UC 12: Act in Quality programs and

Hospital certification - 48 hours

Curricular unit: works in quality and hospital certification programs

Indicators
• Monitor care indicators according to programs of
quality and accreditation manual.
• Collects data on hospital infection, health indicators and
adverse events according to the institution's protocols and norms
regulatory.
• Indicates compliance and non-compliance according to the
institution protocols.
• Proposes actions for improvement in the certification processes
hospital according to the regulations of the different
levels of accreditation.
Curricular unit: works in quality and hospital certification programs

Knowledge:
• Quality program: committees, purpose and tools
of quality.
• Accreditation processes: historical context, concept, types,
protocols, manuals, standard operating procedures (SOPs)
applicability and limits of action.
• Quality indicators in assistance: purposes,
applicability, measurement, monitoring, analysis and results.
• Patient experience: concept, strategic differential and
innovations in health.

• Transplant programs and organ procurement: concept,

processes, structure, purpose and action of the technician e
nfermage
Curricular unit: works in quality and hospital certification programs

Knowledge:
• Commissions: definition, applicability, nursing practice,
structures and functioning.
• Institutional documents: concept, mission, vision, and values.

• Notification of adverse events: concept, type, applicability

and the methodology.

• Systematization of Nursing Assistance as

quality management tool for care.
• Quality management: concept, classification, applicability,
nursing team.
• Risk management: concept, purpose, and action of
nursing technician.
Curricular unit: works in quality and hospital certification programs

Knowledge:
• Patient safety core: concept, purpose and
performance.
• International patient safety goals: concept,
historical, interdisciplinary team, responsibilities and
attributions.
• Hospital infection control service: history, bases
legal purposes, organizational structure and activities of
nursing.

.
Curricular unit: works in quality and hospital certification programs

Skills:
• Identify international patient safety goals.

• Organize work processes.

• Use technical terms in work routines.

• Report adverse events.

• Interpret technical documents.

• Communicate assertively.

.
Curricular unit: acts in quality and hospital certification programs

Skills:
• Identify care risks.

• Collect notification data.

• Identify quality patterns.

• Operate technological resources applied to health.

• Mediating conflicts in the workplace.

• Perform laboratory test collection.

.
Curricular unit: works in quality programs and hospital certification

Attitudes/Values:
• Commitment to humanized care.

• Responsibility in the use of organizational resources.

• Collaboration in team work development.

• Flexibility in various work situations.

• Commitment to the care provided.

• Sustainable attitude in the utilization of resources.

• Initiative for the organization of work activities.

.
Curriculum unit: works in quality and hospital certification programs

Attudes/Valores:
• Respect for diversity and moral, cultural values
religious.
• Proactivity in problem-solving.

• Respect for the limits of professional practice.

• Confidentiality in the handling of data and information.

• Responsibility in compliance with safety standards.

• Adopt measures for the promotion and recovery of health.

.
1 USE OF ALL WHITE UNIFORM IS MANDATORY: CLOTHING AND
SHOES. STUDENT WITHOUT COMPLETE UNIFORM AND RELEASE OF
PEDAGOGICAL COORDINATION WILL NOT ENTER THE CLASSROOM.

2
NO FEET ALLOWED TO SIT IN PAIRS.

3 PAY ATTENTION TO THE ATTENDANCE LIMIT, THE COURSE HAS 48 HOURS.

4 PARTICIPATE IN ALL EVALUATIVE ACTIVITIES.

REAPPLICATION ONLY IN CASES OF MEDICAL CERTIFICATE AND
RELEASE BY THE PEDAGOGICAL COORDINATION.
 WHAT IS QUALITY??
•QUALITY MANAGEMENT - ACTION AIMED AT LEADING AND
CONTROL ALL ORGANIZATIONAL PROCESSES (FINANCE,
ACCOUNTING, HUMAN RESOURCE MANAGEMENT, DATA MANAGEMENT, AMONG OTHERS
OTHERS); ALLOWING FOR THE IMPROVEMENT OF PRODUCTS AND SERVICES,
SEEKING TO ENSURE COMPLETE SATISFACTION OF NEEDS
OR THE SURPASSING OF CUSTOMER EXPECTATIONS AND FOCUS ON
PATIENT SAFETY.
• SYSTEMIC VISION
• PEOPLE DEVELOPMENT
• PATIENT-CENTERED CARE
• LEADERSHIP
• FOCUS ON SECURITY
• CULTURE OF INNOVATION
• PROCESS MANAGEMENT
• CONTINUOUS IMPROVEMENT
• ETHICS AND TRANSPARENCY
Pioneers of Quality
JOSEPH M. JURAN

