Working towards the implementaion of an international accreditation programme in a Nuclear Medicine Department of a South African teaching hospital

Eiselen, Thea (2005-04)

Thesis (MSc)--Stellenbosch University, 2005.

Thesis

ENGLISH ABSTRACT: Introduction: Quality assurance in Nuclear Medicine is of utmost importance in order to ensure optimal scintigraphic results and correct patient management. A customised Quality Management System (QMS) should be documented and implemented by following the international guidelines set by the International Standardisation Organization (ISO). Materials & Methods: A Quality Control Manual (QCM), defining the departmental quality policy, mission, vision and objectives was customised following the framework of a tried and tested design. As ISO focuses on client satisfaction and staff harmony, the following departmental objectives were audited in working towards the accreditation of the Nuclear Medicine Department of Tygerberg Hospital: referring physician satisfaction, patient satisfaction as well as staff satisfaction and harmony. Information was collected by means of questionnaires completed by referring physicians and staff members. One-on-one interviews were executed on patients. An international ISO accredited Nuclear Medicine department was visited to establish the suggested path to follow en route to successful ISO accreditation and certification. Results: Referring physicians indicated overall satisfaction with service provision, but a need for electronic report and image transfers seemed too dominant. The patient satisfaction survey resulted into overall satisfaction with personal service providing, but the provision of written and understandable information, long waiting times and t equipment must receive attention. Staff questionnaires indicated a general lack of communication between different professional groups and the need for interpersonal loyalty and team building. Improvement measures were identified to ensure the continuous improvement of the QMS by focusing on these quality parameters. Conclusion: The department has QA procedures in place, but does not meet all criteria for external accreditation. In order to ensure departmental harmony and sustainability of client and staff satisfaction, the departmental objectives in measured and improved where needed. The successful implementation and continuous improvement of a customised QMS, following the guidelines outlined in the QCM will lead to successful accreditation.

AFRIKAANSE OPSOMMING: Inleiding: Die belangrikheid van kwaliteit versekering in Kerngeneeskunde vir die versekering van optimale flikkergrafiese resultate en korrekte pasient handtering kan nie onderskat word me. 'n Klantgerigte Kwaliteitsbeheersisteem (KBS) moet gedokumenteer en geimplimenteer word vir die Kerngeneeskunde Departement deur die riglyne te volg soos uiteengesit deur die Internationale Standardiserings Organisasie (ISO). Materiale & Metodes: 'n Kwaliteitskontrol handleiding (KB), wat die departementele kwaliteitsbeleid, die missie en visie asook die departementele doelwitte definieer is ontwerp en saamgestel vir die Kerngeneeskunde departement van Tygerberg Hospitaal. Hierdie ontwerp is gebaseer op die raamwerk van 'n aanvaarde kwalteitsbeheersisteem. ISO fokus op klante tevredenheid asook personeel harmonie en tevredenheid. Vir hierdie rede is daar 'n tevredenheidpeiling uitgevoer op die klante en personeel in die strewe na ISO akkreditasie en sertifikasie. Inligting was versamel deur vraelyste wat ingevul was deur die verwysende geneeshere, pasiente en personeel. Resultate: 'n Kwaliteitskontrole handleiding was saamgestel VIr gebruik in die Kerngeneeskunde department. Die interne audit resultate het aangedui dat die verwysende geneeshere tevrede is met die algehele dienslewering. Die behoefde aan elektronies versende verlae en beelde was dominerend. Die pasient tevredenheidspeiling het bevestig dat die pasiente tevrede is met persoonlike dienslewering, maar 'n tekort aan verstaanbare en geskrewe inligting was geidentifiseer. Die lang wagtye en stukkende apparaat is ook gebiede wat verbertering benodig. Algemene gebrek aan komminukasie tussen die verskillende beroepsgroepe, die behoefte aan interpersoonlike lojaliteit en span werk was die hoof bevindinge van die personeel tevredenheidspeiling. Verbeterings maatreels, gefokus op hierdie departementele doelwitte, was geidentifiseer ten eide te verseker dat die KBS voordurend verbeter en in stand gehou word. Samevatting: Alhoewel die departement wel KB prosedures in plek het, voldoen dit nie aan al die criteria vir eksterne akkreditasie nie. Ten einde departementele harmonie en kliente tevredenheid te verseker, met die oog op ISO sertifikasie, moet die departmenteIe doelwitte deurlopend gemeet en verbeter word.

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