1. Presented by Salma Jaouni, CEO, Health Care Accreditation Council First Dubai Health Regulation Conference for the MENA region 22-23 October, 2014 Regulatory Standards Do they promote continuous quality improvement!

2. 2 Some standards are more comprehensive others less! HCAC Standards MM.7.2 A system to control the use and distribution of high alert medications is in place according to laws and regulations. _  Critical Measurable Elements:  There is a policy/procedure to control the use and distribution of high alert medications, which includes::  List of high alert medications  Procedure for storing, securing of high alert medications  Safety practices have been implemented to reduce harm associated with high alert medications including removing high alert medication from patient care units or limit or standardize their numbers.  Strategies have been developed to identify and mitigate errors associated with high alert medications when they occur.  The policy has been communicated to relevant staff members.  The policy/procedure is carried out JFDA Article (74): The pharmacist in charge, who is licenced to dispense narcotics and hallucinators, may dispense those items prepared for medical use to the following persons:- Article (75): A -It is prohibited to dispense any special medical prescription containing any narcotics or hallucinators unless such prescription has met the following terms: B -Taking into consideration the provisions of clause (8) of paragraph (A) of this article, the pharmacist in charge must not dispense any prescriptions containing any narcotics and hallucinators to cancer patients except when the following terms are fulfilled:- Article (76): In case any special medical prescription does not fulfill any of the provisions specified in article (75) of this law, or in case the pharmacist is doubtful of its authenticity, he then must not dispense the same and must Article 77-87 High Alert Medication

3. 3 Some standards are more comprehensive others less! HCAC Standards related to a regulation HRM.7 The hospital has a process, defined in writing for verification of the license, education, experience, and certification for all licensed professional staff. MM.1 Pharmacy services and medication management processes within the hospital comply with applicable laws and regulations. IP.1.3 Infection prevention and control activities are in compliance with laws and regulations. Additional standards on the same topic IPC.7 Isolation precautions are in place when indicated. IPC 6.6 The surveillance data results and reports are disseminated to senior management and concerned department or units to be utilized for improving the quality of care. ST.1 The hospital has a central sterilization supply department (CSSD). ST 1.1 Sterilization processes are managed by individual who is qualified by training and experience. Infection Control

4. 4 Quality improvement is an activity that requires a continuous cycle of assessment re-asseessment checking double checking implementing feedback and updating

5. 5 In any type of standard development, there should be room for revision, growth and raising the bar Review of literature to develop first draft Step 2Step 3Step 4Step 5 Step 6 Step 7 Review first draft by a local experts Task Force to determine: Appropriateness for Jordan & the region Clarity and correctness of wording Classification of standards (critical, core, stretch) Review second draft by an external committee of experts to ensure that the standards are internationally acceptable Review fourth draft by the HCAC Board Technical Committee and recommend approval to the full board Translate into Arabic and send for ISQua accredita tion Field test the third draft by to ensure applicability and smoothness Collect feedback, Q&A, and assess implementation - review and update every 3 years Needs Assessment Step 1 HCAC Standards Development

6. 6 In accreditation standards, there is a consultative process that ensures many qualities to the standards Standards reflect legislative requirements, safety and good practice Standards should be relevant, understandable, measurable, beneficial and achievable. Standards reflect legislative requirements, safety and good practice Standards should be relevant, understandable, measurable, beneficial and achievable.  Reviewing other accreditation and certification organization standards  Incorporating legislative, technical and safety requirements  Incorporating best practice where evidence is available  Ensuring the standards are client focused, cover the functions or systems of a whole organization or service, address the dimensions of quality and support quality improvement  Consulting stakeholder groups, including and consumer groups  Involving stakeholders in standards development committees and working groups  Developing the measurement system for measuring compliance with/achievement of the standards  Testing the standards and the way they are rated through self-assessment, pilot surveys  Using feedback from testing to improve the standards and rating system  Developing guidelines to assist users to interpret and apply standards  Get standards approved by accreditation organization governing body

7. 7 Accreditation standards differ from regulatory ones in referencing criteria and measurement systems Measurable Elements Requirements of the standard that will be reviewed and assigned a score during the accreditation survey process Each Cluster is composed of 4 line items Classification  Critical (24 Standards): Address laws and regulations and, if not met, may cause death or serious harm to patients, visitors, or staff  Core (98 standards): Address systems, processes, policies and procedures that are important for patient care  Stretch (7 standards): Important standards, but not easy to implement due to time or resource constraints, or a need for culture change Standards Statements Survey Process HCAC PRIMARY HEALTH CARE STANDARDS

8. 8 Accreditation standards also have characteristics that are at the core of their aim  Dignity and respect: Values, beliefs and cultural backgrounds  Information sharing: Share perspectives & questions  Participation: Patients and families  Continuity: Continuum; designing systems that promote seamless transitions Characteristics of Standards  Provide guidelines for quality patient care  Are not prescriptive in nature  Are Patient centered  Are educational in aim What is Patient Centered Care? HCAC STANDARDS

9. 9 Accreditation Standards also have dimensions that are crucial to their applicability Characteristics of Good Standards Based on scientific evidence or other acceptable experience, expert consensus at a minimum Valid Leads to the same result each time it is applied by anyone who uses it. Reliable Understood in the same way by everyone; not subject to misinterpretation Clear Can be achieved with existing resources, suited to the setting Realistic Can be quantified or count Measurable

10. 10 This is what makes accreditation a continuous quality improvement process New standards every other year Contiguous engagement Un-announced midpoint assessment Mystery client Continued reporting HCAC Accreditation Model

11. 11 This does not mean that regulatory standards can not promote continuous improvement! Ireland: http://www.hiqa.ie/

12. 12 As long as the standards follow the characteristics, but more importantly continue to progress in a process! Consult- ative Evidence based implement- ed measured Needs assess- ment  Developed based on evidence based practice in both clinical and managerial aspects  Updated frequently and when needed  There is a system that ensure the implementation that:  enforce the development of organizational P&P that translate the requirements into practice  include active monitoring system of implementation by auditing or frequent submission of related indicators  The intent of the regulatory system foster quality improvement and patients safety:  promote the quality cycle component (PDSA: plan, do, study, act)  Covered all quality principles and aspects requirements

13. Questions and Comments 13

14. Thank You