‫بسم هللا الرحمن الرحيم‬
You can’t manage what
you can’t measure
Accreditation
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
Benefits of Accreditation
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Shows commitment to quality
Improves communication and collaboration
within the organisation
Promotes team building
Increases credibility
Demonstrates accountability
Improves productivity
Obtaining advice from surveyors (mentoring)
Studies show positive effect for:
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Patient (satisfaction, quality of care and
safety)
Staff (satisfaction and good work
condition)
Organisation (productivity, strategic
performance and financial viability)
Brief History
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Earnest Codman: End result system
(effectiveness of treatment) 1910
The era of minimal standards 1917-1965
The era of optimal achievable standards
66-87
The era of performance evaluation
1988…..
Accreditation methodology
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Function based (tracer methodology)
Department based
JCAHO(U.S)
1-Patient-Focused Functions
-Rights, ethics, responsibilities
-Provision of care, treatment,
services
-Medication management
-Surveillance, prevention, infection
control
JCAHO (cont…)
2-Organization Functions
-Performance improvement
-Leadership
-Management of environment of care
-Management of information
3-Structures With Functions
-Medical staff
-Nursing
Joint commission international
(JCI)
A new task force in 1997
In EU, Middle east and Far east
and then everywhere
JCI (cont…)
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ACC (Access to care and continuity if care)
PFR (Patient and Family Rights)
AOP (Assessment Of Patients)
COP (Care Of Patients)
ASC (Anesthesia and Surgical Care)
MMU (Medication Management and Use)
JCI (cont…)
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PFE (Patient and Family Education)
QPS (Quality improvement and Patient
Safety)
PCI (Prevention and Control of Infections)
GLD (Governance, Leadership and
Direction)
FMS (Facility Management and Safety)
JCI (cont…)
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SQE (Staff Qualifications and Education)
MCI (Management of Communication and
Information)
Egypt
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WHO and MOHP
From 1995
Critical standards 69
Core standards 322
Non core standards 325
Egypt (cont…)
The first award in middle east from ISQua
(the accreditor of accreditors )
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Lebanon
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World bank and MOPH
Department based standards
Basic standards and accreditation
standards (2001)
Second accreditation standards(2003)
Canada
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Canadian Commission On Hospital
Accreditation 1952
Monopoly
Including mental health and rehabilitation
facilities as well as general hospitals
Recently outcome measures
94% of hospital beds
U.K
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Though NHS had an agenda for accreditation but there
was not any response
Patient’s Charter (department of health’s standards for
patient services)
Investors in people (department of trade and industry)
King’s Fund Organizational Audit
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
China
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Formal Accreditation by MOPH
Three levels of hospitals
-Neighborhood or township level
-District, country, industrial complex
level
-Large municipal and teaching level
Australia
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Australian Council On Hospital Standards
1974
Utilization of resources
Quality of care
Clinical outcome
Fully accredited 3 years and partially
accredited 1 year
Newly a 5 year has been introduced
China (cont...)
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Four areas of treatment :
-Prevention
-Healthcare reconstruction
-Support and participation in disease
prevention and care
-Healthcare activities
China (cont…)
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Every 3 years
Only accredited hospitals get license to
operate
Government can close non accredited
hospital
The most important challenge :the
number of trained surveyors necessary
(120000 surveyor)
Latin America and the Caribbean
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Has begun in early nineties
PAHO and Latin American Federation Of
Hospitals
Also a draft by MOPH of Argentina
Latin America and the Caribbean
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14000 hospitals (most of them <70 beds)
Compulsory minimum standards and noncompulsory standards
Latin America and the Caribbean (con…)
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Compulsory minimum standards :
- Medical care
- Technical and support areas
- Building documentation
- Functional physical structure
- Installations
Non compulsory :critical area,
neonatology, nuclear medicine and …
India
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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
National Institute for Health and Family
welfare (NIHFW 1992)…standards for >50
beds only for equipment
Government standards for secondary level
hospitals
Pyramid of documentation
QM
Policies and
procedures
Instructions
Forms
Records
Standards Should Be
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Explicit (written)
Degree of excellence
Objective (not subjective)
Compatible with culture and abilities
Able to improve continuously
Compatible with government requirements
Compatible with minimum community content
Motive the leadership Vs management (not like
classification systems)
‫با تشکر‬
‫والسالم عليکم‬