Hospital Accreditation - UPCPH-MHA202 - Blended Learning - 14oct7

Hospital Accreditation

Reynaldo O. Joson, MD, MHA, MHPEd, MSc SurgOctober 7, 2014

UP Manila College of Public Health

Processes by which a hospital voluntarily applies for recognition or attestation of compliance to certain set of

standards by a third-party

What is Hospital Accreditation?

Accredited / Accreditation Certified / CertificationAwarded / Award

ComplianceDemonstration of competency / consistency

ProductsProcessesSystemsPersons

Compliance, Accreditation, Certification, AwardHospital

SetStandards

CriteriaIndicators

Satisfactorydegree of compliance / achievement

Certification AwardAccreditation

Third-partyAssessor/ Auditor

Philippine Quality Award

ISO 9001

ISO 14000

PhilHealth / Benchbook

PCAHO

JCI

ACI

NABH

Levels

Compliance, Certification, Accreditation, Award

Compliance

Accredited certifying body

Certification

Accreditation

Award (recognition)

Certifying / awarding body


Compliance


Certification

Accreditation

Award (recognition)


PQA

DTI


Compliance


Certification

Accreditation

Award (recognition)


PhilHealthPhilHealth


Compliance


Certification

Accreditation

Award (recognition)


JCI / ACI / NABH

ISQUA

JCI / ACI / NABH


Compliance


Certification

Accreditation

Award (recognition)


ISO 9001 / 14000ISO

AJA / TUV

What is the concept of “hospital accreditation”?

A hospital seeking accreditation from an accrediting body is done on a voluntary basis.

The hospital has the freedom to choose the set of standards it wants to be assessed or evaluated on by an accrediting body.

It also has the liberty to choose the accrediting body to do the assessment or evaluation.


The standards may be on • quality management system• quality health care and patient safety management

system• human resource management system • environment management system• emergency and disaster management system• others


Hospital accreditation almost always entails fees:• fee for the survey or assessment • fee for the certificate

How much the fees are is dependent on the accrediting body.

What are the benefits of hospital accreditation?What are the goals and objectives of having a hospital accreditation?

There are a lot of benefits that can be derived from hospital accreditation.

Some can be considered as major benefits and some, as minor benefits. Some can be considered as primary benefits and others, as off-shoots of the primary, or secondary.

These benefits are translatable to goals and objectives of having a hospital accreditation.


The overarching major primary benefit or goal is to promote the business development program of the hospital so as to make it viable and sustainable.


The secondary benefits or objectives can and should be the following: To use the accreditation project as an assessment tool on hospital performance as well as a change management tool.

To identify and institute areas of improvement towards excellence with the help of the hospital accreditation project.To educate the staff on performance excellence with the help of the hospital accreditation project.


The secondary benefits or objectives can and should be the following: To increase the hospital’s credibility and to demonstrate its accountability to the community using an attained hospital accreditation.

To enhance the hospital reputation so as to attract more clients utilizing its services.To increase its leverage with the potential partners and collaborators in the health care industry using the attained hospital accreditation.

Accreditation as a Strategy / Tool

for Hospital Quality Service /Improvement

Use it as change agent!

•Know & fulfill requirements of quality! (with assessment –

internal and external)•Educate staff on quality!•Motivate staff on quality!

What are the currently sought accreditation by hospitals in the Philippines, fees, advantages and recommendations?

In a hospital setting in the Philippines, as of 2014,

the following local and international documented sets of standards should guide all hospitals in achieving a high level of quality and performance:

What are the currently sought accreditation by hospitals in the Philippines, fees, advantages and recommendations?

• Philippine Quality Award Criteria for Performance

Excellence• ISO Quality Management System• PhilHealth Benchbook (including PH statutory and

regulatory requirements)• Joint International Commission, Accreditation Canada

International, National Accreditation Board for Hospitals and Healthcare Providers (choose one)

• Investors in People

What are the currently sought accreditation by hospitals in the Philippines?

