International Accreditation Programme - Manajemen Rumah Sakit ...
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International Accreditation Programme - Manajemen Rumah Sakit ...

International Accreditation ProgrammeTriona FortuneDirector of Programmes8/11/2012

WHO – Fact FileAdverse EventsDeveloping Countries 1.4 million HAI 1.3 million die unsafeinjection Cost $6 – 29 billion 20 times higher Up to 70% of syringesreused

What do we need?

Quality & Patient Safety ToolsLocal Departmental National PDCA Donabedian RCA Fishbone TQM Six Sigma Lean EFQM ISO Accreditation

AccreditationAccreditation is a self-assessment and externalpeer review process used by health careorganizations to accurately assess their levelof performance in relation to establishedstandards and to implement ways tocontinuously improve the health caresystem.ISQua 1998

Why the demand? Accreditation of healthcare services is indemand in many countries:• By government, funders, patients andcommunities They all want to know that care is SAFE That treatment is effective That limited resources are used efficiently

ISO vs. AccreditationShaw et al ISQua 2010 Accreditation and ISO certification: Do they explain differences in quality management in European hospitals?Sept 2010

Accreditation Bodies 1951-2009454035302520151050195119531955195719591961196319651967196919711973197519771979198119831985198719891991199319951997199920012003200520072009Government Mixed IndependentOctober 2010 International survey results 9Shaw et al, 2010 International Survey of Accreditation Organisations 2009

Benefits of Accreditation Still a dearth of scientific research outliningbenefits but improving Difficult to measure as variables difficult tocontrol

Accreditation Canada (2011)Value and impact of accreditation: a literaturereview25 Benefits Listed Risk Mitigation System Strengthens interdisciplinary team effectiveness Improves communication Promotes measurement and use of indicatorsImprovements needed Does not increase patient satisfaction Data capture

What does the evidence show?“In many parts of the world, accreditation is accepted as animportant element of quality improvement activities” Research shows inconsistent findings – but accreditationdoes promote change and professional development and may• have an organizational financial impact• improve measured quality performance• with public disclosure of outcomes, increase thecredibility of the hospital with the community There is insufficient evidence to know if accreditationimproves patient satisfactionHealth Sector Accreditation Research: a systematic reviewGreenfield and Braithwaite. Int. Journal for Qual. in Healthcare.20:172 -183 2008

Clinical benefits an exampleGratwohl et al (2011), Patient outcome was systematically betterwhen the transplantation centre was at a more advanced phase ofJACIE accreditationLichtman et al (2011), CVA accreditation resulted in reducedmortality rate but no change in readmission ratesMenachemi et al (2008), Ambulatory care centres, patients in JCIaccredited facilities were significantly less likely to be re hospitalizedafter colonoscopyWeeks et al (2007), Among JCAHO accredited hospitals, higheraccreditation scores did not consistently discern better surgicaloutcomes.

Cost Does improving quality save money: A review ofresearch into productivity and the economics ofquality improvement• unsafe care is expensive• improving clinical co-ordination saves money• CQI may reduce costs but can be limitedØvretveit 2009. The Health Foundation.

Accrediting the AccreditorsInternational AccreditationProgrammes (IAP)• Standard• Organisation• Surveyor TrainingProgramme

17AccreditationIs aprocessNot an event

18How is a survey conducted?A four year cycle of...AccreditationAwardFull report &recommendationsContinuousAssessmentStandardsPeer ReviewSelf-assessment

Organisational AccreditationGovernance Strategic, Management Risk ManagementEight StandardsHuman ResourcesAssessmentManagementInformationManagementSurveyorManagementAccreditation Award19

ISQua Surveys 2008 -2011Opportunities to improve Effectiveness of the governance not evaluated -60% No orientation for board members -46% Strategic plan not fully developed -40% Risk Management Framework needs further work-55%20

Principles for Standard DevelopemntSix PrinciplesQualityImprovementPatient SafetyPatient /Service UserFocusStandardsDevelopmentOrganisationalPlanning &PerformanceStandardsMeasurement21

IAP Awards to Date 38 organizations 84 sets of standards 16 surveyor training programmesSetting exemplary standards

Accredited Organisations• American Association of Blood Banks - AABB• Accreditation Canada• The Australian Council on Healthcare Standards - ACHS• Aged Care Standards and Accreditation Agency, Australia - ACSAA• Australian General Practice Accreditation Limited / Quality in Practice - QIP/AGPAL• Council for Health Service Accreditation of Southern Africa - COHSASA• Diagnostic Accreditation Program of British Columbia, Canada - DAP• Global-Mark Pty Ltd, Healthcare Certification Programme, Australia• Haute Autorité de santé, France - HAS• Health Care Accreditation Council of Jordan - HCAC• Health and Disability Auditing Australia - HDAA• Health and Disability Auditing New Zealand - HDANZ• Instituto Colombiano de Normas Técnicas y Certificación- ICONTEC Columbia• The Danish Institute for Quality and Accreditation in Healthcare - IKAS• Joint Commission International, USA - JCI• Malaysian Society for Quality in Health - MSQH• Netherlands Institute for Accreditation in Healthcare - NIAZ• Quality Improvement Council and the QIC Accreditation Program, Australia - QIC• Taiwan Joint Commission on Healthcare Accreditation - TJCHA• National Accreditation Board for Hospitals & Health Care Providers, India - NABH

IAP International ReachAustraliaBrazilCanadaColumbiaCroatiaCzech RepublicDenmarkDubaiEgyptFranceHong KongIndiaIndonesiaJapanJordanKazakhstanKoreaKyrgyzstanMalaysiaNetherlandsNew ZealandNorwayPhilippinesSaudi ArabiaSouth AfricaSpainTaiwanThailandUnited KingdomUnited States

Why ISQua Accreditation International Accreditation Programmes arevaried in approach and content ISQua accreditation helps to standardise byproviding• current evidence based standards, self-assessment,peer review and consistent application• all organisations despite maturity level assessedagainst the same standards

Patient Safety Friendly Hospital EMRO 2008 Requires different strategies• Limited capacity• Minimal data Standards

PSFH Standards Leadership and Management Patient and Public Involvement Safe Clinical Practices Supported by Evidence Safe Environment Lifelong Learning

PSFHThe hospital has a safe medication systemCoreCriteriaDevelopmentalCriteriaC.5.1.1. The hospital‘s safe medication system coversthe following: selection and procurement, storage of medication, ordering and transcribing, preparing and dispensing, administration and follow-up.C.5.1.2. The hospital ensures legible handwriting whenprescribing or writing doctors orders.C.5.1.3. The hospital ensures availability of life savingmedications at all times.C.5.1.4. The hospital ensures medicine reconciliation atadmission and dischargeC.5.1.5. The hospital ensures the patient (or carer) iseducated about medication at dischargeC.5.2.1. The hospital has process to ensure pharmacistreview of medication orders

ISQua’s other activitiesIJQHCConferenceNewEducationFellowshipWHO official relations

MissionInspiring, promoting and supportingcontinuous improvement in the quality andsafety of healthcare worldwide

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