Assessing Regional Blood Assessing Regional Blood CentersCenters

Using Foreign Using Foreign or International Standards or International Standards

Abdulla A. Alkhashan MS, ASCP, NCAAbdulla A. Alkhashan MS, ASCP, NCA

King Abdulaziz Medical City-RiyadhKing Abdulaziz Medical City-Riyadh

For the 10For the 10thth Arab Transfusion Medicine Course Arab Transfusion Medicine Course Kuwait City, KuwaitKuwait City, Kuwait

2929thth November to 1 November to 1stst December, 2012 December, 2012

Presentation Outline•Nature of Modern Health Care SystemNature of Modern Health Care System

•History of Accreditation in Health History of Accreditation in Health

Care Care

•The Value and Impact of AccreditationThe Value and Impact of Accreditation

•Accreditation in the Developing Accreditation in the Developing

CountriesCountries

•The Pitfalls of SurveyingThe Pitfalls of Surveying

•Accreditation in the KSAAccreditation in the KSA

Nature of Modern Health Care Nature of Modern Health Care SystemSystem 44,000–98,000 annual deaths occur as a result 44,000–98,000 annual deaths occur as a result

of errorsof errors

National Institute of Medicine report published in1999

2,956,351 Transfusions2,956,351 Transfusions

8 Mortalities (1:370,000 Transfusions )8 Mortalities (1:370,000 Transfusions )

117 Morbidities (1:25,000 Transfusions 117 Morbidities (1:25,000 Transfusions

))

SHOT Report 2011

Nature of Modern Health Care Nature of Modern Health Care SystemSystem

Nature of Modern Health Care Nature of Modern Health Care SystemSystem

Not Monitored (Don’t Have Any)Not Monitored (Don’t Have Any)

Nature of Modern Health Care Nature of Modern Health Care SystemSystem

Facts patients need to live with it !Facts patients need to live with it !

Nature of Modern Health Care Nature of Modern Health Care SystemSystem Investigated individually (case-by-Investigated individually (case-by-

case)case)

Nature of Modern Health Care Nature of Modern Health Care SystemSystem Investigated individually (case-by-Investigated individually (case-by-

case)case)What is wrong with this approach? Reactive

Focus on individuals

Focus on corrective measures and may be taken ineffective preventive measures

No long term gains (such event may occur in the future)

Nature of Modern Health Care Nature of Modern Health Care SystemSystem

Excellen

ce

Quality ball on the Hill; Koch, 1991

Nature of Modern Health Care Nature of Modern Health Care SystemSystem

Excellen

ce

Nature of Modern Health Care Nature of Modern Health Care SystemSystem

Excellen

ce

Standards and Accreditation

Nature of Modern Health Care Nature of Modern Health Care SystemSystem

Excellen

ce

Standards and Accreditation

Proactive Approach

Nature of Modern Health Care Nature of Modern Health Care SystemSystem

Excellen

ce

Standards and Accreditation Proactive Approach

Risk Reduction

Nature of Modern Health Care Nature of Modern Health Care SystemSystem

Excellen

ce

Standards and Accreditation Proactive Approach

Risk Reduction

Organization Wide

Nature of Modern Health Care Nature of Modern Health Care SystemSystem

Excellen

ce

Standards and Accreditation Proactive Approach

Risk Reduction Organization Wide

System Focus

Nature of Modern Health Care Nature of Modern Health Care SystemSystem

Excellen

ce

Standards and Accreditation Proactive Approach

Risk Reduction Organization Wide System Focus

Stimulate Continuous Improvements

History of AccreditationHistory of AccreditationAccreditation is a voluntary Accreditation is a voluntary

program, in which authorized program, in which authorized

external peer reviewers evaluate external peer reviewers evaluate

the compliance of a health care the compliance of a health care

organization with pre-organization with pre-

established performance established performance

standards.standards.

History of AccreditationHistory of Accreditation

Licensure is a process by which Licensure is a process by which

a government authority grants a government authority grants

permission to an individual permission to an individual

practitioner or healthcare practitioner or healthcare

organization to operate in an organization to operate in an

occupation or profession.occupation or profession.

