French Accreditation of Dar Amal University Hospital. More value More safety in order to enforce our Patient is always right vision..

Transcription

1 French Accreditation of Dar Amal University Hospital More value More safety in order to enforce our Patient is always right vision.. 1

2 Dar Al Amar University Hospital Located at Baalbeck. Founded in 1986 The patient is always right. A general hospital with 200 beds (ICU, CCU, ICN, CSU, PICU, dialysis, openheart and general surgery, obstetrics and maternity...etc) Characterized by a unique and qualified health care in the region (for the neonatology, adult and pediatric intensive care, dialysis, chemotherapy, opthalmic and cosmetic surgery, etc.) Accredited without reservation or recommendation in 2011 (Lebanese accreditation) Nursing school Partnership with - University Hospital Hôtel Dieu de France Beirut - Swiss hospital group (EOC ente ospedale la Carita) since

3 Dar Al Amal into an international recognition Why French Accreditation? International system with worldwide acceptance Has a consideration to Arab and Lebanese health systems and culture -Patient care oriented -Excellence in safety (ID, Medication flow, infection control, anaesthesiology, etc.), Sustainable growth, Patient rights, Patient involvement (committee members, Patient user committee, etc.), Focused care (Eldery, Pediatric, Cancer, Palliative), Patient record (patient access), Patient tracers (EPP tools), Patient followup (in-out, self management, therapeutic education) etc.

4 What benefits does French accreditation offer? Better acceptance by our national and international partners More patient trust in the quality and safety of healthcare Objective proof of quality and competence in compliance with international French standards Competitive advantages Supplementary legislation (. waste management, patient rights, etc.) Continuos improvement of manpower 4

5 Accreditation steps Written application Application study by France Accreditation and approval Accreditation arrangement signature (octob.2011) Initial survey (dates and survey team allocated) Self-evaluation (technical review, submission nov.2013) Accreditation survey (assessment may. 2014) Accreditation decision, report public publishing (web) And continuous assessment (oct.2014) Accreditation cycle Non profit French organization Promotes the French accreditation Adopts the French standards with foreign health facilities Manage French survey teams with the foreign healthcare facilities Coaches professionals and healthcare facilities towards the French accreditation mentioned in the final report of the accreditation published in web Valid for three years 5

6 French Hospital Manual (Standards) 2 chapters Healthcare Organization management + Patient (user) Management 8 main Parts Strategic Management Resource Management Quality Management and Patient Safety Right and Patient Centred Data Patient Management Patient Flow Specific Care Professional Practice Appraisal (EPP) Criteria

7 Required Priority Practice Criteria Fundamental for the improvement of healthcare quality and safety Failure to achieve a significant level of compliance with leads to an adverse accreditation decision or even to a decision of non accreditation Indicators Criteria Develop a culture in which quality of healthcare can be measured Have available ways of measuring quality, safety and clinical practices Increase the leverage for continuous improvement Useful for the self-evaluation and the survey to evaluate the quality level attained for specific criteria

8 Trace survey (3 French surveyors) Evidence check Documentation check Professional interview - committee meeting Data cross (evidence, meetings, observations, interviews, etc.) Trace approach Process trace (exp. clinical units, emergency, ICU, etc.) System trace (exp. Medical record, patient safety, infection control, EPP, etc.) Patient trace (as EPP tools)

9 to ACCREDITATION REPORT PUBLISHING (web) Survey REPORT OBSERVATIONS 1 month PEER DEC. ACCREDITATION REPORT 1 month PUBLISHING Web Site + 3 weeks + 3 months + 4 months + 7 months Follow-up 9

10 4 accreditation levels (decision) 1. Accreditation 2. Without recommendation 3. Accreditation with recommendation(s) At least one recommendation 4. Accreditation with reservation(s) At least one reserve (with possible recommendations) 5. No accreditation Many major reservations or/ and Decision to suspend the accreditation

11 Prise en charge des urgences et des soins non programmés Prise en charge médicamenteuse du patient Organisation des endoscopies Organisation du bloc opératoire Politique et organisation de l'évaluation des pratiques professionnelles 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Programme d'amélioration de la qualité et de le sécurité des soins Gestion des évènements indésirables Maîtrise du risque infectieux Système de gestion des plaintes et des réclamations Management de la prise en charge médicamenteuse du patient Prise en charge de la douleur Identification du patient à toutes les étapes de sa prise en charge Accès du patient à son dossier Prise en charge des patients en fin de vie Gestion du dossier du patient Accreditation without recommendation