Transcript American University of Beirut Faculty of Medicine

New Mowasat Hospital
Accreditation
Dr. Ghaleb Okla, FAAMA
Diplomat in Health Care
CEO/VP Health Care
September, 2003
Commitment to Quality
If Quality Is Sacrificed
Society Is Not Truly Served
Philosophy Statement
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Accreditation Provides The
FRAMEWORK That Allows You to
Improve QUALITY!
What is Accreditation
Accreditation provides a visible commitment
by an organization to improve the quality of
patient care, endure a safe environment, and
continually work to reduce risks to patients and
staff.
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What is Accreditation
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“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?
It is a requirement for some government
programs
 Demonstrates minimum level of quality
 Stimulates internal quality improvement
 Enhances community confidence
 Aids in retention recruitment of highly
qualified staff
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Why Seek Accreditation?
Leaders want it
 Enhances customers attraction
 Enhances businesses
 Gives the system an added competition
 Improves the marketing and PR strategy
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Accrediting Agencies
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Related to Quality planning
I. Directed at organizations
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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 Agencies
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Related to Quality planning
II. Directed at organizations
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Malcolm Baldridge Award (USA)which was created to:
– Build awareness about quality improvement;
– Recognize accomplishments about quality improvement
– Transfer information about quality improvement
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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.
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CAMH
Accrediting Agencies
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Related to Quality planning
– Directed Individuals
Licensing
 Certification
 Credentialing
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– For government or organizations
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National clinical practice guideline development
Quality control
– Performance measurement
Commitment to QUALITY
Quality Products and Service
will never exceed
the Quality of the
LEADERSHIP TEAM
Accreditation Categories
Accreditation
 Accreditation with Type I
Recommendations
 Provisional Accreditation
 Conditional Accreditation
 Preliminary Denial of Accreditation
 Accreditation Denied
 Accreditation Watch
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Preparation
Senior Leadership Support
 Lead Individual- Dedicated time
 Multi-disciplinary team
 Coordinating Meetings
 Start 9-12 months in advance of Survey
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Preparation
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Document review
Leadership/strategic planning review
Visit to patient care setting
Function interviews
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Human resources
Infection control
Information management/Medical records
Performance measurement
Leadership interviews
– Administrative
– Medical
– Nursing
Survey
Survey Team- Clinical Administrative
 Lasts 2-4 days
 Primary Focus is on Performance
Improvement
 Examine activity/ Outcomes/People not
Policies/ Paper
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Applicable Chapters
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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 Chapters
Management of Information
 Surveillance Prevention, and Control of
Infection
 Governance
 Management
 Medical Staff
 Nursing
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The Survey Process
The Survey
Process
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Main Question:
What is your policy?
Opening Conference
– Meet key leaders of the organization
– Review survey schedule
– Inquire about the occurrence of sentinel events
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Quality Management & Improvement Presentation
– Orientation to the organizations Quality Management and
Improvement Program
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Document Review
– Assesses compliance to standards from a design (P&P)
standpoint
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Leadership/Medical Staff/Surveyor Interviews
– Assesses compliance to leadership responsibilities
The Survey
Process
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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
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Function Team Interviews
– Reviews compliance to key functions of the organization
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Facility Management and Safety
– Building tour and unit visits
Sample JCAHO Questions About
Measurement
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How do you measure the performance of your
processes for medication use? Does this
measurement include the following:
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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
ED
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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
Process
Cost
 Office of Inspector General
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-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 Costs
Survey Costs
 Personnel Time
 Opportunity Cost
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Challenges/Obstacles
Board of Directors Support
 Medical Staff Issues
 Administrative Support
 Budgetary Issues
 Turf Issues
 Information Support
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Challenges/Obstacles
Lack of Technical
Support
 Country Regulations
 Political Issues
 Human Resources Issues
 Willingness to Change
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Internal Strategies To Overcome
Barriers
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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
Barriers
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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 Impact
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Meet External Expectations
Assist Contract
Negotiations/Marketing
Move Organization to Focus
on PI and Customer Service
Survey Preparation/Accreditation
Count Down Starts from the Date of Assembling the Team
 2-3 Years Prior to Survey
– Overall System Preparation
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15 Months Prior to Survey
– Educational Session and Baseline Assessment
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12 Months Prior to Survey
– Follow-Up Assessments / Support
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3 Months Prior to Survey
– Formal “Mock Survey”
Your Turn
Any Questions?