Transcript Slide 1

National vs. International Accreditation
‘A Kuwaiti Experience in private and public sector’
Ahmad Nasrallah, MPH.
Chief Operating Officer
Dar Al Shifa Hospital (DASH)
Kuwait
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Content
1. National (Kuwaiti) Vs. International
Accreditation (similarities &
differences)
2. A glance at Kuwaiti Accreditation System
3. CCHSA Accreditation (as an international sample)
4. DASH Real Life Experience
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National Vs. International Accreditation
“similarities”
• Both aim at achieving QUALITY & PATIENT SAFETY
• Both utilize certain set of standards to compare actual
practice against
• Both use surveyors to accomplish them
• Both utilize a multidisciplinary approach (with differences)
• Self Assessment is one of the process cornerstone
elements
• Top management COMMITMENT is a necessity
• Clients’ involvement and education is elaborated
• Closing the LOOP is a MUST
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Kuwaiti National Accreditation vs.
International Accreditation
‘Differences’
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National
For governmental hospitals
and clinics only
Mandatory
Mainly structure-focus
Few indicators are utilized
(administrative, outcome)
Free of charge
Limited resources
2-year cycle (theoretically)
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International
For governmental and
private health organizations
Voluntary
Mainly process& outcome –
focus
Comprehensive process is
identified to go through
starting from assessment to
final survey
Many indicators are utilized
(structure, process,
outcome)
Relatively expensive
More resources are available
3-year cycle
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National Accreditation As A Tool for
Adopting International Quality Standards
• Introduces the local clients and organizations to the
concepts of accreditation & quality in an
incremental way therefore; buying in and
committing to it will be easier
• Facilitates building the infrastructure for quality,
hence becomes more sustainable
• Helps to transform the current punitive culture into a
learning culture which is considered a primary yet
crucial step farther
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Content
1. National vs. International Accreditation
(similarities & differences)
2. A glance at Kuwaiti Accreditation
System
3. CCHSA Accreditation (as an international sample)
4. DASH Real Life Experience
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Kuwait National Accreditation
“History”
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Commenced in the year 2000, Guided by the M.O.H Quality
Department.
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Started by a gap analysis conducted to the 15 governmental
hospitals
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Implementation was divided into two phases:
1.
Preparation Phase: during which the basic requirements’ draft was
prepared (based on the M.O.H circulars) & implemented by the
hospitals
2.
Adoption Phase: during which the established standards were
adopted by the hospitals to evaluate their performance against them
and identify opportunities for improvement
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First External Survey was conducted in 2004
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Kuwait National Standards:
• A Total of 266 basic requirements
• Involved the work processes of the different
committees and sections
Aspects covered by the requirements:
• Hospital’s Top Management (Hospital’s Director,
Deputy Director, Assistant Director for
Administrative Affairs)
• Heads of Clinical and Non Clinical Units &
Departments
• Hospital wide committees(Hospital Administrative
Board,Morbidity & Mortality Committee,Medical Record Review
Committee,Infection Control Committee,Code Blue Committee
(ER),Accreditation Preparation Committee…
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Dimensions of Kuwait National
Accreditation
1.
2.
3.
4.
Compliance
Coordination
Communication
Client-Centered
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Evolved around Patient Safety:
• Coordination of services (amongst the different
specialties and units)
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Standardization of clinical practices
Integrated Medical Records
Continuous education & training
Fire Safety Program
Emergency Preparedness Plan
Infection Control Program
Risk Management
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Client-Centered:
• Involvement of patients and their families in their care &
treatment therefore; they can make informed decisions
• Patients & Families’ Rights and education.
• Patient Satisfaction Survey
• Staff Satisfaction Survey
• Orientation Programs
• Home Care
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Tools
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Periodic Clinical Audits including clinical guidelines
Medical Records’ Review
Indicators
Policies & Procedures Review
Quality Improvement Projects
Feedback Surveys
Self assessment : A continuous review and follow
up of implementation progress.
• External Survey: Independent Surveyors are sent
by MOH for external evaluation
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Kuwaiti Accreditation Cycle
Report on Quality
Improvement
Initiatives to MOH Higher
Accreditation Committee
Report on Recommendation
Back to the Hospital’s
Accreditation committee
2-year Cycle
Self Assessment by
Hospital’s Accreditation
Committee
External survey by
( Independent surveyors )
Implementation of
Recommendation
By the Hospital
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National Accreditation as a Tool to
Adopting International Accreditation
International
Accreditation
Quality infrastructure & Culture Adaptation
National Accreditation
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Supportive Infrastructure Components
Information Management
Learning Culture
Competent Committed
Reward System
Human Resources
Recognition & Motivation
Education & Training
Benchmarking
Quality Infrastructure
Measurements &
Monitoring Activities
Documentation
P&P
Practice Guidelines
Performance Standards
Top Management
Commitment
Supportive Committees
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Next Move
An Integrated contract has been prepared with
the Canadian Council On Health Services
Accreditation ( CCHSA). Final steps
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Content
1. National vs. International Accreditation
(similarities & differences)
2. A glance at Kuwaiti Accreditation System
3. CCHSA Accreditation (as an international
sample)
4. DASH Real Life experience
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CCHSA Accreditation Process
Self Assessment
CLIENT
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Principles of CCHSA Accreditation
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CCHSA Standards
 A total of 473 criteria falls under 178 standards.