According to Juran, "Quality must be planned, but it is achieved by suitability for use" - the basis of the continuous improvement principle of agile methods, total quality is not a result
From the applied theory, this is just the beginning of the journey, achieved through the improvement of daily practice, which must be planned, controlled, and improved in each cycle.

1904-2008, Electrical engineer of

training, working in large
companies throughout their career
as a Quality consultant.
PIONEERS OF QUALITY
PIONEERS OF QUALITY
2. WILLIAM EDWARD DEMING

There are three widely held beliefs by Deming in organizational management, which are: constancy of purpose; constant improvement;

deep knowledge, whose guidelines are translated into its fourteen principles for quality:

1900- 1993,Estatístico,
university professor, author,
speaker and consultant.
Pioneers of Quality
2. WILLIAM EDWARD DEMING
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2. WILLIAM EDWARD DEMING
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Pioneers of Quality
3. KAORU ISHIKAWA

One of the seven most used Quality tools and, equally, one of the most famous, theCause and effect diagram(also called

The Ishikawa Diagram, Fishbone Diagram, or 6M Diagram is Ishikawa's most well-known contribution to Quality.

1915-1989, Chemical Engineer,

university professor.
Pioneers of Quality
QUALITY IN HEALTH SERVICES
QUALITY MANAGEMENT DOCUMENT PYRAMID

1 Select the image of the robot on the right.

2 Digital animation in the box Say to me choose

Add Animation.

3 Choose an effect of
animation, like Zoom, and
see what happens.
QUALITY MANAGEMENT DOCUMENT PYRAMID

1 Select the image of the Robot on the right.

2 Digitization in the box Say-mee choice

Add Animation.

3 Choose an effect of
animation, like Zoom, and
look what happens.
PIONEERS OF QUALITY
4. KAORU ISHIKAWA
1919-2000, Doctor, researcher on Quality.

He stood out in the field of health quality study, being recognized for having conceived a quality assessment model: the 'Model' or 'Donabedian Triad.'
4. KAORU ISHIKAWA
1919-2000, Doctor, researcher on Quality.

He stood out in the field of health quality studies, being recognized for having conceived a quality assessment model: the "Model" or "Donabedian Triad."
AND ME? HOW DO I CONTRIBUTE TO THIS PROCESS?

FROM THE MOMENT WE IDENTIFY AN OPPORTUNITY FOR IMPROVEMENT

THE PROCESS OR IN FRONT OF AN ERROR.

THE NURSING TEAM HAS THE LARGEST NUMBER OF PROFESSIONALS WITHIN

A HOSPITAL INSTITUTION USES MOST OF THE SUPPLIES.
24H ASSISTANCE TO THE PATIENT, AND BECOMES MORE VULNERABLE TO ERRORS DUE TO VARIOUS

FACTORS.

THE ERROR, WHEN IT OCCURS, MUST BE ANALYZED NOT WITH A PUNITIVE CHARACTER OF
A PROFESSIONAL, BUT ANALYZING THE PROCESS. WELL-DESCRIBED PROCESSES AND
ORIENTED TOWARDS ALL EMPLOYEES MINIMIZE ERRORS, AND WHEN THESE
HAPPEN, THEY ARE EASILY IDENTIFIED, TREATED AND CORRECTED.
QUALITY DOCUMENTS

THEY ARE ALL THE DOCUMENTS OF AN INSTITUTION THAT ARE USED FOR
REGISTRATION OF ALL ROUTINE IN EACH SECTOR OF THE HOSPITAL INSTITUTION.

