Dr hanan abbas Lecturer of Family Medicine TQM DIPLOMA AUC 2002
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Dr hanan abbas
Lecturer of Family Medicine
TQM DIPLOMA AUC 2002
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It is based on written and published standards
Reviews are conducted by professional peers
The accreditation process is administered by an
independent body
The aim of accreditation is to encourage
organizational development.
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Fundamental characteristics of accreditation:• Participation in the accreditation process is
voluntary and is an earned and renewable status.• Member institutions develop, amend, and approveaccreditation requirements.• The process of accreditation is representative,
responsive, and appropriate to the types ofinstitutions accredited.• Accreditation is a form of self-regulation.• Accreditation requires institutional commitment andengagement.• Accreditation is based upon a peer review process•Accreditation requires institutional commitment tothe concept of quality enhancement throughcontinuous assessment and improvement
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Before you start … ➜What do you expect to gain?➜What are the risks, costs?➜What are the incentives, or sanctions?➜ Do you have a choice of provider?➜ Do you have commitment from:• Governing board?
• Senior management? • General staff? • Medical staff?
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To implement a system which aims to:
• prevent errors and promote high quality
• apply best practice to the daily work
• build bridges between the health sectors• improve the quality of the patients’ journey
• create continuous quality development
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When the organizations have implemented the accreditationstandards which constitute its Healthcare Quality Programme,they must undergo an external survey.
A team of specially trained healthcare professionals will assess
the level in which the organizations meet the standards.
Accreditation is based on the surveyors’ assessment.
Accreditation take place every third year.
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Patient Safety
Staff and employee safety
Environment and community safety
Information Education and Communication
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An accreditationstandard is a standardfor good quality.
An example of a standardwithin medication:
”Drugs used in acute situations are easily accessible.”
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Basic Ingredients◦ Organizations apply on prescribed format giving
details as required
◦
Submission of a self assessment form indicating theoutcomes of its QMS and Internal Audits
◦ Extent of adherence to the laid down standards
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Completeness
Accuracy
Clarifications sought if required
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To ascertain the readiness of the organisation
for Accreditation Overview of the organizational preparedness
and commitment to quality goals andstandards
Deficiencies noticed informed to theorganisation
Advice rendered on the methodology to befollowed during the Accreditation Survey
Time frame worked out for the survey inmutual consultation
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Carried out by a team of Assessors depending
upon the size, complexity and facilities
provided by the organisation
Scope will include all standards related
functions and all patient care settings
Onsite survey will consider specific cultural and
legal factors which may influence or shape
decisions regarding the provision of care and
/or policies and procedures
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Initial presentation by the organization
Document Review
Adherence to statutory obligations Visits to various areas
Facility surveys and tours
Random structured interviews
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Organogram Quality management Team
Methodology followed for Quality Improvement
Facilities provided
Inputs on resources provided for QualityImprovement
Identified high Risk Areas for patient care andsafety
Sentinel Events being monitored
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Key Monitoring Indicators◦ Resource
◦ Volume
◦ Utilization
◦ Performance
Control charts
Problems faced and remedial measures
undertaken/ being undertaken
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•Quality Manual
•Various Policies and Procedures
•Minutes of Meetings of various committees
•Medical Records
•Medical / Nursing Audit•Adverse Events
•HAI
•Action Taken Reports
•Personal Records of Staff
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•Facility Safety
•Level of compliance with laid down policies and
procedures
•Standard Precautions
•Patient care
•Fire Safety
•Equipment Management
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• Staff Interview
• To determine their level of awareness and
compliance with organization policies and
procedures
• To assess their awareness levels of theirrights, privileges and patient rights
• To determine their satisfaction levels
• Patient and family Interview• To assess their level of awareness of the care
process and their rights
• To determine their satisfaction levels
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Pattern
◦ Non-compliance 0◦ Partial compliance 5◦
Full compliance 10
No standard can have more than one zero
The average for a standard must exceed 5
The overall average score must exceed 7 No zeros in legal requirements
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Accredited◦ HCO shows acceptable compliance with laid downstandards in all areas
