Joint Commission International. Accreditation. Paul vanostenberg, DDS, MS Senior Advisor Joint Commission International

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1 Accreditation Paul vanostenberg, DDS, MS Senior Advisor Joint Commission International

2 Accreditation A Definition Usually a voluntary process by which a government or non-government agency grants recognition to health care institutions which meet certain standards that require continuous improvement in structures, processes, and outcomes. 2

3 Necessary Elements for a Health Care Accreditation System Standards of Performance Infrastructure Field Operations Design Accreditation System Decision Process Sources of Funding Database 3

4 How Accreditation Works Voluntary or mandatory Basis in health professions and health care delivery Consensus standards Peer evaluation Independent third party objective evaluation Recognition for achievement Re-review periodically 4

5 Impact on Quality Over 100 years of experience Risk reduction strategy The vehicle for evolving quality improvement methodologies Absorbed the patient safety movement Creates the capacity for continuous improvement in an organization 5

6 Steps in Process Obtain and study standards Implement standards and prepare for the evaluation External evaluation Decision and recognition Re-review 6 months months 3-5 days 1 month 2-4 years 6

7 What Accreditation Can Influence Enhance staff recruitment, retention, and satisfaction Improve patient confidence Improve or expand sources of payment for patient care Increase chances to enter networks and new provider arrangements Provide greater independence from government oversight Provide comparison with self, others, and best practices 7

8 Strengths of the Accreditation Methodology Uses consensus standards Offers external, objective evaluation Involves the health professions Is proactive, not reactive Is implemented organizationwide Focuses on systems, not individuals Stimulates quality culture in the organization Provides periodic re-evaluation against standards Can be delivered through public-private partnerships 8

9 Weaknesses of the Accreditation Methodology Seems unreachable to low resource countries The standards are not uniform in content and language, even those ISQua accredited Some standards codify law and regulation and seem to take the place of licensing The evaluation process varies widely The decision process varies widely The re-evaluation varies in length and content 9

10 SafeCare Initiative Mission: Place the issue of safe health care provision on the agenda in resource-restricted settings and create a platform for like-minded organisations and people who wish to provide safe health care despite resource constraints

11 SafeCare graded recognition leading to accreditation SafeCare Essentials Entry phase Graded recognition Phase: SafeCare standards Accreditation Minimal patient safety standards rapid risk assessment Continuous quality improvement Optiional % of standard compliance Full standards compliance Micro Loans Health Insurance Fund

12 Closing Thoughts Accreditation is a credible improvement methodology Accreditation is hard to study as it is not standardized Most studies are related to developed countries National licensure should be a prerequisite Confusion exists between national and international accreditation Little research on what makes a program sustainable Possibly need to use External Quality Evaluation rather than Accreditation 12

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