IN THESE DOCUMENTS, IT IS POSSIBLE TO OBSERVE THE STEP BY STEP OF A

DETERMINED SECTOR, WHAT RISKS, HOW TO RECORD AN UNDESIRABLE EVENT,
PRAISES, COMPLAINTS, AMONG OTHERS...

EACH INSTITUTION FOLLOWS A NAMING STANDARD, BUT THE ESSENCE OF

THE PROCESS IS THE SAME.
INSTITUTIONAL PROTOCOLS

THESE ARE MANAGEABLE ASSISTANCE GUIDELINES THAT MONITOR

CONTINUOUSLY THE QUALITY INDICATORS OF THE PRACTICE
CLINIC AND OTHER ASSISTANCE AREAS, AIMING TO ENSURE
SAFETY AND QUALITY IN INTEGRATED PATIENT CARE,

EXAMPLES:

- CHEST PAIN PROTOCOL

- COVID 19

- FALL PROTOCOL

- PROTOCOL IN CASES OF FIRE

INSTITUTIONAL PROTOCOLS

- SKIN INJURY PROTOCOL

- STROKE PROTOCOL

- SAFE SURGERY PROTOCOL

- PAIN PROTOCOL

- EMPLOYEE SECURITY PROTOCOL

- PROTOCOL IN CASES OF POWER OUTAGE

- PROTOCOL FOR DEEP VEIN THROMBOSIS

- SEPSIS PROTOCOL
NON-CONFORMITIES

It is the non-fulfillment of a pre-requirement

established. These requirements may vary between

external factors (Such as accreditation standards,
like THIS, ONA or the products provided by
a supplier) and internal factors (Like the
processes and procedures of the company.

Normally, the non-conformities are

registered in systems developed for
manage all quality issues of
institution, following the guidelines mentioned at
side
INDICATORS

Quality indicators are used to measure/evaluate and verify the

performance of a company/sector/process, analyzing the operation and
proposing negotiations for improvement when the goal is not achieved, thus
how to show the effectiveness of work when it is well executed.

It constitutes the ratio between variables that describe a given

situation and what is used to measure the behavior of a certain type
of information that is intended to be monitored.

Example of indicators:

- Occurrence of pressure injury in the Inpatient Unit

- Fall of the patient

RISK MANAGEMENT AND PATIENT SAFETY

Risk Management in Health is the systemic application and

continuous policies, procedures, conduct, and resources in
risk assessment and adverse events that affect safety
human health, professional integrity, the environment and the
institutional image

According to Anvisa, risk is the combination of the probability of

occurrence of damage and the severity of such damage. And the

Risk Management, in turn, is the decision-making.

regarding the risks or actions to reduce the consequences
the probability of occurrence.
RISK MANAGEMENT AND PATIENT SAFETY

Health Risk Management is the systemic and continuous application of policies,

procedures, conduct and resources in the assessment of risks and adverse events affecting
safety, human health, professional integrity, the environment and image
institutional

According to Anvisa, risk is the combination of the likelihood of harm occurring and the
severity of such damage. And Risk Management, in turn, is the decision-making
related to risks or actions for reducing the consequences or probability of
occurrence.
CLASSIFICATION OF INCIDENTS AND EVENTS - WHO
CLASSIFICATION OF INCIDENTS AND EVENTS - WHO
CLASSIFICATION OF INCIDENTS AND EVENTS - WHO
INTERNATIONAL PATIENT SAFETY GOALS
SWISS CHEESE THEORY
INCIDENTS CASCADE

AN EVENT/ACCIDENT IS NOT AN EVENT

ISOLATED. HE IS PERCEIVED AS A
SEQUENCE OF EVENTS STRONGLY
INTERCONNECTED, COMPLEX E
MULTICAUSAL.

THIS UNDERSTANDING REPRESENTS A

ADVANCE TOWARDS ABANDONMENT OF
MODELS OF CAUSALITY OF
ACCIDENTS CENTERED US
COLLABORATORS FOR ANALYSIS OF
CAUSE IN THE PROCESSES.
PATIENT SAFETY

PATIENT SAFETY IS
DIRECTLY LINKED TO THE PROCESS OF
WORK AND NOT ONLY IN THE PROFESSIONAL.

