New Mowasat HospitalNew Mowasat Hospital

Accreditation

Dr. Ghaleb Okla, FAAMADiplomat in Health Care

CEO/VP Health CareSeptember, 2003

Commitment to QualityCommitment to Quality

If Quality Is Sacrificed

Society Is Not Truly Served

Philosophy StatementPhilosophy Statement

Accreditation Provides The FRAMEWORK That Allows You to Improve QUALITY!

What is AccreditationWhat is Accreditation

Accreditation provides a visible commitmentby an organization to improve the quality ofpatient care, endure a safe environment, andcontinually work to reduce risks to patients andstaff.

What is AccreditationWhat is Accreditation

“An external procedure of evaluation which is aimed at carrying out an independent assessment of the quality of an establishment” (French ordinance, 1996)

Voluntary Conducted by non-governmental organization Focuses on the process and outcomes of care

Why Seek Accreditation?Why Seek Accreditation?

It is a requirement for some government programs

Demonstrates minimum level of qualityStimulates internal quality improvementEnhances community confidenceAids in retention recruitment of highly

qualified staff

Why Seek Accreditation?Why Seek Accreditation?

Leaders want itEnhances customers attractionEnhances businessesGives the system an added competitionImproves the marketing and PR strategy

Accrediting AgenciesAccrediting Agencies

Related to Quality planningI. Directed at organizations

Licensing Accreditation JCIA (The Joint Commission International Accreditation): a

division of the JCAHO. Its mission is to improve the quality of health care in the international community by providing worldwide accreditation services.

ISO Certification (The International Organization for Standardization): a worldwide federation of national standards bodies.

Accrediting AgenciesAccrediting Agencies

Related to Quality planningII. Directed at organizations

Malcolm Baldridge Award (USA)which was created to:– Build awareness about quality improvement;– Recognize accomplishments about quality improvement– Transfer information about quality improvement

EFQM (European Foundation for Quality Management) one of its goals is to:

– Stimulate and assist all organizations throughout Europe to participate in improvement activities leading ultimately to excellence in customer satisfaction.

CAMH

Accrediting AgenciesAccrediting Agencies

Related to Quality planning– Directed Individuals

LicensingCertificationCredentialing

– For government or organizationsNational clinical practice guideline development

Quality control– Performance measurement

Commitment to QUALITYCommitment to QUALITY

Quality Products and Servicewill never exceed the Quality of the

LEADERSHIP TEAM

Accreditation CategoriesAccreditation Categories

AccreditationAccreditation with Type I

RecommendationsProvisional AccreditationConditional AccreditationPreliminary Denial of AccreditationAccreditation DeniedAccreditation Watch

PreparationPreparation

Senior Leadership SupportLead Individual- Dedicated timeMulti-disciplinary teamCoordinating MeetingsStart 9-12 months in advance of Survey

PreparationPreparation Document review Leadership/strategic planning review Visit to patient care setting Function interviews

– Human resources– Infection control– Information management/Medical records– Performance measurement

Leadership interviews– Administrative– Medical – Nursing

SurveySurvey

Survey Team- Clinical AdministrativeLasts 2-4 daysPrimary Focus is on Performance

ImprovementExamine activity/ Outcomes/People not

Policies/ Paper

Applicable ChaptersApplicable Chapters Patient Rights and Organization Ethics Assessment of Patients Care of Patients Education Continuing of Care Improving Organization Performance Leadership Management of the Environment of Care Management of Human Resources

Applicable ChaptersApplicable Chapters

Management of InformationSurveillance Prevention, and Control of

InfectionGovernanceManagementMedical StaffNursing

The Survey ProcessThe Survey Process

The Survey The Survey ProcessProcess

Opening Conference– Meet key leaders of the organization – Review survey schedule– Inquire about the occurrence of sentinel events

Quality Management & Improvement Presentation– Orientation to the organizations Quality Management and

Improvement Program Document Review

– Assesses compliance to standards from a design (P&P) standpoint

Leadership/Medical Staff/Surveyor Interviews– Assesses compliance to leadership responsibilities

Main Question:

What is your policy?

Main Question:

What is your policy?

The Survey The Survey ProcessProcess

Main Question:

Does practice follow Policy?

Main Question:

Does practice follow Policy?

Patient Care Setting Visits– 100% of anesthetizing locations Building tour and unit visits

– At least 50% of all patient care units comprised of: Tour of unit

- Open medical record review

- Multidisciplinary care team interview

- Possible patient interview

Function Team Interviews– Reviews compliance to key functions of the organization

Facility Management and Safety– Building tour and unit visits

Sample JCAHO Questions About Sample JCAHO Questions About MeasurementMeasurement

How do you measure the performance of your processes for medication use? Does this measurement include the following:– Prescribing or ordering– Preparing and dispensing– Administering– Monitoring medications effects on patients

Do you have a systematic process to assess collected data?

Do you have a systematic approach for redesigning current processes or acting on opportunities for improvement?

Sample JCAHO Questions About Sample JCAHO Questions About EDED

How do you assess pain in ED? How does staff demonstrate specific competency? What is the institution’s Emergency preparedness plan? What is your policy for alcohol and drug abuse? Do you have observation care? If patient is dropped off in the parking lot and left there, what

is your policy for treating him? What are you doing for PI? How do you assure oxygen is coming out when you turn it

on? How does staff demonstrate age specific competency? How do you assess pain in the ED? What is you on call policy?

Deficiencies With the Accreditation Deficiencies With the Accreditation ProcessProcess

CostOffice of Inspector General

-Surveys are too tightly scripted-no time for probing issues

-Unlikely to find substandard care or individual practitioners with questionable skills

-Not enough unannounced surveys-Does not make meaningful distinctions among hospitals

General CostsGeneral Costs

Survey CostsPersonnel TimeOpportunity Cost

Challenges/ObstaclesChallenges/Obstacles

Board of Directors SupportMedical Staff IssuesAdministrative SupportBudgetary IssuesTurf IssuesInformation Support

Challenges/ObstaclesChallenges/Obstacles

Lack of Technical Support

Country Regulations Political IssuesHuman Resources IssuesWillingness to Change

Internal Strategies To Overcome Internal Strategies To Overcome BarriersBarriers Educate Ministers of Health Communication with

consumers/users Show financial value to users Disseminate information to

leadership Focus attention on obtaining the

support of the movers and shakers within region

Public Relations, marketing, and media campaigns

External Strategies To Overcome External Strategies To Overcome BarriersBarriers

Invite well-known international speakers to create awareness

Foster participation of leaders and policy makers to visit model programs

Adopt foreign standards and adapt to country situation

Affiliate with other country’s accrediting bodies

Create regional agency to validate Create a task force to sponsor

regional activities

Long Term ImpactLong Term Impact

Meet External Expectations Assist Contract

Negotiations/Marketing Move Organization to Focus

on PI and Customer Service

Survey Preparation/AccreditationSurvey Preparation/Accreditation

Count Down Starts from the Date of Assembling the Team 2-3 Years Prior to Survey

– Overall System Preparation

15 Months Prior to Survey– Educational Session and Baseline Assessment

12 Months Prior to Survey– Follow-Up Assessments / Support

3 Months Prior to Survey– Formal “Mock Survey”

Your TurnYour Turn

Any Questions?