Rabab Diab, RN, MSN, CPHQHCAC, Deputy CEO and Director of Education & Consultation
Iraqi Health Conference – ErbilMonday, 28 May 2013
Accreditation Standards for Medical Staff Management
Outline
• Healthcare System in Jordan• Medical Staff in Jordan and Challenges• Quality and Patient Safety Journey in Jordan• Quality and Patient Safety Challenges • Accreditation Standards for Medical Staff
Management• Conclusion
Outline
• Healthcare System in Jordan• Medical Staff in Jordan and Challenges• Quality and Patient Safety Journey in Jordan• Quality and Patient Safety Challenges • Accreditation Standards for Medical Staff
Management• Conclusion
Introduction
• Upper middle-income country
• Population of 6.2 million• Per-capita GNI of
US$4,340• Youngest among upper-
middle income countries with 38 percent under the age of 14
Healthcare Providersby Sector
Public Sector
Royal medical services
Ministry of health (primary
healthcare centers and hospitals)
University hospitals
Private Sector
Hospitals
Private clinics
Diagnostic and treatment centers
International Sector
UNRWA
Outline
• Healthcare System in Jordan• Medical Staff in Jordan and Challenges• Quality and Patient Safety Journey in Jordan• Quality and Patient Safety Challenges • Accreditation Standards for Medical Staff
Management• Conclusion
Number of Physicians/10,000 Population2005 – 2010
Wor
ld
Algeria
Bahra
in
Djibou
ti
Egypt
Iran
(Islam
ic Rep
ublic
of)
Iraq
Isra
el
Jord
an
Kuwait
Leba
non
Libya
n Ara
b Ja
mah
iriya
Malt
a
Mor
occo
Oman
Qatar
Saudi
Arabia
Syrian
Ara
b Rep
ublic
Tunisi
a
United
Ara
b Em
irate
s
United
King
dom
United
Sta
tes
of A
mer
ica
Yemen
0
5
10
15
20
25
30
35
40
45
50
14.212.1
14.4
2.3
28.3
8.96.9
36.5
24.5
17.9
35.4
19
31.1
6.2
19
27.6
9.4
15
11.9
19.3
27.4
24.2
3
Number of Physicians/10,000 Population
WHO, World Health Statistics 2012, 2012. See also, WHO, Global Health Observatory.
Medical staff management in Jordan have different strengths but face several challenges
Strengths Strengths
Established education programs
Qualified medical staff Good health out come
indictors in terms of communicable diseases, infant and maternal health
Challenges Challenges
Lack of leadership competency
Lack of regulations No policies, procedures,
clinical guidelines Lack of credentialing and
privileging system for medical staff
No relicensing system Continuous education No medical liability laws
Outline
• Healthcare System in Jordan• Medical Staff in Jordan and Challenges• Quality and Patient Safety Journey in Jordan• Quality and Patient Safety Challenges • Accreditation Standards for Medical Staff
Management• Conclusion
10
Quality improvement for Jordan started with a visionary Minister who took a leap for accreditation…
2003
2004
2005
2007
2008
2009
2010
2011
2012
2013
12 members from a
National Accreditation Committee
was approved
USAID Agrees to support initiative of Minister of
Health
Pilot Hospitals
HCAC registered as a non-profit
private sector company
ISQUA accredits hospital
standards
ISQua accredits Surveyor
Certification Course
1st edition Primary Health Care Standard
ISQua accredits HCAC
First Regional Conference
NQSGs launched
Cardiac Standards
Patient Safety Center
/ Institute
Diabetes Standards
Second Regional
Conference
Public Awareness
Medical Transport Standards
Breast imaging Units
Standards
Centers of Excellence
Pilot Hospitals and
First draft of Jordanian Hospital
standards
First Surveyor Certification
course started
11
So HCAC was established in 2007 as a nonprofit private shareholding company with the aim to raise the quality of health services…
HCAC
MissionMission
VisionVision
To foster the continuous improvement of the quality and safety of health care facilities, services and programs through developing internationally accepted standards, capacity building and awarding accreditation
HCAC services and accreditation will be the primary choice of healthcare facilities and organizations in Jordan and the region
ValuesValues
Continuous Improvement
Customer Focus
Impartiality
Integrity
Learning
Teamwork
Transparency
12
…Through a range of different services stemming out of two separate arms of the organization
FunctionsFunctions
Accreditor
Enabler
Consultant Development
Training and Certified Courses
Preparedness
Consulting for Government
Mock Surveys
Accreditation
Surveyor Development
Standards Development
Education and ConsultationDepartment