THE ORGANIZATION PROCESSES AND

QUALITY OF ASSISTANCE CANNOT BE
THE OBJECTIVE IS NOT PUNITIVE IN NATURE, BUT RATHER

IDENTIFICATION AND RESOLUTION OF ALL

RISKS THAT INVOLVE OUR PRACTICE OF
PROFESSIONAL EXERCISE.
PATIENT SAFETY

BEFORE JUDGING, ASSESS, WEAVE

COMMENTS OR ANY OTHER
ARBITRARY TYPE OF SENTENCE, EVALUATE
THE WHOLE PROCESS AND DO NOT EXPOSE THE

PROFESSIONAL/ COMPANY/ INSTITUTION

HOSPITAL

THE CAUSES ARE THE MOST DIVERSE, AND

BEFORE ANALYZING ALL THE RISKS,
WE NEED TO KEEP CONFIDENTIALITY.
ACCREDITATION
HOSPITAL
WHAT IS HOSPITAL ACCREDITATION?
Hospital accreditation is a method of
evaluation of health services that
to ensure quality and the
assistance security. It occurs through
means of standards and requirements
previously defined by the entities of
accreditation.
How the National Organization of
Accreditation (ONA), a Joint Commission
International, the National Accreditation
Integrated for Health Organizations
(NIAHO), a Healthcare Information and
Management Systems Society (HIMSS)
and Accreditation Canada.
WHAT IS HOSPITAL ACCREDITATION?
The evaluation methodology for
accreditation is done voluntarily and
reserved, not having a supervisory nature.
And its main function is to be a
continuing education program within
of health services. In this way, the
evaluation is conducted periodically, with the
objective of stimulating continuous improvement
of the processes.

The Assessment of Quality in Health

it began in the last century, when it was
formed the American College of
Surgeons (CAC) that established, in
mid-1924 the Program of
Hospital Standardization - PPH
WHAT IS HOSPITAL ACCREDITATION?
In 1918, the first was held.
hospital evaluation in the States
United. Of 692 hospitals with 100 beds
evaluated, only 89 complied with the
standards recommended by the PPH. In
counterpart in 1950, the number of
hospitals approved by the evaluation of
PPH reached 329.

In 1949, the Standardization Manual

more developed, presented 118
pages, but the American College of
Surgeons began to have difficulty in
keep it.
WHAT IS HOSPITAL ACCREDITATION?
Partly due to the rise in costs,
increasing sophistication of medical assistance,
the increase in the number of institutions, the
complexity and the high demand for
non-surgical specialties after the
World War II.

From there, CAC started partnerships with

American Medical Association, Association
Canadian doctor, American College of
Clinicians and American Hospital Association
for support and participation with others
organizations entirely dedicated to
improvement and promotion of accreditation
voluntary.
 WHAT IS HOSPITAL ACCREDITATION?
With the union of these groups in the United States,
In 1951, the Joint Commission was created.
Accreditation of Hospitals (CCAH) which soon,
December 1952, officially delegated the
Joint Commission Accreditation Program
Accreditation of Hospitals. This was a company
of a private nature, which at the time sought
introduce and emphasize in medical culture
hospital quality at the national level. This
the "culture of quality" spread in the spaces
academic and institutional what forced the
approval of more complex laws in the area of
health, as well as they began to be emphasized
aspects of assessment, education, and consultancy
hospital
What is hospital accreditation?

