2. New Mowasat Hospital Accreditation Dr. Ghaleb Okla, FAAMA Diplomat in Health Care CEO/VP Health Care September, 2003

3. Commitment to Quality If Quality Is Sacrificed Society Is Not Truly Served

4. Philosophy Statement  Accreditation Provides The FRAMEWORK That Allows You to Improve QUALITY!

5. 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.

6. What is Accreditation  “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

7. 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

8. Why Seek Accreditation? Leaders want it Enhances customers attraction Enhances businesses Gives the system an added competition Improves the marketing and PR strategy

9. Accrediting Agencies Related to Quality planning I. Directed at organizations 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.

10. Accrediting Agencies Related to Quality planning II. Directed at organizations Malcolm Baldridge Award (USA)which was created to: –Build awareness about quality improvement; –Recognize accomplishments about quality improvement –Transfer information about quality improvement 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. CAMH

11. Accrediting Agencies Related to Quality planning –Directed Individuals Licensing Certification Credentialing –For government or organizations National clinical practice guideline development Quality control –Performance measurement

12. Commitment to QUALITY Quality Products and Service will never exceed the Quality of the LEADERSHIP TEAM

13. Accreditation Categories Accreditation Accreditation with Type I Recommendations Provisional Accreditation Conditional Accreditation Preliminary Denial of Accreditation Accreditation Denied Accreditation Watch

14. Preparation Senior Leadership Support Lead Individual- Dedicated time Multi-disciplinary team Coordinating Meetings Start 9-12 months in advance of Survey

15. Preparation Document review Leadership/strategic planning review Visit to patient care setting Function interviews –Human resources –Infection control –Information management/Medical records –Performance measurement Leadership interviews –Administrative –Medical –Nursing

16. Survey Survey Team- Clinical Administrative Lasts 2-4 days Primary Focus is on Performance Improvement Examine activity/ Outcomes/People not Policies/ Paper

17. Applicable Chapters 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

18. Applicable Chapters Management of Information Surveillance Prevention, and Control of Infection Governance Management Medical Staff Nursing

19. The Survey Process

20. Opening Conference –Meet key leaders of the organization –Review survey schedule –Inquire about the occurrence of sentinel events Quality Management & Improvement Presentation –Orientation to the organizations Quality Management and Improvement Program Document Review –Assesses compliance to standards from a design (P&P) standpoint Leadership/Medical Staff/Surveyor Interviews –Assesses compliance to leadership responsibilities Main Question: What is your policy? Main Question: What is your policy?

21. The Survey Process Main Question: Does practice follow Policy? 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 Function Team Interviews –Reviews compliance to key functions of the organization Facility Management and Safety –Building tour and unit visits

22. Sample JCAHO Questions About Measurement How do you measure the performance of your processes for medication use? Does this measurement include the following: –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?

23. Sample JCAHO Questions About ED 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?

24. Deficiencies With the Accreditation Process Cost Office of Inspector General -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

25. General Costs Survey Costs Personnel Time Opportunity Cost

26. Challenges/Obstacles Board of Directors Support Medical Staff Issues Administrative Support Budgetary Issues Turf Issues Information Support

27. Challenges/Obstacles Challenges/Obstacles Lack of Technical Support Country Regulations Political Issues Human Resources Issues Willingness to Change

28. Internal Strategies To Overcome Barriers 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

29. External Strategies To Overcome Barriers 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

30. Long Term Impact Meet External Expectations Assist Contract Negotiations/Marketing Move Organization to Focus on PI and Customer Service

31. Survey Preparation/Accreditation Count Down Starts from the Date of Assembling the Team 2-3 Years Prior to Survey –Overall System Preparation 15 Months Prior to Survey –Educational Session and Baseline Assessment 12 Months Prior to Survey –Follow-Up Assessments / Support 3 Months Prior to Survey –Formal “Mock Survey”

32. Your Turn Any Questions?