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ACCREDITATION
Dr.Elham Fetouh Mohamed
Director of Quality Department Alexandria Health Affair Directorate MOH by

DEFINITION OF ACCREDITATION
It is an external audit of the ability of the health facility e.g. hospital, to provide a high quality service to the patient and to minimize the various dangers in an environment potentially subject to high risks.

A process of recognition of capacity based

on comparing recent and on going activities with a set of previously established standards.

by an independent body.

*Is the process by which a recognized body (usually a nongovernmental organization(NGO), assesses and recognizes that a health care organization meets pre-determined and published standards.

*Accreditation is often a voluntary process in which organizations

choose to participate, rather than one required by law and regulation..

There are three primary approaches for external evaluation of healthcare quality:

Licensure. Accreditation.

Certification.

All the three approaches use standards to determine the level of quality achieved by individuals or organizations.

To protect basic public health and safety. Licensure standards address the minimum legal requirements or qualifications. It is carried out by legal health authorities.

Usually done only once, prior to the beginning of operations.

Application To both individuals and organizations.

Certification involves a recognized authority or board

granting. Recognition to individuals who have demonstrated

specialized knowledge and skill and to organizations

that have the ability to practice in a certain area or specialty.

It focuses on:
Achievement of optimal quality standards. continuous improvement strategies.

On going education and consultation.

THE MAJOR PURPOSES OF ACCREDITATION

Improve the quality of health care by establishing optimal achievement goals in meeting standards for health care organizations Stimulate and improve the integration and management of health services Establish a comparative database of health care organizations able to meet selected structure, process, and outcome standards or criteria
Quality Associates Inc

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THE MAJOR PURPOSES OF ACCREDITATION..

Reduce health care costs by focusing on increased

efficiency and effectiveness of services.

Provide education and consultation to health care

organizations, managers, and health professionals

on quality improvement strategies and best practices in health care.
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THE MAJOR PURPOSES OF ACCREDITATION .

Strengthen the publics confidence in the quality of health care, and Reduce risks associated with injury and infections for patients and staff

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Quality Associates Inc

Variety of evaluation strategies to determine compliance, performance, and quality of care, such as: Document and record reviews Interviews Observations Achievement evaluations Facility inspections Tracing

In July 2007, the Egyptian accreditation standards for Hospital, Ambulatory Clinics and Primary Health Care were accredited by The International Society for Quality Health Care (ISQua) - the Accreditors of the Accreditors. ISQua, is a non-profit, independent organization.

It works to provide services to guide health professionals, providers, researchers, agencies, policy makers and consumers.
It is an accreditor of STANDARDS.

Egypt is the first Middle Eastern country to achieve ISQua Accreditation of its standards.

These standards provide both significant challenge and a clear roadmap for everyone to work collaboratively to improve the quality of performance in healthcare facilities.
A STANDARDS: Policies/procedures, plans, required committees.

B&C STANDARDS: Implementation standards.

Patient Rights & responsibilities, Org. ethics Access and Assessment of Patients Providing Care, Diagnostic service, invasive procedures, patient & family Education. Medication management Patient safety, Infection Control and Environmental safety Information Management Performance improvement Organization management Community Involvement

A-Structures :
policy/procedures, plans, required committees (all or none scoring). Met

Present all elements.

Not present with all elements.

Not Met

N NA

PR. 16

The organization has a list of procedures or treatments for which informed consent is

required, including the following:

PR. 16.1 PR. 16.2 Surgery and invasive procedures. Anesthesia/moderate or deep sedation.

PR. 16.3 PR. 16.4

Use of blood. High-risk procedures or treatments (including but not limited to Electro convulsive treatment, radiation therapy, chemotherapy). Family planning interventions.
Research

PR. 16.5
PR. 16.6

B&C- implementation :frequency based-observations of deficiencies. Met Zero to 1 observed or documented deficiency. Partially Met 2 observed or documented deficiencies. Not Met 3 or more observed or documented deficiencies.

B versus C standards

B standards are to be implemented first (easier).

C standards are more difficult to implement or not needed for an initial survey.
M P N NA

PR. 14

General consent for treatment is obtained when the patient seeks service for the organization. Patients and families are informed about how to donate organs and other tissues according to law and regulation and policy.

M P

N NA

PR. 29

ACCREDITATION PROCESS
(According to standards of Ministry of Health & Population).

The accreditation process begins with an initial self assessment. Assistance may be requested - for clarification of applicability of a standard or set of standards to the organization. Prior to an initial survey, a pre-survey visit will be scheduled to validate the application information.

Pyramid of Excellence in Health Care Accreditation

Accreditation

Egypt

Basic Quality Level Foudation Level Pre survey assessment Application Validation Application Self Assessment

A report of deficiencies relating to only the A and Patient Safety standards will be left with the organization to enable further preparation. A full survey team will be scheduled when the organization has at a minimum a 4 month track record of achievement with these selected standards. After the survey, a report will be given to the organization with an outcome of the level achieved, and a list of all Not Met standards followed by all Partially Met standards

An on-site re-survey could occur depending on the problem or lack of ability to correct deficiencies.
A mid cycle (approximately 18 month) assessment process will occur. This assessment consists of a combination of self assessment and on-site survey by a team. A full on-site survey conducted by a team of surveyors will occur in the 3rd year.

It stimulates the improvement of care delivered to patients It strengthens community confidence in its hospital It reduces unnecessary costs It increases efficiency It provides credentials for education, internships, and residencies It can protect against lawsuits It facilitates acceptance by and funds from thirdparty payers

Accreditation is not the goal; the goal is to improve the quality of hospital service.

The emphasis is on the total hospital system.

Educational programs are essential.

Standards for accreditation will evolve as the

countries hospital services progress.