In the 60s, like most

there were already two American hospitals
achieved the minimum standards
initially recommended, a Joint
then sought to modify the degree of
requirement.
With this, in 1970, he published the
Accreditation Manual for Hospital
containing optimal quality patterns,
also considering processes and
results of the assistance.
WHAT IS HOSPITAL ACCREDITATION?
In recent years, the Joint Commission on
Accreditation of Healthcare Organization
(JCAHO) began to direct its actions in
It is about prioritizing the emphasis on assistance.
clinic through monitoring of
performance indicators adjusted to
gravity, to institutional performance and,
finally recently took on the role
of education with monitoring, seen in
consulting activities and the publication of
a series of documents such as standards,
standards and recommendations.
STANDARDIZATION AND CLASSIFICATION OF HOSPITALS
The term Quality or Continuous Improvement of
Quality in the most modern concepts is a
continued phenomenon of improvement, that
gradually establishes the standards,
result of studies of historical series in the
same organization or comparison with
other similar organizations, in search of
zero defect - a situation that, although not achievable
In practice, it guides and filters all action and management of
quality.
It is also an essentially cultural process.
and in this way involves motivation, commitment and
education of the participants of the entity, who are
thus encouraged to a long-term participation
deadline in the progressive development of
processes, patterns and the products of the entity
STANDARDIZATION AND CLASSIFICATION OF HOSPITALS

Quality is understood as:

A dynamic, uninterrupted process of
exhaustive permanent activities of
identification of failures in the routes and
procedures that must be
periodically reviewed, updated and
disseminated, with participation from senior management
do hospital até seus funcionários mais
basics.
STANDARDIZATION AND CLASSIFICATION OF HOSPITALS

In Brazil, perhaps the first study in the sense of

improving the quality in the organization of
hospitals have been of Odair Pedroso in 1935,
when designing a Hospital Inquiry Form
for the Hospital Assistance Commission of
Ministry of Health, later replaced
by the Social Medicine Service, now extinct.
STANDARDIZATION AND CLASSIFICATION OF HOSPITALS
In the Brazilian healthcare system, the
classification initiatives and
categorization of hospitals and others
health services have always belonged
to the public authorities.

Efforts in this direction date back to

1930s, with the Hospital Census
of the State of São Paulo, in which
a first proposal was formulated for
regionalization and hierarchization of
services, which did not come to be
implemented, but served as inspiration
for other classifications created
subsequently.
EVALUATION OF QUALITY THROUGH THE ACCREDITATION PROCESS
Accreditation is a word originating from English,
used by the Brazilian Accreditation Manual and
by the Manual of Service Providing Organizations
Hospital Services.
Accreditation is the evaluation procedure of
institutional resources, volunteer, journal,
reserved and confidential, which tends to guarantee
quality of care through standards
previously accepted.
The standards can be minimum (defining the floor
or more elaborate and demanding,
defining different levels of satisfaction and
qualification as a complement.
EVALUATION OF QUALITY THROUGH THE ACCREDITATION PROCESS
Since 1970, the Ministry of Health has been developing the theme
Quality and Hospital Evaluation starting from the beginning of
publication of Standards and Ordinances in order to
regulate this activity and currently works in
implementation of an effective and capable system to
control health care assistance in Brazil.
For the World Health Organization - WHO as of
Since 1989, Accreditation has become an element
strategic for the development of quality in
Latin America. In 1990, a treaty was made.
with the Pan American Health Organization - PAHO,
the Latin American Federation of Hospitals and the
Ministry of Health to develop the Manual of
Padrões de Acreditação para América Latina.
QUALITY ASSESSMENT BY THE ACCREDITATION PROCESS

Resuming the development of Accreditation in

Latin America, in April 1992, the PAHO
promoted in Brasília, the first Seminar
National Accreditation, in which it was
presented the OPAS Accreditation Manual.
Some conclusions emerged in this seminar.
about how to control the quality of services
health, highlighting that accreditation would be a
a valid mechanism to control quality. The
Proposed Accreditation Manual would be a
important basic instrument to start the
process and the participants would bring the discussion
for your entities.
QUALITY ASSESSMENT THROUGH THE ACCREDITATION PROCESS
Resuming the development of
Accreditation in Latin America, in April of
In 1992, the OPAS held an event in Brasília,
first National Seminar on
Accreditation, in which was presented the
OPAS Accreditation Manual. In this
some conclusions emerged from the seminar
about how to control the quality of
health services, emphasizing that the
accreditation would be a valid mechanism for
control quality. The Manual of
The proposed accreditation would be an instrument
important basics to start the process and
the participants would bring the discussion to
its entities.
EVALUATION OF QUALITY THROUGH THE ACCREDITATION PROCESS

