The Road To Hospital Quality Accreditation:
What’s In It For Us? Is It Even Worth The Expense?
Reynaldo O. Joson, MD, MHA,...
The Road To Hospital Quality Accreditation:
What’s In It For Us? Is It Even Worth The Expense?
Some questions and instruct...
Q. When does one say that a hospital is delivering service
excellence? What makes a hospital excellent?
Macro-indicators of Performance Excellence (Baldrige):
Integrated approach to organizational performance
management that r...
3 Macro-indicators of Excellent Hospital (ROJoson):
•Contributing to achievement of targeted health
outcomes in its catchm...
3 Macro-indicators of Excellent
Hospital:
•Contributing to achievement of
targeted health outcomes in its
catchment commun...
3 Macro-indicators of Excellent
Hospital:
•Contributing to achievement of
targeted health outcomes in its
catchment commun...
Macro-indicators of Performance
Excellence:
•Integrated approach
•Delivery of ever-improving value
to customers and stakeh...
Macro-indicators of Performance
Excellence:
•Integrated approach
•Delivery of ever-improving value
to customers and stakeh...
Hospital’s Steadfast Strategic Objectives
   
STRATEGIC OBJECTIVES
PERSPECTIVES   OBJECTIVES
Governance, Service, and 
Fin...
Hospital’s Steadfast Strategic Objectives
   
STRATEGIC OBJECTIVES
PERSPECTIVES   OBJECTIVES
Governance, Service, and 
Fin...
MDH Journey towards Excellence - 2013
2013
2013
Certification
Accreditation
Award
Compliance, Certification, Accreditation, Award
Compliance, Certification, Accreditation, Award
• ISO/IEC 17000 defines certification as “third-party
attestation related ...
Compliance, Certification, Accreditation, Award
Compliance
Accredited 
certifying body
Certification
Accreditation
Award 
...
Compliance, Certification, Accreditation, Award
Compliance
Accredited
certifying body
Certification
Accreditation
Award
(r...
Compliance, Certification, Accreditation, Award
Compliance
Accredited
certifying body
Certification
Accreditation
Award
(r...
Compliance, Certification, Accreditation, Award
Compliance
Accredited
certifying body
Certification
Accreditation
Award
(r...
Compliance, Certification, Accreditation, Award
Compliance
Accredited
certifying body
Certification
Accreditation
Award
(r...
Compliance, Accreditation, Certification, Award
Hospital
Set
Standards
Criteria
Indicators
Satisfactory
degree of complian...
Compliance, Accreditation, Certification, Award
Hospital
Set
Standards
Criteria
Indicators
Satisfactory
degree of complian...
Learning Issues and Contents:
 
What is the concept of “hospital accreditation?”
What are the benefits of hospital accredi...
Learning Issues and Contents:
 
What are quality and performance
standards?
What are the currently sought accreditation
by...
Learning Issues and Contents:
 What are the similarities and differences
between and among the currently sought
accreditat...
What is the concept of “hospital accreditation”?
 
Hospital accreditation is a set of processes that starts
with a hospita...
What is the concept of “hospital accreditation”?
 
A hospital seeking accreditation from an accrediting
body is done on a ...
What is the concept of “hospital accreditation”?
 
The standards may be on
• quality management system
• quality health ca...
What is the concept of “hospital accreditation”?
 
Hospital accreditation almost always entails fees:
• fee for the survey...
What are the benefits of hospital accreditation?
What are the goals and objectives of having a hospital accreditation?
 
T...
What are the benefits of hospital accreditation?
What are the goals and objectives of having a hospital accreditation?
 
T...
What are the benefits of hospital accreditation?
What are the goals and objectives of having a hospital accreditation?
 
T...
What are the benefits of hospital accreditation?
What are the goals and objectives of having a hospital accreditation?
 
T...
What are quality and performance standards?
Quality and performance standards refer to
• standards on quality and performa...
What are the currently sought accreditation by hospitals in the Philippines,
fees, advantages and recommendations?
 
