Study On Accreditation and Barriers Of Implementation

48 

Loading....

Loading....

Loading....

Loading....

Loading....

Full text

(1)

Presented By:

Dr. Minhaj A. Qidwai

MBBS, MPH (USA), MBA (USA), CMC (Canada)

Program Director, Health Management

Institute of Business Administration, Karachi. Pakistan

Supported By:

Dr. Sarosh Siddiqui

Assistant Professor Jinnah Sindh Medcial University

Karachi-Pakistan

Study On Accreditation and Barriers

Of Implementation

(2)

A process

Through a Third party entity,

separate

and proven, competent evaluator, distinct

from the hospital

,

Assesses the hospital to determine if

it:

Meets a set of standards d

esigned to

improve:

Quality and

Safety of care

(3)

Accreditation supports...

Quality improvement

Patient safety

Risk management

Strategic change and risk

Management

Pro-activeness

Transparent and rigorous

analysis of service

(4)

Does accreditation make a difference?

Better

communication

and

collaboration

Stronger

inter-disciplinary teams

Increased

credibility

and

accountability

Accredited hospitals report significant

improvements in:

Leadership and decision making

Promotes measurement and use of indicators

improvements

Medical records management

Infection control

Clinical Outcomes

Reduction in medication errors

Staff training and professional credentialing

(5)

-

What sectors of the health system should be accredited

hospitals, ambulatory and primary care facilities, or both?

Should both public and private sectors be included?

To what extent should community representatives participate

on accreditation boards or survey teams?

Should the accrediting bodies be governmental or non

-governmental organizations?

Should accreditation surveys be scheduled or ―surprise

visits‖ or both?

IMPORTANT QUESTIONS CONSIDERING

ACCREDITATION

(6)

6

ELEMENTS OF AN ACCREDITATION

PROCESS

Accreditation Body

Standards

Assessors

(7)

Certification

Written assurance (the certificate) by an independent external body that

processes or products conform to the requirements specified in the

standard.

Accreditation

Is a formal recognition by an accreditation body that a person or institution

is competent to carry out the certification in specified business sectors (=

certification of the certification body)

Certification versus Accreditation

(8)

Assessment: Norms and Accreditation-Module 11 8

PROCÈS FOR ACCRÉDITATION

not one to be taken lightly

or without forethought

Requirements

Knowledge

Resources

(9)

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)

(10)

Improves professional staff development.

Provides education on consensus standards.

Provides leadership for quality improvement within medicine and

nursing.

Increases satisfaction with continuous learning, good working

environment, leadership and ownership.

(11)

Improves care.

Stimulates continuous improvement.

Demonstrates commitment to quality care.

Raises community confidence.

Opportunity to benchmark with the best.

(12)

Quality revolution

Disaster preparedness

Epidemics

Access to comparative database

(13)

Continuity of care & Safe transport

Pain management & Focus on patient safety

Patient satisfaction is evaluated

Rights are respected and protected

Access to a quality focused organization

Credentialed and privileged medical staff

High quality of care

Understandable education and communication

(14)

Accreditation

INPUT

Is a

PROCESS

Not an

event

OUTPUT

Summary-What is Accreditation?

OUTCOME

(15)
(16)

Accreditation

INPUT

Is a

PROCESS

Not an

event

OUTPUT

Summary-What is Accreditation?

OUTCOME

IMPACT

(17)
(18)

Professional Accrediting Bodies

International Professional Bodies National Professional Bodies Regional Professional Bodies

(19)

International Quality Assurance

Bodies

Regional Quality Assurance

Bodies

National Quality Assurance

Bodies

Professional Bodies

(20)

Selected Systems:

• International Organization for Standardization – ISO

• European Foundation for Quality Management – EFQM

• Joint Commission International – JCI

• The Accreditation Commission for Health Care (ACHC)

Quality Management Systems used

in health care organizations

(21)

• World's largest developer and publisher of international standard

• Standards are applicable to many kinds of organizations including clinical and public health laboratories

