Study On Accreditation and Barriers Of Implementation

Transcription

1 Study On Accreditation and Barriers Of Implementation 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

2 Definition of Accreditation 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 designed 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 provision

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 IMPORTANT QUESTIONS CONSIDERING ACCREDITATION 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 nongovernmental organizations? Should accreditation surveys be scheduled or surprise visits or both?

6 ELEMENTS OF AN ACCREDITATION PROCESS Accreditation Body Standards Assessors 6

7 Certification Written assurance (the certificate) by an independent external body that processes or products conform to the requirements specified in the standard. Accreditation Certification versus 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) Source:

8 PROCÈS FOR ACCRÉDITATION not one to be taken lightly or without forethought Commitment Planning Requirements Knowledge Resources Assessment: Norms and Accreditation-Module 11 8

9 Benefits of Accreditation 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 Benefits For The Staff 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 Benefits For The Hospitals Improves care. Stimulates continuous improvement. Demonstrates commitment to quality care. Raises community confidence. Opportunity to benchmark with the best.

12 Benefits To The Community Quality revolution Disaster preparedness Epidemics Access to comparative database

13 BENEFITS TO THE PATIENTS 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 Summary-What is Accreditation? Accreditation INPUT Is a PROCESS Not an event OUTPUT OUTCOME

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16 Summary-What is Accreditation? Accreditation INPUT Is a PROCESS Not an event OUTPUT OUTCOME IMPACT

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18 Professional Accrediting Bodies International Professional Bodies Regional Professional Bodies National Professional Bodies

19 International Quality Assurance Bodies Regional Quality Assurance Bodies National Quality Assurance Bodies Professional Bodies Internal Quality Assessment

20 Quality Management Systems used in health care organizations Selected Systems: International Organization for Standardization ISO European Foundation for Quality Management EFQM Joint Commission International JCI The Accreditation Commission for Health Care (ACHC)

21 International Organization for Standardization (ISO) 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 International Standards covering almost every aspects of technology and manufacturing Source:

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 organisations in Europe use the Model» Provide training, assessment tools and recognition for high performing organisations EFQM Excellence Award Source:

23 Founded in 1951 Joint Commission on Accreditation of Healthcare Organizations - JCAHO 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 Source:

24 Joint Commission International - JCI 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 Source:

25 World Health Organization Has developed several standards for diseasespecific diagnostic laboratories, such as polio, tuberculosis, influenza, measles 25

26 Canada 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 U.K. 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 Australia 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 China 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 ( surveyor)

30 Pakistan 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 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 Development of Hospital Standards 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 Sections of The Pakistan Hospital Standards Part A: Management Standards 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.

33 Part B: Service Delivery Standards 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 Part C: Auxiliary (Support) Services Standards 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

35 Part D: Infection Control, Hygiene and Waste Management Standards These set of standards expects hospitals to : Develop and implement hospital infection control program, Handling of sterile supplies, Cleanliness and sanitation and waste management

36 Qualitative Study on Barriers to PSQCA set Hospital Standards 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.

37 Qualitative Study on Barriers to PSQCA set Hospital Standards 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.

38 Qualitative Study on Barriers To PSQCA set Hospital Standards-Results Majority of the respondent were unaware of the PSQCA standards for hospitals. Table 1 - Aware of PSQCA documentation for Hospital Standards

39 Qualitative Study on PSQCA set Hospital Standards-Results Respondents were aware of international accreditation organizations for such a process. Table 2 - Aware of any International Accreditation Organization for setting Hospital Standards:

40 Qualitative Study on PSQCA set Hospital Standards-Results Leadership not interested in change Organizational politics, culture and policies, Financial constraints, Lack of infrastructure, Bureaucracy Status Quo Study highlighted barriers included Lack of supportive environment, Ill equipped workforce, Unsure of ROI Compliance and Regular monitoring.

41 Qualitative Study on PSQCA set Hospital Standards-Results-Overcoming Barriers 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.

42 Qualitative Study on PSQCA set Hospital Standards-Results-Overcoming Barriers 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.

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

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45 Accreditation does not guarantee success, it is only one step along the quality journey QUALITY MANAGEMENT ERROR REDUCTION CUSTOMER SATISFACTION ACCREDITATION CONTINUAL IMPROVEMENT 45

46 Without change there is no innovation, creativity, or incentive for improvement. We are on a journey! Those who initiate and measure the change will have a better opportunity to manage and lead the change that is inevitable.

47 We are on a journey! 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) Lead a change towards Accreditation of Your Institution. You can t manage, what you can t measure

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