APPENDIX 1

MINISTRY OF HEALTH

REVISED DRAFT POLICY WHITE PAPER

for the establishment of

THE HEALTH SERVICES

ACCREDITATION COUNCIL

MOH, December, 2008

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POLICY PAPER

FOR ACCREDITATION BILL

1. INTRODUCTION/BACKGROUND

1.1 Modernizing and improving health systems is central to all efforts made by the international development community to assist developing countries reach their Millennium Development Goals (MDGs 2015) - with the promise of vastly improved human and economic welfare.

1.2 Additionally, there is a growing worldwide demand for quality in health care and for mechanisms such as accreditation programmes to promote and maintain quality health services. Half of these programmes have been funded or managed by Governments and used as tools for regulation and public accountability rather than as a means of voluntary self development.

1.3 Despite broad agreement with respect to the complex and multidisciplinary nature of health systems and resolving widespread concerns about quality of care cannot be underestimated. The general public, organizations of patients and disabled persons, and third party payers demand more objective assessments of health service quality (World Bank).

1.4 Countries have taken different approaches to maintaining quality and improving standards: Trinidad and Tobago is no exception. The Government of the Republic of Trinidad and Tobago identified quality improvement as one of its key strategic initiatives under the Health Sector Reform Programme. A comprehensive Sector-Wide Programme was developed and a structured approach to implementation commenced using a structured approach to laying the foundation for continuous quality improvement.

1.5 A key strategy identified in the Quality 2001: A Reality policy document was the establishment of a Health Services Accreditation System Pg 17.1.5. This policy framework was guided by the principles of equity, accessibility, appropriateness, acceptability, effectiveness, efficiency and safety.

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1.6 In addition, the final report of the Government's Vision 2020 Sub-Committee on Health recognizes accreditation as a mechanism for recognition of institutional competence and endorses the establishment of a Health Services Accreditation Programme as a key objective.

2. LICENSING AND ACCREDITATION IN TRINIDAD AND TOBAGO

2.1 In Trinidad and Tobago the system for registering Private Hospitals is the Private Hospitals Act 2 of 1960 Chapter 29:03. This legislation requires Private Institutions to meet the minimum standards stated in the Act, in order to obtain approval to operate as Private Hospitals. These institutions are expected to pay a nominal annual fee in order to continue operating; however there is no regular monitoring of these Private institutions notwithstanding that the Act provides for such.

2.2 The health professional regulatory councils set conditions and issue licenses for health professionals/providers such as physicians, nurses, pharmacists, midwives, health visitors, dentists, enrolled nursing assistants and the professions related to medicine. In the past, these regulatory councils also approved the respective educational programmes for the preparation of these disciplines. However, with the establishment of the Accreditation Council of Trinidad and Tobago for Tertiary Educational Institutions (ACTT), this responsibility has now been shifted; i.e ACTT will accredit the educational programmes for all professionals including health professionals

2.3 It must be noted that while licensing speaks to minimum standards; accreditation refers to optimum standards. It must also be noted that there is a distinct difference between the roles of ACTT and the proposed Health Services Accreditation Council of Trinidad and Tobago. While ACTT sets standards and conducts evaluation of all tertiary level and post secondary educational institutions and their programmes; the Health Services Accreditation Council shall set standards and conduct evaluation of all health care systems and services at the ambulatory, primary, secondary and tertiary care levels. This body will have a symbiotic relationship with ACTT while focusing on accreditation of health services/care delivery to ensure that Trinidad and Tobago develop a modern responsive high quality health care system.

2.4 In the absence of a legal framework to support optimal standards, the growth of the public health sector under health reform and the rapid

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expansion of the private health sector in the last decade, has created a number of challenges for health care professionals and managers. Queries have also been made and legal action taken by enlightened consumers about variable standards and quality of care.

2.5 Currently, except for the inadequate Private Hospitals Act, there is no mechanism in country to ensure that individual or group practitioner(s) offering health care services including diagnostic services to the public meet with any nationally approved standards or quality criteria. Additionally there is no legal framework that addresses the issue of health criteria for health care quality

3 NEED FOR LEGISLATION

3.1 In the past decade, science and technology have made tremendous advances in the field of medicine and healthcare. Telemedicine has created borderless hospitals and treatment centres. It is now possible for a specialist surgeon to sit in Toronto and direct a surgical intervention in Port of Spain through the use of technology. Strategic alliances are being formed between governmental and non-governmental agencies to make care more accessible to the population e.g cardiac surgeries, organ transplants.