• 1947: Creating the International Organization for Standardization

• 2012: ISO is a network of national standards institutes from 163 countries

• 2012: Over 19 000 International Standards covering almost every aspects of technology and manufacturing

International Organization for

Standardization (ISO)

(22)

European Foundation for Quality

Management – EFQM

» Founded in 1989 by 14 European organisations, in order to increase the competitiveness of European organisations

» Not-for-profit membership foundation based in Brussels » Creator of „The EFQM Excellence Model“

» The aim of the Model is to improve performance in order to reach „Excellence“

» 2012: more than 30 000 organisations in Europe use the Model

» Provide training, assessment tools and recognition for high performing organisations  EFQM Excellence Award

(23)

• Founded in 1951

• Independent, not-for-profit organization

• Define quality standards specially tailored for health care facilities

• focuses on safety quality of medical services, patient and employee satisfaction

• All processes are assessed (from patient registration, examination, treatment up to the transfer and discharge of a patient)

• Accredits and certifies more than 19,000 health care organizations and programs in the United States

• The whole organization, not just individual departments are being evaluated

Joint Commission on Accreditation

of Healthcare Organizations - JCAHO

Source: www.jointcommissioninternational.org www.jointcommission.org

(24)

Joint Commission International – JCI

Created in 1994

Implements the goals of the JCAHO at an international

level

Supports health care organizations through accreditation,

education and technical assistance

Accreditation of an organization: Is a recognition given to

the healthcare organization, which meet the

JCI standards

JCI has a presence in organizations in

more than 90 countries

Joint Commission International

-JCI

Source: www.jointcommissioninternational.org www.jointcommission.org

(25)

Has developed several standards for

disease-specific diagnostic laboratories, such as polio,

tuberculosis, influenza, measles

25

(26)

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

(27)

• 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

(28)

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

(29)

• Formal Accreditation by Ministry of Public Health (MOPH)

• Three levels of hospitals

-Neighborhood or township level

-District, country, industrial complex level -Large municipal and teaching level

• Four areas of treatment : -Prevention

-Healthcare reconstruction

-Support and participation in disease prevention and care -Healthcare activities

• Every 3 years, only accredited hospitals get license to operate

• Challenge :the number of trained surveyors necessary (120000 surveyor)

(30)

• The Pakistan Standards and Quality Control Authority, under the Ministry of Science and Technology, is the national standardization body.

• In performing its duties and functions, PSQCA came into operation in Dec. 2000.

• It has been given the task of not only formulation of Pakistan Standards, but is also responsible for promulgation thereof.

• A technical committee comprising of multidisciplinary representation from public and private healthcare sector of Pakistan worked under the auspices of (PSQCA) to develop the first edition of Pakistan’s Hospital Accreditation Standards.

(31)

• Pakistan’s Hospital Standards and their criteria were specifically developed in 2013 in the context of Pakistan’s “

• National culture,

• Healthcare infrastructure, and

• Availability of resources.

• Any hospital may use this standard framework for continual improvement of its structures, processes and outcomes.

• Quality Improvement will proceed most efficiently and effectively if the

structures and processes chosen have been demonstrated to be associated with the desired outcomes of care. It comprised of following sections:

(32)

• These set of standards expects hospitals to define:

• Its objectives and mission statement,

• Establish governing boards and leadership responsibilities,

• Develop risk management and QI plans,

• Financial management procedures,

• Human resource management procedures,

• Promote patient rights and complaints management, and

• Respect patient’s privacy.

Sections of The Pakistan Hospital Standards

Part A: Management Standards

(33)

• These set of standards expects hospitals to improve:

• Accessibility of services,

• Continuity of care,

• Assessments,

• Care planning,

• Monitoring and evaluations,

• Treatments,

• Care documentation,

• Discharge,

• Specific Processes for: referral, operation theatre. ER, Intensive care, resuscitative and maternity.

(34)

These set of standards expects hospitals to:

Improve clinical laboratory services,

diagnostic radiology services,

and pharmacy services.

