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Leuven University Hospital

Update: 2015/2/13      View:
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Introduction



 Leuven University Hospital






High-quality patient care and patient safety

Thanks to the constant dedication, motivation and skills of all its personnel, UZ Leuven is able to offer its patients high-quality care. As a result, our hospital has been able to develop into a leading reference centre. In the future, UZ Leuven intends to consolidate and further develop its position as a leading university medical centre. Working at all times for better, safer patient care is the essence of the hospital’s operating philosophy.

UZ Leuven has demonstrated this by gaining accreditation from an external, independent organisation. In view of the hospital’s international positioning, the Joint Commission International (JCI) was selected for this task.


JCI accreditation

Joint Commission International

JCI is an organisation which sets the international JCI standards for care quality and patient safety. If inspection by JCI shows that the care institution’s quality system meets the high requirements set by the standards, JCI issues hospital accreditation.

The accreditation also reveals points for improvement in an organisation and checks whether a culture prevails in the organisation of addressing such points and striving to optimise care and quality. This is done with reference to the 300 JCI standards, which are translated into 1,300 objective and measurable criteria.

JCI is active worldwide and is a division of the Joint Commission USA, which was set up 50 years ago and accredits around 90 percent of American hospitals.

At UZ Leuven’s request, JCI audited the entire hospital. In early July, JCI then awarded accreditation to UZ Leuven, making it the first Belgian hospital to achieve this distinction. JCI has thus confirmed UZ Leuven’s focus on superior quality and on the constant improvement of patient safety.

How does JCI accreditation work?

JCI inspects the hospital from the viewpoint of how it works from day to day. The most important approach involves following what happens to the individual patient during all aspects of treatment and care, from pre-admission to post-discharge. Personnel, patients and visitors are all involved in the evaluation.

Analogous approaches are used to evaluate the prevention and control of infections, medication policy, personnel policy, building and infrastructure safety, fire safety and clinical policy. There too, it is important for the JCI standards to be monitored.

This method predicated on a patient focus distinguishes JCI from other forms of recognition and certification, which are often heavily based on a policy and organisational viewpoint. JCI’s approach focuses on all aspects of the hospital’s functioning right across the institution.
The audits are performed by a group of JCI-trained and JCI-appointed auditors.

The period leading up to the first accreditation

UZ Leuven has focused on quality and patient safety for years, relying on the knowledge, motivation and outstanding team spirit of its personnel. In this quality culture, in order to raise patient care and its results to ever higher levels, the accreditation process was started two years ago.

In addition to the existing measures, procedures were optimised and new ones implemented to ensure a safe, high-quality hospital for patients, visitors and personnel on an ongoing basis.



Key elements of the JCI standards

The JCI standards firstly relate to how care providers deal with patients, but also to the organisational structure around the patient. The whole process is evaluated with reference to a total of 1,300 measurable elements.

One priority point for attention is the international patient safety goals. Complying with these six standards is a minimum requirement to be eligible for accreditation. They are a matter of priority and an absolute necessity for safe care provision.

  1. Identifying patients by means of double identification
  2. Noting down and repeating phone messages  
  3. Increasing safety during the use of high-risk medication
  4. Performing the right intervention, at the right time, on the right patient
  5. Reducing the risk of infection through correct hand hygiene
  6. Preventing falls

Next, other standards relating to quality patient care and safety for patients, visitors and personnel are investigated and evaluated in detail. Among other points, these involve:

  • Evaluation and daily monitoring of every patient
  • Safe care in the case of vulnerable patient groups and high-risk procedures
  • Striving for a hospital with less pain
  • Informing the patient accurately via informed consent
  • Managing privacy and confidentiality
  • A safe medication policy
  • Preventing and controlling infections
  • The importance of a good infrastructure
  • What to do in the event of danger, fire or a resuscitation
  • Monitoring the clinical performance of personnel
  • Working with procedures and protocols





Quality culture as a driver of continuous care excellence and patient safety

Quality challenges

UZ Leuven’s social role as an academic medical centre is to provide a combination of specialised patient care, training for care providers and translational research – based on its link with K.U.Leuven.

UZ Leuven is constantly striving further to develop its position as one of Europe’s leading academic centres.

Delivering systematic quality

Safeguarding quality cannot be left to chance. Especially in an extremely complex organisation like UZ Leuven, care quality and the safety of patients and care providers are dependent on the efficiency of care processes. The risk of error can only be eliminated or minimised if there is a systematic way of working which ensures that the high quality of care is rarely if ever jeopardised. Only the best possible method is acceptable – for every patient who is treated.

A human task

Building and continuously improving a quality system is a human task. Designing and maintaining a watertight quality system does not happen of its own accord: it is the result of determined effort by everyone who works at UZ Leuven. The outstanding quality care that UZ Leuven aspires to provide is only achievable if every employee is passionate about seeking working methods which are more effective and reduce the risk of error. Critical reflection, eagerness to learn, and seeking to identify and being open to changes are all crucial elements of a philosophy and culture of quality.

Learning from mistakes

Learning from mistakes: ‘no blame’ as a characteristic of quality culture. One element of quality culture is that mistakes do not simply lead to a knee-jerk negative assessment and a reprimand for the employee: above all, they give rise to a critical examination of the way of working, ‘the system’. Where is the weakness in the current way of doing things that has led to things repeatedly going wrong at precisely that point, and to people easily making mistakes? Is it not possible to arrange our care process in such a way as to substantially reduce – or, better still, completely eliminate – the chance of mistakes? Thus mistakes become a golden opportunity to ask questions about the current way of working and together consider ways of refining the care process. This reduces the chance of the mistake being repeated and safeguards care quality and patient safety more effectively.

This philosophy is also strongly supported by a JCI accreditation process. The JCI standards help with the ongoing efforts to ensure a safe, high-quality environment for patients, visitors and personnel.


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