الرحيم الرحمن الله الرحيم بسم الرحمن الله بسم

You can’t manage what You can’t manage what you can’t measureyou can’t measure

AccreditationAccreditation

Definition :Definition :

Assessment of health services Assessment of health services according to a set of standards according to a set of standards describing the structures and describing the structures and processes that contribute to processes that contribute to desirable patient outcomes based on desirable patient outcomes based on quality of care and patient safetyquality of care and patient safety

Benefits of AccreditationBenefits of Accreditation

Shows commitment to quality Shows commitment to quality Improves communication and Improves communication and

collaboration within the organisationcollaboration within the organisation Promotes team buildingPromotes team building Increases credibilityIncreases credibility Demonstrates accountabilityDemonstrates accountability Improves productivityImproves productivity Obtaining advice from surveyors Obtaining advice from surveyors

(mentoring)(mentoring)

Studies show positive effect for:Studies show positive effect for:

Patient (satisfaction, quality of care Patient (satisfaction, quality of care and safety)and safety)

Staff (satisfaction and good work Staff (satisfaction and good work condition)condition)

Organisation (productivity, strategic Organisation (productivity, strategic performance and financial viability)performance and financial viability)

Brief HistoryBrief History

Earnest Codman: End result system Earnest Codman: End result system (effectiveness of treatment) 1910(effectiveness of treatment) 1910

The era of minimal standards 1917-The era of minimal standards 1917-19651965

The era of optimal achievable The era of optimal achievable standards 66-87standards 66-87

The era of performance evaluation The era of performance evaluation 1988….. 1988…..

Accreditation methodologyAccreditation methodology

Function based (tracer methodology)Function based (tracer methodology) Department basedDepartment based

JCAHO(U.S)JCAHO(U.S)

1-Patient-Focused 1-Patient-Focused FunctionsFunctions

-Rights, ethics, responsibilities-Rights, ethics, responsibilities-Provision of care, treatment, -Provision of care, treatment,

servicesservices-Medication management-Medication management-Surveillance, prevention, -Surveillance, prevention,

infection control infection control

JCAHO (cont…)JCAHO (cont…)

2-Organization Functions2-Organization Functions

-Performance improvement-Performance improvement-Leadership-Leadership-Management of environment of care-Management of environment of care-Management of information -Management of information 3-Structures With Functions3-Structures With Functions-Medical staff-Medical staff-Nursing-Nursing

Joint commission international Joint commission international (JCI)(JCI)

A new task force in 1997A new task force in 1997

In EU, Middle east and Far In EU, Middle east and Far east and then everywhereeast and then everywhere

JCI (cont…)JCI (cont…)

ACC (Access to care and continuity if care)ACC (Access to care and continuity if care) PFR (Patient and Family Rights)PFR (Patient and Family Rights) AOP (Assessment Of Patients)AOP (Assessment Of Patients) COP (Care Of Patients)COP (Care Of Patients) ASC (Anesthesia and Surgical Care)ASC (Anesthesia and Surgical Care) MMU (Medication Management and Use)MMU (Medication Management and Use)

JCI (cont…)JCI (cont…)

PFE (Patient and Family Education)PFE (Patient and Family Education) QPS (Quality improvement and Patient QPS (Quality improvement and Patient

Safety)Safety) PCI (Prevention and Control of PCI (Prevention and Control of

Infections)Infections) GLD (Governance, Leadership and GLD (Governance, Leadership and

Direction) Direction) FMS (Facility Management and Safety)FMS (Facility Management and Safety)

JCI (cont…)JCI (cont…)

SQE (Staff Qualifications and SQE (Staff Qualifications and Education)Education)

MCI (Management of Communication MCI (Management of Communication and Information)and Information)

Egypt Egypt

WHO and MOHPWHO and MOHP From 1995From 1995 Critical standards 69Critical standards 69 Core standards 322Core standards 322 Non core standards 325Non core standards 325

Egypt (cont…) Egypt (cont…)

The first award in middle east from The first award in middle east from ISQuaISQua

(the accreditor of accreditors )(the accreditor of accreditors )

Lebanon Lebanon

World bank and MOPHWorld bank and MOPH Department based standardsDepartment based standards Basic standards and accreditation Basic standards and accreditation

standards (2001)standards (2001) Second accreditation Second accreditation

standards(2003)standards(2003)

CanadaCanada

Canadian Commission On Hospital Canadian Commission On Hospital Accreditation 1952Accreditation 1952