 Scored the standards within 4 parameters; compliance,
communication, coordination, & client-focus
 Emphasized the vitality of clients’ safety (internal &
external customers) in all standards.
 Created 21 Required Organizational Practices (ROPs)
that supports patient safety. By January 2006,
compliance with these ROPs became a requirement of
accreditation surveys.
 Developed five patients’ safety areas and six patients’
safety goals.
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CCHSA - Patient Safety Area 1/3
The 6 patient safety goals are organized into five areas:
1. CULTURE
Goal 1: Create a culture of safety within the
organization.
2: COMMUNICATION
Goal 2: Improve the effectiveness and coordination of
communication among care/service providers and
with the recipients of care/service across the
continuum.
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CCHSA - Patient Safety Area 2/3
3. MEDICATION USE
Goal 3: Ensure the safe use of high risk medications
Goal 4: Ensure the safe administration of parenteral
medications.
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CCHSA - Patient Safety Area 3/3
4: WORKLIFE/WORK FORCE
Goal 5: Create a work life and physical environment
that supports the safe delivery of care/service
5: INFECTION CONTROL
Goal 6: Reduce the risk of health service
organization-acquired infections, and their impact
across the continuum of care/service.
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Client/Patient and Family Care
Preparing for
Care and
Treatment
Assessment
Care and
Treatment
Planning
Implementation
and Evaluation
of Care and
Treatment
Discharge
And
Follow-up
Quality
Monitoring
And
Improvement
Quality Monitoring and Improvement
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 Canadian Council on Health Services Accreditation
Survey Simulation
Client interviews
Indicators
Patient Tracer
Self-assessment
Team interviews
Surveyor
Rating
On-site
documentation
Focus groups
Required
Information
Tours
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What should you learn from
the process?
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Self assessment
Vision
Mission
Values
Communicatio
n
Process
Co-ordination
Structure
Client
input
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Content
1. National vs. International Accreditation
(similarities & differences)
2. A glance at Kuwaiti Accreditation System
3. CCHSA Accreditation (as an international sample)
4. DASH Real Life experience
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History of DASH
 The first Private Hospital in Kuwait that was established
in 1961. It began with Maternity department only (30
beds).
 In 1995, it evolved into a hospital that provides a
broader scope of services. Various departments were
launched;
Dentistry , Pediatrics , Internal Medicine , Plastic Surgery, ENT ,
Dermatology , General Surgery , Orthopedics , Ophthalmology , in addition
to Cardiac Sonar & Radiology, Laboratory and Pharmacy.
 2004: Transferred to the new building in the District of
Hawally.
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Nowadays:
 A total of 100 in-patient beds including SCBU, NICU,
ICU, CCU, and Day Case Surgery.
 A total of 23 medical specialities and 12
subspecialities.
 A total of 52 out patient clinics.
 6 operating theatres
 Cardiac Catheterization Lab was launched on May 07
 A total of 776 diverse workforce
 Started a massive expansion project.
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DASH; A Month In Life….
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
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20217
1041
500
5500
5289
475
40
18
20048
1020
253
1244
Outpatient visits
People are admitted
Deliveries
Patients are seen in Emergency Room
New patients are accepted in all specialties
Patients have surgical procedures
IVF cycles
Total Knee Replacements Performed
Laboratory tests are analyzed
Routine radiological studies are performed
CT/MRI studies are done
Ultrasound studies are performed
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Turnover Trends at DASH
25000
20000
OP.Visits
Emergency Pts
15000
Deliveries
Admitted Pts
10000
New Patients
5000
0
2004
2005
2006
2007
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DASH
The first hospital in Kuwait that signed up for accreditation
with a world-wide recognized accrediting body, and…
The first hospital in Kuwait that was granted the
accreditation certificate on Dec.2007
By
The Canadian Council On Health Services
Accreditation
CCHSA
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DASH Approach To Achieving CCHSA
Accreditation
Communication
Organization’s
Culture
Organization wide
Committees
Patient safety
Accreditation
Quality
Infrastructure
Self Assessment
Medical Record
Education & Training
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DASH Self Assessment Teams
A Total of 11 multidisciplinary teams were made up to :
1.
Conduct periodic self assessment of the organization
2.
Liaise between the departments and the Quality
Management Office
3.