3.2 In the present environment there is no legal framework to facilitate assessment of the quality of services being provided by local or foreign suppliers, or demand compliance. Also, there is limited capacity to assess private hospitals.

3.3 Further delay in being able to give the population assurance of standards and improvement in the quality of care/services offered at local institutions can impact on the quality of life of the citizens, as well as productivity and the economy or economic growth. This also has implications for the portability of professionals, goods and services espoused in the CARICOM Single Market and Economy (CSME).

3.4 In the past five years, there has been significant increase in public and private sector investments in healthcare. More investment, in the absence of a coherent legal framework to address healthcare criteria, will not produce quality as evidenced by customer satisfaction surveys and audits. A framework for maintaining competence and introducing accountability is absolutely necessary.

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3.5 In order to ensure that the interest of patients and other health care consumers are protected, the country must implement a systematic approach of monitoring and evaluating health service standards for all ambulatory, primary, secondary and tertiary health care facilities.

3.6 Health legislation must be developed and/or amended to strengthen the regulatory framework to facilitate the conduct of periodic reviews of health facilities in the public and private sectors (MOH Health Policy 1999).

3.7 Accreditation in health originated in hospitals, as did the general concept of quality improvement. From the hospital environment, it moved out into community services and thence into networks of preventive and curative services. The current shift of emphasis towards primary care may reflect a move to population-based medicine. A global survey of programmes in 2000 and a further survey in Europe in 2002 showed that in the 40 years prior to 1991, eight (8) accreditation programmes were started. In the following decade, nearly three times that much was introduced, more than a half of these in Europe.

3.8 Rooney AL, van Ostenberg summarizes the main purpose of accreditation as:

a) To improve the quality of health care, by establishing optimal achievement goals in meeting standards for health care organizations.

b) To stimulate and improve the integration and management of health services;

c) To reduce health care costs by focusing on increased efficiency and effectiveness of services;

d) To reduce risks associated with injury and infections for patients and staff;

e) To establish a comparative database of health care organizations, that can meet selected structure, process and outcome standards or criteria;

f) To provide education and consultation to health care organizations, managers, and health professionals on quality improvement strategies and "best practices" in health care; and

g) To strengthen the public's confidence in the quality of health care.

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3.9 FRAMEWORK ACCOUNTABILITY In Trinidad and Tobago the Health Services Accreditation Programme will not only provide the framework for health care quality and accountability, but facilitate the implementation of decisions of CARICOM in the area of shared services and portability of health professionals across the Caribbean, through a framework for common standards. It will also support the implementation of the Patient's Charter of Rights and Obligations. (2005)

3.10 A Pan American Health Organisation sub-regional workshop on "Accreditation of Health Services" held in Barbados December 2005, noted that Trinidad and Tobago had done more significant groundwork for introducing a National Health Services Accreditation Programme than other countries in the Caribbean.

3.11 The meeting also noted that some countries because of their size, do not/will not have the capacity to establish and maintain a national system. These countries may have to purchase such services.

3.12 The meeting also recognized that national accreditation programmes were a pre-requisite to the introduction of National Health Insurance Systems.

4. DEVELOPMENT OF A NATIONAL HEALTH SERVICES ACCREDITATION PROGRAMME.

4.1 Considerable preparatory work has been done by the Ministry of health in laying the foundation for the successful implementation of a National Health Services Accreditation Programme. This work was spearheaded by the Directorate of Quality Management and supported by technical assistance under the Health Sector Reform Programme from the most experienced body in the world on health accreditation, Joint Commission International of the USA.

4.2 Work that has been completed includes:

i. The pilot testing and development of Health Services Accreditation Standards.

ii. The development of an Assessment Instrument.

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iii. The production, of three thousand copies of the Standards

Manual and dissemination to public and private health facilities.

iv. The Sensitization of key Stakeholders in public and private institutions.

v. The training of some surveyors. vi. The conduct of an educational survey across a sample of RHAs

and private facilities.

vii. The development of a framework for establishing the Health Services Accreditation Council for Trinidad and Tobago.

