You cant manage what you cant measure Accreditation

You can’t manage what you can’t measure

Accreditation

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

Benefits of Accreditation n n n Shows commitment to quality Improves communication and collaboration within the organisation Promotes team building Increases credibility Demonstrates accountability Improves productivity Obtaining advice from surveyors (mentoring)

Studies show positive effect for: n n n Patient (satisfaction, quality of care and safety) Staff (satisfaction and good work condition) Organisation (productivity, strategic performance and financial viability)

Brief History n n Earnest Codman: End result system (effectiveness of treatment) 1910 The era of minimal standards 1917 -1965 The era of optimal achievable standards 66 -87 The era of performance evaluation 1988…. .

Accreditation methodology n n Function based (tracer methodology) Department based

JCAHO(U. S) 1 -Patient-Focused Functions -Rights, ethics, responsibilities -Provision of care, treatment, services -Medication management -Surveillance, prevention, infection control

JCAHO (cont…) 2 -Organization Functions -Performance improvement -Leadership -Management of environment of care -Management of information 3 -Structures With Functions -Medical staff -Nursing

Joint commission international (JCI)

A new task force in 1997 In EU, Middle east and Far east and then everywhere

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

JCI (cont…) n n n PFE (Patient and Family Education) QPS (Quality improvement and Patient Safety) PCI (Prevention and Control of Infections) GLD (Governance, Leadership and Direction) FMS (Facility Management and Safety)

JCI (cont…) n n SQE (Staff Qualifications and Education) MCI (Management of Communication and Information)

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

Egypt (cont…) The first award in middle east from ISQua (the accreditor of accreditors ) n

Lebanon n n World bank and MOPH Department based standards Basic standards and accreditation standards (2001) Second accreditation standards(2003)

Canada n n n Canadian Commission On Hospital Accreditation 1952 Monopoly Including mental health and rehabilitation facilities as well as general hospitals Recently outcome measures 94% of hospital beds

U. K n n n Though NHS had an agenda for accreditation but there was not any response Patient’s Charter (department of health’s standards for patient services) Investors in people (department of trade and industry) King’s Fund Organizational Audit Eventually accreditation as an integrate system (King Edward’s Hospital Fund for London (mission: quality improvement in NHS) Resemble to U. S , Canada and especially Australia

China n n Formal Accreditation by MOPH Three levels of hospitals -Neighborhood or township level -District, country, industrial complex level -Large municipal and teaching level

Australia n n n Australian Council On Hospital Standards 1974 Utilization of resources Quality of care Clinical outcome Fully accredited 3 years and partially accredited 1 year Newly a 5 year has been introduced

China (cont. . . ) n Four areas of treatment : -Prevention -Healthcare reconstruction -Support and participation in disease prevention and care -Healthcare activities

China (cont…) n n Every 3 years Only accredited hospitals get license to operate Government can close non accredited hospital The most important challenge : the number of trained surveyors necessary (120000 surveyor)

Latin America and the Caribbean n Has begun in early nineties PAHO and Latin American Federation Of Hospitals Also a draft by MOPH of Argentina

Latin America and the Caribbean n n 14000 hospitals (most of them <70 beds) Compulsory minimum standards and noncompulsory standards

Latin America and the Caribbean (con…) n n Compulsory minimum standards : - Medical care - Technical and support areas - Building documentation - Functional physical structure - Installations Non compulsory : critical area, neonatology, nuclear medicine and …

India n n Voluntary accreditation by Indian Hospital Association (IHA) failed in 1993 Bureau of Indian Standards (BIS) has laid down standards for 30, 100 and 250 beds National Institute for Health and Family welfare (NIHFW 1992)…standards for >50 beds only for equipment Government standards for secondary level hospitals

Pyramid of documentation QM Policies and procedures Instructions Forms Records

Standards Should Be 1. 2. 3. 4. 5. 6. 7. 8. Explicit (written) Degree of excellence Objective (not subjective) Compatible with culture and abilities Able to improve continuously Compatible with government requirements Compatible with minimum community content Motive the leadership Vs management (not like classification systems)