External Audit in HPH

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External Audit in HPH

• ?.?.????? ???????????
• 18 19 ?.?.52

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????????

• ?????? 17 ?.?.53
• ????????????????????????? Audit
• ???????????????????????? External Audit
  (??????????????????? ?????????????????????????????
  ? HPH)
• ????????????????? Check List ??????????????????
• ?????? 18 ?.?. 53
• ??????????????????????????????? HPH ???
  ?.?.???????
• ?????? 19 ?.?..53
• ??????????? ???????????? External audit

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1.??????????????????? Audit
4
???????????????????????? External Audit
???????????????? ????????????
Standard Body ???????????? ???????????????????????????????????????
Accreditation Body ??????? Certify body
Certify Body (CB) ?????????????????????????????????
?????????????????????????? ???????????????????????????????? ????????????????????????????????
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?????????????????? Internal External Audit
External Audit Internal Audit
Auditors ????????????????? ???????????????????????????????? ??????????????????????????????????????????? Audit
??????? Compliance Audit ?????????????????????????????????????? Compliance Audit ??? Performance Audit ????? CQI ????????????????
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?????????????????? ???????? ??? External Audit
???????? (Consultant) External Audit
???????????? ??????? ????? ???? Coaching ??????????????????????????????????????????? ?????????????????????????? (??????/???????????) ?????????????????????????? ??????????????????????????????? consultant
Conflict of Interest CB ?????????? (consultant) ??????????? Audit ??? CB ????????????????????????????
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???????????? Auditors

• ?????????????? ?????????????????????????????????
  ????????????? ???????????????? ???????????
• ?????????????? Auditors
• ???????????????????????????????????????????
  ??????????????????????????????????????????????????
  ????????????
• ????????????? ????????????????????? ?????????
• ??????????????????????????
• ???????????

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Quality Assurance ??? Quality Control
Quality Control Quality Assurance
?????????? ??????? End Product ?????????????? ?????????????????????? ?????????? ??????? ????????????????? End Product
????????? ??????????????????????? ????????????????????? ?????????????????????
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2.???????????????
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???????????????????

1. ??????????????????????????
2. ?????????????????????????? (Site visit)
3. ????????????????????? (After Action Review)

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1.??????????????????????????

1. ???????????????????????????????
2. ??????????????????????????
3. ??? Standardized Auditors ??????????????
4. ??????????????????? check list ??????????????

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???????????????????????????????

1. ??????????????????????????? ?????????????????
   Authority ??????????????
2. ???????????????????????????????
   ????????????????????? ???????????????????????
3. ??????????????????????????????????????????????????
   ???????????????? Format ??????????????
4. ??????????????? Auditors ???????? auditors
5. ?????????????????????????????????
6. Scoring System ??? Decision making ??????????????
   ????????????
7. ???????????????????????????

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?????????????????????????????

1. ?????????????????
2. Lead Auditor , Auditors
3. ?????????????? (Desk Study) ?? 3 C (Context ,
   Comply, Core Value)
4. Context ???? ??.?????? ???? ?.?.???????????? ???.
   ???? ???.???? 200 ???????????? Excellence Center
   ???? heart Trauma
5. Comply to Standard ?? Approach ???????????????????
   ??????? ?????????????????????????? (Basic
   Requirement) ????????????????????
6. Core Value
7. ????? check List

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????? 3 C
??? Built in ?????????????? ????????????????? ????
Context
??? 1.Hospital Profile Web site 2.KPI
???? ??????
Core Value
Comply
???????????????
???????????????
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Context

• ?????
• Hospital Profile Web Site (?????)
• KPI ???????????????????????????

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19
??????????

• ??????????????????????????????????????????????????
  ????????????????????????????? 5
  ??????????????????????????????????????????????????
  ?

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???????

1. ??????????????????????????????????????????????????
   ???????????????????????????? ?????????????????????
   ??????????? ??????????????????????
2. ??????????????????????????????????????????????????
   ? ??????? ???????????????????????????????????
3.  ?????????????????????????????????????????????????
   
4. ??????????????????????????????????????????????????
   ?????????????????????????????
5. ??????????????????????????????????????????????????
   ????????6. ????????????????????????????????

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KPI ???????????????????????
Diseases Approach Diseases Approach Age Group Age Group Age Group
NCD CD ?????????? ??????? ??????????
0301DM,HT. CVD 0302 Ca Cx 0303 ????????? 0304 TB 0305 Food Poisoning 0306 ?????? 0307 Perinatal Death 0308 ??????? 0309 ???????????? ( ??????To be No1 ???????????) 0310 LTC Team
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(No Transcript)
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(No Transcript)
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Core Value
Context
Standard
1.Visionary Leader 2.Focus on Future 3.???????????
4.Customer Focus 5.Management by
fact 6.Innovation. 7.Value Staff 8.Agility 9.Organ
ization Learning 10.System Perspective. 11.Social
Responsibility.
Core Value
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ADLI ????????????????????? 1-6

• Approach ???????? / ?????????????????????????
  (???????????????) Key word ???????
  ??????????????????????
• Deploy ???????????? (???????????????)
  ???????????????? Approach ????? Key word ????????
  ???????????????????
• Leaning ???????????????? ???????????? PDCA ?????
  CQI ??? KM ?????????? Learning ???????????????????
  ????????????????????????
• Integrate ???? 2 ???????
• Alignment ?????????????????????/????/?? ???
  ??????????? ??????????
• Integration ????????????????? Alignment ,KPI
  ??? Cascade ????? Personal KPI

