1. بسم الله الرحمن الرحيم

2. You can’t manage what you can’t measure

3. Accreditation

4. Definition : Assessment of health services according to a set of standards describing the structures and processes that contribute to desirable patient outcomes based on quality of care and patient safety

5. Benefits of Accreditation Shows commitment to quality Shows commitment to quality Improves communication and collaboration within the organisation Improves communication and collaboration within the organisation Promotes team building Promotes team building Increases credibility Increases credibility Demonstrates accountability Demonstrates accountability Improves productivity Improves productivity Obtaining advice from surveyors (mentoring) Obtaining advice from surveyors (mentoring)

6. Studies show positive effect for: Patient (satisfaction, quality of care and safety) Patient (satisfaction, quality of care and safety) Staff (satisfaction and good work condition) Staff (satisfaction and good work condition) Organisation (productivity, strategic performance and financial viability) Organisation (productivity, strategic performance and financial viability)

7. Brief History Earnest Codman: End result system (effectiveness of treatment) 1910 Earnest Codman: End result system (effectiveness of treatment) 1910 The era of minimal standards 1917-1965 The era of minimal standards 1917-1965 The era of optimal achievable standards 66-87 The era of optimal achievable standards 66-87 The era of performance evaluation 1988….. The era of performance evaluation 1988…..

8. Accreditation methodology Function based (tracer methodology) Function based (tracer methodology) Department based Department based

9. JCAHO(U.S) 1-Patient-Focused Functions 1-Patient-Focused Functions -Rights, ethics, responsibilities -Provision of care, treatment, services -Medication management -Surveillance, prevention, infection control

10. JCAHO (cont…) 2-Organization Functions 2-Organization Functions -Performance improvement -Leadership -Management of environment of care -Management of information 3-Structures With Functions 3-Structures With Functions -Medical staff -Nursing

11. Joint commission international (JCI)

12. A new task force in 1997 In EU, Middle east and Far east and then everywhere

13. JCI (cont…) ACC (Access to care and continuity if care) ACC (Access to care and continuity if care) PFR (Patient and Family Rights) PFR (Patient and Family Rights) AOP (Assessment Of Patients) AOP (Assessment Of Patients) COP (Care Of Patients) COP (Care Of Patients) ASC (Anesthesia and Surgical Care) ASC (Anesthesia and Surgical Care) MMU (Medication Management and Use) MMU (Medication Management and Use)

14. JCI (cont…) PFE (Patient and Family Education) PFE (Patient and Family Education) QPS (Quality improvement and Patient Safety) QPS (Quality improvement and Patient Safety) PCI (Prevention and Control of Infections) PCI (Prevention and Control of Infections) GLD (Governance, Leadership and Direction) GLD (Governance, Leadership and Direction) FMS (Facility Management and Safety) FMS (Facility Management and Safety)

15. JCI (cont…) SQE (Staff Qualifications and Education) SQE (Staff Qualifications and Education) MCI (Management of Communication and Information) MCI (Management of Communication and Information)

16. Egypt WHO and MOHP WHO and MOHP From 1995 From 1995 Critical standards 69 Critical standards 69 Core standards 322 Core standards 322 Non core standards 325 Non core standards 325

17. Egypt (cont…) The first award in middle east from ISQua The first award in middle east from ISQua (the accreditor of accreditors )

18. Lebanon World bank and MOPH World bank and MOPH Department based standards Department based standards Basic standards and accreditation standards (2001) Basic standards and accreditation standards (2001) Second accreditation standards(2003) Second accreditation standards(2003)

19. Canada Canadian Commission On Hospital Accreditation 1952 Canadian Commission On Hospital Accreditation 1952 Monopoly Monopoly Including mental health and rehabilitation facilities as well as general hospitals Including mental health and rehabilitation facilities as well as general hospitals Recently outcome measures Recently outcome measures 94% of hospital beds 94% of hospital beds

20. U.K Though NHS had an agenda for accreditation but there was not any response Though NHS had an agenda for accreditation but there was not any response Patient’s Charter (department of health’s standards for patient services) Patient’s Charter (department of health’s standards for patient services) Investors in people (department of trade and industry) Investors in people (department of trade and industry) King’s Fund Organizational Audit King’s Fund Organizational Audit Eventually accreditation as an integrate system (King Edward’s Hospital Fund for London (mission: quality improvement in NHS) Eventually accreditation as an integrate system (King Edward’s Hospital Fund for London (mission: quality improvement in NHS) Resemble to U.S,Canada and especially Australia Resemble to U.S,Canada and especially Australia

21. China Formal Accreditation by MOPH Formal Accreditation by MOPH Three levels of hospitals Three levels of hospitals -Neighborhood or township level -Neighborhood or township level -District, country, industrial complex level -District, country, industrial complex level -Large municipal and teaching level -Large municipal and teaching level

22. Australia Australian Council On Hospital Standards 1974 Australian Council On Hospital Standards 1974 Utilization of resources Utilization of resources Quality of care Quality of care Clinical outcome Clinical outcome Fully accredited 3 years and partially accredited 1 year Fully accredited 3 years and partially accredited 1 year Newly a 5 year has been introduced Newly a 5 year has been introduced

23. China (cont...) Four areas of treatment : Four areas of treatment : -Prevention -Prevention -Healthcare reconstruction -Healthcare reconstruction -Support and participation in disease prevention and care -Support and participation in disease prevention and care -Healthcare activities -Healthcare activities

24. China (cont…) Every 3 years Every 3 years Only accredited hospitals get license to operate Only accredited hospitals get license to operate Government can close non accredited hospital Government can close non accredited hospital The most important challenge :the number of trained surveyors necessary (120000 surveyor) The most important challenge :the number of trained surveyors necessary (120000 surveyor)

25. Latin America and the Caribbean Has begun in early nineties Has begun in early nineties PAHO and Latin American Federation Of Hospitals PAHO and Latin American Federation Of Hospitals Also a draft by MOPH of Argentina Also a draft by MOPH of Argentina

26. Latin America and the Caribbean 14000 hospitals (most of them <70 beds) 14000 hospitals (most of them <70 beds) Compulsory minimum standards and non- compulsory standards Compulsory minimum standards and non- compulsory standards

27. Latin America and the Caribbean (con…) Compulsory minimum standards : Compulsory minimum standards : - Medical care - Medical care - Technical and support areas - Technical and support areas - Building documentation - Building documentation - Functional physical structure - Functional physical structure - Installations - Installations Non compulsory :critical area, neonatology, nuclear medicine and … Non compulsory :critical area, neonatology, nuclear medicine and …

28. India Voluntary accreditation by Indian Hospital Association (IHA) failed in 1993 Voluntary accreditation by Indian Hospital Association (IHA) failed in 1993 Bureau of Indian Standards (BIS) has laid down standards for 30,100 and 250 beds Bureau of Indian Standards (BIS) has laid down standards for 30,100 and 250 beds National Institute for Health and Family welfare (NIHFW 1992)…standards for >50 beds only for equipment National Institute for Health and Family welfare (NIHFW 1992)…standards for >50 beds only for equipment Government standards for secondary level hospitals Government standards for secondary level hospitals

29. Pyramid of documentation QM Policies and procedures Instructions Forms Records

30. Standards Should Be 1. Explicit (written) 2. Degree of excellence 3. Objective (not subjective) 4. Compatible with culture and abilities 5. Able to improve continuously 6. Compatible with government requirements 7. Compatible with minimum community content 8. Motive the leadership Vs management (not like classification systems)

31. با تشکر والسلام عليکم