◦ Includes the scope of services for which accredited◦ Any increase in scope the survey has to be done for the
increased scope
Accreditation denied◦ HCO is consistently non compliant with standards or non
adherence to safe and ethical practices
Accreditation withdrawn◦
HCO withdraws voluntarily◦ Due to consistent non compliance
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Generally three years with one Reassessment
survey to ensure continued compliance and to
assess the CQI programme
If during accreditation The Accreditation
organization receives inputs that the organization
is substantially out of compliance with the currentstandards then Resurvey or withdrawal of
accredited decision may be resorted to
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Create willingness
Initial impetus from Top management
Requires involvement of all staff
This requires repeated training and briefing Once consensus is there identify core coordinating
or Quality management Team
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Examine what are you doing
Find what you should be doing
Document the gaps
Compare with the standards
Complete gap analysis
Identify areas for improvement
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Focus on uniform training of all employees in key areas
Encourage by financial and / or non-
financial incentives Initially prepare to provide extra
resources
Avoid disappointments if initial benefits do not accrue as expected
Be prepared for a longer gestation
period for benefits to accrue
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Quality Consciousness at all levels will take time
Sustenance and consistency of efforts will berequired
Commitment on a consistent basis
High rates of attrition will require repeated andcontinual training
Public Sector will take a longer time to get intothe process
Quality and consistency of assessors andassessments
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Global WHO initiativesInternational health system benchmarking
The world health report 2000 – Health
systems: improving performance used five
indicators to rank the overall performance ofnational health systems:
• overall level of population health; • health inequalities (or disparities) within the
population;• overall level of health system
responsiveness (a combination of patientsatisfaction and how well the systemperforms);
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• distribution of responsiveness within thepopulation (how well people of varyingeconomic status find that they are served bythe health system);
• distribution of the health system’s financialburden within the population (who pays thecosts).
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On these indicators, the report concludedthat France provided the best overall health
care, followed by Italy, Spain, Oman, Austriaand Japan.
The United States health system spends ahigher portion of its gross domestic product(GDP) than any other country but ranked 37thout of 191 countries according to these
criteria; the United Kingdom, which spends just 6% of
GDP on health services, ranked 18th.
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Any PHC facility in Egypt is eligible toparticipate in the MOHP accreditationprogram. A part of HSR program, theaccreditation shall be:
Obligatory to all PHC facilities interested in joining the reform program and contractingwith the family health fund.
Voluntary to any other facility interested in
being accredited.
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Has instituted a process to monitor, evaluateand improve the quality of care to it ispatients.
Has instituted the patient record system
designed to document key patientinformation. Provide a defined package of services
including reproductive health, neonatal care,childcare, adult care, basic emergency care,
and preventive health services. Provide services that include ambulatory
care with or without inpatient services.
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The facility must be:
1. Operated for at least six months
2. Have appropriate licensure by MOHP.3. In compliance with all government laws and
regulations
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The survey is a key step in the accreditationprogram. It is an organized and structuredmechanism to identify strengths and weakness of ahealth care facility.
The survey process consists of a site visit to thefacility conducted by a team of expert trained inaccreditation using a pre-set accreditation surveyinstruments and tools.
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The purpose is to evaluate the extent towhich healthcare facilities comply with thenationally established MOHP accreditationstandards.
The results of the survey determine whethera facility is awarded or denied accreditation.In addition surveys are useful in exchanging
skills and expertise between the surveyorsand the facility staff.
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Applying for accreditation
Awareness seminars
Pre-accreditation visit
Accreditation awards: the results of the survey willlead to three decisions:
Full accreditation
Provisional accreditation
Denied accreditation
The duration for which an accreditation statusremains valid is two years.
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Record review where specific administrativeand clinical records will be reviewed
Personal interviews, and
Observation where the performance of specific tasks in certain areas are observed.
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SOURCE: Team analysis and Ministry of Health primary care department 38
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ACCREDITATION IS A JOURNEY
AND NOT A DESTINATION.
BON VOYAGE !!!!!