The Brazilian Accreditation Program was

officially launched in November 1998, in
International Quality Congress in
Health Assistance in Budapest, as well as the
national instrument developed and conducted
by Humberto de Moraes Novaes.
NATIONAL ACCREDITATION ORGANIZATION - ONA
In the period between 1998 and 1999, the Ministry of Health
carried out the advertisement project for the "Accreditation in
Brazil. It consisted of a series of lectures.
involving 30 locations, on a national level, among
they are the 27 state capitals, thus reaching
all regions of the country.
The lecture series aimed to present the
project developed by the Ministry, to raise awareness
and improve understanding of the Brazilian System
of Accreditation as well as its form of
operationalization which resulted in the creation of the
ONA entity - National Accreditation Organization
tation, in May 1999.
NATIONAL ACCREDITATION ORGANIZATION - ONA
ONA is a private, non-profit organization.
profitable and of collective interest, which has
as main objectives for the implementation and
national implementation of a process
permanent quality improvement of
health assistance, stimulating everyone
health services reaching higher standards
high quality, within the Process
of Accreditation.
Accrediting Institutions are companies
private law, accredited by the ONA,
who has the responsibility to proceed with the
evaluation and certification of quality
health services on a national level.
NATIONAL ACCREDITATION ORGANIZATION - ONA
The service-providing organization of
health that adheres to the accreditation process
will be revealing your responsibility and the
your commitment to safety, with the
professional ethics, with procedures that
carry out and with the quality assurance of
service to the population.
The evaluation process of Accreditation takes place
based on previously established patterns
established, that is, compare what is
found in services with the standard
considered as a reference.
Thus, it is verified whether the service reaches
or not the criteria recommended as
desirable.
NATIONAL ACCREDITATION ORGANIZATION - ONA
Check items point to the sources where the
evaluators may look for the tests, or what the
hospital can present to indicate that it complies
with a certain pattern and at what level. These sources
they can be hospital documents, interviews with
the service heads, employees, customers and
relatives, medical records, records of
patients and others.
The evaluation and visit phase consists of two
great moments: the pre-visit and the visit
properly speaking.
In the pre-visit, the hospital prepares for the process.
with the internal dissemination and distribution of the Manual to
employees.
The visit will only take place after the formal request.
hospital volunteer, to the Accreditation Institution.
NATIONAL ACCREDITATION ORGANIZATION - ONA
The duration of the evaluators' visit is variable in
function of the size and complexity of the hospital. In
Visit, all sectors and units are evaluated
within a defined programming, along with
hospital officials.
The report is prepared by the evaluators for the
Hospital and for the management of the Accrediting Institution
with a final opinion from the evaluators (of consensus)
about the indication for accreditation and at what level.
The Certificate is issued by the Accrediting Institution and
it has a validity of two years, for 'Accredited' and
"Fully Accredited." Then there is "Accredited with Excellence".
it has a validity period of three years. Once these are over
deadlines, the institution must submit to a new
evaluation process.
NATIONAL ACCREDITATION ORGANIZATION - ONA

•The health organization meets or exceeds 70% or more of the quality and safety standards defined by ONA. All areas of the institution's activities are evaluated, including structural and healthcare aspects.

Valid certificate for two years.

NATIONAL ACCREDITATION ORGANIZATION - ONA
Level 2 - Full Accreditation
The organization needs to meet two criteria:
1) meet or exceed 80% or more of the quality and safety standards;
2) fulfill or exceed, by 70% or more, the ONA standards of integrated management, with processes occurring smoothly and full communication between activities.
•Certificate valid for two years.
NATIONAL ACCREDITATION ORGANIZATION - ONA
Level 3 - Accredited with Excellence
The organization needs to meet three criteria:
1) meet or exceed 90% or more of the quality and safety standards;
2) comply with or exceed, by 80% or more, the integrated management standards;
3) to comply with or exceed 70% or more of the ONA standards of Excellence in Management, demonstrating an organizational culture of continuous improvement with institutional maturity.
Valid certificate for three years.
NATIONAL ACCREDITATION ORGANIZATION - ONA
The duration of the evaluators' visit is variable in
function of the size and complexity of the hospital. In
Visit, all sectors and units are evaluated
within a defined programming, along with
hospital officials.
The report is prepared by the evaluators for the
Hospital and for the management of the Accrediting Institution
with a final opinion from the evaluators (of consensus)
about the indication for accreditation and at what level.
The Certificate is issued by the Accrediting Institution and
it has a validity of two years, for 'Accredited' and
"Fully Accredited." Then there is "Accredited with Excellence".
it has a validity period of three years. Once these are over
deadlines, the institution must submit to a new
evaluation process.
NATIONAL ACCREDITATION ORGANIZATION - ONA
•Imaging Diagnosis Services, Radiotherapy and Medicine
Nuclear