4.3 Work in progress includes:

a) Implementation of RHA Action Plans aimed at making facilities/services ready for accreditation.

b) Development of protocols and practice standards congruent with the Accreditation Standards Manual of Trinidad and Tobago.

c) Development of procedure manuals.

d) Repeat sensitization sessions.

e) Accreditation self assessment surveys aimed at assessing state of readiness and empowering staff for full implementation.

f) Provision of technical advice and accreditation instruments to Private Sector Health Facilities.

g) Exploring consultative partnership with the Canadian Health Services Accreditation Council (the first accreditation body in health to be certified by the International Society for Quality in Health Care.)

4.4 In order to advance the process and ensure that citizens of Trinidad and Tobago benefit from this programme, it is imperative that a Health Services Accreditation Act be developed and promulgated as high priority. This Act will create the legal framework for the establishment of the Health Services Accreditation Council of Trinidad and Tobago (HSACTT).

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4.5 The Ministry of Health recognizes that the Minister is ultimately accountable to the Parliament for health services provided to the people of Trinidad and Tobago. As the main purchaser of health services the Ministry of Health has the responsibility to ensure that quality health care is delivered to the Public throughout the sector.

4.6 In respect of the publicly funded health facilities the Ministry of Health must assure that health care dollars are used effectively, efficiently and equitably.

4.7 The Model proposed for Trinidad and Tobago is based on several elements including an adaptation of the model proposed by Joint Commission International's Consultation Report titled T&T Health Sector Accreditation Programme 2002 and the characteristics of a successful accreditation programme (ISQua Toolkit for Accreditation Programmes). A combination of the common characteristics among experienced international accreditors, developments occurring in the health sector as a result of the Health Sector Reform Programme, the principles and philosophies of Government's Vision 2020 and national norms.

4.8. The model will allow for collaborative relationships with international/regional health services accreditation bodies that are comparable with the philosophy and principles of HSACTT.

5 ESTABLISHMENT OF THE HEALTH SERVICES ACCREDITATION COUNCIL OF TRINIDAD AND TOBAGO

5.1 As the Ministry of Health transitions to a purchaser and regulator of health care rather than a provider of health care, a Partnership Model is proposed for the Health Services Accreditation Programme.

5.2 The Model involves the use of a public body established by Parliament on the advice of the Cabinet under legal authority granted by the Health Services Accreditation Act.

5.3 The Health Services Accreditation Council will carry out accreditation activities in order to evaluate the level of compliance with the standards for the provision of quality health care provided by health care facilities.

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5.4 The Ministry of Health and by extension the Government will remain responsible and accountable for the quality of care provided to the public and continues to serve as the guarantor of quality care.

5.5 Governance of the Health Services Accreditation Programme.

The Health Services Accreditation Council will be governed by a Board comprising representatives from key stakeholder organizations and healthcare disciplines including consumer representation. See Appendix I.

The Board would be appointed by and be accountable to the Minister of Health who has the fiduciary responsibility for health care in Trinidad and Tobago.

The Minister of Health would appoint a person who has no vested interest in any healthcare facility and who has knowledge of the operations, delivery of healthcare/clinical practice and management of health services who is not a medical practitioner as Chairman of the Board.

The Executive Director will be an ex-officio member of the Board with non-voting rights

The Minister of Health shall give general or specific directions to the Council

The Board shall submit minutes of all Board meetings and quarterly reports to the Minister

The Board shall publish an Annual Report which the Minister will lay in Parliament and make available to the public

Further details on governance issues are contained in pages 18 – 20 of Appendix iv

5.6 The Board's role would be to:

1. Develop policies to implement the Accreditation Programme.

2. Approve strategic and management plans for the Health Services Accreditation Programme.

3. Collaborate with the Minister of Health on the budget and allocation of resources to carry out the HSAP Mission.

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4. Provide the Minister with Minutes of all Board meetings, quarterly and annual reports

5. Approve accreditation standards and survey process instruments.

6. Appoint an Executive Director and Senior Management of the Accreditation Council.

7. Receive and review survey reports and finalise accreditation decision.

8. Establish a non-adversarial process for appeals.

5.7 The Executive Director represents management on the Board and performs duties that would assist the Board in carrying out its responsibilities. The Executive Director in collaboration with the Human Resource Committee of the Board would recruit management and staff to carry out organization functions such as standards and survey process development, business operations and accreditation operations. Management and staff would report to the Executive Director. See Appendix 11

5.8 The Ministry of Health shall be represented on the Board of the Accreditation Council.

9 The HSACTT would have financial accountability to the Ministry of Health since initial and possibly on going financial support would come from the Ministry of Health. The HSACTT would also generate revenue from conducting surveys, training and other accreditation activities.

