بسم الله الرحمن الرحيم. You can’t manage what you can’t measure.
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Transcript of بسم الله الرحمن الرحيم. You can’t manage what you can’t measure.
Definition :Definition :
Assessment of health services Assessment of health services according to a set of standards according to a set of standards describing the structures and describing the structures and processes that contribute to processes that contribute to desirable patient outcomes based on desirable patient outcomes based on quality of care and patient safetyquality of care and patient safety
Benefits of AccreditationBenefits of Accreditation
Shows commitment to quality Shows commitment to quality Improves communication and Improves communication and
collaboration within the organisationcollaboration within the organisation Promotes team buildingPromotes team building Increases credibilityIncreases credibility Demonstrates accountabilityDemonstrates accountability Improves productivityImproves productivity Obtaining advice from surveyors Obtaining advice from surveyors
(mentoring)(mentoring)
Studies show positive effect for:Studies show positive effect for:
Patient (satisfaction, quality of care Patient (satisfaction, quality of care and safety)and safety)
Staff (satisfaction and good work Staff (satisfaction and good work condition)condition)
Organisation (productivity, strategic Organisation (productivity, strategic performance and financial viability)performance and financial viability)
Brief HistoryBrief History
Earnest Codman: End result system Earnest Codman: End result system (effectiveness of treatment) 1910(effectiveness of treatment) 1910
The era of minimal standards 1917-The era of minimal standards 1917-19651965
The era of optimal achievable The era of optimal achievable standards 66-87standards 66-87
The era of performance evaluation The era of performance evaluation 1988….. 1988…..
Accreditation methodologyAccreditation methodology
Function based (tracer methodology)Function based (tracer methodology) Department basedDepartment based
JCAHO(U.S)JCAHO(U.S)
1-Patient-Focused 1-Patient-Focused FunctionsFunctions
-Rights, ethics, responsibilities-Rights, ethics, responsibilities-Provision of care, treatment, -Provision of care, treatment,
servicesservices-Medication management-Medication management-Surveillance, prevention, -Surveillance, prevention,
infection control infection control
JCAHO (cont…)JCAHO (cont…)
2-Organization Functions2-Organization Functions
-Performance improvement-Performance improvement-Leadership-Leadership-Management of environment of care-Management of environment of care-Management of information -Management of information 3-Structures With Functions3-Structures With Functions-Medical staff-Medical staff-Nursing-Nursing
A new task force in 1997A new task force in 1997
In EU, Middle east and Far In EU, Middle east and Far east and then everywhereeast and then everywhere
JCI (cont…)JCI (cont…)
ACC (Access to care and continuity if care)ACC (Access to care and continuity if care) PFR (Patient and Family Rights)PFR (Patient and Family Rights) AOP (Assessment Of Patients)AOP (Assessment Of Patients) COP (Care Of Patients)COP (Care Of Patients) ASC (Anesthesia and Surgical Care)ASC (Anesthesia and Surgical Care) MMU (Medication Management and Use)MMU (Medication Management and Use)
JCI (cont…)JCI (cont…)
PFE (Patient and Family Education)PFE (Patient and Family Education) QPS (Quality improvement and Patient QPS (Quality improvement and Patient
Safety)Safety) PCI (Prevention and Control of PCI (Prevention and Control of
Infections)Infections) GLD (Governance, Leadership and GLD (Governance, Leadership and
Direction) Direction) FMS (Facility Management and Safety)FMS (Facility Management and Safety)
JCI (cont…)JCI (cont…)
SQE (Staff Qualifications and SQE (Staff Qualifications and Education)Education)
MCI (Management of Communication MCI (Management of Communication and Information)and Information)
Egypt Egypt
WHO and MOHPWHO and MOHP From 1995From 1995 Critical standards 69Critical standards 69 Core standards 322Core standards 322 Non core standards 325Non core standards 325
Egypt (cont…) Egypt (cont…)
The first award in middle east from The first award in middle east from ISQuaISQua
(the accreditor of accreditors )(the accreditor of accreditors )
Lebanon Lebanon
World bank and MOPHWorld bank and MOPH Department based standardsDepartment based standards Basic standards and accreditation Basic standards and accreditation
standards (2001)standards (2001) Second accreditation Second accreditation
standards(2003)standards(2003)
CanadaCanada
Canadian Commission On Hospital Canadian Commission On Hospital Accreditation 1952Accreditation 1952
MonopolyMonopoly Including mental health and Including mental health and
