1. Rabab Diab, RN, MSN, CPHQ HCAC, Deputy CEO and Director of Education & Consultation Iraqi Health Conference – Erbil Monday, 28 May 2013 Accreditation Standards for Medical Staff Management

2. Outline Healthcare System in Jordan Medical Staff in Jordan and Challenges Quality and Patient Safety Journey in Jordan Quality and Patient Safety Challenges Accreditation Standards for Medical Staff Management Conclusion

3. Outline Healthcare System in Jordan Medical Staff in Jordan and Challenges Quality and Patient Safety Journey in Jordan Quality and Patient Safety Challenges Accreditation Standards for Medical Staff Management Conclusion

4. Introduction Upper middle-income country Population of 6.2 million Per-capita GNI of US$4,340 Youngest among upper- middle income countries with 38 percent under the age of 14

5. Healthcare Providers by Sector Public Sector Royal medical services Ministry of health (primary healthcare centers and hospitals) University hospitals Private Sector HospitalsPrivate clinics Diagnostic and treatment centers International Sector UNRWA

6. Outline Healthcare System in Jordan Medical Staff in Jordan and Challenges Quality and Patient Safety Journey in Jordan Quality and Patient Safety Challenges Accreditation Standards for Medical Staff Management Conclusion

7. Number of Physicians/10,000 Population 2005 – 2010 WHO, World Health Statistics 2012, 2012. See also, WHO, Global Health Observatory.World Health Statistics 2012Global Health Observatory

8. Medical staff management in Jordan have different strengths but face several challenges Strengths  Established education programs  Qualified medical staff  Good health out come indictors in terms of communicable diseases, infant and maternal health Challenges  Lack of leadership competency  Lack of regulations  No policies, procedures, clinical guidelines  Lack of credentialing and privileging system for medical staff  No relicensing system  Continuous education  No medical liability laws

9. Outline Healthcare System in Jordan Medical Staff in Jordan and Challenges Quality and Patient Safety Journey in Jordan Quality and Patient Safety Challenges Accreditation Standards for Medical Staff Management Conclusion

10. 10 Quality improvement for Jordan started with a visionary Minister who took a leap for accreditation… 2003 2004 2005 2007 2008 2009 2010 2011 2012 2013 12 members from a National Accreditation Committee was approved USAID Agrees to support initiative of Minister of Health Pilot Hospitals HCAC registered as a non-profit private sector company ISQUA accredits hospital standards ISQua accredits Surveyor Certification Course 1st edition Primary Health Care Standard ISQua accredits HCAC First Regional Conference NQSGs launched Cardiac Standards Patient Safety Center / Institute Diabetes Standards Second Regional Conference Public Awareness Medical Transport Standards Breast imaging Units Standards Centers of Excellence Pilot Hospitals and First draft of Jordanian Hospital standards First Surveyor Certification course started

11. 11 So HCAC was established in 2007 as a nonprofit private shareholding company with the aim to raise the quality of health services… HCAC Mission Vision To foster the continuous improvement of the quality and safety of health care facilities, services and programs through developing internationally accepted standards, capacity building and awarding accreditation HCAC services and accreditation will be the primary choice of healthcare facilities and organizations in Jordan and the region Values  Continuous Improvement  Customer Focus  Impartiality  Integrity  Learning  Teamwork  Transparency

12. 12 …Through a range of different services stemming out of two separate arms of the organization Functions Accreditor Enabler Consultant Development Training and Certified Courses Preparedness Consulting for Government Mock Surveys Accreditation Surveyor Development Standards Development Education and ConsultationDepartment ConsultationDepartment Surveys and Standards Development Department Surveys and Standards Development Department “A Comprehensive Model of Quality Improvement Services” Firewall

13. 13 HCAC can now showcase a multitude of successes… Standards  Hospital Accreditation Standards - 3rd edition  Primary Health Care & Family Planning Accreditation Standards– 2nd edition  Medical Transport Services Certification Standards- 1st edition  Breast Imaging Units Certification Standards- 1st edition  Diabetes Care standards 1st edition  Cardiac Care standards being developed 2012- 2013  National Quality and Safety Goals 2009, 2010, 2011, 2012, 2013  Family Planning & Reproductive Health Centers of Excellence Program- 1st edition Accreditation Education & Consultation  41 certified hospital surveyors  31 certified PHC surveyors  17 hospitals accredited – four in the pipeline  45 PHC accredited – 60 in the pipeline  4 Certified Breast Imaging Unit  Preparing 8 hospitals for Accreditation, 5 breast imaging units  Graduated groups from :  Certified Consultant Training program  Certified Quality professionals  Certified Infection Control professionals  Certified Risk Management  Leadership & Management

14. 14 Measurable Elements Requirements of the standard that will be reviewed and assigned a score during the accreditation survey process The HCAC Hospital Standards Manual (3rd ed.) is divided into 14 clusters entailing 347 standards and 1238 measurable elements The Clusters  Cluster 1: Ethics and Patients’ Rights  Cluster 2: Access and Continuity of Care  Cluster 3: Patient Care  Cluster 4: Diagnostic Services  Cluster 5: Medication Management  Cluster 6: Infection Prevention and Control  Cluster 7: Environmental Safety  Cluster 8: Support Services  Cluster 9: Quality Improvement and Patient Safety  Cluster 10: Medical Records  Cluster 11: Information Management  Cluster 12: Human Resources Management  Cluster 13: Management and Leadership  Cluster 14: Education and Training Each Cluster is composed of 4 line items Classification  Critical (57 Standards): Address laws and regulations and, if not met, may cause death or serious harm to patients, visitors, or staff  Core (257 standards): Address systems, processes, policies and procedures that are important for patient care  Stretch (33 standards): Important standards, but not easy to implement due to time or resource constraints, or a need for culture change Standards Statements Survey Process