Education and ConsultationDepartment
Surveys and Standards
Development Department
Surveys and Standards
Development Department
“A Comprehensive Model of Quality Improvement Services”
Fir
ewal
l
13
HCAC can now showcase a multitude of successes…
StandardsStandards
Hospital Accreditation Standards - 3rd edition
Primary Health Care & Family Planning Accreditation Standards– 2nd edition
Medical Transport Services Certification Standards- 1st edition
Breast Imaging Units Certification Standards- 1st edition
Diabetes Care standards 1st edition
Cardiac Care standards being developed 2012-2013
National Quality and Safety Goals 2009, 2010, 2011, 2012, 2013
Family Planning & Reproductive Health Centers of Excellence Program- 1st edition
AccreditationAccreditation Education & ConsultationEducation & Consultation
41 certified hospital surveyors
31 certified PHC surveyors
17 hospitals accredited – four in the pipeline
45 PHC accredited – 60 in the pipeline
4 Certified Breast Imaging Unit
Preparing 8 hospitals for Accreditation, 5 breast imaging units
Graduated groups from :
q Certified Consultant Training program
q Certified Quality professionals
q Certified Infection Control professionals
q Certified Risk Management
q Leadership & Management
14
Measurable ElementsRequirements of the standard that will be reviewed and assigned a score during the accreditation survey process
The HCAC Hospital Standards Manual (3rd ed.) is divided into 14 clusters entailing 347 standards and 1238 measurable elements
The ClustersThe Clusters
Cluster 1: Ethics and Patients’ Rights
Cluster 2: Access and Continuity of Care
Cluster 3: Patient Care
Cluster 4: Diagnostic Services
Cluster 5: Medication Management
Cluster 6: Infection Prevention and Control
Cluster 7: Environmental Safety
Cluster 8: Support Services
Cluster 9: Quality Improvement and Patient Safety
Cluster 10: Medical Records
Cluster 11: Information Management
Cluster 12: Human Resources Management
Cluster 13: Management and Leadership
Cluster 14: Education and Training
Each Cluster is composed of 4 line itemsEach Cluster is composed of 4 line items
Classification Critical (57 Standards):
Address laws and regulations and, if not met, may cause death or serious harm to patients, visitors, or staff
Core (257 standards):Address systems, processes, policies and procedures that are important for patient care
Stretch (33 standards):Important standards, but not easy to implement due to time or resource constraints, or a need for culture change
Standards Statements
Survey Process
Outline
• Healthcare System in Jordan• Medical Staff in Jordan and Challenges• Quality and Patient Safety Journey in Jordan• Quality and Patient Safety Challenges • Accreditation Standards for Medical Staff
Management• Conclusion
chemical exposure
Lack of radiation safety
Absence of basic hygiene
Violation of human rights
Flies in operating rooms
Open sewage systems within hospitals
Lack of privacy
No fire safety procedures and systems
Untrained staff on basic resuscitation
Lack of medical staff management systems
Competency of healthcare providers
No documented policies, procedures, plans,
No clinical guidelines
Not in compliance with laws and regulations regarding fire safety, radiation safety, staff qualifications, and medication management processes.
Quality and Patient safety still faces many challenges in Jordan
Outline
• Healthcare System in Jordan• Medical Staff in Jordan and Challenges• Quality and Patient Safety Journey in Jordan• Quality and Patient Safety Challenges • Accreditation Standards for Medical Staff
Management• Conclusion
Medical Staff Management Standards
• Credentialing and privileging • Medical staff file • Medical staff governance system• Medical graduate program• Performance appraisal
19
Medical staff
management standards
Human Resources
Education and
Training
Quality Improvement and Patient
Safety
Patient Care
Medical Record Documentation
Management and
Leadership
The standards of medical staff management are integrated in all clusters
20
The process of obtaining, verifying, and assessing the qualifications of a licensed independent practitioner
Why? To determine whether he/she is qualified and able to
provide patient care services and to participate on the medical staff””
HRM.7 The hospital has a process, defined in writing for verification of the license, education, experience, and certification for all licensed professional staff.