Identify opportunities for improvement and define
quality improvement projects in collaboration with the
relevant departments/units and guided by the Quality
Management Department
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Self Assessment Teams
• Service Delivery Teams
• Support Services teams
• Administrative Teams
• Environment Care Team
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Service Delivery Teams
1. Surgical Care Team
2. Maternal/ Child Team
3. Medical Care Team
4. Emergency Care Team
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Support Services Teams
5. Pharmacy Team
6. Diagnostic Services’ Team
7. Laboratory Team
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Administrative Teams
8. Leadership & Management Team
9. Human Resources Team
10.Information management Team
11. Environment Care Team
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Accreditation Process/DASH
60%
50%
40%
30%
20%
10%
0%
Not in Place
In Development
Implemented
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Mock Survey Results
Adequate Standards
Improvement Required
Not in Place
63%
36%
1%
70%
60%
50%
40%
30%
20%
10%
0%
Adequate
Improvement
Required
Not in Place
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Final Survey’s Results
Substantial Compliance
Partial Compliance
Minimal Compliance
65%
35%
0%
70%
60%
50%
40%
30%
20%
10%
0%
Substantial
Compliance
Partial
Compliance
Minimal
Compliance
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Challenges Faced During The Process
1.
Resistance: it was dependant on employees characteristics
most resistance had come from physicians
2. Inconsistency between the strategic direction of the top
management and subordinates
3. Culture : both patients and employees
4. Compliance to documentations’ standards was crucial
5. Lack of understanding of the main purpose for as such
process by the employees
6. Absence of Teamwork
7. Communication
8. Politics
9. Lack of employees’ involvement in major decision
making
10. Lack of feedback activities
11. Multidisciplinary Approach
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However; towards the final survey many
people bought in due to….
1.
2.
3.
4.
5.
6.
7.
8.
9.
Continuous education and training
Open door policy and open channels of communication
Open meetings between top managers and employees
Staff satisfaction survey
Feedback mechanisms in place
Involvement in setting up the alternate strategic direction of
the organization
Emphasizing important ethics of organizational justice,
teamwork, recognition, and rewards
Creating positive competition through continuous internal
benchmarking and role modeling
Most important: transforming the organization into a
LEARNING ORGANIZATION and adopting an OPEN,
NON-PUNITIVE CULTURE
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Resistance Trend Towards the Process
80%
60%
PRO
40%
CON
Passive
20%
0%
Initially
3 Months
later
6 Months
later
Nov-07
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Performance Improvement Projects &
Indicators
Examples for Demonstration
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Compliance Rate with Proper Documentation
within the Patients’ Medical Records- 2007
70%
60%
50%
40%
30%
20%
10%
0%
1st Quarter
2nd Quarter
3rd Quarter
4th Quarter
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Falls’ Preventive Programs
year 2007
3.5
3
2.5
2
1.5
1
0.5
December
November
October
September
August
July
June
May
April
0
Num ber of falls
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Pressure/Bed Sores Preventive Program year
2007.
2.5
2
1.5
1
0.5
December
November
October
September
August
July
June
May
April
0
No. Bedsores
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Thrombo-phlebitis incidence Rates At DASH2007
12%
10%
8%
6%
4%
2%
0%
December
November
October
September
August
July
June
May
April
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Proper Hand Washing Rates vs. Infection Rates
66% decline in the infection rate was directly correlated
to improvements in hand washing practices:
80%
70%
60%
50%
40%
30%
20%
10%
Rate of Proper Handwashing
December
November
October
September
Augu st
July
June
May
April
March
0%
Rate of Infections
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Morbidity Report 1/2
Morbidity Report - 2007
Fever
Post-Wound Infection
Neonatal - Jaundice
6
Umblical Infection
5
Birth Asphyxia
Anaemia (After Surgery)
4
Intravenous Infiltration
Blood Transfusion Reaction
3
Pulmonary Embolism(After Surgery)
2
Neonatal Seizures after Vac.Delivery
Allergic Reaction To
Inj.Rocephin/Inj.Mesporin
1
Anaphylactic Shock
0
Postpartum Haemorrhage
Ju
l
Au
g
Se
p
O
ct
N
ov
D
ec
Ja
n
Fe
b
M
ar
Ap
r
M
ay
Ju
n
Pulmonary Edema
Abscess Formation after Intramuscular
Injection
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Morbidity Rates
2/2
Anaemia (Af ter Surgery)
6
Intravenous Inf iltration
5
Abdominal Distention (Af ter
Surgery)
4
Blood Transf usion Reaction
Pulmonary Embolism(Af ter
Surgery)
3
Aspiration Pneumonia
2
Ovarian Hyperstimulation
Syndrome
Secondary Post-Tonsillectomy
Haemorrhage
1
Scalp Injury w ith Erb's Palsy
af ter Vac.Delivery
N
ov
S
ep
Ju
l
ay
M
ar
Birth Encephalopathy
M
Ja
n
0
Neonatal Seizures af ter
Vac.Delivery
Allergic Reaction To
Inj.Rocephin/Inj.Mesporin
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Patient Satisfaction Rate
2007
62%
60%
58%
56%
54%
52%
50%
48%
2nd Quarter
3rd Quarter
4th Quarter
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“Thank You”
www.daralshifa.com
[email protected]
phone: (Office): (965) 223-1111
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