CBAHI - Proconsultations

CONSULTATION PROPOSAL

consultations and development | 1


HOSPITAL ACCREDITATION

CBAHI

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HOSPITAL CBAHI ACCREDITATION

BEST PRACTICE

Our Mission

Our Vision

Our Values

TO UPGRADE HUMAN HEALTH BY IMPROVING THE QUALITY OF HEALTHCARE SERVICES, PATIENT SAFETY PROMOTION AND BUILDING SAFETY CULTURE THROUGH A TOTAL QUALITY MANAGEMENT SYSTEM INCLUDING PLANNING, MEASUREMENT, TRAININGAND IMPROVEMENT WITH FULL COMMITMENT OF HEALTHCARE STAKEHOLDERS

TO BE THE LARGEST HEALTHCARE QUALITY CONSULTANT COMPANY IN THE MIDDLE2020 EAST IN

HONESTY EXCELLENCECOMMITMENTCONFIDENTIALITYLOYALTYTEAMWORK

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HOSPITAL


AS A CONSULTATION COMPANY, WE ARE DEDICATED TO HELPING HEALTHCARE ORGANIZATIONS EVALUATE, IMPROVE AND DEMONSTRATE THEIR QUALITY OF PATIENT CARE TO COMPLY WITH THE INTERNATIONAL AND DOMESTIC HEALTHCARE QUALITY AND PATIENT SAFETY STANDARDS. FOR A HOSPITAL THAT IS DEDICATED TO CLINICAL EXCELLENCE FOR ALL ITS PATIENTS, THE MOST IMPORTANT BENEFIT OF ACCREDITATION IS ITS ENHANCED REPUTATION AMONG STAKEHOLDERS AND THE LOCAL COMMU-NITY. MAKING A DECISION TO OBTAIN ACCREDITATION IS A JOURNEY, A CULTURE SHIFT, AND A VISIBLE COMMIT-MENT TO IMPROVE THE QUALITY OF PATIENT CARE AND SERVICES.

IMPROVE PUBLIC TRUST AS AN ORGANIZATION THAT VALUES QUALITY AND PATIENT SAFETYINVOLVE PATIENTS AND THEIR FAMILIES AS PARTNERS IN THE CARE PROCESS BUILD A CULTURE OPEN TO LEARNING FROM ADVERSE EVENTS AND SAFETY CONCERNS ENSURE A SAFE AND EFFICIENT WORK ENVIRONMENT THAT CONTRIBUTES TO STAFF SATISFACTION ESTABLISH COLLABORATIVE LEADERSHIP THAT STRIVES FOR EXCELLENCE IN QUALITY AND PATIENT SAFETY UNDERSTAND HOW TO CONTINUOUSLY IMPROVE CLINICAL CARE PROCESSES AND OUTCOMES ACHIEVE EFFICIENCY OF USE OF HOSPITAL RESOURCES IN ALL SETTINGS.DECREASE PREVENTABLE MEDICAL ERRORS THAT MINIMIZES CLAIM PROCESSES.

BENEFITS OF ACCREDITATION FOR YOUR ORGANIZATION

CBAHI ACCREDITATION

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BEST PRACTICE

THE KEY TO SUCCESS IN YOUR JOURNEY TO ACCREDITATION IS THE COMMITMENT TO THE PROCESS BY HOSPITAL TOP MANAGEMENT INCLUDING, GENERAL MANAGER AND THE CLINICAL LEADERS IN YOUR ORGANIZATION. BE-CAUSE SENIOR LEADERS ARE ACCOUNTABLE FOR THE OVERALL SYSTEM’S PROCESSES TO ENSURE QUALITY AND PATIENT SAFETY, THEIR SUPPORT AND COMMITMENT ARE ESSENTIAL TO YOUR ORGANIZATION BEING SUCCESS-FUL. ACCREDITATION PREPARATION MUST BE A PRIORITY IN YOUR ORGANIZATION TO ACHIEVE THE PREDETER-MINED GOALS..

FOR A HOSPITAL TO ADMIT TO CBAHI ACCREDITATION JOURNEY IT NEEDS TO GO THROUGH THE FOLLOWING PROCESS AND COM-PLY WITH THE REQUIRED OBLIGATIONS:

THE ASSESSMENT WILL COVER THE ENTIRE ORGANIZATION AND INCLUDE ALL THE CHAPTERS RE-LATED TO PATIENT-FOCUSED STANDARDS AND ORGANIZATIONAL MANAGEMENT STANDARDS.

