1.1.03 Quality and compliance objectives of the hospital

1 Aim and purpose

Specification of the priority objectives to be achieved to improve the quality situation. Quality objectives are defined by the management for all clinics, institutes and functional areas following the management review (annually). This also includes other objectives such as occupational health and safety objectives, environmental protection objectives and risk management objectives (safety objectives).

The requirements for performance, product conformity and customer satisfaction should be taken into account.

Quality objectives can be described with quantitative and non-quantitative characteristics so that they are measurable and verifiable.

The objectives should be formulated in such a way that it is possible to check whether and to what extent they have been achieved.
The measures, resources and responsibilities (project plans, working groups, etc.) should be described in more detail.
The quality targets should be communicated to the employees.

Regulation on changes to quality targets.

2 Application

At the beginning of the calendar year, by the end of January at the latest, the Medical Director of the department sets the quality targets for the current year. The quality targets are based on the result of the management review in December of the previous year, on the general quality targets of the Cardiovascular Centre and the University Hospital.

3 Description

(here follows an example)

3.1 Overarching objectives

Establishment of a quality assurance system in accordance with DIN EN ISO 9001 and DIN EN 15224 in the interpretation of "Good Hospital Practice", completion and consolidation of documentation, verification of conformity by a notified body. An internal audit plan will be drawn up in 20xx to review the implementation of the system in the department and to promote continuous further development. Further details are set out in the internal audit procedure. The aim is to achieve certification before the end of 20xx.

3.2 Healthcare

In patient care, the focus is on improving the service function of the department: (e.g. ....)

3.3 Findings

Problem: A personal survey of the directors ... revealed that the referring colleagues see the immediate transmission of a written report as an essential requirement. Target: Reduction of process times for the written creation and transmission of findings. Measures: If possible, the written findings are prepared by the person(s) making the findings themselves. This depends on the quantity of findings and the staffing of the typing service. The findings are entered directly into the HIS and handed to the patient in an envelope or forwarded to the ward by fax. A written report should be available within 24 hours in 90% of cases. Indicator: During the course of the year, a sample is collected via a query in the HIS, in which the runtimes from the generation of findings to the documentation of findings are measured.

3.4 Reduction of waiting times for transport

Problem: The evaluation of the complaints book showed that the long waiting times for patient transport in the department for ..... are a frequent cause of complaint among patients and staff. Goal: Reduction in patient waiting times for transport. Measures: Dhe suggestions for improvement from the "Reducing waiting times" working group are transferred to the patient transport system at .... in order to reduce transport waiting times Indicator: The order times and transport times are recorded by the patient transport system. After linking the data, the waiting time can be determined in the computer system.

3.5 Research

Problem: According to the internal evaluation of research performance by the Department of Medicine, the department .... ranks in the upper midfield. The results of the evaluation process, e.g. publications and third-party funding acquired by a department, are incorporated into the internal allocation of funds. Target: The department for xxx is aiming for a place in the top third in 20xx. Measures: Meetings on research projects are held at regular intervals. Their results are documented. Each member of staff undertakes to present their current projects for discussion. Participation in conferences and publication of the results in the appropriate specialist journals are planned. In order to facilitate the written preparation of the publication, the employee concerned is granted a temporary leave of absence. In the 20xx financial year, work will begin on a ... project for ..... In the 20xx financial year, at least ... projects in the field of magnetic resonance tomography will be newly applied for at .... Indicator: Evaluation by the hospital. Amount of third-party funding

3.6 Devices

Problem: The department takes over the (device) in the course of the year. The .... employees are to be trained. The use of the device is to be linked to the IT system. Target: Improving the digital documentation of findings Measures: Introduction of electronic dispatch of findings via the HIS system. Indicator: Completion of all individual steps in the introduction of the new device. Review of implementation by the end of 20xx.

4 Documentation

List of quality objectives and initiated projects Project plan...

Quality policy of the clinic

Protocol of the management review

5 Resources

6 Responsibility, qualification

QM conference supervises the project plan

Appointment of a project manager Working groups

Responsibility: QMK

7 Notes and comments

8 Applicable documents

JCI: GLD.12, GLD 13; QM-RL G-BA:2015 §2 sentence 5 + 6; DIN EN ISO 9001:2015 and DIN EN 15224:2017: 6.2.1; ISO 19600 6.2.

9 Systems

Appendix 1:

Summary of the quality objectives as a circular letter to all employees