Quality and safety
Quality marks
In 2008, the Bronovo-Nebo Foundation (i.e. the Bronovo Hospital, the Nebo Nursing Home and Wassenaar Health Centre) was the first to be accredited by NIAZ
1 in the Netherlands. The fact that the whole of the association was accredited is unique and as a pilot project, the NIAZ audit was done for the first time together with a quality review of three departments, i.e. the Departments of Gynaecology, Orthopaedics and Internal Medicine. The accreditation by NIAZ is a follow-up accreditation for Bronovo Hospital (Bronovo received the first accreditation certificate in 2004). The accreditation certificate is valid for four years, after which a new assessment will take place. The Bronovo-Nebo Foundation will therefore be re-accredited in 2012.
What does NIAZ accreditation mean?NIAZ stands for
Netherlands Institute for the Accreditation of Hospitals (NIAZ). NIAZ is an institute reviewing the quality and safety certifications of health care institutions. The standards as set by the NIAZ Health Care Institution Quality Standards form the basis for the accreditation. The Health Care Institution Quality Standards contain quality criteria for the organisational terms and conditions for quality care, which apply to the institution of health care as a whole. The NIAZ verifies whether requirements exist to improve and safeguard the quality of care and service provision in the organisation. Quality care must be firmly embedded in the organisation. In addition, the organisation must additionally generate an atmosphere to note opportunities for improvement and to take these on. As a result of the NIAZ accreditation and thorough research, independent organisations will have confidence in the safety and quality of our hospital. The audit team was impressed by the development of the Safety Management System as well as the involvement of medical staff in the quality policy.
1 NIAZ = ‘‘Nederlands Instituut voor Accreditatie van Ziekenhuizen’ = Netherlands Institute for the Accreditation of Hospitals
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TopCare accreditations for Bronovo Hospital from the health insurance company named Menzis
At the end of 2011 theMenzis Top Health Care designation (Topzorgpredikaten) for hip osteoarthritis with a total hip prosthesis was renewed for three years. In addition Bronovo Hospital received for the first time a Top Health Care designation for rughernia (slipped disc) operations. From 1st Januari 2011, the Top Health Care designation (Topzorgpredikaten) Menzis Breast Cancer and Inguinal Hernia have been extended for a period of 3 years.
In 2009 Bronovo Hospital again received three TopCare accreditations from health insurance company Menzis. This time for: the surgical treatment of knee arthrosis with a total knee prothesis and hip arthrosis with a total hip prothesis and for the surgical treatment of adenoids and tonsils.
The Menzis TopCare accreditaions has been awarded to Bronovo Hospital for medical quality, quick diagnoses and treatment as well as patient information. Collaboration with Family Doctor (GP) is intended in the agreement on Top Health Care in which price and volume also play a significant role.
Menzis is of the opinion that patients around the area of The Hague are well cared for at Bronovo Hospital for aforementioned conditions, as far as the best hospital care and prompt treatment is concerned. Menzis advises its policy holders to select a TopCare provider.
Health insurance company Menzis – of which Azivo is also a part – proceeded with the awarding of the Menzis TopCare designation. The health insurance company has selected its providers for TopCare on the basis of very stringent guidelines. Hospitals that offer the highest quality will be eligible for the TopCare designation given by Menzis.
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Mark of quality - Maternity and Paediatric ward
Bronovo Hospital received a second Smiley from the “Child and Hospital Foundation (Stichting Kind en Ziekenhuis)” for the maternity ward Amalia, which was completely renovated. This quality mark was awarded for the family-oriented care and because the Bronovo maternity ward meets all of the set criteria. The national foundation bestows the Smiley quality mark on hospitals that distinguish themselves by offering quality care for parents and children.
Maternity ward Amalia has 16 single rooms, that all offer the possibility of 'rooming in'. This means the baby stays in the room with the mother day and night. If desired, the partner can stay the night with mother and child, and is free to visit at any time. Also, the maternity ward and incubator ward are located close to each other, and epidural analgesia during delivery (commonly known as an ‘epidural’) is available 24 hours per day, seven days per week. The Bronovo maternity ward has also received the WHO/UNICEF certificate from the “Care for Breastfeeding Foundation (Stichting Zorg voor borstvoeding)” and offers breastfeeding support by a lactation expert.
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In April 2008, the Child and Hospital Foundation awarded a mark of quality - the ‘Smiley’ – to Bronovo Hospital for the paediatric ward. This national foundation awards the Smiley mark of quality to hospitals that are rated highly for the facilities they offer to children and parents. The Smiley award is evidence of the fact that care at Bronovo's paediatric ward meets all the criteria set by the Child and Hospital Foundation: The parents can stay night and day with their child that is admitted to hospital. Before a surgical procedure takes place, the parents and the child can speak to an anaesthesiologist to make preparations for the procedure. In the event of planned and emergency surgical procedures the parents may be present when the anaesthetic is administered. Parents may also be present when the child awakes from an anaesthetic.And finally, parents will be provided with written information about the rights of minors regarding health care in accordance with the Medical Treatment Agreement Act (WGBO
3 ).