5.10 Functions of the Health Services Accreditation Council The Health Services Accreditation Council of Trinidad and Tobago shall have the power to accredit ambulatory, primary, secondary and tertiary health care institutions and services; to collaborate with recognized international health accreditation agencies, to recognize awards obtained elsewhere to determine the equivalence of these awards and their acceptability in Trinidad and Tobago and the Caribbean.

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The Functions of the Executive Management of the Council will include:

• Development and maintenance of accreditation standards for health care facilities;

• Regularly conducting credible, reliable and consistent accreditation surveys of health care facilities;

• Conferring accreditation status based on a consistent and transparent decision-making methodology; this may range from non-accreditation through to accreditation.

• Ensuring appropriate linkages with regulatory bodies, the Health Sector Quality Council, professional groups and other stakeholders with an interest in health care delivery and in the development of accreditation standards and other accreditation activities;

• Compiling and maintaining a data base of healthcare institutions in Trinidad and Tobago and their accreditation history and status.

• Sharing appropriate information about accredited organizations/facilities and accreditation decisions with various stakeholders such as the Ministry of Health, the agency with responsibility for the operation and management of the National Health Service, other regulatory bodies and the public;

• Promoting concepts of continuous quality improvement in compliance with the standards;

• Disseminating to health care facilities, accreditation standards, information about accreditation, and how to comply with standards;

• Acting as a resource centre for quality improvement standards, methods and experience, and as a focal point for the collection of local information as well as for comparison with other countries,

• Serving as an access point for clinical practice guidelines, health technology assessment and evidence-based medicine.

• Educating and consulting with healthcare organizations, managers and health professionals on quality and best practices in health care.

• Collaborating with teaching institutions in curriculum development.

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5.11. Functional Relationship between Accreditation Council and Stakeholders The Health Services Accreditation Council will establish functional relationships with organizations such as the Ministry of Health, the National Health Service body, Regional Health Authorities, private providers and health professional disciplines, educational institutions and health insurance bodies in the process of conducting its business. These relationships shall be clearly defined since HSACTT will need mechanisms for interacting with each of these groups. See Appendix 111. Linkages could also be made with other accrediting bodies within and outside Trinidad and Tobago for the purpose of strengthening and improving accreditation processes within the Health Services Accreditation Programme.

6 CONCLUSION The concept of establishing a health services accreditation programme has been engaging the attention of the Ministry of Health since 1994 with the pilot testing of standards developed by the Pan American Health Organisation for accreditation of hospitals.

The Ministry's development and introduction of health services accreditation standards at all health facilities in 2002 signaled Government's intention to formally establish a national health accreditation programme.

International experience has shown a correlation between participation in health services accreditation and improved quality of life, economic growth and development. Health services accreditation has also resulted in preference from private insurers, advantage in the competitive market place, improved patient safety and decrease in the incidence of risk.

The development of a Health Services Accreditation Act and establishment of the Health Services Accreditation Council of Trinidad and Tobago will demonstrate to the national and regional communities the Government's commitment to quality health care, Vision 2020 and the CSME. The policy statements for the establishment of the HSACTT are attached as Appendix IV.

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APPENDIX I

PROPOSED MEMBERSHIP OF HSACTT BOARD

The Minister shall appoint the Board to comprise representatives of the following organisations

• Ministry of Health 2

• Regional Health Authorities 1

• Private Hospitals Board 1

• Consumers 1

• NHS body 1 Additional members will be selected from among the following disciplines of:-

• Medicine

• Nursing

• Pharmacy

• Dentistry

• Laboratory Medicine

• Radiography

• Medical/ Psychiatric Social Work

• Nutrition and Dietetics

• Medical Laboratory Technology

• Physiotherapy

• Law

• Chairman to be appointed by the Minister

• Executive Director as ex-officio member

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APPENDIX II

ORGANIZATIONAL STRUCTURE – HEALTH SERVICES ACCREDITATION PROGRAMME OF TRINIDAD AND TOBAGO

MINISTER

BOARD

Health Services Accreditation Council of Trinidad and Tobago

Executive Director

Management & Staff

Governance Committee

Finance Committee

Accreditation Committee

Human Resource Committee

Standard and Survey Process

• Development / Maintenance of Standards and Survey Process Activities

• Dissemination and Education of Standards

• Surveyor training

Accreditation Operations

• Survey scheduling

• Processing of survey Instrument

• Creation of Accreditation report

• Database Management

Business Operations

• Finance Operations

• Information Management

• Quality Improvement & Risk Management

• Human Resource Management

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APPENDIX III MOH, RHA, Private Providers, Professional Bodies and Regulatory Bodies FUNCTIONAL RELATIONSHIP TO ACCREDITING BODY (HSACTT)