In a ...
What are the currently sought accreditation by hospitals in the Philippines,
fees, advantages and recommendations?
 
• Bal...
What are the recommendations on compliance and accreditation?
• Baldrige Health Care Criteria for Performance Excellence /...
What are the currently sought accreditation by hospitals in the
Philippines?
 
Accreditation Standards URLs
PhilHealth Ben...
What are the currently sought accreditation by hospitals in the
Philippines and their accreditation fees?
 
Accreditation ...
What are the currently sought accreditation by hospitals in the Philippines,
advantages and recommendations?
 
Accreditati...
What are the currently sought accreditation by hospitals in the Philippines,
advantages and recommendations?
 
Accreditati...
What are the currently sought accreditation by hospitals in the Philippines,
advantages and recommendations?
 
Accreditati...
Baldrige Health Care Criteria for Performance Excellence
PQA Business Criteria for Performance Excellence
ISO 9000 QMS
What are the currently sought accreditation by hospitals in the Philippines,
advantages and recommendations?
 
Accreditati...
What are the currently sought accreditation by hospitals in the Philippines,
advantages and recommendations?
 
Accreditati...
What are the currently sought accreditation by hospitals in the Philippines,
advantages and recommendations?
 
Accreditati...
What are the similarities and differences between and among the
currently sought accreditation standards?
 ISO / PQA JCIA ...
Comparison of Standards
PhilHealth Benchbook Joint Commission International Accreditation Canada
• Patient Rights and
Orga...
Comparison of Standards
Baldrige Health Care Criteria
for Performance Excellence
ISO 9001:2008 Investors in People
• Leade...
What are the recommended processes in going for hospital
accreditation?
 Starting point:
Top management decides to have a ...
What are the recommended processes in going for hospital
accreditation?
 
Top management creates a Steering Team / Committ...
What are the recommended processes in going for hospital
accreditation?
 Cross-sectoral or multisectoral membership with r...
What are the recommended processes in going for hospital
accreditation?
 Steering Team formulates a master plan for Hospit...
What are the recommended processes in going for hospital
accreditation?
 Contents of master plan for Hospital Accreditatio...
What are the common problems or challenges in hospital
accreditation?
 
Common problems and challenges (commitment, cooper...
Best Management Practices to Ensure Financial Viability:
Manila Doctors Hospital's Experience
ROJ’s Perceptions on Good-to...
Best Management Practices to Ensure Financial Viability:
Manila Doctors Hospital's Experience
ROJ’s Perceptions on Good-to...
Best Management Practices to Ensure Financial Viability:
Manila Doctors Hospital's Experience
ROJ’s Perceptions on Good-to...
2013
The Road To Hospital Quality Accreditation:
What’s In It For Us? Is It Even Worth The Expense?
Some questions and instruct...
The Road To Hospital Quality Accreditation:
What’s In It For Us? Is It Even Worth The Expense?
Does it matter? (to have a ...
The Road To Hospital Quality Accreditation:
What’s In It For Us? Is It Even Worth The Expense?
Does it matter? (to have a ...
The Road To Hospital Quality Accreditation:
What’s In It For Us? Is It Even Worth The Expense?
Does it matter? (to have a ...
Advantages of Being Compliant with Local and International
Standards of Quality and Safe Patient Services
• Stimulate cont...
Advantages of Being Compliant with Local and International
Standards of Quality and Safe Patient Services
• Increase effic...
Integrating Hospital Quality and Performance
Standards
• Baldrige Health Care Criteria for
Performance Excellence / Philip...
Integrating Hospital Quality and Performance
Standards
• Baldrige Health Care Criteria for
Performance Excellence / Philip...
Integrating Hospital Quality and Performance
Standards
• Baldrige Health Care Criteria for
Performance Excellence / Philip...
The Road To Hospital Quality Accreditation:
What’s In It For Us? Is It Even Worth The Expense?
Reynaldo O. Joson, MD, MHA,...
Hospital Quality Accreditation - UPCPH - ROJoson - 2013-08-16
Hospital Quality Accreditation - UPCPH - ROJoson - 2013-08-16
Hospital Quality Accreditation - UPCPH - ROJoson - 2013-08-16
Hospital Quality Accreditation - UPCPH - ROJoson - 2013-08-16
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Hospital Quality Accreditation - UPCPH - ROJoson - 2013-08-16