15. Outline Healthcare System in Jordan Medical Staff in Jordan and Challenges Quality and Patient Safety Journey in Jordan Quality and Patient Safety Challenges Accreditation Standards for Medical Staff Management Conclusion

16.  chemical exposure  Lack of radiation safety  Absence of basic hygiene  Violation of human rights  Flies in operating rooms  Open sewage systems within hospitals  Lack of privacy  No fire safety procedures and systems  Untrained staff on basic resuscitation  Lack of medical staff management systems  Competency of healthcare providers  No documented policies, procedures, plans,  No clinical guidelines  Not in compliance with laws and regulations regarding fire safety, radiation safety, staff qualifications, and medication management processes. Quality and Patient safety still faces many challenges in Jordan

17. Outline Healthcare System in Jordan Medical Staff in Jordan and Challenges Quality and Patient Safety Journey in Jordan Quality and Patient Safety Challenges Accreditation Standards for Medical Staff Management Conclusion

18. Medical Staff Management Standards Credentialing and privileging Medical staff file Medical staff governance system Medical graduate program Performance appraisal

19. 19 Medical staff management standards Human Resources Education and Training Quality Improvement and Patient Safety Patient Care Medical Record Documentation Management and Leadership The standards of medical staff management are integrated in all clusters

20. 20 The process of obtaining, verifying, and assessing the qualifications of a licensed independent practitioner Why? To determine whether he/she is qualified and able to provide patient care services and to participate on the medical staff”” HRM.7 The hospital has a process, defined in writing for verification of the license, education, experience, and certification for all licensed professional staff.

21. 21  Current licensure  Relevant training and experience  Current competence  Peer recommendations  Clinical privilege delineation Essential Data in the Credentialing Process

22. 22 Privileging  The process of evaluation of an individual’s performance to determine if he/she is qualified and able to perform specific patient care services related to his/her specialty  Privileging of medical staff accompanies credentialing process.

23. 23 Granting Clinical Privileges  Delineation of clinical privileges  Delineation of admitting privileges  Categories of privileges  Limitations of privileges  Practicing within scope

24. 24 Other Data  Ability to perform  Challenges to licensure/registration  Voluntary/involuntary terminations or restrictions  Professional liability

25. 25 Medical Staff Management Standards  Credentialing and privileging  Medical staff file  Medical staff governance system  Medical graduate program  Performance appraisal

26. 26 -Documents related to license -Education -Experience -Certification HRM.9 a personnel file is maintained for each employee

27. Medical Staff Management Standards Credentialing and privileging Medical staff file Medical staff governance system Medical graduate program Performance appraisal

28. HRM.13 A governance system is in place for the medical staff to ensure the quality of patient care. Categories of medical staff Privileging Medical staff bylaws Medical staff issues Quality improvement activities Medical staff committee Role of medical staff members in committees Quality improvement initiatives Hospital-wide quality improvement program

29. Medical Executive Committee 29

30. Medical Staff Bylaws Medical staff structure Medical executive committee Credentialing and privileges processes Membership, delineation of clinical privileges, and termination Participation in organization improvement activities 30

31. ML.8 Each Administrative and Clinical Department has an assigned department head with specific responsibilities Each clinical department has a designated medical staff head who is board certified in a relevant specialty. The assigned department head responsibilities include: -Ensuring and overseeing the development and implementation of the departmental policies and procedures -Ensuring that quality improvement and patient safety activities are carried out (PDSA) 31

32. Medical Staff Management Standards Credentialing and privileging Medical staff file Medical staff governance system Medical staff graduate training program Performance appraisal 32

33. HRM.15 Hospitals that participate in professional under graduate education programs have a well-defined system for training. Supervision of trainees by qualified members and their relationship with the hospital Clear process for trainee orientation 33

34. Medical Staff Management Standards Credentialing and privileging Medical staff file Medical staff governance system Medical graduate program Performance appraisal 34

35. 35 HRM.8.1 Performance appraisals measure the performance of the employee against criteria related to evidence-based practice, innovation and/or research. Performance criteria are written supporting evidence-based practice, innovation and/or research for each category of employee including medical staff. Performance criteria are measurable, understandable, verifiable, equitable, and achievable.

36. Other Related Standards Medical Record Documentation All patient medical record entries are legible, complete, dated, timed, and authenticated. Clinical Practice Guidelines CPGs are adopted/developed and implemented for priority clinical services. Individual healthcare providers’ compliance with the clinical practice guidelines. Anesthesia Standards Current anesthesia evidence-based guidelines. Patients are managed by a qualified physician. 36

37. Outline Healthcare System in Jordan Medical Staff in Jordan and Challenges Quality and Patient Safety Journey in Jordan Quality and Patient Safety Challenges Accreditation Standards for Medical Staff Management Conclusion

38. 38 The future of Quality Improvement is full of commitments  Commitment to the QUALITY  Commitment to PATIENT SAFETY  Commitment to CAPACITY BUILDING  Commitment to RESEARCH and POLICY …HCAC is in continuous improvement itself…

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