5.4 Improvement measures

The hospital management should make every effort to fulfil the increasing quality requirements. Quality improvement activities must be promoted. To this end, an atmosphere must be created in which suggestions can be taken up and discussed, changes implemented and successes and failures critically assessed. Improvement measures must be planned, managed in co-operation with all professional groups and introduced throughout the hospital. They should be brought to a verifiable conclusion. Improvement measures can extend to the way in which services are provided, to the introduction of new treatment measures and to the QM system itself. Measures to reduce energy and water consumption and to avoid waste serve to protect the environment. Quality improvements in the provision of hospital services can be triggered by quality control data, the handling of adverse events or comparisons with other hospitals.

A formalised procedure will be introduced to identify, trace and clarify the causes of errors. Preventive measures are to be included in the procedure. Consideration should be given to the risks and potential for error inherent in the procedure. New medical treatment procedures that offer patients advantages in terms of efficacy, safety and acceptability and can be provided economically should be recognised and introduced. The validity of the new procedures should be ensured by data. The introduction should be systematically planned and, if necessary, trialled in a pilot phase. The effectiveness of the procedure should be reviewed after a certain period of time.

The results of the internal audits should be summarised by the hospital management to assess whether their instructions are necessary and sufficient to achieve the quality policy and quality objectives.

Consideration should be given to adapting the QM system to changing objectives, requirements or environmental conditions. The result of the assessment should be documented in the form of conclusions and recommendations. New quality objectives should be set and described for the necessary measures.

DIN EN ISO 9001:2015 and DIN EN 15224:2017 10.3