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The Road To Hospital Quality Accreditation: What’s In It For Us? Is It Even Worth The Expense?” Lecture to Master in Hospital Administration students of the University of the Philippines College of Public Health on August 16, 2013.

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  • I am grateful for this file Dr. Joson. It builds a strong determination and rationale to who's who will benefit for the hospital accreditation. Kudos and GOD Bless to you and your endeavor. I am a Psychiatric nurse assistant Unit-charge Male Forensic of Al Masarra Hospital-Sultanate of Oman.. Email ad: delfin.b1@moh.gov.om
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  • Hello..I am new to hospital administration. I was just offered a job as Asst. Quality Assurance Director. I believe reading your presentation really helps me a lot. Am grateful for such! really beneficial to healthcare providers..Thanks much..
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  • To those who downloaded my slides, I would appreciate your giving me your complete name and email address as well as feedback. Thanks.
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Hospital Quality Accreditation - UPCPH - ROJoson - 2013-08-16

  1. 1. The Road To Hospital Quality Accreditation: What’s In It For Us? Is It Even Worth The Expense? Reynaldo O. Joson, MD, MHA, MHPEd, MSc Surg August 16, 2013 UP College of Public Health HA 202 [Organization and Management of the Different Hospital Departments]
  2. 2. The Road To Hospital Quality Accreditation: What’s In It For Us? Is It Even Worth The Expense? Some questions and instructions to me: • What is accreditation? • What are some of the accrediting agencies? International or local? • Does it matter? • What are the benefits? • What are the disadvantages? • Give a brief background of the Manila Doctors Hospital experience.
  3. 3. Q. When does one say that a hospital is delivering service excellence? What makes a hospital excellent?
  4. 4. Macro-indicators of Performance Excellence (Baldrige): Integrated approach to organizational performance management that results in (1)delivery of ever-improving value to customers and stakeholders, contributing to organizational sustainability (2)improvement of overall organizational effectiveness and capabilities (3)organizational and personal learning GOAL (short-/long-term)
  5. 5. 3 Macro-indicators of Excellent Hospital (ROJoson): •Contributing to achievement of targeted health outcomes in its catchment community •Providing value-based health care services •Sustainable while providing excellent services GOAL (short-/long-term)
  6. 6. 3 Macro-indicators of Excellent Hospital: •Contributing to achievement of targeted health outcomes in its catchment community •Providing value-based health care services •Sustainable while providing excellent services GOAL (short-/long-term) Formal - Objective - Stringent Assessment (Internal & External)
  7. 7. 3 Macro-indicators of Excellent Hospital: •Contributing to achievement of targeted health outcomes in its catchment community •Providing value-based health care services •Sustainable while providing excellent services GOAL (short-/long-term) Formal - Objective - Stringent Assessment (Internal & External) Internal Auditors with Checklists- Rating Scales External Auditors PQA PhilHealth DOH Others (Int’l)
  8. 8. Macro-indicators of Performance Excellence: •Integrated approach •Delivery of ever-improving value to customers and stakeholders, contributing to organizational sustainability •improvement of overall organizational effectiveness and capabilities •Organizational and personal learning GOAL (short-/long-term) Formal - Objective - Stringent Assessment (Internal & External) Internal Auditors with Checklists- Rating Scales External Auditors PQA PhilHealth DOH Others (Int’l)
  9. 9. Macro-indicators of Performance Excellence: •Integrated approach •Delivery of ever-improving value to customers and stakeholders, contributing to organizational sustainability •improvement of overall organizational effectiveness and capabilities •Organizational and personal learning GOAL (short-/long-term) Formal - Objective - Stringent Assessment (Internal & External) Internal Auditors with Checklists- Rating Scales External Auditors PQA PhilHealth DOH Others (Int’l) Accreditation Certification External Award of Excellence
