Dr hanan abbas Lecturer of Family Medicine TQM DIPLOMA AUC 2002

It is based on written and published standards Reviews are conducted by professional peers The accreditation process is administered by an independent body The aim of accreditation is to encourage organizational development.

Accreditation can be defined as

Quality assessment, where an acknowledged authority assesses whether an activity, service or institution meets a set of joint standards

Fundamental characteristics of accreditation: Participation in the accreditation process is voluntary and is an earned and renewable status. Member institutions develop, amend, and approve accreditation requirements. The process of accreditation is representative, responsive, and appropriate to the types of institutions accredited. Accreditation is a form of self-regulation. Accreditation requires institutional commitment and engagement. Accreditation is based upon a peer review process Accreditation requires institutional commitment to the concept of quality enhancement through continuous assessment and improvement

Before you start What do you expect to gain? What are the risks, costs? What are the incentives, or sanctions? Do you have a choice of provider? Do you have commitment from: Governing board? Senior management? General staff? Medical staff?

To implement a system which aims to:

prevent errors and promote high quality apply best practice to the daily work build bridges between the health sectors improve the quality of the patients journey create continuous quality development

When the organizations have implemented the accreditation standards which constitute its Healthcare Quality Programme, they must undergo an external survey.
A team of specially trained healthcare professionals will assess the level in which the organizations meet the standards. Accreditation is based on the surveyors assessment. Accreditation take place every third year.

Patient Safety

Staff and employee safety

Environment and community safety Information Education and Communication

An accreditation standard is a standard for good quality.

An example of a standard within medication:

Drugs used in acute situations are easily accessible.

Basic Ingredients
Organizations apply on prescribed format giving
details as required Submission of a self assessment form indicating the

outcomes of its QMS and Internal Audits

Extent of adherence to the laid down standards

Completeness
Accuracy Clarifications sought if required

To ascertain the readiness of the organisation for Accreditation Overview of the organizational preparedness and commitment to quality goals and standards Deficiencies noticed informed to the organisation Advice rendered on the methodology to be followed during the Accreditation Survey Time frame worked out for the survey in mutual consultation

Carried out by a team of Assessors depending upon the size, complexity and facilities provided by the organisation Scope will include all standards functions and all patient care settings related

Onsite survey will consider specific cultural and legal factors which may influence or shape decisions regarding the provision of care and /or policies and procedures

Initial presentation by the organization

Document Review
Adherence to statutory obligations

Visits to various areas

Facility surveys and tours Random structured interviews

Organogram Quality management Team Methodology followed for Quality Improvement Facilities provided Inputs on resources provided for Quality Improvement Identified high Risk Areas for patient care and safety Sentinel Events being monitored

Key Monitoring Indicators

Resource
Volume Utilization Performance

Control charts Problems faced and remedial undertaken/ being undertaken measures

 Quality Manual Various Policies and Procedures

Minutes of Meetings of various committees

Medical Records Medical / Nursing Audit

Adverse Events
HAI Action Taken Reports

Personal Records of Staff

 Facility Safety Level of compliance with laid down policies and procedures Standard Precautions Patient care

Fire Safety
Equipment Management

 Staff Interview

To determine their level of awareness and compliance with organization policies and procedures To assess their awareness levels of their rights, privileges and patient rights To determine their satisfaction levels
Patient and family Interview

To assess their level of awareness of the care process and their rights To determine their satisfaction levels

Pattern

Non-compliance Partial compliance Full compliance

0
10

No standard can have more than one zero The average for a standard must exceed 5 The overall average score must exceed 7 No zeros in legal requirements

Accredited

HCO shows acceptable compliance with laid down standards in all areas Includes the scope of services for which accredited Any increase in scope the survey has to be done for the increased scope HCO is consistently non compliant with standards or non adherence to safe and ethical practices HCO withdraws voluntarily Due to consistent non compliance

Accreditation denied

Accreditation withdrawn

Generally three years with one Reassessment survey to ensure continued compliance and to assess the CQI programme

If

during

accreditation

The

Accreditation

organization receives inputs that the organization is substantially out of compliance with the current

standards

then

Resurvey

or

withdrawal

of

accredited decision may be resorted to

Create willingness Initial impetus from Top management Requires involvement of all staff This requires repeated training and briefing Once consensus is there identify core coordinating or Quality management Team

Examine what are you doing

Find what you should be doing

Document the gaps Compare with the standards Complete gap analysis Identify areas for improvement

Focus on uniform training of all employees in key areas Encourage by financial and / or nonfinancial incentives Initially prepare to provide extra resources Avoid disappointments if initial benefits do not accrue as expected Be prepared for a longer gestation period for benefits to accrue

Quality Consciousness at all levels will take time Sustenance and consistency of efforts will be required Commitment on a consistent basis High rates of attrition will require repeated and continual training Public Sector will take a longer time to get into the process Quality and consistency of assessors and assessments

Global WHO initiatives International health system benchmarking

The world health report 2000 Health systems: improving performance used five indicators to rank the overall performance of national health systems: overall level of population health; health inequalities (or disparities) within the population; overall level of health system responsiveness (a combination of patient satisfaction and how well the system performs);

distribution of responsiveness within the population (how well people of varying economic status find that they are served by the health system); distribution of the health systems financial burden within the population (who pays the costs).

On these indicators, the report concluded that France provided the best overall health care, followed by Italy, Spain, Oman, Austria and Japan. The United States health system spends a higher portion of its gross domestic product (GDP) than any other country but ranked 37th out of 191 countries according to these criteria; the United Kingdom, which spends just 6% of GDP on health services, ranked 18th.

Any PHC facility in Egypt is eligible to participate in the MOHP accreditation program. A part of HSR program, the accreditation shall be: Obligatory to all PHC facilities interested in joining the reform program and contracting with the family health fund. Voluntary to any other facility interested in being accredited.

Has instituted a process to monitor, evaluate and improve the quality of care to it is patients. Has instituted the patient record system designed to document key patient information. Provide a defined package of services including reproductive health, neonatal care, childcare, adult care, basic emergency care, and preventive health services. Provide services that include ambulatory care with or without inpatient services.


1.

The facility must be:

Operated for at least six months Have appropriate licensure by MOHP. In compliance with all government laws and regulations

2.
3.

The survey is a key step in the accreditation program. It is an organized and structured mechanism to identify strengths and weakness of a health care facility. The survey process consists of a site visit to the facility conducted by a team of expert trained in accreditation using a pre-set accreditation survey instruments and tools.

The purpose is to evaluate the extent to which healthcare facilities comply with the nationally established MOHP accreditation standards. The results of the survey determine whether a facility is awarded or denied accreditation. In addition surveys are useful in exchanging skills and expertise between the surveyors and the facility staff.

Applying for accreditation Awareness seminars Pre-accreditation visit Accreditation awards: the results of the survey will lead to three decisions: Full accreditation Provisional accreditation Denied accreditation The duration for which an accreditation status remains valid is two years.

Record review where specific administrative and clinical records will be reviewed Personal interviews, and Observation where the performance of specific tasks in certain areas are observed.

SOURCE: Team analysis and Ministry of Health primary care department

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SOURCE: Team analysis and Ministry of Health primary care department

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SOURCE: Team analysis and Ministry of Health primary care department

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SOURCE: Team analysis

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SOURCE: Team analysis

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ACCREDITATION IS A JOURNEY
AND NOT A DESTINATION. BON VOYAGE !!!!!