• Presents the Bill to Legally establish the Health Services Accreditation Council • Appoints the Chairman, Deputy Chairman and members of the Board • Establish the composition and functions of the Accrediting Body • Source Budget • Approves Policy and receives minutes, quarterly and annual reports • Maintain oversight and accountability

• Representation on the Accrediting Board. • Recommend policy changes based on internal assessment findings. • Share relevant reports of the Health Quality Council with the HSACTT. • Issue facility and professional licenses and monitor compliance with licensure regulations. • Establish the minimum standards that would allow health care facilities to be licensed. While the accrediting

body would be responsible for establishing the maximum achievable standards for accreditation. • Utilize information from accreditation surveys to help with determining compliance with licensure requirements

and conduct additional inspection activities as needed. • Share Quality Improvement Reports to inform revision of standards. • Develop Regulations for licensure • Register and issue licenses for medical devices

• Representation on the Accrediting Board • Representation at an advisory level on accreditation, standards development and survey process issues. • Establish leadership infrastructure to implement the standards within the regional hospitals and primary care

facilities

• Ensure that the hospitals and primary care facilities are accredited

MINISTER

MINISTRY OF HEALTH

REGIONAL HEALTH

AUTHORITIES

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Professional disciplines and others External

To RHAs

• Representation in an advisory capacity to the accrediting body regarding standards

development and survey process. • Ensure compliance with the standards • Establish internal systems and processes to achieve compliance with the standards • Integrate accreditation standards requirements and survey findings into the Q.I. Plan

• Representation on the Accrediting Board/ Standing Committees • Representation in an advisory capacity to the Accrediting Body regarding standards

development and survey process • Professional regulatory bodies and training provider agencies have a complementary role in the

implementation of the system.

• Representation on Board/Standing Committees • Utilise Accreditation Awards to issue contracts/reimburse claims • Utilise Accreditation Reports to address appeals • Complementary role in ensuring provider compliance with standards

Agency with responsibility for the National Health Service

Health Care Facilities/Providers Government and Private: • Hospitals • Primary Care Facilities • Ambulatory Care Facilities

Medicine, Nursing, Pharmacy Laboratory Medicine, Dentistry Radiography, Physiotherapy Nutrition and Dietetics

Medical/Psychiatric Soc. work Dentistry l Consumers Private Hospitals

Medical Lab. Technology Law

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APPENDIX IV

Policy Statements to inform Legislation for the Establishment of the Health Services Accreditation Council of Trinidad and Tobago

(HSACTT)

Item Recommendations Definitions Health care Facilities shall be defined as: all institutions falling under

the Regional Health Authority Act No. 5 of 1994 and all institutions

registered under the Private Hospitals Act Chapter 29: 02.

Survey Instrument shall be defined as the accreditation standards

and the assessment instrument.

Establishment and

incorporation

The Health Services Accreditation Council of Trinidad and Tobago

(herein referred to as the accrediting body) shall be created to carry

out accreditation activities in order to evaluate the level of

compliance with the standards and the quality of care provided by

health care facilities.

The Health Services Accreditation Council of Trinidad and Tobago

shall be a body corporate and shall be managed by a Board of

Directors appointed by the Minister of Health

Functions and

Powers

The following shall be the powers and functions of the HSACTT:

• Development and maintenance of accreditation standards for

health care facilities;

• Regularly conducting credible, reliable and consistent

accreditation surveys of health care facilities;

• Conferring accreditation status;

• Fostering linkages with regulatory bodies, the Health Sector

Quality Council, professional groups, international and

regional accreditation bodies and other stakeholders with an

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Item Recommendations interest in health care delivery and in the development of

accreditation standards and other accreditation activities;

• Sharing information about accredited organizations/facilities

and accreditation decisions with various stakeholders such as

the Ministry of Health, the National Health Service body,

other regulatory bodies and the public;

• Promoting concepts of continuous quality improvement in

compliance with the standards;

• Compiling and maintaining a database of healthcare

institutions in Trinidad and Tobago and accreditation history

and status

• Disseminating to health care facilities, accreditation

standards, information about accreditation, and how to

comply with standards;

• Acting as a resource centre for quality improvement

standards, methods and experience, and as a focal point for

the collection of local information as well as for comparison

with other countries, " Serving as an access point for clinical

practice guidelines, health technology

assessment and evidence-based medicine; and

• Educating and consulting healthcare organizations, managers

and health professionals on quality and best practices in health

care.

