Sei sulla pagina 1di 28
ميحرلا نمحرلا الله مسب ” نولعف ت امبريبخ هنا ءي ش لك نقتأ ىذلا

ميحرلا نمحرلا الله مسب

ميحرلا نمحرلا الله مسب ” نولعف ت امبريبخ هنا ءي ش لك نقتأ ىذلا

نولعف ت امبريبخ هنا ءي ش لك نقتأ ىذلا الله عنص

يمظعلا الله قدص

لمنلا ةروس نم )88(

:ملسو هيلع الله يلص الله لوسر لاق

هنقتي نأ لامع مكدحأ لمع اذا بحي الله نا

فيرش ثيدح

ACCREDITATION by
ACCREDITATION
by

Dr.Elham Fetouh Mohamed

Director of Quality Department

Alexandria Health Affair Directorate MOH

DEFINITION OF ACCREDITATION
DEFINITION OF ACCREDITATION
It is an external audit of the ability of the health facility e.g. hospital, to
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
 A process of recognition of capacity based on comparing recent and on going activities
 A process of recognition of capacity based on comparing recent and on going activities
 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 non- governmental organization (NGO),
* Is the process by which a recognized body (usually a non- governmental organization (NGO),
* Is the process by which a recognized body (usually a non- governmental organization (NGO),

*Is the process by which a recognized body (usually a non-

governmental 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

is often a voluntary process in which organizations choose to participate, rather than one required by
There are three primary approaches for external evaluation of healthcare quality:  Licensure.  Accreditation.
There are three primary approaches for external evaluation of healthcare quality:  Licensure.  Accreditation.
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
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.

Application To both individuals and organizations.

Certification involves a recognized authority or boardApplication To both individuals and organizations. granting. Recognition to individuals who have demonstrated specialized

Certification involves a recognized authority or board granting. Recognition to individuals who have demonstrated

granting.

Recognitioninvolves a recognized authority or board granting. to individuals who have demonstrated specialized knowledge

to

individuals

who

have

demonstrated

specialized knowledge and skill and to organizations

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

specialized knowledge and skill and to organizations that have the ability to practice in a certain
It focuses on: Achievement of optimal quality standards. continuous improvement strategies. On going education and
It focuses on: Achievement of optimal quality standards. continuous improvement strategies. On going education and

It focuses on:

It focuses on: Achievement of optimal quality standards. continuous improvement strategies. On going education and

Achievement of optimal quality standards. continuous improvement strategies. On going education and consultation.

on: Achievement of optimal quality standards. continuous improvement strategies. On going education and consultation .
on: Achievement of optimal quality standards. continuous improvement strategies. On going education and consultation .
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

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

THE MAJOR PURPOSES OF ACCREDITATION …  Reduce health care costs by focusing on increased

THE MAJOR PURPOSES OF ACCREDITATION

THE MAJOR PURPOSES OF ACCREDITATION …  Reduce health care costs by focusing on increased efficiency

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 practicesin health care.

THE MAJOR PURPOSES OF ACCREDITATION … .  Strengthen the public ’ s confidence in

THE MAJOR PURPOSES OF ACCREDITATION .

THE MAJOR PURPOSES OF ACCREDITATION … .  Strengthen the public ’ s confidence in the

Strengthen the publics confidence in the quality of health care, and

Reduce risks associated with injury and infections for patients and staff

 Variety of evaluation strategies to determine compliance, performance, and quality of care, such as:
 Variety of evaluation strategies to determine compliance, performance, and quality of care, such as:
 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
In July 2007, the Egyptian accreditation standards for Hospital, Ambulatory Clinics and Primary Health Care
In July 2007, the Egyptian accreditation standards for Hospital, Ambulatory Clinics and Primary Health Care
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
Egypt is the first Middle Eastern country to achieve ISQua Accreditation of its standards. These
Egypt is the first Middle Eastern country to achieve ISQua Accreditation of its standards. These
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.
Policies/procedures, plans, required committees.

B&C STANDARDS: :

Implementation standards.