ROADMAP TO ACCREDITATION:

A. ASSESSMENT:

For a hospital to admit to CBAHI accreditation journey it needs to go through the following process and comply with the required obliga-tions:

a. Assessment

b. Planning

c. Implementation Plan

d. Documents Preparation

e. Training and Education

f. Monitoring of Compliance with Ac-creditation Standerds.

g. Mock Survey

h. Reporting



THE ASSESSMENT WILL ALSO COVER THE INTERNATIONAL PATIENT SAFETY GOALS AND IDENTIFY GAPS IN THE ORGANIZATIONS PERFORMANCE AND EXPECTATIONS OF THE GOALS. IN YOUR BASELINE ASSESSMENT, WE WILL ALSO LOOK AT QUALITY DATA CURRENTLY AVAILABLE IN THE ORGANIZATION AND COMPARE THAT DATA TO THE REQUIREMENTS OF THE QUALITY MONITORING STANDARDS. RE-SULTS OF YOUR BASELINE ASSESSMENT, GUIDE THE DEVELOPMENT OF A DETAILED ACTION PLAN. THE BASELINE ASSESSMENT WILL BE ARRANGED ACCORDING TO THE CBAHI STANDARDS AND ARRANGED TO COMPARE YOUR ORGANIZATIONS STATUS AGAINST THESE STANDARDS, THIS WILL LEAD TO REACHING THE FINDINGS AND THE REQUIRED RECOMMENDATIONS TO ACHIEVE COMPLIANCE.

OUR CONSULTANTS SHALL PLAN WITH YOU TO ESTABLISH APPROPRIATE STEPS TO REACH YOUR ORGANIZA-TIONAL GOALS. A MAIN EXECUTIVE PLAN LEADS THE WAY FOR ORGANIZATIONAL SUCCESS AND PRIORITIZES OPERATIONAL PLANS THAT WILL BE SUBMITTED TO ADDRESS THE FINDINGS WITH EFFICIENT AND EFFECTIVE USE OF HOSPITAL RESOURCES.

BEFORE YOU CAN GET STARTED, YOUR ORGANIZATION’S LEADERSHIP SHOULD DESIGNATE AN INDIVIDUAL TO BE RESPONSIBLE FOR COORDINATING THE ACCREDITATION ACTIVITIES. THIS INDIVIDUAL NEEDS TO BE A FULL-TIME EMPLOYEE OF YOUR ORGANIZATION WHO WILL BE RESPONSIBLE FOR ALL ACCREDITATION PREPARATION

C •IMPLEMENTATION PLAN

Period

Period

Deliverables

Deliverables

according to hospital size and scope of service rangingfrom 3 to 7 days

According to defects men-tioned in the initial assess-ment

Full written assessment re-ports include the needs and the requirements

Detailed Comprehensive executive plan with departmental assignments, the plan shall be implemented in phases depending on the initial assessment results.

B. PLANNING:

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BEST PRACTICE

ACTIVITIES PRIOR TO THE SURVEY, AS WELL AS MONI-TORING CONTINUOUS COMPLIANCE ONCE THE SURVEY IS OVER. THIS INDIVIDUAL IS DESIGNATED AS THE CBAHI SUR-VEY COORDINATOR AND WILL BE YOUR ORGANIZA-TION’S KEY CONTACT TO THE CBAHI ACCREDITATION PROGRAM. IN ADDITION TO WORKING CLOSELY WITH OUR CONSULTATION TEAM DURING THE PREPARATION PHASE AND THE APPLICATION PROCESS, YOUR CBAHI SURVEY COORDINATOR WILL ALSO COORDINATE AC-TIVITIES WITH CBAHI SURVEYORS. FOR MOST ORGANIZATIONS, THE PROCESS OF PREPAR-ING FOR A CBAHI ACCREDITATION SURVEY WILL TAKE BETWEEN 12 AND 24 MONTHS ACCORDING TO YOUR ORGANIZATION INITIAL ASSESSMENT. IN SOME CASES, ACHIEVING COMPLIANCE WITH THE STANDARDS MAY REQUIRE ALLOCATION OF RESOURCES, WHICH COULD INCLUDE ENHANCEMENT TO YOUR FACILITY RECRUIT-MENT, STAFF TRAINING, AND REDESIGNING CARE DE-LIVERY PROCESSES AND SYSTEMS. THE AVAILABILITY OF THESE RESOURCES WILL DECIDE THE PREPARATION

