access or use Determine purpose of medical record Communication, continuity of care, & quality assessment 1 1 Policies on security & confidentiality 2 2 Need assessment providers, management, individuals, external agencies 3 Education System design 4 Patient to access data 3 Policies & guidelines Record, correct, receive order, code, store, access, & destroy Implement 4 Quality patient care information 5 Code & index Evaluate & improve

II – 5.2 Patient Medical Record Every patient has a sufficiently detailed medical record for the purpose of communication, continuity of care, education, research, evaluation, and medico-legal requirement. 1 2 Sufficient information to: -identify the patient -support the diagnosis -justify the treatment -know the course and results of treatment -promote continuity of care -give correct coding -use for medico-legal purpose -assess quality of patient care Review medical record Completeness, accuracy, and timely completion

II – 6.1 Medication Planning, Management, and Storage The organization ensures safety, appropriateness and effectiveness of medication management system and availability of high quality medication. a. Planning and Management b. Medication Storage 3 Procurement Formulary drugs, drug shortage, urgently need drug 1 2 Proper & safe store Adequate, quality and stability, ready-to-use Hospital formulary Limit choice, safety measures for new drugs & non-formulary drugs 4 4 1 Lower the risks Identify, design processes Essential emergency drug Control, replace Multi- disciplinary team Direction & support efficient system Returned drug 2 Safe drug dispense when pharmacy is closed 3 ME/ADE prevention 5 Appropriate response to ME/ADE High quality drug available Drug use Training 6 Evaluate & improve 7

II – 6.2 Medication Use The organization ensures safety, accuracy, appropriateness and effectiveness in the prescribing and administration of the medication. a. Ordering and Transcribing b. Preparing, Dispensing and Administering 10 5 Drug Reconcile Admit, transfer, discharge ยาที่ผู้ป่วยนำมา 4 Patient information 1 Provide to patient care unit 1 Review order Appropriateness, safety Order Clear, appropriate Drug information Verify 2 7 2 Prepare Administer 4 9 Transcribe / communicate Accurate, standardized ME/ADE prevention policies Patients/families Active partners, education 3 Label 3 ติดตามผล บันทึก 8 Provide to patient Review 5 7 Physical environment Clean, adequate space & lighting, no distraction Adverse drug reaction /medication error Notify 6

II – 7.1 Diagnostic Investigation and Related Services: General Requirements The diagnostic investigation services provide accurate and reliable diagnostic information with minimum hazards to patient and staff. a. Planning, Resources, and Management b. Service Provision Competent staff 2 Space & environment Direct examination to patient Assess, prepare, inform 3 1 1 Equipment Maintenance & calibration 4 Plan Referral laboratories Evaluate, select, and monitor Interpret 5 Equipment, supplies, reagents Select, procure, inventory Document 2 6 Communicate Communication with users 7

II – 7.2 a. Medical Laboratory / Clinical Pathology The examination processes and quality management system of the medical laboratory ensure reliable and accurate results. 2 Quality Management System Problem / OFI identification, error records & incident reports, KPI monitoring, corrective / preventive actions, pre-analytic and post-analytic variables monitoring, document controls, patient safety goals, & appraisal of the QM program effectiveness 1 Proficiency Test verify Examination Appropriate standard test methods that are validated Input Reagent, equipment, analytical instruments 5 Reliable & accurate results Planning, resources, management Sampleafter exam Store for repeat exam, safely dispose 7 4 Specimen Collect, handling, identify, packaging, label, preserve, requisition, transport, storage, evaluate 6 Report Confidentiality, critical level, retrieval of reported resultcopies Quality control 3

II – 7.2 b. Blood Bank The organization complies with the Standard of Blood Transfusion and Blood Banking issued by the National Blood Service, Thai Red Cross Society. General policies Quality system, safety Donor selection Qualification, risk assessment, provide information Preparation of blood component Whole blood, pack red cell, plasma, platelet Blood transfusion Blood collection Prevent contamination, Collect blood, quantity, temperature, donor care Blood testing ABO, Rh, other Ab, disease markers Transfusion reaction monitoring Response

