Organizational Chart CBAHI Theme

Transcription

1 Vision To become the regional leaderin improving healthcare quality and safety. Mission To promote quality and safety by supporting healthcare facilities to continuouslycomply with accreditation standards. Organizational Chart CBAHI Theme Accreditation Preparation Monitoring Demographic Background Saudi Arabia, officially known as the Kingdom of Saudi Arabia, is the second largest Arab state (the first is Algeria) and comprises the majority of the Arabian Peninsula. According to thecensus held in 0, the population of the country is estimated to be 9,95,895 - the 4rd largest in the world. The middle age group of 5-64 makes up the greatest share of the total population - about 64.8%.

2 Distribution of Healthcare Facilities Large number and wide geographic distribution of healthcare facilities in KSA. Type of facility Total number in KSA MOH- General Hospitals 7 MOH- Specialized Hospitals 5 MOH- Medical cities Total MOH Hospitals 55 Non-MOH Govt. Hospitals 4 Private hospitals Total Hospitals 48 Ambulatory Care Centers,500 Primary Health centers,09 Laboratories 90 Regional & Ref. Labs 7 Total Healthcare Facilities: 5,4 HC Operating Co. (estimate) ~00 Total entities 5,4 7 Healthcare Accreditation Scope Standards Surveyors Survey Process Standard Development During phase, standard development will be done in six streams. CBAHI has developed two standard manuals, which will be updated and upgraded; while four new standards programs will be developed: Standard Program Standards Hospitals (HomeHealthcare as a chapter in the manual) Primary Healthcare rd Edition st Edition Ambulatory Care st Edition National Laboratory Dental Care Psychiatric Start Revision nd Edition Start develop Start develop EffectiveDate of st Edition EffectiveDate of st Edition 0 Standard Development and Maintenance CBAHI Standard Development Committee (SDC) Review Publication Distribution Bases of National Healthcare Standards Review Response to healthcare industry changes; Scientific literature Emerging Quality and Patient Safety Issues; Sentinel events reports; National and cultural interest; Senior authorities strategic objectives; Authority directives in response to the needs and complains of the public

3 Bases of National Hospital Standards Review Input from healthcare professionals and subject matter experts; Inputs from accredited organizations including comments and satisfaction surveys. CBAHI surveyors feedback CBAHI surveyor s report quality control Steps and duration of Standards Development The estimated period between developing the standards and implementation will be 8 4 months. Following are the process steps: Writing of Standards Pilot of standards for applicability First Draft Field Review National Consensus 8 months m m m m Approval- The Chairman (Council of Health Services) m Posted on CBAHI's website (incorporate feedback) 6 m Design the survey process (parallel to post on line) m Pilot of the survey Process (parallel to post on line) m Implementation of the standards 4 Surveyors ISQua Accreditation In June 0-06 Surveyors 5 6 The Number of Surveyors Number of Hospital Surveyors Per Sector Primary HealthCare Hospitals Ministry of Health National Guard - Military - Armed Forces Private Sector King Faisal Specialist Hospitals Medical Cities Universities Others 9 8

4 Number of Hospital Surveyors Per Region Phases of Survey Activities Najran Region, Tabouk Region, Hael Region, Al Baha Region, Al Qaseem Region, 4 Jeezan Region, Maddinah Region, 5 Aseer Region, 4 Eastern Region, 6 Makkah Region, 58 Riyadh Region, 4 Riyadh Region Makkah Region Eastern Region Maddinah Region Aseer Region Al Qaseem Region Najran Region Tabouk Region Hael Region Al Baha Region Jeezan Region Pre Survey On site Post Survey 9 Phases of Survey Activities Surveyors Selection & Training Path CVs Screening PRE SURVEY ON SITE POST SURVEY Primary Selection Call interview Selection of surveyors Opening Conference Accreditation Decision and Certification Reference Check Personal Interview Survey Application Survey Activities Appeal Process Theoretical Training ( days) Practicum ( days) Visit Preparation Exit Conference Survey Feedback Observation Visit (can be more than one) Mentored Mock Survey Visit Visit Preparation Survey Process Scheduling of Surveys Survey Team Composition Survey Agenda Survey Logistics 4

5 Survey Activities Opening Conference 7 Surveyors as: Survey Process Testing Evidence of Compliance (EOC) distribution Survey Activities Document Review Medical Record Closed Review Medical Record Open Review Interview (Leadership & Staff) Personnel Files Unit visit Core Team / days visit 4 Specialties / days visit Exit Conference 0//0 Survey Process Testing Evidence of Compliance (EOC) distribution Spec. Review LD Interview Interv iew LD NA 6 7 NA 47 MD NA 50 5 NR NA 60 IC 6 NA Ph 66 NA LB 9 NA FMS 06 NA Med. Staff Pers. Record Record Interview Files Closed Open NA NA 0 70 NA 89 NA NA 6 6 NA 4 NA 7 NA 6 NA NA Unit Visit Observation Interview Total NA 66 NA 84 Total Electronic Applications for Hospitals Electronic Application Demographic Questionnaire Hospital Resource Manual Hospital Self Assessment Application Hospital Scoring Application (Comments) Hospital Result and Executive Report Demographic Questionnaire Electronic Application Hospital Standards Resources Manual 5

6 Hospital Self Assessment Electronic Application Hospital Scoring Application (Comments) Hospital Result and Executive Report Feedback Surveyors Competency Assessment Healthcare Accreditation Department Hospital Surveyors Evaluation Process Peer/visit Specialty Team Leader - Content of Report - Percentage of Improvement - Participation of CBAHI activity - Skills How has accreditation made an impact on healthcare facilities and patient safety? 5 6 6

7 Quality Dimension - Staff competency -CBAHI score Mock Real Mock Mock Real 0 Comparison between Mock and Real Survey Scores Training Workshops to Hospitals 00.00% 90.00% 80.00% 70.00% 60.00% 50.00% 40.00% 0.00% 0.00% 0.00% 0.00% Workshops for Hospitals (7) Main Workshops (7 ) Specialized Workshops Medical Nursing 4 Leadership Pharmacy Laboratory Facility Management Infection Control Patient Education Pain Management Conscious Sedation Rapid Response Medical Records Medication Safety Risk Management E-Exams AHA Certification Center CHC Certified Healthcare Constructor CHESP Certified Healthcare Environmental Services Professional CHFM Certified Healthcare Facility Manager CMRP Certified Materials & Resource Professional CPHRM Certified Professional in Healthcare Risk Management BCEN Board of Certification for Emergency Nursing CEN Certified Emergency Nurse CBIC Certification Board of Infection Control & Epidemiology CIC Certification in Infection Control CBPPS Certification Board for Professionals in Patient Safety CPPS Certified Professional in Patient Safety HIMSS Healthcare Information & Management Systems Society CPHIMS Certified Professional in Healthcare Information & Management Systems 7

8 HQCC Healthcare Quality Certification Commission CPHQ Certified Professional in Healthcare Quality JRC Joint Commission Resources CJCP Certified Joint Commission Professional Jeddah Testing Center since February 008 Number of Hosted Exams = 0 NBPHE National Board of Public Health Examiners / CPH Certified in Public Health Number of Examinees = 57 NBRC National Board for Respiratory Care ACCS Adult Critical Care Specialty CPFT Entry Level Certified Pulmonary Function Technologist CRT Entry Level Certified Respiratory Therapist NPS Neonatal/Pediatric Specialty RPFT Registered Pulmonary Function Technologist RRT Registered Respiratory Therapist (RRT is two separate exams WRT and CSE) SDS Sleep Disorders Specialty 8