TIME, THAT MIGHT BE LIMITED AT BEST TO NINE MONTHS.IN ADDITION WE WILL HAVE TO CHOOSE –TOGETHER- A GROUP OF COORDINATORS AMONG ALL HOSPITAL DEPARTMENTS TO UNDERGO TRAINING PROGRAM FOR CERTAIN SKILLS, TOOLS AND TASKS TO BE ABLE TO INTEGRATE ALL ACCREDITATION STANDARDS IMPLE-MENTATION REQUIREMENTS AMONG ALL HOSPITAL DEPARTMENTS AND UNITS, WHETHER MEDICAL OR ADMINISTRATIVE.THE QUEST FOR QUALITY AND PATIENT SAFETY NEVER ENDS. ONCE YOUR ORGANIZATION IS ACCREDITED AND AS YOUR JOURNEY CONTINUES, YOUR ORGANIZATION MUST CONTINUE TO FOCUS ON MAINTAINING CONTIN-UOUS STANDARDS COMPLIANCE. BEST PRACTICE WILL BE AVAILABLE TO OFFER GUIDANCE, AS WELL AS PROVIDE IMPORTANT STANDARDS INTERPRETATION INFORMATION, NEWSLETTERS, AND TOOLS TO ASSIST YOU IN YOUR CONTINUED COMPLIANCE AND READI-NESS THROUGHOUT THE THREE-YEAR ACCREDITATION CYCLE.

DOCUMENTS PREPARATION, MODIFICATION AND REVIEW OFFER THE HOSPITAL A WAY TO POSSESS PLANS, FORMS, POLICIES AND PROCEDURES TO MEET STANDARDS COM-PLIANCE PRIOR TO IMPLEMENTATION.

D. DOCUMENTS PREPARATION:

Deliverables:

Quality Manual, Internal policies &procedures and Ad-ministrative Manual.



OUR CONSULTANTS PROVIDE EDUCATION FOR ORGANIZATIONAL PERFORMANCE IMPROVE-MENT, ACCREDITATION PREPARATION AND REGULATORY COMPLIANCE TO FAMILIARIZE ORGANIZATIONS WITH NEW EXPECTATIONS. OUR CONSULTANTS SUPPORT YOUR STAFF WITH EDUCATION, TRAINING, COACHING AND THE AP-PLICATION OF PERFORMANCE IMPROVEMENT METHODOLOGIES IN ADDITION TO TRAINING ON THE PREPARED DOCUMENTS.

ON-SITE DOCUMENT REVIEW AND TRACERS SURVEYS ADDRESS POTENTIAL COMPLIANCE ISSUES THROUGH COLLABORATION WITH KEY PLAYERS AND THE CREATION OF APPROPRIATE STRATEGIES TO FOSTER COMPLIANCE.

OUR CONSULTANTS PROVIDE PRACTICAL EXERCISES TO GUIDE STAFF AND LEADERS THROUGH INTERVIEWS, UNIT VISITS AND DOCUMENT REVIEWS TO ENABLE THEM TO UNDERSTAND AND DE-VELOP CONFIDENCE IN SURVEY APPROACHES. OUR CONSULTANTS TEACH YOUR STAFF THE METHODS TO REDUCE APPREHENSION OR ANXIETY AND ENABLE YOUR STAFF TO MANAGE THE SURVEY PRO-CESS. WE ASSIST YOUR STAFF IN PLANNING FOR THE ADDRESSING UNEXPECTED SITUATIONS CALMLY TO ACHIEVE POSITIVE SURVEY OUTCOMES.

E. TRAINING & EDUCATION:

F. MONITORING OF COMPLIANCE WITH ACCREDITATION STANDARDS:

G. MOCK SURVEY:

Deliverables:

Deliverables:

Period: Deliverables:

Quarter report

General Scored Report.

All over the project periodOrganization wide and Departmental training time-table with training objectives and outlines, with post training feedback reports to top management.

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BEST PRACTICE

REPORTING:

THE PROGRESS WILL BE REPORTED BIWEEKLY TO THE TOP MANAGEMENT OF THE HOSPITALS AND ANY NONCOMPLIANCE OR OBSTACLES ARE ILLUSTRATED TO LEADERS TO PLAN TO SOLVE THEM.IT IS MANDATORY THAT LEADERS SOLVE ANY INCOMPLIANCE ISSUES TO ACHIEVE THE PROJECT PLAN ON THE PREDETERMINED TIME.

THE HOSPITAL OBLIGATION

1LEADERSHIP

S

2STAFF

ACQUISITION

5RESOURCES

6IN-PLACE

OFFICE

4QUALIFIED STAFF

3COMMITTEES

7MEETING

ROOM

8SECRETARIES

1. Full leadership support & participation in all changes and quality activities with great commitment to work with our consultation team to bridge the gap.

2. Assigning suitable staff as accreditation chapters’ coordinators and safety coordinators.

3. Forming the necessary committees and overseeing its roles and regular meetings according to the require-ments of the standards and the recommendations of the consultation team.

4. Recruitment of the qualified staff according to the requirements of the standards and the recommenda-tions of the consultation team.

5. Offering the required resources, medical and nonmedical equipments and civil reconstructions if needed to meet the related standards.

