2.4 Guiding the treatment

The management of the hospital should define in procedural instructions which activities are necessary to effectively direct the individual activities relevant to quality in such a way that the individual treatment of the patient always meets the set objectives. To this end, the most important actions in the course of treatment must be identified. The characteristics of the activities must be analyzed according to their importance for the success of the treatment.

The procedures for ensuring that the established rules are followed should be summarized. These include regular meetings, visits by chief physicians, senior physicians and wards, OR meetings and any audit procedures that are yet to be introduced and that relate to individual process parameters and characteristics.

A responsible person should be identifiable for each treatment.

A point in time should be defined in the treatment procedures when the treatment decision is reconsidered.

Test procedures must be embedded in the treatment process in order to verify its stability and identify the need for correction in the event of deviations. Measurable and testable properties should be selected. Methods with which these can be continuously observed should be established and applied. Where possible, limits should be defined within which a variation can be assumed to be random. Warning and intervention limits should be derived from this. The test procedures used for quality control must be defined and monitored.

Important test steps in the treatment process can be

• Indication for an operation
• Determining the urgency
• Call to the hospital
• Actual execution of the intervention.

Test characteristics and procedures can be:

• Time between the indication and the actual execution of the procedure
• Second opinion by the senior physician
• Daily rounds
• Event data in control charts (statistical process control)