بسم الله الرحمن الرحيم

1. بسم الله الرحمن الرحيم

2. You can’t manage what you can’t measure

3. Accreditation

4. 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

5. Benefits of Accreditation • 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)

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

7. Brief History • 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…..

8. Accreditation methodology • Function based (tracer methodology) • Department based

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

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

11. Joint commission international (JCI)

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

13. JCI (cont…) • 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)

14. JCI (cont…) • 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)

15. JCI (cont…) • SQE (Staff Qualifications and Education) • MCI (Management of Communication and Information)

16. Egypt • WHO and MOHP • From 1995 • Critical standards 69 • Core standards 322 • Non core standards 325

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

18. Lebanon • World bank and MOPH • Department based standards • Basic standards and accreditation standards (2001) • Second accreditation standards(2003)

19. Canada • 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

20. U.K • 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

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

22. Australia • 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

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

24. China (cont…) • 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)

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

26. Latin America and the Caribbean • 14000 hospitals (most of them <70 beds) • Compulsory minimum standards and non-compulsory standards

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

28. India • 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

29. Pyramid of documentation QM Policies and procedures Instructions Forms Records

30. Standards Should Be • 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)

31. با تشکر والسلام عليکم