rehabilitation facilities as well as rehabilitation facilities as well as general hospitalsgeneral hospitals
Recently outcome measuresRecently outcome measures 94% of hospital beds 94% of hospital beds
U.KU.K
Though NHS had an agenda for accreditation but Though NHS had an agenda for accreditation but there was not any responsethere was not any response
Patient’s Charter (department of health’s Patient’s Charter (department of health’s standards for patient services)standards for patient services)
Investors in people (department of trade and Investors in people (department of trade and industry)industry)
King’s Fund Organizational AuditKing’s Fund Organizational Audit Eventually accreditation as an integrate system Eventually accreditation as an integrate system
(King Edward’s Hospital Fund for London (mission: (King Edward’s Hospital Fund for London (mission: quality improvement in NHS)quality improvement in NHS)
Resemble to U.S ,Canada and especially Australia Resemble to U.S ,Canada and especially Australia
ChinaChina
Formal Accreditation by MOPHFormal Accreditation by MOPH Three levels of hospitalsThree levels of hospitals
-Neighborhood or township level-Neighborhood or township level
-District, country, industrial -District, country, industrial complex levelcomplex level
-Large municipal and teaching -Large municipal and teaching level level
AustraliaAustralia
Australian Council On Hospital Australian Council On Hospital Standards 1974Standards 1974
Utilization of resources Utilization of resources Quality of careQuality of care Clinical outcomeClinical outcome Fully accredited 3 years and partially Fully accredited 3 years and partially
accredited 1 yearaccredited 1 year Newly a 5 year has been introducedNewly a 5 year has been introduced
China (cont...)China (cont...)
Four areas of treatment :Four areas of treatment :
-Prevention-Prevention
-Healthcare reconstruction-Healthcare reconstruction
-Support and participation in -Support and participation in disease prevention and caredisease prevention and care
-Healthcare activities-Healthcare activities
China (cont…)China (cont…)
Every 3 yearsEvery 3 years Only accredited hospitals get license Only accredited hospitals get license
to operateto operate Government can close non Government can close non
accredited hospitalaccredited hospital The most important challenge :the The most important challenge :the
number of trained surveyors number of trained surveyors necessary (120000 surveyor)necessary (120000 surveyor)
Latin America and the CaribbeanLatin America and the Caribbean
Has begun in early ninetiesHas begun in early nineties PAHO and Latin American Federation PAHO and Latin American Federation
Of HospitalsOf Hospitals Also a draft by MOPH of ArgentinaAlso a draft by MOPH of Argentina
Latin America and the CaribbeanLatin America and the Caribbean
14000 hospitals (most of them <70 14000 hospitals (most of them <70 beds)beds)
Compulsory minimum standards and Compulsory minimum standards and non-compulsory standardsnon-compulsory standards
Latin America and the Caribbean (con…)Latin America and the Caribbean (con…)
Compulsory minimum standards :Compulsory minimum standards : - Medical care- Medical care - Technical and support areas - Technical and support areas - Building documentation- Building documentation - Functional physical structure- Functional physical structure - Installations- Installations Non compulsory :critical area, Non compulsory :critical area,
neonatology, nuclear medicine and neonatology, nuclear medicine and ……
IndiaIndia
Voluntary accreditation by Indian Hospital Voluntary accreditation by Indian Hospital Association (IHA) failed in 1993Association (IHA) failed in 1993
Bureau of Indian Standards (BIS) has laid Bureau of Indian Standards (BIS) has laid down standards for 30,100 and 250 bedsdown standards for 30,100 and 250 beds
National Institute for Health and Family National Institute for Health and Family welfare (NIHFW 1992)…standards for >50 welfare (NIHFW 1992)…standards for >50 beds only for equipmentbeds only for equipment
Government standards for secondary Government standards for secondary level hospitalslevel hospitals
Pyramid of documentationPyramid of documentation
QM
Policies and
procedures
Instructions
Forms
Records
Standards Should BeStandards Should Be
1.1. Explicit (written)Explicit (written)2.2. Degree of excellence Degree of excellence 3.3. Objective (not subjective)Objective (not subjective)4.4. Compatible with culture and abilitiesCompatible with culture and abilities5.5. Able to improve continuouslyAble to improve continuously6.6. Compatible with government requirementsCompatible with government requirements7.7. Compatible with minimum community Compatible with minimum community
contentcontent8.8. Motive the leadership Vs management Motive the leadership Vs management
(not like classification systems)(not like classification systems)