Prod Cliff HughesA0 Jakarta 8 August 2017

ISQua’s Role in the Governance of

Quality & Safety
Prof Cliff Hughes
President ISQua
 ISQua
• Not for Profit Membership
Organisation

• Mission is to inspire and drive

improvement in the quality and safety
of healthcare worldwide through
education and knowledge
sharing, external
evaluation, supporting health
systems, and connecting people
through global networks

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 Why work with ISQua?

ISQua’s mission is to:

To inspire and drive improvement in the quality

and safety of healthcare worldwide through
education and knowledge sharing, external
evaluation, supporting health systems and
connecting people through global networks
Networking events
Person Centred Care is at our core
Develop communities of practice
 The ISQua Network system

Policy Experts IAP

Development

Quality External
Improvement evaluation
Membership
and Patient Accreditation
Safety

Innovation and Accreditation

research Education Council
Fellowship
International Accreditation
Programme (IAP)
IAP Global Presence
66 Organisations in 34 Countries
IAP Global Presence
66 Organisations in 34 different countries
 Language / Terminology

Accreditation is a self-assessment and external peer

review process used by health care organisations
to accurately assess their level of performance in
relation to established standards and to
implement ways to continuously improve the
health care system.
ISQua 1998
 Codman 1913
1. There will be an organised medical staff.
2. That membership of this staff be limited to licensed
physicians who are competent and of worthy character
and who are professionally ethical.
3. That the staff develop rules and regulations governing
professional work in the hospital.
4. Each patient will have a comprehensive medical record.
5. That diagnostic and therapeutic facilities are under
competent supervision and includes, at least, laboratory
and x-ray departments.

Ernest Codman, 1913

© 2005 HMI 8/6/2017 12

 History of Accreditation

• US – 1910’s – JCI
• Canada – 1950’s - AC
• Australia – 1980’s - ACHS
• UK – 1980’s – CHI / HQS / HCC / CQC

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 Accreditation Bodies 1951-2009
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Government Mixed Independent
October 2010 International survey results 14
Shaw et al, 2010 International Survey of Accreditation Organisations 2009
 ISO vs. Accreditation

Shaw et al, ISQua 2010. Accreditation and ISO certification: Do they explain differences in quality management in European
hospitals?
Sept 2010
 Benefits of Accreditation

• Need more research

• Difficult to measure as variables difficult to

control
 What does the evidence show?

Australia 2008
• Research shows inconsistent findings – but accreditation does
promote change and professional development
• and may
– have an organizational financial impact
– improve measured quality performance
– with public disclosure of outcomes, increase the
credibility of the hospital with the community
• There is insufficient evidence to know if accreditation improves
patient satisfaction

Greenfield and Braithwaite, 2008. Health Sector Accreditation Research: a systematic review Greenfield
and Braithwaite. Int. Journal for Qual. in Healthcare.
 Canada 2011 (Updated 2015)

30 Benefits Listed
•Risk Mitigation System
•Strengthens interdisciplinary team effectiveness
•Improves communication
•Promotes measurement and use of indicators
Improvements needed
•Does not increase patient satisfaction
•Data capture
Accreditation Canada, 2015. Value and impact of accreditation: a literature review.
 Clinical benefits an example

• Gratwohl et al (2011), Patient outcome was systematically better when

the transplantation centre was at a more advanced phase of JACIE
accreditation

• Lichtman et al (2011), CVA accreditation resulted in reduced mortality

rate but no change in readmission rates

• Menachemi et al (2008), Ambulatory care centres, patients in JCI

accredited facilities were significantly less likely to be re hospitalized after
colonoscopy
 Accreditation
Opportunities for Improvements
• Reduce work load associated with accreditation
– reduce burden of excessive audits
• Move from structure – process model to more outcomes
focused model
• Strengthening data collection
• More and better research – non acute
• Improve service user and medical involvement
• Inform public and measure satisfaction
– adverse events may still occur in an accredited
hospital
• Promote transparency
 Recent trends
• Unannounced surveys – no rigorous empirical
evidence to support these surveys’ presumed
benefits
• Patient satisfaction surveys – requiring patient
satisfaction surveys as part of accreditation process.
• Mandatory accreditation
– Australia – National Safety and Quality Health
Service (NSQS) Standards – hospitals, day
procedure centres and public dental services
– Canada – Mandatory in Quebec and Alberta
 IAP international reach
 Argentina  India  Philippines
 Australia  Indonesia  Saudi Arabia
 Brazil  Ireland  Slovenia
 Canada  Japan  South Africa
 Columbia  Jordan  Spain
 Croatia  Kazakhstan  Taiwan
 Czech Republic  Korea  Tajikistan
 Denmark  Kyrgyzstan  Thailand
 Dubai  Lebanon  Turkey
 Egypt  Malaysia  UAE
 France  Netherlands  United Kingdom
 Hong Kong  New Zealand  United States
 Norway

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 ISQua Accredited Organisations

 CHKS Accreditation Unit, UK

 Haute Autorité de Santé – DAQSS
 Accreditation Canada  Canadian Accreditation Council of Human Services - CAC
 Joint Commission of Taiwan – JCT  Global-Mark Pty Ltd, Australia
 Council for Health Service Accreditation of
Southern Africa - COHSASA  Health and Disability Auditing New Zealand - HDANZ
 Danish Institute for Quality and Accreditation  Australian Aged Care Quality Agency - AACQA
in Health Care - IKAS
 The Healthcare Accreditation Institute (Public
 Diagnostic Accreditation Programme, British
Organization), Thailand - HAI
Columbia
 Health and Disability Auditing Australia Pty Ltd  Australian General Practice Accreditation Ltd / Quality in
- HDAA Practice Pty Ltd – AGPAL/QIP
 Joint Commission International - JCI  Japan Council for Quality Health Care - JCQHC
 Malaysian Society for Quality in Health - MSQH
 The Australian Council on Health Care Standards - ACHS
 Quality Improvement Council, Australia - QIC
 National Accreditation Board for Hospitals &  Health Care Accreditation Council, Jordan - HCAC
Health Care Providers, India - NABH
 DNV GL Business Assurance, Norway
 DAA Group Limited, New Zealand
 AABB, USA  Associacao Brasileira de Acreditacao De Sistemas e Servicos
de Saude, Brazil – CBA
 Netherlands Institute for Accreditation in
Healthcare - NIAZ  KARS Komisi Akreditasi Rumah Sakit
 ICONTEC Health Accreditation
Service, Columbia
 IAP- 4 year cycle

• Critical path issued

• Technical review
• Final Submission of Self Assessment
• Surveyor Assessment (survey)
• Factual Review
• Report Validated by Panel
• Accreditation Decision
• Award Pack to Organisation
• Continuous Assessment – 12 and 30 months post survey
 IAP - Principles and Standards

4th Edition, V1.2 4th Edition, V1.2 3rd Edition, V1.0

Published in September 2015 Published in September 2015 Published in September 2016
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 Standards

• Guidelines and Principles for the Development of

Health and Social Care Standards, 4th Edition 2014

• Surveyor Training Programme, 2nd Edition 2009

• Guidelines and Standards for External Evaluation

Organisations, 4th Edition 2014
Guidelines and Standards for External
Evaluation Organisations 4th Edition, 2014

8 Standards
Governance
Strategic, operational and
financial management
Risk management and
performance
Human resources management
Information management
Surveyor management
Survey and client management
Accreditation or certification
awards
Learning and Knowledge network
Membership network
Email: plachman@isqua.org

@peterlachman
Join the conversation

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