  10. 10. Hospital’s Steadfast Strategic Objectives     STRATEGIC OBJECTIVES PERSPECTIVES   OBJECTIVES Governance, Service, and  Finance 1 Systems perspective in governance   2 Integrated value-based health care service   3 Physician engagement (patronage and  loyalty)   4 Maximal utilization of services with  controlled expenses and losses Customer 5 Customer delight Process 6 Fully compliant with the quality and  performance standards (local and  international)   7 Integrated IT-enabled operations system Learning and Growth of People 8 Staff engagement   9 Learning organization CSR 10 CSR program with tangible social impact
  11. 11. Hospital’s Steadfast Strategic Objectives     STRATEGIC OBJECTIVES PERSPECTIVES   OBJECTIVES Governance, Service, and  Finance 1 Systems perspective in governance   2 Integrated value-based health care service   3 Physician engagement (patronage and  loyalty)   4 Maximal utilization of services with  controlled expenses and losses Customer 5 Customer delight Process 6 Fully compliant with the quality and  performance standards (local and  international)   7 Integrated IT-enabled operations system Learning and Growth of People 8 Staff engagement   9 Learning organization CSR 10 CSR program with tangible social impact Accreditation Certification External Award of Excellence
  12. 12. MDH Journey towards Excellence - 2013
  13. 13. 2013
  14. 14. 2013 Certification Accreditation Award
  15. 15. Compliance, Certification, Accreditation, Award
  16. 16. Compliance, Certification, Accreditation, Award • ISO/IEC 17000 defines certification as “third-party attestation related to products, processes, systems or persons.” ISO/IEC 17011 defines accreditation as “third-party attestation related to a conformity assessment body conveying formal demonstration of its competence to carry out specific conformity assessment tasks.”
  17. 17. Compliance, Certification, Accreditation, Award Compliance Accredited  certifying body Certification Accreditation Award  (recognition) Certifying /  awarding body
  18. 18. Compliance, Certification, Accreditation, Award Compliance Accredited certifying body Certification Accreditation Award (recognition) Certifying / awarding body PQA DTI
  19. 19. Compliance, Certification, Accreditation, Award Compliance Accredited certifying body Certification Accreditation Award (recognition) Certifying / awarding body PhilHealth PhilHealth
  20. 20. Compliance, Certification, Accreditation, Award Compliance Accredited certifying body Certification Accreditation Award (recognition) Certifying / awarding body JCI / ACI / NABH ISQUA JCI / ACI / NABH
  21. 21. Compliance, Certification, Accreditation, Award Compliance Accredited certifying body Certification Accreditation Award (recognition) Certifying / awarding body ISO 9001 / 14000ISO AJA / TUV
  22. 22. Compliance, Accreditation, Certification, Award Hospital Set Standards Criteria Indicators Satisfactory degree of compliance / achievement Certification AwardAccreditation Third-party Assessor / Auditor Philippine Quality Award ISO 9001 ISO 14000 PhilHealth / Benchbook PCAHO JCI ACI NABH
  23. 23. Compliance, Accreditation, Certification, Award Hospital Set Standards Criteria Indicators Satisfactory degree of compliance / achievement Certification AwardAccreditation Third-party Assessor / Auditor Philippine Quality Award ISO 9001 ISO 14000 PhilHealth / Benchbook PCAHO JCI ACI NABH Levels
  24. 24. Learning Issues and Contents:   What is the concept of “hospital accreditation?” What are the benefits of hospital accreditation? What are the goals and objectives of having a hospital accreditation?
  25. 25. Learning Issues and Contents:   What are quality and performance standards? What are the currently sought accreditation by hospitals in the Philippines, fees, advantages and recommendations? What are the recommendations on compliance and accreditation?
  26. 26. Learning Issues and Contents:  What are the similarities and differences between and among the currently sought accreditation standards? What are the recommended processes in going for hospital accreditation? What are the common problems or challenges in hospital accreditation?
  27. 27. What is the concept of “hospital accreditation”?   Hospital accreditation is a set of processes that starts with a hospital deciding to apply for accreditation to an accrediting body; then, the accrediting body assessing compliance of the hospital to a selected and agreed set of standards; and, if the hospital is compliant, the accrediting body issuing the accreditation certification.