History of AccreditationHistory of Accreditation

American College of Surgeons in American College of Surgeons in 19171917

History of AccreditationHistory of Accreditation

International Standards International Standards Organization (ISO) in 1947Organization (ISO) in 1947

1917 - ACS

History of AccreditationHistory of Accreditation

American Association of Blood American Association of Blood Banks (AABB) 1947Banks (AABB) 1947

1917 - ACS 1947 - ISO

History of AccreditationHistory of Accreditation

Joint Commission on Accreditation Joint Commission on Accreditation of Healthcare Organizations of Healthcare Organizations

(JCAHO) 1951(JCAHO) 1951

1917 - ACS 1947 - ISO 1947 - AABB

History of AccreditationHistory of Accreditation

AABB Accreditation Program -1957AABB Accreditation Program -1957

1917 - ACS 1947 - ISO 1947 - AABB 1951 - JCAHO

History of AccreditationHistory of Accreditation

CAP Accreditation Program (1961)CAP Accreditation Program (1961)

1917 - ACS 1947 - ISO 1947 - AABB 1951 - JCAHO 1957 - AABB AP

History of AccreditationHistory of Accreditation

Accreditation modules exported Accreditation modules exported (1960s)(1960s)

1917 - ACS 1947 - ISO 1947 - AABB 1951 - JCAHO 1957 - AABB AP 1961 - CAP AP

History of AccreditationHistory of Accreditation

ISQua’s International Accreditation Program(1985)(1985)

1917 - ACS 1947 - ISO 1947 - AABB 1951 - JCAHO 1957 - AABB AP 1961 - CAP AP 1960s – Export of AP

The Value and Impact of The Value and Impact of AccreditationAccreditation

Helps set national standards forHelps set national standards for

health care health care

Improves patient careImproves patient care

Helps set national standards for health care

The Value and Impact of The Value and Impact of AccreditationAccreditation

Makes information available to Makes information available to

the publicthe public

Helps set national standards for health care Improves patient care

The Value and Impact of The Value and Impact of AccreditationAccreditation

Lenient accreditation Lenient accreditation

requirementsrequirements

Helps set national standards for health care Improves patient care Makes information available to the public

The Value and Impact of The Value and Impact of AccreditationAccreditation

Makes health care more Makes health care more

expensiveexpensive

Helps set national standards for health care Improves patient care Makes information available to the public Lenient accreditation requirements

The Value and Impact of The Value and Impact of AccreditationAccreditation

Accreditation in the Developing Accreditation in the Developing CountriesCountries

Absence of strong regulatory Absence of strong regulatory

and local accreditation bodiesand local accreditation bodies

Accreditation in the Developing Accreditation in the Developing CountriesCountries

Used as a term for contracting Used as a term for contracting

with hospital's operating with hospital's operating

companiescompanies

Absence of strong regulatory and local accreditation bodies

Accreditation in the Developing Accreditation in the Developing CountriesCountries

Business owners recognized Business owners recognized

accreditation a powerful accreditation a powerful

marketing toolmarketing tool

Absence of strong regulatory and local accreditation bodies

Term for contracting with hospital's operating companies

Accreditation in the Developing Accreditation in the Developing CountriesCountries

Skeptical about the impact of Skeptical about the impact of foreign or international foreign or international

accreditation on the quality of accreditation on the quality of healthcare services providedhealthcare services provided

Absence of strong regulatory and local accreditation bodies.

Term for contracting with hospital's operating companies

Powerful marketing tool

Accreditation in the Developing Accreditation in the Developing CountriesCountries

Prohibitively expensive and Prohibitively expensive and unjustifiedunjustified

Absence of strong regulatory and local accreditation bodies.

Term for contracting with hospital's operating companies

Powerful marketing tool Skeptical about the impact

Accreditation in the Developing Accreditation in the Developing CountriesCountries

Improve efficiency and clinical Improve efficiency and clinical outcomes of a wide spectrum of outcomes of a wide spectrum of

clinical conditionsclinical conditions

Absence of strong regulatory and local accreditation bodies.

Term for contracting with hospital's operating companies

Powerful marketing tool Skeptical about the impact Prohibitively expensive and unjustified

The Pitfalls of Surveying The Pitfalls of Surveying

Interrogating and Inspecting Interrogating and Inspecting

instead of Interviewing and instead of Interviewing and

AssessingAssessing

The Pitfalls of Surveying The Pitfalls of Surveying

Consideration to the local Consideration to the local

circumstances and available circumstances and available

resourcesresources

Interrogating and Inspecting instead of Interviewing and Assessing

The Pitfalls of Surveying The Pitfalls of Surveying

Misconception of the process Misconception of the process

ownerowner

Interrogating and Inspecting instead of Interviewing and AssessingConsideration to the local circumstances and available resources