Accreditation Standards URLs PhilHealth Benchbook http://www.philhealth.gov.ph/providers/institu

tion/benchbook.htm

Joint Commission International (JCI)Accreditation International (ACI) National Accreditation Board for Hospitals and Healthcare Providers (NABH)

http://www.jointcommissioninternational.org/http://www.internationalaccreditation.ca/en/home.aspx

http://www.nabh.co/

Philippine Quality Awards (equivalence of Baldrige Awards of )

http://www.pqa.org.phhttp://www.dti.gov.ph/dti/index.php?p=492http://www.nist.gov/baldrige/publications/hc_criteria.cfm

ISO (International Organization for Standardization)

http://www.iso.org/iso/home.html

Investors in People http://www.investorsinpeople.co.uk/Pages/Home.aspx

http://www.philhealth.gov.ph/providers/institution/benchbook.htm

http://www.philhealth.gov.ph/providers/institution/benchbook.htm

http://www.jointcommissioninternational.org/

http://www.internationalaccreditation.ca/en/home.aspx

http://www.internationalaccreditation.ca/en/home.aspx

http://www.nabh.co/

http://www.pqa.org.ph/

http://www.dti.gov.ph/dti/index.php?p=492

http://www.nist.gov/baldrige/publications/hc_criteria.cfm

http://www.nist.gov/baldrige/publications/hc_criteria.cfm

http://www.iso.org/iso/home.html

http://www.investorsinpeople.co.uk/Pages/Home.aspx

http://www.investorsinpeople.co.uk/Pages/Home.aspx

What are the similarities and differences between and among the currently sought accreditation standards?

ISO / PQA JCIA / ACI / NABH / PhilHealth Benchbook

Origin manufacturing industry

hospital industry

Language manufacturing health care

Product easily defined, tangible item

clinical aspects of health care, not easily defined, not readily tangible

What are the currently sought accreditation by hospitals in the Philippines and their accreditation fees?

Accreditation Standards Accreditation Fees (Assessment

and Certification)As of 2014 (may change anytime)

PhilHealth Benchbook PhP 10TJCIACINABH

JCI – PhP 14 MACI – PhP 8 MNABH – PhP 3 M


PhP 30T – small organizationsPhP 50 – medium to big organizations

ISO (International Organization for Standardization)

PhP 300T

Investors in People PhP 1M

What are the currently sought accreditation by hospitals in the Philippines, advantages and recommendations?

Accreditation Standards Advantages

PhilHealth Benchbook Designed to encourage Philippine hospitals improve on their quality management system and to improve quality and safe patient care

Joint Commission International (JCI)Accreditation International (ACI)National Accreditation Board for Hospitals and Healthcare Providers (NABH)

Designed to improve quality and safe patient careDesigned to assess and improve organization performance based on internationally agreed standards and stimulating continuous improvement to achieve optimum outcomes on healthcare

Comparison of StandardsPhilHealth Benchbook Joint Commission International Accreditation Canada

• Patient Rights and

Organizational Ethics

• Patient Care

• Leadership and Management

• Human Resource Management

• Information Management

• Safe Practice and Environment

• Performance Improvement

Patient-centered Standards

•Access to Care and Continuity of Care•Patient and Family Rights•Assessment of Patients•Care of Patients•Anesthesia and Surgical Care•Medication Management and Use•Patient and Family Education

Health Care Organization Management Standards

•Quality Improvement and Patient Safety•Prevention and Control of Infections•Governance, Leadership, and Direction•Facility Management and Safety•Staff Qualifications and Education•Management of Communication and Information

Individual Client / Patient Care Groups (14)

Information Management

Human Resources Development and Management

Environmental Management

Leadership and Partnerships

Comparison of StandardsAccreditation

Canada Joint Commission International National Accreditation Board

for Hospitals Individual Client

/ Patient Care Groups (14)

Information Management

Human Resources Development and Management

Environmental Management

Leadership and Partnerships

Patient-centered Standards

•Access to Care and Continuity of Care•Patient and Family Rights•Assessment of Patients•Care of Patients•Anesthesia and Surgical Care•Medication Management and Use•Patient and Family Education

Health Care Organization Management Standards

•Quality Improvement and Patient Safety•Prevention and Control of Infections•Governance, Leadership, and Direction•Facility Management and Safety•Staff Qualifications and Education•Management of Communication and Information

• Access and Planning of Services

• Customer Rights and Education

• Care of Customers• Management of

Medication, Consumables and Equipments (including Instruments)

• Infection Control

• Continual Quality Improvement

• Responsibilities of Management

• Facility Management and Safety

• Human Resource Management

• Information Management System


Accreditation Standards Advantages and *Recommendations

PhilHealth Benchbook Local standards directly related to PH hospitals; will be needed for licensure with DOH.*All PH hospitals must have, for viability and sustainability; establish complete and sustainable compliance to serve as a foundation for other hospital accreditations, if needed.