These set of standards expects hospitals to Improve health and safety

of all by:

Development and implementation of life safety,

Health safety,

fire safety/emergency preparedness, equipment safety and environment safety

Part C: Auxiliary (Support) Services

Standards

(35)

These set of standards expects hospitals to :

Develop and implement hospital infection control program,

Handling of sterile supplies,

Cleanliness and sanitation and waste management

Part D: Infection Control, Hygiene and Waste

Management Standards

(36)

Healthcare organizations opt for accreditation to:

Become part of a recognized entity,

Meet its standards in order to, achieve excellence, strategic

management and improvement in operational processes,

Stand out among the competitors.

Raising their own standards,

Better market share, and other benefits.

Qualitative Study on Barriers to PSQCA

set Hospital Standards

(37)

• With all the inherent benefits of accreditation, what are the barriers, which prevent organizations from getting Accreditation?

• A research was undertaken recently, to study the barriers of implementing “Hospital Standards” developed by Pakistan Standards and Quality Control Authority (PSQCA).

• It used semi-structured qualitative questionnaire, for data collection from hospital administrators in Karachi-Pakistan.

• Total 200 forms were distributed to hospital administrators and CEOs’ and analysis was undertaken on the received 82 forms.

Qualitative Study on Barriers to PSQCA

set Hospital Standards

(38)

Majority of the respondent were unaware of the PSQCA standards for

hospitals.

Table 1 - Aware of PSQCA documentation for Hospital Standards

Qualitative Study on Barriers To PSQCA

set Hospital Standards-Results

(39)

Respondents were aware of international accreditation organizations

for such a process .

Table 2 - Aware of any International Accreditation Organization

for setting Hospital Standards:

Qualitative Study on PSQCA set Hospital

Standards-Results

(40)

Leadership not interested in change

Organizational politics, culture and

policies,

Financial constraints,

Lack of infrastructure,

Bureaucracy

Status Quo

Qualitative Study on PSQCA set

Hospital Standards-Results

Lack of supportive environment,

Ill equipped workforce,

Unsure of ROI

Compliance and

Regular monitoring.

(41)

Understanding of Accreditation Process by Top Leadership.

Capacity building of all concerned.

Organize training on a national level on Quality, Patient

Safety and change management,

Ensuring adequate resources for Accreditation.

Make separate standards for Public and Private hospitals.

Bringing the quality conscious hospitals’ on one platform.

Qualitative Study on PSQCA set Hospital

Standards-Results-Overcoming Barriers

(42)

Start in a step by step manner.

Initiate Quality Improvement Programs as a first step.

Develop and implement SOPs’.

Business Oriented Management.

Ensure job security.

Transparency.

Qualitative Study on PSQCA set Hospital

Standards-Results-Overcoming Barriers

(43)

43

Conclusion

Standards developed by Accreditation Entities provide guidelines that

form the basis for quality practices and patient safety.

The model of Input, Processes, Output, Outcome and Impact can be

incorporated for the desired results.

Accreditation and certification are processes which recognize that an

entity is meeting the designated standards.

An active quality management program can be the first step in towards

creating an aura of “accreditation-readiness”.

(44)
(45)

45

Accreditation does not

guarantee

success,

it is only one step along the quality journey

CONTINUAL IMPROVEMENT QUALITY MANAGEMENT CUSTOMER SATISFACTION ACCREDITATION ERROR REDUCTION

(46)

Without change there is no innovation, creativity,

or incentive for improvement.

Those who initiate and measure the change will

have a better opportunity to manage and lead the

change that is inevitable.

(47)

A journey that will take enormous efforts to change. It is clear that improvement

in patient safety and quality will take time,

but the time for change is now

. Our

patients, residents, families and communities depend on providers to start now

and commit to the difficult yet achievable work ahead”

(Hassen & Dingwall, 2008)

We are on a journey!

Lead a change towards Accreditation of Your

Institution.

(48)

Figure

Updating...

References

Updating...

Related subjects :