From 1977 onwards, the national Child and Hospital Foundation has supported the improvement of the well-being of children before, during and after admission to a hospital. The foundation wants to encourage the hospitals by conferring a distinction: the Smiley. This quality mark can be obtained for paediatric wards, outpatients’ clinics and maternity wards.
Meanwhile a Smiley has been requested for the maternity ward and day care. Bronovo Hospital hopes to obtain these certificates in the spring of 2011. With a breastfeeding certificate and a maternity ward with brand-new studios all the requirements for the certificate will have been met.
More information on the Child and Hospital Foundation and the Smileys can be found on: www.kindenziekenhuis.nl
3 WGBO = ‘Wet op de geneeskundige behandelingsovereenkomst’ = Medical Treatment Agreement Act
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Vascular Quality Mark 2011
In 2011 the Heart & Vascular Group
4 again conferred the Vascular Quality Mark on the Bronovo Hospital vascular surgical centre, that had received the quality mark the first time in 2007. The Vascular Quality Mark is focussed on the quality of treatments for disorders in the arteries of the legs, pelvis, stomach, aorta and throat. The criteria for 2011 were adapted to new insights. Bronovo Hospital again meets the quality requirements.
For more information please go to:
www.hartenvaatgroep.nl4 Hart&VaatGroep – the Heart & Vascular Group
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Bronovo Hospital has received an award for the quality of care given to patients with colon cancer (colorectal carcinoma). The award was presented by various cooperative patient cancer organisations. They hereby indicate that Bronovo Hospital completely meets the quality requirements set by these organisations.
The patient organisations tested the care provided according to fifteen conditions. It appears that the care offered by Bronovo Hospital is well organised and meets the quality requirements. A patient guide was set up using these criteria. This varions guide provides information about the various aspects of quality of care, such as multidisciplinary cooperation within the hospital and with general practitioners and home care and the optimal support given to patients during the treatment and follow-up care. The patient guide supports patients in selecting a hospital.
The patient guide can be found at
www.nfk.nl
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In 2010, the Dutch Breast Cance Association (BVN) again awarded Bronovo Hospital the Pink ribbon for services in the care of breast cancer patients. By awarding the pink ribbon, the Breast Cancer Association has indicated that Bronovo meets the requirements set in the field of breast cancer care.
More information:
www.monitorborstkankerzorg.nl
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In 2010, the national foundation Zorg voor borstvoeding (‘Care for Breastfeeding’) awarded Bronovo Hospital the global breastfeeding certificate. This means that Bronovo meets the international ’10 guidelines for breastfeeding’ and thus offers high quality support concerning breastfeeding to mother and child. Bronovo may now call itself a Baby Friendly Hospital, an initiative by UNICEF and the World Health Organisation (WHO).
According to the standards for the certificate, mothers must receive good information about breastfeeding, during the pregnancy, after the birth and during the maternity period. Doctors, midwives and nurses have been specially trained for this. The testing was performed by the Zorg voor borstvoeding foundation and will be repeated every three years.
Thanks to the good cooperation between the primary Bronovo Midwifery Practice and the various departments in Bronovo involved in Mother and Child Care, such as the delivery rooms, the maternity ward and the paediatric ward, all these departments have received their own certificate.
More information:
www.zorgvoorborstvoeding.nl
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The clinical Chemical and Haematological Laboratory of Bronovo Hospital has been an accredited laboratory since January 2001. The accreditation was extended again for four years by
CCKL in 2009.
The laboratory meets the assessment criteria set by the CCKL
5, the authority for the accreditation of all medical laboratories in the Netherlands. The accreditation comprises the professional competence of the laboratory management and its staff members, the quality system of the laboratory and the performance in various research areas.
5 CCKL = ‘Coördinatie Commissie ter bevordering van de Kwaliteitsbeheersing op het gebied van Laboratoriumonderzoek in de Gezondheidszorg’ = Coordination Committee for the promotion of Quality Control in the field of Laboratory Research in Health Care.
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In 1999 the Internal Services Department was certified in accordance with the NEN-EN-ISO 9001-2000 standards. Since then the service has been audited annually by the Kema to establish whether the standards are being met once again. The Catering service was certified for the first time in 2004 in accordance with the HACCP (Hazard Analysis Critical Control Points) guidelines. An assessment of this service occurs twice a year.
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