•Dental Services

•Clothing Processing Services for Health

•Dietotherapy Services

•Compounding Services

•Sterilization and Reprocessing Services for Materials

ACCREDITATION

Considering external evaluations as a means of

implement equity in the development of criteria,
there are five initiatives currently in Brazil: ISO,
National Quality Award, Accreditation, Audit
Medical and Legal Professional Risk Analysis.

Each health institution, according to the profile of

your business should seek the accreditations for your
service. Hospitals are currently seeking to have in
at least two: ISO 9001 and ONA.
PATIENT SAFETY AND ACCREDITATION

WHICH OF US DOES NOT WANT TO BE SERVED IN

A HOSPITAL THAT TRANSMITS QUALITY

IN ASSISTANCE??

IT'S NOT GOOD TO FEEL SAFE IN ONE

DELICATE HEALTH MOMENT?

ACCREDITATION IS A PROCESS OF
IMPROVEMENT FOR THE INSTITUTION, LIKE
ALSO A WAY OF CAPTURING
CLIENTS AND HUMAN RESOURCES AND
FINANCIALS!!
PATIENT SAFETY AND ACCREDITATION

AND WOULD YOU LIKE TO WORK IN A HOSPITAL

ACCREDITED? DO YOU THINK THIS HAS AN IMPACT?
ABOUT YOUR PROFESSIONAL CAREER??
INFECTION CONTROL
HOSPITAL
What is Hospital Infection?

Hospital infection, currently referred to as infections

related to health care assistance (IRAS), is defined as
that which is acquired after the patient's hospitalization, which can
not only pose health risks to the hospitalized patient, but also
attributing longer hospital stays resulting in higher costs,
besides being one of the leading causes of death during the
hospitalization.
What is Hospital Infection?

The main causes of Hospital Infection are: sterilization and

inadequate disinfection of articles and equipment, breakage of
hospital cleaning routines, breaking of procedures
nursing and medical routine, and lack of biosafety.
PCIH and CCIH

The Hospital Infection Control Program

(PCIH) is a set of actions developed
deliberately and systematically, with the goal of
maximum possible reduction of incidence and
severity of hospital-acquired infections.
For the PCIH to be executed properly,
hospitals must establish a Commission of
Hospital Infection Control (CCIH) and
Hospital Infection Control Center
(NCIH), its members being appointed by the
clinical director or technical responsible of the institution.
Functions
• Elaborate, plan, execute, maintain, and evaluate the Control Program
Hospital Infection, through the following actions:
• Obey all the rules established by ANVISA;
• Implement an Epidemiological Surveillance System for Infections
Hospitals;
• Create a manual of rules and conduct that must be implemented and
followed by the entire hospital team;
Functions
• Use antimicrobials, germicides, and any other appropriately.
chemical product
• Evaluate and supervise the actions carried out by the executing members;
• Disseminate to the entire hospital institution the actions and norms for
control and prevention of hospital infections;
.
Functions
• Establish a contingency plan in case of detected infection.
• Supervise the operational routines;
• Constantly promote training, capacity building, and actions to
guidance of the medical-hospital team on prevention and control of
hospital infections;
• The Hospital Infection Control Program must be included
with various preventive actions and routines, such as for example, the
correct hand hygiene
.
PCIH and CCIH