The Health Services Accreditation Council of Trinidad and Tobago

shall have the power to accredit health care facilities; to collaborate

with recognized international health accreditation and regional health

care agencies, to recognize awards obtained elsewhere; to determine

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Item Recommendations the equivalence of these awards and their acceptability in Trinidad

and Tobago and to offer accreditation services to regional health care

facilities.

Governance

The Board shall be appointed by the Minister of Health and shall

comprise representatives of the following organisations:

* Two (2) persons employed in the Ministry of Health;

* One (l) member nominated by the Regional Health Authorities as

their representative and who is employed in an RHA.

* One (l) member of the Private Hospitals Board;

*One (l) Consumer Representative and

* One (1) member of the NHS body

Additionally one member will be drawn from each of the

disciplines of:-

* Medicine; * Nursing ; * Pharmacy; * Dentistry; * Laboratory

Medicine; * Radiography; * Medical/ Psychiatric Social Work;

*Nutrition and Dietetics; * Medical Laboratory Technology;

*Physiotherapy; *Law; and

* a person who does not have vested interest in any health facility and who in the opinion of the Minister has knowledge of the operations delivery of health care and clinical practice and the management of health services and who is not a medical practitioner shall be appointed by the Minister as the Chairman; and

• The Executive Director as ex officio member with non -

voting rights.

The Deputy Chairman shall be selected by the Minister of Health.

In respect of each Director, the Nominating Agency shall in like

manner designate an alternate member.

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Item Recommendations

The appointment of each Director, save for member nominated by the Regional Health Authority, shall be for a period of three (3) years and such members are eligible for re-appointment. The appointment of the member nominated by the Regional Health Authorities shall be for one (l) year and shall be selected from each Regional Health Authority consecutively.

Meetings of the

Board and

reporting

requirement

The Board shall meet for a minimum of eight (8) times per year or

more frequently as may be deemed necessary by issuing seven (7)

days notice to its members. The Board shall provide the Minister

with minutes of all meetings, quarterly and annual reports. Annual

reports shall be laid in Parliament and made available to the public

Functions and Powers of the Board

The Board shall have the following functions and powers. Powers to:

• Provide governance and leadership to the Health Services

Accreditation Council of Trinidad and Tobago;

• approve strategic and management plans for the Health

Services Accreditation Program;

• prepare an annual budget and allocate resources to carryout

the HSAP Mission;

• approve accreditation standards and survey process

instruments;

• appoint an Executive Director and Senior Management of the

Accreditation Council;

• appoint standing committees for addressing matters arising out

of or in connection with its powers;

• establish a non-adversarial process for appeals;

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Item Recommendations • recruit appropriate staff including an Executive Director.

The Board shall have the power to appoint Committees to examine

and report on matters arising out of or in connection with its powers. These Committees shall include inter alia a Governance Committee, a Finance Committee, an Accreditation Committee, Human Resources, and a Survey Advisory Committee. Each committee shall be chaired by a Board member and include two other members of the Board

In the exercise and performance of its functions and powers, the

Board shall act in accordance with the Health Services Accreditation

Act of Trinidad and Tobago. As the sponsor of the accreditation

program, the Ministry of Health shall play a major role in providing

policy direction for the accreditation programme prior to the

enactment of the legislation

Funds of the

HSACTT

The funds of the HSACTT shall consist of:

• such amounts as may be appropriated by Parliament;

grants and donations provided by the state or international

agencies

• revenue generated from registration fees, fees for accreditation

services and fees for educational development and other

activities approved by the Board;

• sums borrowed.

Financial

Provisions

Remuneration of Board Members. The Chairman and Members may

be paid a stipend approved by the Minister.

Financial

Accountability

The Board shall have a financial year of twelve (12) months

beginning in October and ending in September of each year.