21
21
Current licensure
Relevant training and experience
Current competence
Peer recommendations
Clinical privilege delineation
Essential Data in the Credentialing Process
22
22
Privileging
The process of evaluation of an individual’s performance to determine if he/she is qualified and able to perform specific patient care services related to his/her specialty
Privileging of medical staff accompanies credentialing process.
23
23
Granting Clinical Privileges
Delineation of clinical privileges
Delineation of admitting privileges
Categories of privileges
Limitations of privileges
Practicing within scope
24
24
Other Data
Ability to perform
Challenges to licensure/registration
Voluntary/involuntary terminations or restrictions
Professional liability
25
Medical Staff Management Standards
Credentialing and privileging
Medical staff file
Medical staff governance system
Medical graduate program
Performance appraisal
26
- Documents related to license- Education - Experience- Certification
HRM.9 a personnel file is maintained for each employee
Medical Staff Management Standards
• Credentialing and privileging • Medical staff file • Medical staff governance system• Medical graduate program• Performance appraisal
HRM.13 A governance system is in place for the medical staff to ensure the quality of patient care.
• Categories of medical staff • Privileging
Medical staff bylaws
• Medical staff issues• Quality improvement
activities
Medical staff committee
• Role of medical staff members in committees
• Quality improvement initiatives
Hospital-wide quality improvement
program
Medical Executive Committee
Bylaws Rules and regulations
Organization structure Developing policies
and procedures
Medical staff committee
29
Medical Staff Bylaws
Medical staff structureMedical executive committee
Credentialing and privileges processes
Membership, delineation of clinical privileges, and termination
Participation in organization improvement activities
30
ML.8 Each Administrative and Clinical Department has an assigned department head with specific responsibilities
• Each clinical department has a designated medical staff head who is board certified in a relevant specialty.
• The assigned department head responsibilities include:- Ensuring and overseeing the development and
implementation of the departmental policies and procedures
- Ensuring that quality improvement and patient safety activities are carried out (PDSA)
31
Medical Staff Management Standards
• Credentialing and privileging • Medical staff file • Medical staff governance system• Medical staff graduate training program• Performance appraisal
32
HRM.15 Hospitals that participate in professional under graduate education programs have a well-defined system for training.
• Supervision of trainees by qualified members and their relationship with the hospital
• Clear process for trainee orientation
33
Medical Staff Management Standards
• Credentialing and privileging • Medical staff file • Medical staff governance system• Medical graduate program• Performance appraisal
34
35
HRM.8.1 Performance appraisals measure the performance of the employee against criteria related to evidence-based practice, innovation and/or research.
• Performance criteria are written supporting evidence-based practice, innovation and/or research for each category of employee including medical staff.
• Performance criteria are measurable, understandable, verifiable, equitable, and achievable.
Other Related Standards
Medical Record
Documentation
All patient medical record entries are legible, complete, dated, timed, and authenticated .
Clinical Practice Guidelines
CPGs are adopted/developed
and implemented for priority clinical
services.
Individual healthcare providers’
compliance with the clinical practice
guidelines.
Anesthesia Standards
Current anesthesia evidence-based
guidelines.
Patients are managed by a qualified
physician.
36
Outline
• Healthcare System in Jordan• Medical Staff in Jordan and Challenges• Quality and Patient Safety Journey in Jordan• Quality and Patient Safety Challenges • Accreditation Standards for Medical Staff
Management• Conclusion
38
The future of Quality Improvement is full of commitments
Commitment to the QUALITY
Commitment to PATIENT SAFETY
Commitment to CAPACITY BUILDING
Commitment to RESEARCH and POLICY
…HCAC is in continuous improvement itself…
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