  28. 28. What is the concept of “hospital accreditation”?   A hospital seeking accreditation from an accrediting body is done on a voluntary basis. The hospital has the freedom to choose the set of standards it wants to be assessed or evaluated on by an accrediting body. It also has the liberty to choose the accrediting body to do the assessment or evaluation.
  29. 29. What is the concept of “hospital accreditation”?   The standards may be on • quality management system • quality health care and patient safety management system • human resource management system • environment management system • emergency and disaster management system • others
  30. 30. What is the concept of “hospital accreditation”?   Hospital accreditation almost always entails fees: • fee for the survey or assessment • fee for the certificate How much the fees are is dependent on the accrediting body.
  31. 31. What are the benefits of hospital accreditation? What are the goals and objectives of having a hospital accreditation?   There are a lot of benefits that can be derived from hospital accreditation. Some can be considered as major benefits and some, as minor benefits. Some can be considered as primary benefits and others, as off-shoots of the primary, or secondary. These benefits are translatable to goals and objectives of having a hospital accreditation.
  32. 32. What are the benefits of hospital accreditation? What are the goals and objectives of having a hospital accreditation?   The overarching major primary benefit or goal is to promote the business development program of the hospital so as to make it viable and sustainable.
  33. 33. What are the benefits of hospital accreditation? What are the goals and objectives of having a hospital accreditation?   The secondary benefits or objectives can and should be the following: To use the accreditation project as an assessment tool on hospital performance as well as a change management tool. To identify and institute areas of improvement towards excellence with the help of the hospital accreditation project. To educate the staff on performance excellence with the help of the hospital accreditation project.
  34. 34. What are the benefits of hospital accreditation? What are the goals and objectives of having a hospital accreditation?   The secondary benefits or objectives can and should be the following: To increase the hospital’s credibility and to demonstrate its accountability to the community using an attained hospital accreditation. To enhance the hospital reputation so as to attract more clients utilizing its services. To increase its leverage with the potential partners and collaborators in the health care industry using the attained hospital accreditation.
  35. 35. What are quality and performance standards? Quality and performance standards refer to • standards on quality and performance • required or agreed levels of quality or attainment of requirements
  36. 36. What are the currently sought accreditation by hospitals in the Philippines, fees, advantages and recommendations?   In a hospital setting in the Philippines, as of 2013, I believe the following local and international documented sets of standards should guide all hospitals in achieving a high level of quality and performance:
  37. 37. What are the currently sought accreditation by hospitals in the Philippines, fees, advantages and recommendations?   • Baldrige Health Care Criteria for Performance Excellence / Philippine Quality Award Criteria for Performance Excellence • ISO Quality Management System • PhilHealth Benchbook (including PH statutory and regulatory requirements) • Joint International Commission, Accreditation Canada International (either one) (*NABH – National Accreditation Board for Hospitals and Healthcare Providers) • Investors in People
  38. 38. What are the recommendations on compliance and accreditation? • Baldrige Health Care Criteria for Performance Excellence / Philippine Quality Award Criteria for Performance Excellence • ISO Quality Management System • PhilHealth Benchbook (including PH statutory and regulatory requirements) • Joint International Commission, Accreditation Canada International (either one) • Investors in People *RED – go for accreditation / compliance ** BLACK – go for compliance