The Pitfalls of Surveying The Pitfalls of Surveying

Pressured to consider “in Pressured to consider “in

progress” as “compliance”progress” as “compliance”

Interrogating and Inspecting instead of Interviewing and AssessingConsideration to the local circumstances and available resourcesMisconception of the process owner

The Pitfalls of Surveying The Pitfalls of Surveying

The pace of developing Policies The pace of developing Policies

and Procedure faster than the and Procedure faster than the

implementationimplementation

Interrogating and Inspecting instead of Interviewing and AssessingConsideration to the local circumstances and available resourcesMisconception of the process ownerPressured to consider “in progress” as “compliance”

Licensing and Accreditation in Licensing and Accreditation in K.S.AK.S.A

370 Hospital (244 Governmental 370 Hospital (244 Governmental

and 126 Private)and 126 Private)

Licensing and Accreditation in Licensing and Accreditation in K.S.AK.S.A

13 Blood Banks and Transfusion 13 Blood Banks and Transfusion

Services Accredited by the AABB Services Accredited by the AABB

and CAPand CAP

370 Hospital (244 Governmental and 126 Private)

Licensing and Accreditation in Licensing and Accreditation in K.S.AK.S.A

21 Laboratories Accredited by 21 Laboratories Accredited by

the CAP onlythe CAP only

370 Hospital (244 Governmental and 126 Private)

13 AABB/CAP

Licensing and Accreditation in Licensing and Accreditation in K.S.AK.S.A

53 Hospitals Accredited by the 53 Hospitals Accredited by the

JCIJCI

370 Hospital (244 Governmental and 126 Private)

13 AABB21 CAP

Licensing and Accreditation in Licensing and Accreditation in K.S.AK.S.A

74 Hospitals are CBAHI 74 Hospitals are CBAHI AccreditedAccredited

6 Regional Laboratories and 6 Regional Laboratories and Central Blood BanksCentral Blood Banks

370 Hospital (244 Governmental and 126 Private)

13 AABB21 CAP53 JCI

Licensing and Accreditation in Licensing and Accreditation in K.S.AK.S.A370 Hospital (244 Governmental and 126 Private)

13 AABB21 CAP53 JCI74 CBAHI6 CBAHI-RRL

Health Care Providers in Health Care Providers in KSAKSA

1. Ministry Of Health2. Private Hospitals Sector3. National Guards Health Affairs 4. Armed Forces Medical Services Sector5. Ministry of Interior Medical Services6. University Hospitals7. King Faisal Specialized Hospital8. Saudi Aramco Medical Services

1.1. Saudi FDASaudi FDA

2.2. Council of Health ServicesCouncil of Health Services

3.3. Council for Healthcare specialtiesCouncil for Healthcare specialties

4.4. Ministry of Health (licensing)Ministry of Health (licensing)

Health Care Regulators in Health Care Regulators in KSAKSA

CBAHI Accreditation ProgramsCBAHI Accreditation Programs

HospitalsHospitals

Primary Health Care CentresPrimary Health Care Centres

Ambulatory Care CentresAmbulatory Care Centres

Reference Laboratories and Blood Reference Laboratories and Blood

BanksBanks

Central Board of Accreditation Central Board of Accreditation for Healthcare Institutions for Healthcare Institutions (CBAHI)(CBAHI)

Central Board of Accreditation Central Board of Accreditation for Healthcare Institutions for Healthcare Institutions (CBAHI)(CBAHI)

Services of CBAHIServices of CBAHI

Standards Orientation

Training/Education

Onsite Consultation

Mock Survey

Accreditation

Central Board of Accreditation Central Board of Accreditation for Healthcare Institutions for Healthcare Institutions (CBAHI)(CBAHI)

Central Board of Accreditation Central Board of Accreditation for Healthcare Institutions (CBAHI)for Healthcare Institutions (CBAHI)

الصحية المنشآت العتماد المركزي الصحية المجلس المنشآت العتماد المركزي المجلس

www.cbahi.orwww.cbahi.orgg

SummarySummaryPotential benefits of Potential benefits of

accreditation are far beyond the accreditation are far beyond the

anticipated expenses and the anticipated expenses and the

healthcare providers need to be healthcare providers need to be

educated about these benefits educated about these benefits

and convinced by conducting and convinced by conducting

cost / benefit analysis.cost / benefit analysis.

Thank You

alkhashan@ngha.med.sa alkhashan@ngha.med.sa