6. Offering a suitable office with the necessary equipments and supplies according to the the recommenda-tions of the consultation team for preparing and keeping the documentations in safe and accessible way, also PCs, Printers and high speed internet access are required.

7. Offering a meeting room with multimedia show set.

8. Hiring two secretaries with English language and Microsoft office skills for documentations management.



THE ACCREDITATION PREPARATION AND SURVEY EXPERIENCE WILL GIVE YOUR ORGANIZATION AND STAFF THE KNOWLEDGE AND TOOLS FOR MEASURING AND SUSTAINING ENHANCEMENTS IN THE AREAS OF QUALITY PLAN-NING, PROCESS IMPROVEMENT, PATIENT SAFETY, AND QUALITY IMPROVEMENT:

WHOLE PROCESS DELIVERABLES

A. QUALITY PLANNING: B. QUALITY CONTROL:

C. QUALITY PROCESS IMPROVEMENT

D. PATIENT SAFETY

DEVELOPING COMPREHENSIVE, PATIENT-CENTERED PROCESSES THROUGHOUT THE ORGANIZATION. DEVELOPING A QUALITY MANAGEMENT SYSTEM BASED ON THE CBAHI STANDARDS. ESTABLISHING A PERIODIC REVIEW OF DATA ANALY-SIS (INDICATORS) TO SUSTAIN QUALITY IMPROVE-MENTS.DESIGNING AN EFFECTIVE AND EFFICIENT SUR-VEILLANCE SYSTEM TO MONITOR, ANALYZE AND ADDRESS DATA-DRIVEN, SUSTAINABLE IMPROVE-MENTS IN INFECTION CONTROL.

ADHERING TO THE INTERNATIONAL PATIENT SAFETY GOALS TO CREATE A CULTURE OF SAFETY FOR STAFF AND PATIENTS.ADOPTING A HOLISTIC SAFETY APPROACH TO IN-VOLVE PATIENTS, FAMILIES, STAFF, AND VISITORS. ESTABLISHING A TRANSPARENT SAFETY REPORT-ING SYSTEM FOR COMPLAINTS AND SUGGESTIONS FROM EMPLOYEES, PATIENTS AND FAMILIES.

ESTABLISHING A STRUCTURED AND TRANS-PARENT PROCESS TO MONITOR CONTINUOUS COMPLIANCE WITH THE INTERNATIONAL SAFETY GOALS, PRIORITY CLINICAL AND ADMINISTRATIVE AREAS.

ENHANCING INTERDISCIPLINARY COMMUNI-CATION. IMPROVING DOCUMENTATION OF PROCESSES TO ENSURE CONTINUITY OF CARE, PATIENT SAFETY AND CONTINUOUS IMPROVEMENT.IMPROVING MONITORING SYSTEMS AND PROCESSES TO MEASURE ENHANCEMENTS TO QUALITY AND PATIENT SAFETY IN CLINICAL AND MANAGERIAL AREAS.

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BEST PRACTICE

AUTOMATION OF PERFORMANCE MONITORING

CONSULTATION TEAM

SUCCESSFUL PERFORMANCE MANAGEMENT CAN BE ACHIEVED BY MEASURING PERFORMANCE ACCORDING TO SET TARGETS. WE OFFER A SOFTWARE PRODUCT FOR THE MEASUREMENT AND FOR COMMUNICATION OF THE RESULTS AND CORRECTIVE ACTIONS AS WELL AS PROFESSIONAL SERVICES RELATED TO THESE NEEDS.OUR SOFTWARE IS BEING DESIGNED FOR THE FOLLOWING HEALTHCARE PERFORMANCE MANAGEMENT SO-LUTION AREAS

ACCREDITATION READINESSCLINICAL PERFORMANCE MONITORING AND BENCHMARKINGPATIENT SAFETY MONITORING AND BENCHMARKINGSTRATEGY IMPLEMENTATIONBALANCED SCORECARD SOLUTIONS (BSC)PEOPLE PERFORMANCE AND PRODUCTIVITY MANAGEMENT

1. FULL TIME CONSULTANT : ATTEND THE WHOLE WORKING DAYS AND COORDINATING WITH THE PREDE-TERMINED SURVEY COORDINATOR AND CHAPTER COORDINATORS.2. ONE VISITING CONSULTANT AS PART TIME ATTENDING 4 DAYS MONTHLY TO OVERSEE ACTIVITIES AND ASSIGN TASKS TO COORDINATORS.3. SPECIALTY VISITING CONSULTANTS ATTENDING ACCORDING TO NEEDS ESTIMATED BY THE OVERSEEING CONSULTANT.4. FULL TIME QUALITY COORDINATOR TO ASSIST IN DOCUMENT PREPARATION AND REVIEW.

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BEST PRACTICE

CBAHI - Proconsultations

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