Accreditation & Auditing - By - Dr. Ilham Fetoh - 5-3-2014

8/12/2019 Accreditation & Auditing - By - Dr. Ilham Fetoh - 5-3-2014

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ا لرحيحسم

”

مب

خر

اه

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قت ىلا

صنوف”

صدق ا لعظي

(88) ةرس ن:ق ل رسل ا صي ا عه وسم

”ان ي اذا عم حدك عم ن يقه”

حدث شف



ACCREDITATIONby

Dr.Elham Fetouh Mohamed

Director of Quality DepartmentAlexandria Health Affair Directorate

MOH



DEFINITION OF ACCREDITATION

It is an external audit of the ability of the health

facility e.g. hospital, to provide a high quality

service to the patient and to minimize the

various dangers in an environment potentially

subject to high risks.



A process of recognition of capacity based

on comparing recent and on going activities

with a set of previously established standards.

by an independent body.



*Is the process by which a recognized body (usually a non-

governmental organization(NGO), assesses and recognizes that a

health care organization meets

pre-determined and published standards.

*Accreditation is often a voluntary process in which organizations

choose to participate, rather than one required by law and regulation..



There are three primary approaches for external

evaluation of healthcare quality: Licensure.

Accreditation.

Certification.All the three approaches use standards to determine the

level of quality achieved by individuals or organizations.



To protect basic public health and safety.

Licensure standards address the minimum legal

requirements or qualifications.

It is carried out by legal health authorities.

Usually done only once, prior to the beginning ofoperations.



Application To both individuals and organizations

Certification involves a recognized authority or board

granting.

Recognition to individuals who have demonstrated

specialized knowledge and skill and to organizations

that have the ability to practice in a certain area or

specialty.



It focuses on:

Achievement of optimal quality standards.

continuous improvement strategies.

On going education and consultation.



THE MAJOR PURPOSES OF ACCREDITATION

Improve the quality of health care by establishingoptimal achievement goals in meeting standards for

health care organizations

Stimulate and improve the integration andmanagement of health services

Establish a comparative database of health careorganizations able to meet selected structure,process, and outcome standards or criteria

Quality Associates Inc10




Reduce health care costs by focusing on increased

efficiency and effectiveness of services.

Provide education and consultation to health care

organizations, managers, and health professionalson quality improvement strategies and best

practices” in health care.





Strengthen the public’s confidence in the

quality of health care, and

Reduce risks associated with injury and

infections for patients and staff




Variety of evaluation strategies to determinecompliance, performance, and quality of care,

such as: Document and record reviews

Interviews

Observations

Achievement evaluations Facility inspections

Tracing



In July 2007, the Egyptian accreditation standards for

Hospital, Ambulatory Clinics and Primary Health Care were

accredited by The International Society for Quality Health

Care (ISQua) - the “Accreditors of the Accreditors”.

ISQua, is a non-profit, independent organization.

It works to provide services to guide health professionals,providers, researchers, agencies, policy makers and

consumers.

It is an accreditor of STANDARDS.



Egypt is the first Middle Eastern country to achieve ISQua

Accreditation of its standards.

These standards provide both significant challenge and a

clear roadmap for everyone to work collaboratively to

improve the quality of performance in healthcare

facilities.

A STANDARDS:

Policies/procedures, plans, required committees.

B C STANDARDS: Implementation standards.



Patient Rights responsibilities, Org. ethics

Access and Assessment of Patients

Providing Care, Diagnostic service, invasive

procedures, patient family Education.Medication management

Patient safety, Infection Control and Environmental

safety

Information Management

Performance improvement

Organization management

Community Involvement



A-Structures :

policy/procedures, plans, required committees (all ornone scoring).

Met

Present –

all elements.

Not Met

Not present with all elements.



The organization has a list of

procedures or treatments for

which informed consent is

required, including the following:

PR. 16

Surgery and invasive procedures.PR. 16.1

Anesthesia/moderate or deep

sedation.

PR. 16.2

Use of blood.PR. 16.3

High-risk procedures or

treatments (including but not

limited to Electro convulsivetreatment, radiation therapy,

chemotherapy).

PR. 16.4

Family planning interventions.PR. 16.5

ResearchPR. 16.6

M N NA



B C- implementation :-

frequency based-observations of deficiencies.

Met

Zero to 1 observed or documented deficiency.

Partially Met

2 observed or documented deficiencies.

Not Met

3 or more observed or documented deficiencies.



B versus C standards Bstandards are to be implemented first (easier).

Cstandards are more difficult to implement or

not needed for an initial survey.

General consent for treatment is

obtained when the patient seeks

service for the organization.

PR. 14P N NA

Patients and families are informed

about how to donate organs and

other tissues according to law and

regulation and policy.

PR. 29P N NA



ACCREDITATION PROCESS

(According to standards of Ministry of Health Population).

The accreditation process begins with an initial

self assessment.

Assistance may be requested - for clarification of

applicability of a standard or set of standards to

the organization.

Prior to an initial survey, a pre-survey visit will bescheduled to validate the application information.



Pyramid of Excellence inHealth Care Accreditation

ApplicationSelf Assessment

Pre survey assessment Application Validation

Foudation Level

Basic QualityLevel

Egypt Accreditation



A report of deficiencies relating to only the A and

Patient Safety standards will be left with the

organization to enable further preparation.

A full survey team will be scheduled when the

organization has at a minimum a 4 month track record

of achievement with these selected standards.

After the survey, a report will be given to the

organization with an outcome of the level achieved, and

a list of all Not Met standards followed by all Partially

Met standards



An on-site re-survey could occur depending on the

problem or lack of ability to correct deficiencies.

A mid cycle (approximately 18 month) assessmentprocess will occur.

This assessment consists of a combination of self

assessment and on-site survey by a team.

A full on-site survey conducted by a team of surveyors

will occur in the 3rd year.



It stimulates the improvement of care delivered topatients

It strengthens community confidence in its hospital

It reduces unnecessary costsIt increases efficiency

It provides credentials for education, internships,

and residencies

It can protect against lawsuits

It facilitates acceptance by and funds from third-party payers

Accreditation & Auditing - By - Dr. Ilham Fetoh - 5-3-2014

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