Hossam Elamir, MSc.HCM, TQMD, MBBChQuality & Accreditation Office, MKH

Numbers, Charts and Comments on Standards were taken from a presentation of:

Maitham Husain, MD FRCPC National Accreditation Program

Accreditation Department,  Accreditation & Quality Directorate,

MOH

• Accreditation is a QUALTIY PROCESS

• Standards are QUALITY TOOLS• Required Organization Practices Essential service to improve patient safety

& minimize risk

“Quality is NEVER AN ACCIDENT; it is always the result of HIGH INTENTION, SINCERE EFFORT, INTELLIGENT DIRECTION and SKILFUL EXECUTION… the WISE CHOICE of many alternatives.”

William A. Foster, 1917-1945

“First, do no harm” (Kohn et al. 2000) Perhaps the closest

approximation in the Hippocratic Corpus is in Epidemics:

"The physician must ... have two special objects in view with regard to disease, namely, to do good or to do no harm" 

Medicine used to be simple, ineffective & relatively safe… now it is complex, effective & potentially dangerous!

Chantler, C. (1999), The role and education of doctors in the delivery of healthcare, Lancet, 53(9159), 1178–1181.

Medicine used to be simple, ineffective & relatively safe…

Chantler, C. (1999), The role and education of doctors in the delivery of healthcare, Lancet, 53(9159), 1178–1181.

Don’t kill me (no needless deaths)

Do help me & don’t hurt me (no needless pain)

Don’t make me feel helpless

Don’t keep me waitingDon’t waste resources -

mine or anyone else’sBerwick, D. M. (2005), My right knee, Annals of

Medicine, 142 (2), 121-125.

The seven pillars of quality (Donabedian, 1990)

The six aims of quality improvement (IOM, 2001)

The six dimensions of quality (Bengoa et al.,

2006)

Efficacy    

Effectiveness Effective Effective

Efficiency Efficient Efficient

Optimality    

Acceptability Acceptable / patient-centred Patient-centred

Legitimacy(Partially covered by the patient-centred aim)

(Partially covered by the patient-centred dimension)

Equity Equitable Equitable

  Accessible  

  Safe Safe

    Timely

• Standards have been reviewed by:1. A taskforce committee(surveyor, accreditation department, safety

department)

2. Advisory Committee, MoH3. Higher Committee for Accreditation,

MoH

Parameter All Standards PSRA

Average Rate 2.62 2.00

Range 1.92-3.25 1.3-2.38

Median 2.72 2.29

MKH 2.21 2.00

53%

MKH

1.5

0.0

2.0

2.0

2.5

2.0

2.0

1.6

1.63

1.7

1.8

1.1

2.0

1.0

• Recommendation to the Standard of Accreditation

Changes are being introduced to the program that will highlight the significance of the Patient Safety Required Areas as essential practices to improve patient safety in health care organizations.

(In Canadian Standards they are called: ROPsRequired Organisational Practices)

• Each PSRA will be elevated to the criterion level

• The rating scales and calculation of the accreditation decisions are changing for the second cycle of accreditation

• Each individual PSRA will now be assigned its own rating in the self-assessment and on-site survey in a scale of 4

• The 3-point scale for PSRAs will be eliminated and all criteria (including PSRAs) will be rated on the 4-point scale based on test of compliance

Level 1 The plan and policy are developedLevel 2 The plan and policy are partially

implemented in the service area, as per the Test(s) for Compliance

Level 3 The plan and policy are fully implemented in the service area, as per the Test(s) for Compliance

Level 4 The service collects data and analyzes data, and uses the results for improvement

Organizations must achieve a rating of 3 or 4 on the 4-point scale for all (100%) of the PSRAs or the accreditation award will be affected

•If one or more PSRAs is unmet (below level 3 or 4), the accreditation award will be reduced by one level

MKH

3.002.00

2.00

2.00

2.00

1.00

2.00

2.00

2.00

• The leadership section will include a standard on Training on Patient Safety.

11.0 Training on Patient SafetyLevel 1 - Plan and policy are developedLevel 2 - Plan and policy are partially implemented

in the service as per test of complianceLevel 3 - Plan and policy are fully implemented in

the service as per test of complianceLevel 4 - The service collects data, analyses it and

uses results for improvement

53%

MKH

1.5

0.0

2.0

2.0

2.5

2.0

2.0

1.6

1.63

1.7

1.8

1.1

2.0

1.0

Average rating – 2.15 (range 0.8-3.0) or 54%

Area of Special concern (below national average)•Obs./Gyn. 0.8•Human resources 1.2•Emergency service 1.7•Surgical 1.8•Information management 1.8•Intensive care 2.0•Environment 2.1

STANDARD 8 – SAFETY PLAN8.1 Management ensures there is an annual written safety plan8.2 The safety plan is regularly monitored for progress8.3 Results from safety related activities are reported throughout the hospital and management reports findings to governance. 8.4 Resources are provided for quality improvement and safety activities throughout the hospital

Similar changes will be applicable to all clinical and support services.

Each PSRA will appear as criterion and scored accordingly on scale of 0,1,2,3 and 4