Joint Commission International (JCI)Accreditation International (ACI) National Accreditation Board for Hospitals and Healthcare Providers (NABH)

International standards directly related to hospitals all over the world.*Go for one, if hospital has a medical tourism project and needs leverage with international collaborators and partners.


Accreditation Standards Advantages


Designed to help provide hospitals with an integrated approach to organizational performance that results in

Delivery of ever-improving value to customers and stakeholders, contributing to organizational sustainabilityImprovement of overall organizational effectiveness and capabilitiesorganizational and personal learning

ISO (International Organization for Standardization)ISO 9001: Quality Management System

Designed to help organizations ensure that they meet the needs of customers and other stakeholders while meeting statutory and regulatory requirements related to the product.

PQA Business Criteria for Performance Excellence

Baldrige Health Care Criteria for Performance Excellence

ISO 9000 QMS

Comparison of StandardsPQA Criteria for Performance

ExcellenceISO 9001:2008

Leadership Strategic Planning Customer Focus Measurement, Analysis, and

Knowledge Management Workforce Focus Operations Focus Results

4 Quality management system 4.1 General requirements 4.2 Documentation requirements 5 Management responsibility 5.1 Management commitment 5.2 Customer focus 5.3 Quality policy 5.4 Planning 5.5 Responsibility, authority and communication 5.6 Management review 6 Resource management 6.1 Provision of resources 6.2 Human resources 6.3 Infrastructure 6.4 Work environment 7 Product realization 8 Measurement, analysis and improvement 8.1 General 8.2 Monitoring and measurement 8.3 Control of nonconforming product 8.4 Analysis of data 8.5 Improvement


Accreditation Standards Advantages and *Recommendations


Local standards that covers all kinds of industry and there is a specific set of standards in health care*Recommended after PhilHealth Benchbook accreditation; may use the latest US Baldrige Health Care Criteria for Performance Excellence as complementary guide.

ISO (International Organization for Standardization)ISO 9001: Quality Management System

International standards on basic quality management system that are applicable to all kinds of industry including hospitals and health care*Recommended if an international accreditation is deemed needed and cannot afford ACI / JCI / NABH


Accreditation Standards Advantages Investors in People Designed to transform business performance

through people

Comparison of StandardsPQA Criteria for

Performance ExcellenceISO 9001:2008 Investors in People

Leadership Strategic Planning Customer Focus Measurement, Analysis,

and Knowledge Management

Workforce Focus Operations Focus Results

4 Quality management system 4.1 General requirements 4.2 Documentation requirements 5 Management responsibility 5.1 Management commitment 5.2 Customer focus 5.3 Quality policy 5.4 Planning 5.5 Responsibility, authority and communication 5.6 Management review 6 Resource management 6.1 Provision of resources 6.2 Human resources 6.3 Infrastructure 6.4 Work environment 7 Product realization 8 Measurement, analysis and improvement 8.1 General 8.2 Monitoring and measurement 8.3 Control of nonconforming product 8.4 Analysis of data 8.5 Improvement

PlanDo Review1. Business Strategy2. Learning and development strategy3. People management strategy4. Leadership and management strategy5. Management effectiveness6. Recognition and reward7. Involvement and Empowerment8. Learning and development9. Performance Measurement10. Continuous improvement


Accreditation Standards Advantages and *RecommendationsInvestors in People International standards on people

development to promote hospital viability and sustainability*Use the IiP standards to support and complement PhilHealth Benchbook accreditation and Philippine Quality Awards as well as other accreditations; nice to have the IiP accreditation.

Advantages of Being Compliant with Local and International Standards of Quality and Safe Patient Services

• Stimulate continuous improvement in service and patient care processes and outcomes.

• Improve management of health care services particularly on patient safety.

• Provide staff education on better or best practices.

