ensuring quality beyond accreditation - what hospitals need to do to stay one step ahead - rojoson -...

Ensuring Quality Beyond Accreditation – What

Hospitals Need to Do to Stay One Step Ahead?

Reynaldo O. Joson, MD, MHA, MHPEd, MSc SurgConsultant-Advisor

Manila Doctors Hospital Ciudad Medical Zamboanga

Hospital Management Asia 2014August 29, 2014; Cebu City

The scenario: A hospital has recently been given a formal recognition of its quality management system in the form of a certification, accreditation or award.


What are commonly observed courses taken by such a hospital with regards to the quality

management system program?

What are the commonly observed courses taken by such a hospital with regards to the quality management system program?

• Just use certification for marketing purpose as long as it can until its client-attraction force wanes • just fulfill minimum requirements

usual course of hospitals which just look at certification as a marketing tool

What are the commonly observed courses taken by such a hospital with regards to the quality management system program?

• Elevate bar of quality or excellence either by aiming for another quality certification or for a higher or highest level of award

usual course of hospitals which put quality improvement and performance excellence as their primary reason for getting a

certification


What should this hospital do to stay one step ahead to ensure quality beyond accreditation?



• Just use certification for marketing purpose as long as it can until its client-attraction force wanes


Getting a certification does not always mean hospital•has achieved highest level of excellence (most of the time, minimum or lower level)

• Elevate bar of quality or excellence either by aiming for another quality certification or for a higher or highest level of award!


Getting a certification does not always mean hospital•has reached end of the line in continuum of excellence. Absolutely no “period” at end of the journey for excellence, always just a “comma.” Quality is not just an end result but a continuing process or journey.



Stakeholders’ EXPECTATIONS higher when a hospital has achieved a certification•usually higher risk and frequency of criticism and negative feedback •threshold of tolerance for glitches and hitches in quality now lower than before


What should this hospital do to stay one step ahead to ensure quality beyond accreditation?• Elevate bar of quality or excellence either by aiming for

another quality certification or for a higher or highest level of award!

“Your hospital is already ISO-, PQA-, JCI-, ACI-certified,

and yet the quality of service is still

poor…..”


• A hospital being granted highest level of recognition for quality and performance excellence will encounter least frequent negative feedback!



Need for VIGILANCE in maintenance and improvement of quality and performance excellence.

•Good quality today can become poor quality tomorrow. •Performance excellence today can become poor performance tomorrow.



• What contributes greatly to LABILITY is the unavoidable constant change of staff in the hospitals, both in quantity and quality. • Fast turnover of staff• Leaders and followers with different levels of

commitment and competency on quality and performance excellence come and go





Is there more that we can do?

Can we do more than this?

What specifically is or are my recommendations for hospitals to stay one step ahead to ensure quality beyond accreditation?• Elevate bar of quality or excellence either by aiming

for another quality certification or for a higher or highest level of award!

Establish a program that aims for the development of an organizational culture of quality and performance excellence.

Longer-term course of action- steadfast results

in ensuring quality beyond accreditation

Shorter-term course of action

What is an organizational culture of quality and performance excellence?

• consistent observable demonstration of patterns of behavior (norms)

of all hospital staff, inclusive of leaders and followers,

on quality and performance excellence!


• concept of culture

a hospital having developed a culture of quality and performance excellence will surely be able to steadfastly ensure quality beyond accreditation!


• key performance indicators for program that aims for development of organizational culture of quality and performance excellence

will be

documented presence of proven “best practices” in the hospital.


• concept of culture

culture of quality and performance excellence in a hospital

Presence of “Best Practices”

What is a “Best Practice”?

“Best Practice” -a formally documented method or technique that has been institutionalized in the hospital and-that has consistently shown performance excellence results at least if not yet proven superior to those achieved with other means and -which can be or is being used as a benchmark by other hospitals.

What are the “best practices” that will contribute to organizational culture of quality and performance excellence?

At the minimum, the number of proven “best practices” will be in the following areas:•At least one “Best Practice” under each category of the Baldrige Criteria for Performance Excellence:• Leadership• Strategic Planning• Customer Focus• Measurement, Analysis, Knowledge

Management • Workforce Focus• Operations Focus

What are the “best practices” that will contribute to organizational culture of quality and performance excellence?

At the minimum, the number of proven “best practices” will be in the following areas:•At least one “Best Practice” under each category of hospital health care standards:• Patient Safety• Access to Care and Continuity of Care• Patient and Family Rights• Assessment of Patients• Care of Patients• Anesthesia and Surgical Care• Medication Management • Patient and Family Education• Hospital Infection Control

What are the recommended procedures and processes in developing a Program on Best Practice (PBP)?

• Decide on a list of management systems that will be developed into “Best Practices.”


• Formulate a design and development plan or blueprint that will include:• systematic approach in the planning of a

management system; • deployment and implementation; • evaluation, review, and continual improvement; • documentation and archiving;• management review and independent audit.


• In the evaluation plan,always include

timelines

and

measurements with key performanceindicators.


• Track the implementation of the design and development plan.


• Evaluate the results of the implementation for at least 3 years in terms of • level (current level of performance based

on formulated KPI) • trends (rates of performance improvements

and the sustainability of good performance) • comparison (performance relative to

appropriate comparisons such as other similar hospitals and benchmarks or hospital industry leaders)


• If a management system plan has been implemented for at least 3 years and has consistently shown performance excellence results even if not yet proven superior to those achieved with other means, then it can be considered as a “Best

Practice” for the hospital.

Once publicized, it can be used as a benchmark by other hospitals.

April 2014, CMZ has embarked on developing at least 20 “best practices” in the next 5 to 10 years.

• Patient Safety• Access to Care and

Continuity of Care• Patient and Family Rights• Assessment of Patients• Care of Patients• Anesthesia and Surgical

Care• Medication Management • Patient and Family

Education• Hospital Infection Control

• Strategic Planning• Governance • Risk Management• Performance

Management• Workforce Education• Knowledge Management• Workforce Engagement• Customer Engagement• Process Management• CSR• Communication• IT Management System

After 1 year of implementation

After 2 years of implementation

After 3 years of implementation

“Best Practices” = Organizational Culture of Quality and Performance

Excellence• Establishing and developing organizational

culture of quality and performance excellence through the Program on Best Practices to ensure quality beyond accreditation

is not easy as one can deduce from the concept and definition, procedures, and strategies just presented.


Excellence• If you agree with me that it is course of action that

will produce steadfast results in terms of ensuring quality beyond accreditation and • if you put importance on quality and performance

excellence for your hospitals,

I suggest you start now.


Excellence• Ten years from now or even three years from now,

depending on how fast and effective you are with your Program on Best Practice,I am optimistic I will hear you saying:

“it was worth the journey and most important of all, it is efficient in terms of sustainability.”

The scenario:



Establish a program that aims for the development of an organizational culture of quality and performance

excellence through BEST PRACTICES!

A hospital has recently been given a formal recognition of its quality management system in the form of a certification, accreditation or award.

Ensuring Quality Beyond Accreditation – What

Hospitals Need to Do to Stay One Step Ahead?

Reynaldo O. Joson, MD, MHA, MHPEd, MSc SurgConsultant-Advisor

Manila Doctors Hospital Ciudad Medical Zamboanga

Hospital Management Asia 2014August 29, 2014; Cebu City

ensuring quality beyond accreditation - what hospitals need to do to stay one step ahead - rojoson -...

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