The HSACTT shall be audited by the Auditor General or an

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Item Recommendations approved Auditor.

Seal The seal is to be placed on documents valued over $500,000.00

Compulsory

system of

Accreditation

Subsequent to the promulgation of the Health Services Accreditation

Act, every Health Care Facility shall within one year apply to the

HSACTT for accreditation.

Scheduling of

Survey

The accreditation process shall be prescribed.

Survey for cause The accrediting body shall have the power to perform a Short Notice

Survey when it becomes aware of potentially serious patient care or

safety issues in an Accredited Health Facility. Accredited facilities

shall report, to the accrediting body, a patient care or safety incident

that may warrant a survey outside of the facility's accreditation cycle.

Cancellation

Postponement of

Survey

Facilities may request postponement of a survey under one or more

of the following conditions:

• a natural disaster or other major unforeseen event that totally

or substantially disrupts operations occur;

• the facility is involved in a major strike;

• the facility has stopped admitting patients;

• patients, the facility, or both are being moved to another

building during the scheduled survey.

• Any other circumstance which at the discretion of the

Executive Director warrants postponement

Failure to comply Facility that fails to implement the recommendations of an

accreditation report with reasonable justification shall be granted an

extended period with the necessary support. If there be no reasonable

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Item Recommendations cause for non-implementation, the HSACTT shall publish the names

of such facilities in the Gazette of the Republic of Trinidad and

Tobago and to the daily newspapers and withdraw accreditation

award.

Selection of

External

Surveyors

There shall be for the purpose of executing a survey, a team comprising members as may be appointed by the Executive Director. These members can be actively employed in an accredited institution local /regional/international but shall not form part of the survey team for assessing a Health Facility if:

• they were an employee of the institution within the past twelve (12) months;

• any member of his immediate family was a patient at the institution during the last six (6) months ;

• they have a financial interest in the Health Facility.

Recognition by

the State

The state shall not provide grants or concessions to un-accredited

Health Facilities

The state shall not enter into an arrangement for the procurement of

goods or services from un- accredited health facilities.

No un-accredited Health Facility shall register with, or contract for

services with the NHS body (National Health Insurance/financing

System) of Trinidad and Tobago.

Public Information The accreditation body shall cause to have a list of all accredited

Health Facilities published annually in the Gazette of the Republic of

Trinidad and Tobago and the daily newspapers.

Confidentiality

and Public

Disclosure

The accrediting body may disclose to the public the following

information:

In respect of itself:

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Item Recommendations • Annual reports of its operations;

• Applicable standards used in surveys;

In respect to Health Facilities:

• A facility's current accreditation status;

• A facility's accreditation history;

• Aggregate survey data on a facility;

• A list of accredited facilities;

Subject to the Freedom of Information Act, the accrediting body

shall not publicly disclose the following information:

In respect of itself:

• All materials that may contribute to the accreditation process

such as the survey instrument.

In respect to Health Facilities:

• Any written analyses of the survey instrument, minutes and

agenda materials related to the accreditation decision by any

committees involved in making the accreditation decision;

• Information relating to compliance with specific accreditation

standards obtained from a facility before, during or after a

survey;

• The report sent to a facility notifying it of the survey findings

and accreditation decision.

Accreditation The survey report is produced by the surveyors at the client site to

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Item Recommendations decision allow for the correction of factual errors. The report will be reviewed

and edited by the HSACTT with inputs from the survey team; it is

then forwarded to Accreditation Committee of the Board as it makes

its accreditation decision. The accrediting body shall then issue the

accreditation decision and the written report to the Health

Facility/client.

Appeal process of

the Accreditation

Decision and

Report

A Health Facility may within thirty (30) days from receipt of its

official report, appeal in writing protesting any portion of the report

related to survey findings, the accreditation decision or follow-up

activity. The appeal must be accompanied by evidence from the

facility that supports the reason for the appeal.

The accrediting body shall review the evidence submitted and where

necessary approve decisions to be made to the report and the

accreditation decision and shall cause to have revisions of the same.

If, however, in the view of the accrediting body, there are no grounds

for revision of the report or the accreditation decision, the accrediting

body shall provide the facility in writing, just explanation as to why

the appeal for revision of the findings or change in the accreditation

status was not granted.

Judicial Review An aggrieved person may initiate High Court proceedings within

three (3) months of the HSACTT's decision after the appeal process

is exhausted.

This Act This Act shall bind the State.