The CCIH keeps the infection rates at accepted levels.

by the Ministry of Health, strictly following norms and regulations
specific to the Sanitary Surveillance, promoting prevention actions to
infections. Along with the Hospital Management, the committee plans, prepares,
implements, maintains and evaluates the PCIH. The Commission must hold meetings
periodic, at least bi-monthly, must be recorded in minutes.
PCIH and CCIH

The Hospital Infection Control Center (NCIH) are those

that will evaluate the actions of CCIH, almost like an executive role,
composed of professionals with exclusive working hours for actions
of prevention and control of hospital infection.
PCIH and CCIH

They are also the ones who will conduct epidemiological investigation of outbreaks and
implement control measures; act with the various services of
hospital in continuing education programs; and they are the ones who fill
the Inspection Script of Hospital Infection Control that was
regulated by Resolution - RDC No. 48, of June 2, 2000.
PCIH and CCIH

The PCIH began to be regulated in 1983,

with Ordinance MS No. 196/83, which was revoked and
replaced by the MS Ordinance No. 930/92.
Currently, Ordinance No. 2616/GM is in force,
May 12, 1998. This law talks about
obligation for hospitals to maintain a
Hospital Infection Program and its control
same. The non-compliance with the approved regulations
this Ordinance will subject the offender to processes and
the penalties.
Members of the PCIH team

•It is recommended that the CCIH has the following

constitution
•A representative of the medical staff;
•A Representative of the Administrative Board;
•A Pharmacy Representative;
•A representative of the laboratory of
Microbiology;
•A Representative of the Nursing Board;
•Members of the Infection Control Core
Hospital
Members of the CCIH team

•Doctor, preferably an infectious disease specialist,

with experience in control and prevention
of hospital infections and working hours
specific for control actions of
hospital infections;
•Nurse;
•And for every 200 beds or additional fraction,
a doctor and a must be added
nurse with experience in control
of hospital infections;
Physical structure

• The physical area designated for the

functioning of a CCIH
dependerá do tamanho e
conditions of each hospital, well
like the number and gravity of
occurrence of infections. The
minimum would be a room for
leadership and meetings, secretary and
file, laboratory for
epidemiological bacteriology;
Function: environmental control
• Maintain control of infections in all areas of
hospital environment, giving, however, priority to the areas
criticisms. Thus, the efforts of the Commission will be
focused on:
• Development, control, and updating of standards and routines
related to the cleaning and disinfection of environments,
establishing the frequency, type of disinfectant, giving
special emphasis on critical areas: surgical centers,
obstetric, nursery, post-recovery room
anesthetic, intensive care unit, pediatrics
isolation, Nutrition and Dietetics service.
• Training and update programs on cleaning
and environment disinfection.
• Control of concurrent disinfections.
• Control of terminal disinfections.
Função: controle de produtos químicos

• It is up to the CCIH to select the chemical products.

germicides, disinfectants, antiseptics, agents of
cleaning), the control of its acquisition and effectiveness; and the
elaboration of rules and routines regarding the use of the
same.
Key Indicators

• According to Ordinance 2616 of 1998, we have

The Epidemiological Surveillance of infections
hospital care such as active, systematic observation and
continuity of its occurrence and its distribution among
patients, whether hospitalized or not, and of the events and
conditions that affect the risk of its occurrence, with
views on the timely execution of preventive actions and
control.
Main Indicators
• The main indicators of the CCIH are:
• Incidence Density of Primary Bloodstream Infection
related to central venous catheter
• Incidence density of ventilator-associated pneumonia
mechanics
• Incidence density of urinary tract infection related to
bladder probing
• Surgical Site Infection (SSI) rates related
to the surgical procedure under evaluation, during the period.
Main Indicators
• Rate of Utilization of invasive devices (bladder catheter)
delay, mechanical ventilator, central catheter
• Hand hygiene compliance rate
• Isolation rate (specific precautions) by sector
• Among others
• Hospital Infections - Part 1 - YouTube
• Hospital Infections - Part 2 - YouTube
• Patient who contracted hospital infection will be compensated - Via Legal Program No. 712 - YouTube