MonopolyMonopoly Including mental health and Including mental health and

rehabilitation facilities as well as rehabilitation facilities as well as general hospitalsgeneral hospitals

Recently outcome measuresRecently outcome measures 94% of hospital beds 94% of hospital beds

U.KU.K

Though NHS had an agenda for accreditation but Though NHS had an agenda for accreditation but there was not any responsethere was not any response

Patient’s Charter (department of health’s Patient’s Charter (department of health’s standards for patient services)standards for patient services)

Investors in people (department of trade and Investors in people (department of trade and industry)industry)

King’s Fund Organizational AuditKing’s Fund Organizational Audit Eventually accreditation as an integrate system Eventually accreditation as an integrate system

(King Edward’s Hospital Fund for London (mission: (King Edward’s Hospital Fund for London (mission: quality improvement in NHS)quality improvement in NHS)

Resemble to U.S ,Canada and especially Australia Resemble to U.S ,Canada and especially Australia

ChinaChina

Formal Accreditation by MOPHFormal Accreditation by MOPH Three levels of hospitalsThree levels of hospitals

-Neighborhood or township level-Neighborhood or township level

-District, country, industrial -District, country, industrial complex levelcomplex level

-Large municipal and teaching -Large municipal and teaching level level

AustraliaAustralia

Australian Council On Hospital Australian Council On Hospital Standards 1974Standards 1974

Utilization of resources Utilization of resources Quality of careQuality of care Clinical outcomeClinical outcome Fully accredited 3 years and partially Fully accredited 3 years and partially

accredited 1 yearaccredited 1 year Newly a 5 year has been introducedNewly a 5 year has been introduced

China (cont...)China (cont...)

Four areas of treatment :Four areas of treatment :

-Prevention-Prevention

-Healthcare reconstruction-Healthcare reconstruction

-Support and participation in -Support and participation in disease prevention and caredisease prevention and care

-Healthcare activities-Healthcare activities

China (cont…)China (cont…)

Every 3 yearsEvery 3 years Only accredited hospitals get license Only accredited hospitals get license

to operateto operate Government can close non Government can close non

accredited hospitalaccredited hospital The most important challenge :the The most important challenge :the

number of trained surveyors number of trained surveyors necessary (120000 surveyor)necessary (120000 surveyor)

Latin America and the CaribbeanLatin America and the Caribbean

Has begun in early ninetiesHas begun in early nineties PAHO and Latin American Federation PAHO and Latin American Federation

Of HospitalsOf Hospitals Also a draft by MOPH of ArgentinaAlso a draft by MOPH of Argentina

Latin America and the CaribbeanLatin America and the Caribbean

14000 hospitals (most of them <70 14000 hospitals (most of them <70 beds)beds)

Compulsory minimum standards and Compulsory minimum standards and non-compulsory standardsnon-compulsory standards

Latin America and the Caribbean (con…)Latin America and the Caribbean (con…)

Compulsory minimum standards :Compulsory minimum standards : - Medical care- Medical care - Technical and support areas - Technical and support areas - Building documentation- Building documentation - Functional physical structure- Functional physical structure - Installations- Installations Non compulsory :critical area, Non compulsory :critical area,

neonatology, nuclear medicine and neonatology, nuclear medicine and ……

IndiaIndia

Voluntary accreditation by Indian Hospital Voluntary accreditation by Indian Hospital Association (IHA) failed in 1993Association (IHA) failed in 1993

Bureau of Indian Standards (BIS) has laid Bureau of Indian Standards (BIS) has laid down standards for 30,100 and 250 bedsdown standards for 30,100 and 250 beds

National Institute for Health and Family National Institute for Health and Family welfare (NIHFW 1992)…standards for >50 welfare (NIHFW 1992)…standards for >50 beds only for equipmentbeds only for equipment

Government standards for secondary Government standards for secondary level hospitalslevel hospitals

Pyramid of documentationPyramid of documentation

QM

Policies and

procedures

Instructions

Forms

Records

Standards Should BeStandards Should Be

1.1. Explicit (written)Explicit (written)2.2. Degree of excellence Degree of excellence 3.3. Objective (not subjective)Objective (not subjective)4.4. Compatible with culture and abilitiesCompatible with culture and abilities5.5. Able to improve continuouslyAble to improve continuously6.6. Compatible with government requirementsCompatible with government requirements7.7. Compatible with minimum community Compatible with minimum community

contentcontent8.8. Motive the leadership Vs management Motive the leadership Vs management

(not like classification systems)(not like classification systems)

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