Patient Rights & responsibilities, Org. ethics Access and Assessment of Patients Providing Care, Diagnostic service,
Patient Rights & responsibilities, Org. ethics Access and Assessment of Patients Providing Care, Diagnostic service,
Patient Rights & responsibilities, Org. ethics
Patient Rights & responsibilities, Org. ethics
Patient Rights & responsibilities, Org. ethics Access and Assessment of Patients Providing Care, Diagnostic service,

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
Medication management
Patient safety, Infection Control and Environmental
safety
Information Management
Performance improvement
Organization management
Community Involvement
A-Structures : policy/procedures, none scoring). plans, required committees (all or Met  Present – all
A-Structures : policy/procedures, none scoring). plans, required committees (all or Met  Present – all

A-Structures :

policy/procedures, none scoring). plans, required committees (all or Met  Present – all elements. Not
policy/procedures,
none scoring).
plans,
required
committees
(all
or
Met
Present – all elements.
Not Met
 Not present with all elements.

A

M

M N NA

N

NA

PR. 16
PR. 16
PR. 16.1 PR. 16.2
PR. 16.1
PR. 16.2
PR. 16.3 PR. 16.4
PR. 16.3
PR. 16.4
PR. 16.5 PR. 16.6
PR. 16.5
PR. 16.6
The organization has a list of procedures or treatments for which informed consent is required,
The organization has a list of
procedures or treatments for
which informed consent is
required, including the following:
Surgery and invasive procedures.
Anesthesia/moderate or deep
sedation.
Use of blood. High-risk procedures or treatments (including but not limited to Electro convulsive treatment,
Use of blood.
High-risk procedures or
treatments (including but not
limited to Electro convulsive
treatment, radiation therapy,
chemotherapy).
Family planning interventions.
Research
B&C- implementation :- frequency based-observations of deficiencies. Met  Zero to 1 observed or documented
B&C- implementation :- frequency based-observations of deficiencies. Met  Zero to 1 observed or documented
B&C- implementation :- frequency based-observations of deficiencies. Met  Zero to 1 observed or documented
B&C- implementation :- frequency based-observations of deficiencies. Met  Zero to 1 observed or documented
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

B versus C standards

 B standards are to be implemented first (easier).  C standards are more difficult
 B standards are to be implemented first (easier).
 C standards are more difficult to implement or
not needed for an initial survey.

B

M

P

N

NA

C

M

P

N

NA

PR. 14
PR. 14
PR. 29
PR. 29
General consent for treatment is obtained when the patient seeks service for the organization.
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
Patients and families are informed
about how to donate organs and
other tissues according to law and
regulation and policy.

ACCREDITATION PROCESS

ACCREDITATION PROCESS (According to standards of Ministry of Health & Population). The accreditation process begins
ACCREDITATION PROCESS (According to standards of Ministry of Health & Population). The accreditation process begins
(According to standards of Ministry of Health & Population). The accreditation process begins with an
(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

Pyramid of Excellence in Health Care Accreditation Egypt Accreditation Basic Quality Level Foudation Level Pre

Egypt

Accreditation

Basic Quality Level

Care Accreditation Egypt Accreditation Basic Quality Level Foudation Level Pre Application survey assessment
Care Accreditation Egypt Accreditation Basic Quality Level Foudation Level Pre Application survey assessment

Foudation Level

Egypt Accreditation Basic Quality Level Foudation Level Pre Application survey assessment Validation Application

Pre Application survey assessment Validation Application Self Assessment

A report of deficiencies relating to only the A and Patient Safety standards will be
A report of deficiencies relating to only the A and Patient Safety standards will be
A report of deficiencies relating to only the A and Patient Safety standards will be
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
An on-site re-survey could occur depending on the problem or lack of ability to correct
An on-site re-survey could occur depending on the problem or lack of ability to correct
An on-site re-survey could occur depending on the problem or lack of ability to correct
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
It stimulates the improvement of care delivered to patients It strengthens community confidence in its
It stimulates the improvement of care delivered to patients It strengthens community confidence in its
It stimulates the improvement of care delivered to patients It strengthens community confidence in its
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 third-
party payers
Accreditation is not the goal; the goal is to improve the quality of hospital service.
Accreditation is not the goal; the goal is to improve the quality of hospital service.
Accreditation is not the goal; the goal is to improve the quality of hospital service.
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.