II – 7.2 c. Radiology and Other Medical Imaging Services The radiology and other medical imaging services provide quality pictures, reliable and accurate results, with minimal hazards to patient and staff. 6 Quality management system QC in equipment & preventive maintenance, patient & physician needs, risk prevention and monitoring, annual review of the quality management program Facility & equipment Comply with standard, be examined & approved Radiation safety measures Monitor exposure, hazard signs, disposal of radiation material & waste 2 1 Planning, resources, management 4 Indication & communication Professional guidelines & scientific evidences Imaging study Position, exposure, label 3 Reliable & accurate results Interpretation, consultation, review Perform by qualified staff 5 6 Quality management system QC in radiograph technology, review incident & OFI, staff performance evaluation

b. Surveillance Data Collection and Analysis 1 3 4 Analyze & compare Interpret with epidemiology Surveillance CD, NCD, other health hazards Lab Collect & store 5 2 Clinician Monitor situations & trends 6 Quality of data Updated, complete, accurate, timely, comparable Plan prevention & control 7 Project trend c. Response to epidemics of disease and health hazard 1 Set up SRRT Resources & authority 6 Communication channel24 hr 4 Response plan, ensure preparedness 2 7 Investigate Case investigation 5 Preventive & control measures 3 8 Warning message a. Management and Resources d. Information Dissemination and Alert Disease & health hazard Policy & plan 1/2 Report Current situations, to authorities, relevant agencies & mass media Overseeing system Policy & measures, plan & co-ordinate, monitor, evaluate and improve 3 Personnel / resources 4/5 6 Education

II – 8.Disease and Health Hazard Surveillance The organization ensures the efficient surveillance for detecting abnormal occurrence of diseases and health hazards, and the prompt investigation to control further spreading.

II – 9.1Health Promotion for the Community The healthcare team, in collaboration with the communities, provides health promotion program to meet the need of the communities it serves. Define the communities 1 2 Plan and design health promotion serviceswith the communities Healthy, risky, illed Assess needs & capabilities Collect data Identify key target groups Health care Support Facilitate learning Health skill development Guide public policy Networking 3 Collaborate with other providers and organizations Carry out health promotion program Evaluate & improve 4

II – 9.2Community Empowerment The healthcare team works with the communities to support the development of the communities’ capacities to improve its own health and well-being. Collaboration with the communities Participation of the communities Network & partnership Promote the ability of population groups to solve their key problems Promote individual behavior and life skills 1 3 4 Advocating healthy public policy Binding engagement, information exchange Promote physical environment conducive for health Physical & chemical contamination, natural resources, recreation 2 Promote social support services and social climate conducive for health 5 6 Healthy community, well-being of community

PART III PATIENT CARE PROCESSES III - 1 Access & Entry III - 4 Patient Care Delivery III - 6 Continuity of Care III - 3.1 Planning of Care III - 2 Patient Assessment III - 5 Education & Empowerment III - 3.2 Discharge Planning

III –1. Access & Entry The healthcare team ensures access to essential services with minimal barrier, ensures that an entry process is timely, meets patient problems / needs, is coordinated and supported by suitable and effective systems and environment. Refer Initial care, explain, find services Priority for emergency need Access, reduce barrier Physical, language, cultural 2 3 4 Entry to intensive services Established criteria Determine capability Initial assessment Prompt response 1 Entry to general services Inform Conditions, proposed care, expected results & cost Education & empowerment Timely, appropriate, effective entry 5 Consent

III – 2. Patient Assessment All patients have their healthcare needs and problems identified accurately in a comprehensive and appropriate manner. Implement Collaborate & coordinate Analyze, Integrate Reassess a. Patients Assessment 1 5 3 Initial assessment History, PE, perception, psychological, social, and economic factors 2 Identify urgent or important care needs Patient Age, health problems, urgent, education, service Care plan 1 Clinical practice guidelines Record 4 Diagnosis b. Diagnostic Investigation c. Diagnosis Explain Safe environment 6 Investigation 1 Review Evaluate reliability Resources Technology, staff, equipment 2 4 Manage with abnormal results Communicate 3

