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Accreditation & Auditing - By - Dr. Ilham Fetoh - 5-3-2014
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Transcript of Accreditation & Auditing - By - Dr. Ilham Fetoh - 5-3-2014
8/12/2019 Accreditation & Auditing - By - Dr. Ilham Fetoh - 5-3-2014
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ا لرحيحسم
”
مب
خر
اه
ش
قت ىلا
صنوف”
صدق ا لعظي
(88) ةرس ن:ق ل رسل ا صي ا عه وسم
”ان ي اذا عم حدك عم ن يقه”
حدث شف
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ACCREDITATIONby
Dr.Elham Fetouh Mohamed
Director of Quality DepartmentAlexandria Health Affair Directorate
MOH
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DEFINITION OF ACCREDITATION
It is an external audit of the ability of the health
facility e.g. hospital, to provide a high quality
service to the patient and to minimize the
various dangers in an environment potentially
subject to high risks.
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A process of recognition of capacity based
on comparing recent and on going activities
with a set of previously established standards.
by an independent body.
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*Is the process by which a recognized body (usually a non-
governmental organization(NGO), assesses and recognizes that a
health care organization meets
pre-determined and published standards.
*Accreditation is often a voluntary process in which organizations
choose to participate, rather than one required by law and regulation..
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There are three primary approaches for external
evaluation of healthcare quality: Licensure.
Accreditation.
Certification.All the three approaches use standards to determine the
level of quality achieved by individuals or organizations.
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To protect basic public health and safety.
Licensure standards address the minimum legal
requirements or qualifications.
It is carried out by legal health authorities.
Usually done only once, prior to the beginning ofoperations.
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Application To both individuals and organizations
Certification involves a recognized authority or board
granting.
Recognition to individuals who have demonstrated
specialized knowledge and skill and to organizations
that have the ability to practice in a certain area or
specialty.
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It focuses on:
Achievement of optimal quality standards.
continuous improvement strategies.
On going education and consultation.
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THE MAJOR PURPOSES OF ACCREDITATION
Improve the quality of health care by establishingoptimal achievement goals in meeting standards for
health care organizations
Stimulate and improve the integration andmanagement of health services
Establish a comparative database of health careorganizations able to meet selected structure,process, and outcome standards or criteria
Quality Associates Inc10
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THE MAJOR PURPOSES OF ACCREDITATION
Reduce health care costs by focusing on increased
efficiency and effectiveness of services.
Provide education and consultation to health care
organizations, managers, and health professionalson quality improvement strategies and best
practices” in health care.
Quality Associates Inc11
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THE MAJOR PURPOSES OF ACCREDITATION
Strengthen the public’s confidence in the
quality of health care, and
Reduce risks associated with injury and
infections for patients and staff
Quality Associates Inc12
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Variety of evaluation strategies to determinecompliance, performance, and quality of care,
such as: Document and record reviews
Interviews
Observations
Achievement evaluations Facility inspections
Tracing
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In July 2007, the Egyptian accreditation standards for
Hospital, Ambulatory Clinics and Primary Health Care were
accredited by The International Society for Quality Health
Care (ISQua) - the “Accreditors of the Accreditors”.
ISQua, is a non-profit, independent organization.
It works to provide services to guide health professionals,providers, researchers, agencies, policy makers and
consumers.
It is an accreditor of STANDARDS.
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Egypt is the first Middle Eastern country to achieve ISQua
Accreditation of its standards.
These standards provide both significant challenge and a
clear roadmap for everyone to work collaboratively to
improve the quality of performance in healthcare
facilities.
A STANDARDS:
Policies/procedures, plans, required committees.
B C STANDARDS: Implementation standards.
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Patient Rights responsibilities, Org. ethics
Access and Assessment of Patients
Providing Care, Diagnostic service, invasive
procedures, patient family Education.Medication management
Patient safety, Infection Control and Environmental
safety
Information Management
Performance improvement
Organization management
Community Involvement
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A-Structures :
policy/procedures, plans, required committees (all ornone scoring).
Met
Present –
all elements.
Not Met
Not present with all elements.
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The organization has a list of
procedures or treatments for
which informed consent is
required, including the following:
PR. 16
Surgery and invasive procedures.PR. 16.1
Anesthesia/moderate or deep
sedation.
PR. 16.2
Use of blood.PR. 16.3
High-risk procedures or
treatments (including but not
limited to Electro convulsivetreatment, radiation therapy,
chemotherapy).
PR. 16.4
Family planning interventions.PR. 16.5
ResearchPR. 16.6
M N NA
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B C- implementation :-
frequency based-observations of deficiencies.
Met
Zero to 1 observed or documented deficiency.
Partially Met
2 observed or documented deficiencies.
Not Met
3 or more observed or documented deficiencies.
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B versus C standards Bstandards are to be implemented first (easier).
Cstandards are more difficult to implement or
not needed for an initial survey.
General consent for treatment is
obtained when the patient seeks
service for the organization.
PR. 14P N NA
Patients and families are informed
about how to donate organs and
other tissues according to law and
regulation and policy.
PR. 29P N NA
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ACCREDITATION PROCESS
(According to standards of Ministry of Health Population).
The accreditation process begins with an initial
self assessment.
Assistance may be requested - for clarification of
applicability of a standard or set of standards to
the organization.
Prior to an initial survey, a pre-survey visit will bescheduled to validate the application information.
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Pyramid of Excellence inHealth Care Accreditation
ApplicationSelf Assessment
Pre survey assessment Application Validation
Foudation Level
Basic QualityLevel
Egypt Accreditation
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A report of deficiencies relating to only the A and
Patient Safety standards will be left with the
organization to enable further preparation.
A full survey team will be scheduled when the
organization has at a minimum a 4 month track record
of achievement with these selected standards.
After the survey, a report will be given to the
organization with an outcome of the level achieved, and
a list of all Not Met standards followed by all Partially
Met standards
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An on-site re-survey could occur depending on the
problem or lack of ability to correct deficiencies.
A mid cycle (approximately 18 month) assessmentprocess will occur.
This assessment consists of a combination of self
assessment and on-site survey by a team.
A full on-site survey conducted by a team of surveyors
will occur in the 3rd year.
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It stimulates the improvement of care delivered topatients
It strengthens community confidence in its hospital
It reduces unnecessary costsIt increases efficiency
It provides credentials for education, internships,
and residencies
It can protect against lawsuits
It facilitates acceptance by and funds from third-party payers
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