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Approach ??? Deploy ,Learning ,Integration

• Approach ??????????????????
• ???????????? ????? 2
• ??????????? ????? 3
• ???????????? ????? 4,5
• Deploy ??????????????????????????????
• Deploy ??? Approach ???????????
  ??????????????????????
• Deploy ???? ??????????????????????? ????? 2
• Deploy ???? ?????????????????????????????????? 3
• Deploy ???? ?????????????? ????? gap ????? 4
  ????? Gap ??? 5

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Learning Integration

• Learning
• ???????? Evidence base ?? PDCA ???????? 2
• ???????? Evidence base ?? PDCA ?? KM
  ?????????????????????? ????? 3
• ???????? Evidence base ?? PDCA ?? KM
  ??????????????????????????? ????? 4
  ?????????????????????????? 5
• Integration
• ?? Alignment ????? ????????????????? ?????
  Integrate ??? 2
• ?? Alignment ?? Integration ????? 3
• ?? Integration ????? ??? KPI ?????? ? personal
  KPI ????? 4
• ?? Integration ???????????????? ????? 5

ADLI ?????????????????????????? Categories
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?????????????????????????????

• ???? 4 ?????????
• Coverage ???????????????????????????? (???????
  ???????????? ?????)
• Performance
• Trend ????????????
• Comparison ????????????????????????????? ???
  benchmark ???????? Best practice
• ???????????
• Good Coverage Good Trend ????????? good
  performance ????? 2
• Good Coverage Good trend Performance ????? 3
• Good Coverage Good trend Performance ???
  Benchmark ??????????????????? Top 3 ???????? 4,5

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??????????? Result

• ?????????? ???????????????????????????????????????
  ???????? 4-6 ???????????????????????????????
  ?????????????? 1 ???????????????????????? 4-6
  ????? Good Trend ???? performance ??? 2
• ?????????? ???????????????????????????????????????
  ???????? 4-6 ???????????????????????????????
  ???????????? 1 ???????????????????????? 4-6
  ????? Good Trend ???? performance ??? 3

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Human Error ???? System Error

• ???????????????? ????????????????????????????
  ????????? Human Error
• ??????????????????? ????????????????????????????
  ????????? System Error

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?????? Suggestion

• ?????????? (Finding) ????? Root Cause
  ??????????????
• ??? suggestion ??? Suggestion ????????????? ????
  ??????? Transfer ???????????????
  ??????????????????????????????????????????????
  ????? ?????????????????????? ????????
  ??????????????????????????????????????????????
  ??? Suggestion ??? Suggestion ???? ???
  ????????????????????????????????
  ??????????????????????

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2.????????????????????????????

1. ??????????????????????????????? (Document Review)
2. ???????????????????
3. Open Meeting (Lead Auditor) ?????????????????????
   ??????????????? ???????????????? Closed Meeting
   (10 ????) ??????????????????????? (??????? 50
   ????)
4. ???????????????????????? (Auditors Lead )
5. ?????????? Auditors ?????????????? ?Scoring
   system ??????????????????
6. Closed Meeting (Lead Auditor) ???? Finding
   ??????????????????????? (??????? 30 ????)
7. ????????????????????????????

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???????????????????? ???? II -10
??????????????????? ??????????????????????????????
????????????? ????????????????????????????????
SP-HPH-01
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???????? After Action Review ?????????????????
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??????? ????????????????? Document Review 8.30-
9.00 ?.
????? ??????????????
??????????????? ???????????????? ?.?.???????????? ????????????????????? ????????????????????????????????????????????????????????????????????? Document Review
????????? 4 ??????????????? ??????????????????????
??????????? ?.?.??????????? ???????
??????????????? ?????????????????????? document
Review
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Open Meeting 9.00- 9.10 ?.
????? ??????????????
Sequence ??? ??? ??.???????????? ???????? ??????? Hospital Presentation ?????????? Open Meeting ???????????????????? ???????????? ?.?.??? Sequence ????????????
??????????????????????? Open Meeting ????????????????
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Hospital Presentation 9.10 9.50 ?.
????? ??????????????
??????????? ??????????????????????????????? ??????????????????? ???????????????????????????????????????????????????? Deploy ???????? ?????? ?????????? ??? 1,2,7 Best Practice 1 ??????
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?????????????? 10.00 15.00)
????? ??????????????
?????????????????????????????? ?????????????? ?????????????
???????????????? ????????? ???????????????????????????? ??????? ???????????????? ????????????????????????? (RCA) ????????????????????
????????????? ?????????????????????????? ???????????????? ???????????????????????????????
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?????????????? 10.00 15.00)
????? ??????????????
?????????? ??????????????? ??????????????????????????????????? ??????????????????????????????????????????????????????????????
???? Contents ??????? Process
?????????? Area ????????????????????? ???????
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??????????????????? 15.00-15.30
????? ??????????????
Scoring
Decision ??????????????
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Closed Meeting 15.30-16.00
????? ??????????????
????????? ?????????? ????????????? Fix
???????????? ??????????
???????? ?????????
??????????????????? ????????????????
Auditors ????????????? ??????
???????????????????????