  39. 39. What are the currently sought accreditation by hospitals in the Philippines?   Accreditation Standards URLs PhilHealth Benchbook http://www.philhealth.gov.ph/providers/institu Joint Commission International (JCI) Accreditation International (ACI) http://www.jointcommissioninternational.org/ http://www.internationalaccreditation.ca/en/h Philippine Quality Awards (equivalence of Baldrige Awards of ) http://www.pqa.org.ph http://www.dti.gov.ph/dti/index.php?p=492 http://www.nist.gov/baldrige/publications/hc_ ISO (International Organization for Standardization) http://www.iso.org/iso/home.html Investors in People http://www.investorsinpeople.co.uk/Pages/Hom
  40. 40. What are the currently sought accreditation by hospitals in the Philippines and their accreditation fees?   Accreditation Standards Accreditation Fees (Assessment and Certification) As of 2013 (may change anytime) PhilHealth Benchbook PhP 10T Joint Commission International (JCI) Accreditation International (ACI) JCI – PhP 14 M ACI – PhP 8 M Philippine Quality Awards (equivalence of Baldrige Awards of ) PhP 30T – small organizations PhP 50 – medium to big organizations ISO (International Organization for Standardization) PhP 300T Investors in People PhP 1M
  41. 41. What are the currently sought accreditation by hospitals in the Philippines, advantages and recommendations?   Accreditation Standards Advantages PhilHealth Benchbook Designed to encourage Philippine hospitals improve on their quality management system and to improve quality and safe patient care Joint Commission International (JCI) Accreditation International (ACI) Designed to improve quality and safe patient care Designed to assess and improve organization performance based on internationally agreed standards and stimulating continuous improvement to achieve optimum outcomes on healthcare
  42. 42. What are the currently sought accreditation by hospitals in the Philippines, advantages and recommendations?   Accreditation Standards Advantages and *Recommendations PhilHealth Benchbook Local standards directly related to PH hospitals; will be needed for licensure with DOH. *All PH hospitals must have, for viability and sustainability; establish complete and sustainable compliance to serve as a foundation for other hospital accreditations, if needed. Joint Commission International (JCI) Accreditation International (ACI) International standards directly related to hospitals all over the world. *Go for either one, if hospital has a medical tourism project and needs leverage with international collaborators and partners.
  43. 43. What are the currently sought accreditation by hospitals in the Philippines, advantages and recommendations?   Accreditation Standards Advantages Philippine Quality Awards (equivalence of Baldrige Awards of ) Designed to help provide hospitals with an integrated approach to organizational performance that results in Delivery of ever-improving value to customers and stakeholders, contributing to organizational sustainability Improvement of overall organizational effectiveness and capabilities organizational and personal learning ISO (International Organization for Standardization) ISO 9001: Quality Management System Designed to help organizations ensure that they meet the needs of customers and other stakeholders while meeting statutory and regulatory requirements related to the product.
  44. 44. Baldrige Health Care Criteria for Performance Excellence
  45. 45. PQA Business Criteria for Performance Excellence
  46. 46. ISO 9000 QMS
  47. 47. What are the currently sought accreditation by hospitals in the Philippines, advantages and recommendations?   Accreditation Standards Advantages and *Recommendations Philippine Quality Awards (equivalence of Baldrige Awards of ) Local standards that covers all kinds of industry and there is a specific set of standards in health care *Recommended after PhilHealth Benchbook accreditation; may use the latest US Baldrige Health Care Criteria for Performance Excellence as complementary guide. ISO (International Organization for Standardization) ISO 9001: Quality Management System International standards on basic quality management system that are applicable to all kinds of industry including hospitals and health care *Recommended if an international accreditation is deemed needed and cannot afford ACI / JCI
  48. 48. What are the currently sought accreditation by hospitals in the Philippines, advantages and recommendations?   Accreditation Standards Advantages Investors in People Designed to transform business performance through people