Advantages of Being Compliant with Local and International Standards of Quality and Safe Patient Services

• Increase efficiency / reduce cost.• Improve organization performance.• Promote recognition for excellence.• Strengthen public and community confidence.

What are the recommended processes in going for hospital accreditation?

Starting point:

Top management decides to have a Hospital Accreditation Project •To promote the business development program of the hospital so as to make it viable and sustainable.•To use it as a change agent to fast-track quality improvement.


Top management creates a Steering Team / Committee for Hospital Accreditation Project with clear functions and authority.

Membership of Steering Team / CommitteeSenior Management Representative if not the Hospital DirectorChair (with competency in hospital accreditation and leadership)Cross-sectoral or multisectoral membership with representatives from key functional areas in the hospital, such as the following:(Note: the senior management team members may constitute the Steering Team / Committee.)


Cross-sectoral or multisectoral membership with representatives from key functional areas in the hospital, such as the following:(Note: the senior management team members may constitute the Steering Team / Committee.)

Medical service sectorNursing service sectorAncillary medical service sectorAdministrative or support service sectorHuman resource development sectorBusiness development sectorFinance sectorSecretariat


Steering Team formulates a master plan for Hospital Accreditation Project.

Steering Team decides on set of standards to be assessed or evaluated on by an accrediting body.

Steering Team seeks commitment for support and collaboration from top, senior, middle, and lower management on Hospital Accreditation Project.


Contents of master plan for Hospital Accreditation Project

•Goals and objectives of accreditation project (include short- and long-term goals and objectives)•Selection, prioritization, and integration of the accreditation standards •Selection of the accrediting bodies•Expected outputs (short- and long-term)•Expected impact (short- and long-term)•………..


Contents of master plan for Hospital Accreditation Project

•..........•Timelines (short- and long-term)•Strategies and action plans to achieve expected outputs and impacts (short- and long-term)•Budget (short- and long-term)•Monitoring and oversight plan•Evaluation plan (short- and long-term)

Hospital Accreditation: Does it Matter?

It depends on your need and situation!

Need - to participate in National Health Insurance Program and get benefits – go for PhilHealth Accreditation!

Need - to participate in medical tourism program and get benefits – PCAHO, international accreditation (JCI / ACI / NBAH)

Need – to satisfy requirement of corporate accounts – go for accreditation!

Need – to satisfy expectations of the community – go for accreditation!



Situation – to be with the trend of having an international accreditation (not to be left out – strong community expectation) – go for accreditation!

Situation – want to fast-track improvement of quality and safety of operations and services with accreditation – go for accreditation (assessment, training, improvement, evaluation)!



NO need; NO situation

Be COMPLIANT with the standards and criteria without going for formal accreditation!

(self-directed learning and improvement!)

Integrating Hospital Quality and Performance Standards

• Philippine Quality Award Criteria for Performance Excellence

• ISO Quality Management System• PhilHealth Benchbook (including PH

statutory and regulatory requirements)• Joint International Commission,

Accreditation Canada International (either one)


*Compliance but NOT necessarily going for accreditation to all standards, except PhilHealth Benchbook and Philippine Quality Awards for Performance Excellence

Performance Excellence

Use integrated checklists









•Business Development•Efficiency•Learning









Increase in utilization of

services

Increase in corporate

accounts andpatient-clients

What are the common problems or challenges in hospital accreditation?

Common problems and challenges (commitment, cooperation, collaboration, and integration of all stakeholders)

Weakness in:Leadership Management

Planning, implementation, and evaluationIntegration of standards in all units

CommunicationEducation

Aiming for best practices in quality and performance excellence in hospitalsProgram

med Journey of Excellence

Hospital Accreditation

Reynaldo O. Joson, MD, MHA, MHPEd, MSc SurgOctober 7, 2014

UP Manila College of Public Health

Thank you for your kind attention.For queries and feedback:[email protected]

0918-804-0304

mailto:[email protected]

Welcome Queries and Feedback Anytime!

REYNALDO O. JOSON, MD, MHA, MHPEd, MSc Surg0918-804-03-04

[email protected]

Hospital Accreditation - UPCPH-MHA202 - Blended Learning - 14oct7

Health & Medicine

Transcript of Hospital Accreditation - UPCPH-MHA202 - Blended Learning - 14oct7