accreditation principles

8/2/2019 Accreditation Principles

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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.



Fundamental characteristics of accreditation:• Participation in the accreditation process is

voluntary and is an earned and renewable status.• Member institutions develop, amend, and approveaccreditation requirements.• The process of accreditation is representative,

responsive, and appropriate to the types ofinstitutions accredited.• Accreditation is a form of self-regulation.• Accreditation requires institutional commitment andengagement.• Accreditation is based upon a peer review process•Accreditation requires institutional commitment tothe concept of quality enhancement throughcontinuous 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 accreditationstandards 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.

http://www.nydanstempler.dk/kategorier/42150



Patient Safety

Staff and employee safety

Environment and community safety

Information Education and Communication



An accreditationstandard is a standardfor good quality.

An example of a standardwithin 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 theoutcomes 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 andstandards

Deficiencies noticed informed to theorganisation

Advice rendered on the methodology to befollowed during the Accreditation Survey

Time frame worked out for the survey inmutual consultation



Carried out by a team of Assessors depending

upon the size, complexity and facilities

provided by the organisation

Scope will include all standards related

functions and all patient care settings

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 QualityImprovement

Identified high Risk Areas for patient care andsafety

Sentinel Events being monitored



Key Monitoring Indicators◦ Resource

◦ Volume

◦ Utilization

◦ Performance

Control charts

Problems faced and remedial measures

undertaken/ being undertaken



•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 theirrights, 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 0◦ Partial compliance 5◦

Full compliance 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 downstandards 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

Accreditation denied◦ HCO is consistently non compliant with standards or non

adherence to safe and ethical practices

Accreditation withdrawn◦

HCO withdraws voluntarily◦ Due to consistent non compliance



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 currentstandards 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 non-

financial 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 berequired

Commitment on a consistent basis

High rates of attrition will require repeated andcontinual training

Public Sector will take a longer time to get intothe process

Quality and consistency of assessors andassessments



Global WHO initiativesInternational health system benchmarking

The world health report 2000 – Health

systems: improving performance used five

indicators to rank the overall performance ofnational health systems:

• overall level of population health; • health inequalities (or disparities) within the

population;• overall level of health system

responsiveness (a combination of patientsatisfaction and how well the systemperforms);



• distribution of responsiveness within thepopulation (how well people of varyingeconomic status find that they are served bythe health system);

• distribution of the health system’s financialburden within the population (who pays thecosts).



On these indicators, the report concludedthat France provided the best overall health

care, followed by Italy, Spain, Oman, Austriaand Japan.

The United States health system spends ahigher portion of its gross domestic product(GDP) than any other country but ranked 37thout 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 toparticipate in the MOHP accreditationprogram. A part of HSR program, theaccreditation shall be:

Obligatory to all PHC facilities interested in joining the reform program and contractingwith the family health fund.

Voluntary to any other facility interested in

being accredited.



Has instituted a process to monitor, evaluateand improve the quality of care to it ispatients.

Has instituted the patient record system

designed to document key patientinformation. 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.



The facility must be:

1. Operated for at least six months

2. Have appropriate licensure by MOHP.3. In compliance with all government laws and

regulations



The survey is a key step in the accreditationprogram. It is an organized and structuredmechanism to identify strengths and weakness of ahealth care facility.

The survey process consists of a site visit to thefacility conducted by a team of expert trained inaccreditation using a pre-set accreditation surveyinstruments and tools.



The purpose is to evaluate the extent towhich healthcare facilities comply with thenationally established MOHP accreditationstandards.

The results of the survey determine whethera facility is awarded or denied accreditation.In addition surveys are useful in exchanging

skills and expertise between the surveyorsand the facility staff.



Applying for accreditation

Awareness seminars

Pre-accreditation visit

Accreditation awards: the results of the survey willlead to three decisions:

Full accreditation

Provisional accreditation

Denied accreditation

The duration for which an accreditation statusremains valid is two years.



Record review where specific administrativeand clinical records will be reviewed

Personal interviews, and

Observation where the performance of specific tasks in certain areas are observed.



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ACCREDITATION IS A JOURNEY

AND NOT A DESTINATION.

BON VOYAGE !!!!!

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