III – 3.1 Planning of Care The healthcare team ensures a coordinated patient care plan with goals developed in response to health problems / needs of the patient. Patient need assessment 2 Integration & coordination professionals, departments, services 5 Goals, Service to be provided 1 Patient care plan Holistic, appropriate Implement Evidence or guidelines 3 Coordinate & communicate 6 Monitor Patients / families participation 4 Revise 7 Inform patients / families

III – 3.2 Discharge Planning Discharge planning process enables self care of patients and ensures that patient’s ongoing needs after discharge are met. 1 2 Involvement Physicians, nurses, other professionals, patients & families Determine guidelines, indication, and key target conditions Assess need for D/C plan 3 Patient / families are able and have confident for self care Assess need after discharge Discharge plan Implement Integrate with patient care plan, use empowerment concept Update 4 5 6 Evaluate Improve

III - 4.1 General Care Delivery The healthcare team ensures that care is delivered in a timely, safe, and appropriate manner according to professional standards. Keep patients safe from accidents, injuries, or infection Appropriate delineation of clinical responsibility 3 1 Deal with complications, crisis, emergency safely and appropriately Timely, safe, appropriate care, complied with professional standards Current accepted practice 4 Holistic care 5 Environment conducive to quality care 2 Exchange information and coordinate to ensure continuity of care 6 Monitor & evaluate

III - 4.2 Care of High-Risk Patients and Provision of High-Risk Services The healthcare team ensures that care of high-risk patients and high-risk services is delivered in a timely, safe, and appropriate manner according to professional standards. Identify high-risk patients & services Train Practice Policies & procedures 2 1 Timely, safe, appropriate care for high-risk patients Response High-risk procedures Facility, equipment, & assistance staff Monitor 3 Change of care plan 4 Rapid response to clinical instability or deterioration Assessment, stabilization, communication, education, & transfer 5 6 monitor & analyze trend of complication or adverse event Improve care process

III - 5. Information and Empowerment for Patients / Families The healthcare team provides patients and families with information on their health condition and planned activities to empower them, encourages them to carry out their responsibilities, and to facilitate integration of health promotion in all patient pathways. 2 1 Evaluate Perception, understanding, ability to implement Provide information, facilitates learning Plan learning activities Assess Patients / families be able to take care their health Emotional support & counseling problem need emotion & psychology capability readiness 3 Self-management strategies Follow-up 4 5 Skill training 6 Improve Evaluate

III - 6 Continuity of Care The healthcare team collaborates and co-ordinates for effective follow-up and continuity of care. 3 Appointment Communicate patient information 1 Assistant & consultation Patients receive continuity of care & response to needs 2 Collaborate & coordinate Follow-up care Integrate health promotion 4 Review medical record 5 Improve, plan Monitor

PART IV ORGANIZATION PERFORMANCE RESULTS The organization demonstrates good performance and improvement in key area, i.e. health care results, patient and other customer-focused results, financial results, human resource results, process effectiveness results, leadership results, and health promotion results. Outcome, process, safety, functional status IV - 1 Patient Care Results IV - 4 Human Resource Results Engagement, satisfaction, development, capability, staff level, workforce climate IV - 2 Patient / Customer- Focused Results IV - 6 Leadership Results IV - 3 Financial Results Strategy accomplishment, ethic, governance, fiscal accountability, legal compliance, communitysupport Satisfaction, dissatisfaction, perceived value, retention, positive referral, building relationship IV - 5 Process Effectiveness Results work systems, preparedness for disasters or emergencies, key work processes IV - 7 Health Promotion Results Staff, client, community

Healthcare Organization Accreditation Standards