  49. 49. What are the currently sought accreditation by hospitals in the Philippines, advantages and recommendations?   Accreditation Standards Advantages and *Recommendations Investors in People International standards on people development to promote hospital viability and sustainability *Use the IiP standards to support and complement PhilHealth Benchbook accreditation and Philippine Quality Awards as well as other accreditations; nice to have the IiP accreditation.
  50. 50. What are the similarities and differences between and among the currently sought accreditation standards?  ISO / PQA JCIA / ACI / PhilHealth Benchbook Origin manufacturing industry hospital industry Language manufacturing health care Product easily defined, tangible item clinical aspects of health care, not easily defined, not readily tangible
  51. 51. Comparison of Standards PhilHealth Benchbook Joint Commission International Accreditation Canada • Patient Rights and Organizational Ethics • Patient Care • Leadership and Management • Human Resource Management • Information Management • Safe Practice and Environment • Performance Improvement Patient-centered Standards •Access to Care and Continuity of Care •Patient and Family Rights •Assessment of Patients •Care of Patients •Anesthesia and Surgical Care •Medication Management and Use •Patient and Family Education Health Care Organization Management Standards •Quality Improvement and Patient Safety •Prevention and Control of Infections •Governance, Leadership, and Direction •Facility Management and Safety •Staff Qualifications and Education •Management of Communication and Information • Individual Client / Patient Care Groups (14) • Information Management • Human Resources Development and Management • Environmental Management • Leadership and Partnerships
  52. 52. Comparison of Standards Baldrige Health Care Criteria for Performance Excellence ISO 9001:2008 Investors in People • Leadership • Strategic Planning • Customer Focus • Measurement, Analysis, and Knowledge Management • Workforce Focus • Process Management • Results 4 Quality management system 4.1 General requirements 4.2 Documentation requirements 5 Management responsibility 5.1 Management commitment 5.2 Customer focus 5.3 Quality policy 5.4 Planning 5.5 Responsibility, authority and communication 5.6 Management review 6 Resource management 6.1 Provision of resources 6.2 Human resources 6.3 Infrastructure 6.4 Work environment 7 Product realization 8 Measurement, analysis and improvement 8.1 General 8.2 Monitoring and measurement 8.3 Control of nonconforming product 8.4 Analysis of data 8.5 Improvement Plan Do Review 1. Business Strategy 2. Learning and development strategy 3. People management strategy 4. Leadership and management strategy 5. Management effectiveness 6. Recognition and reward 7. Involvement and Empowerment 8. Learning and development 9. Performance Measurement 10. Continuous improvement
  53. 53. What are the recommended processes in going for hospital accreditation?  Starting point: Top management decides to have a Hospital Accreditation Project to promote the business development program of the hospital so as to make it viable and sustainable.
  54. 54. What are the recommended processes in going for hospital accreditation?   Top management creates a Steering Team / Committee for Hospital Accreditation Project with clear functions and authority. Membership of Steering Team / Committee Senior Management Representative if not the Hospital Director Chair (with competency in hospital accreditation and leadership) Cross-sectoral or multisectoral membership with representatives from key functional areas in the hospital, such as the following: (Note: the senior management team members may constitute the Steering Team / Committee.)
  55. 55. What are the recommended processes in going for hospital accreditation?  Cross-sectoral or multisectoral membership with representatives from key functional areas in the hospital, such as the following: (Note: the senior management team members may constitute the Steering Team / Committee.) Medical service sector Nursing service sector Ancillary medical service sector Administrative or support service sector Human resource development sector Business development sector Finance sector Secretariat
  56. 56. What are the recommended processes in going for hospital accreditation?  Steering Team formulates a master plan for Hospital Accreditation Project. Steering Team seeks commitment for support and collaboration from top, senior, middle, and lower management on Hospital Accreditation Project.
  57. 57. What are the recommended processes in going for hospital accreditation?  Contents of master plan for Hospital Accreditation Project Goals and objectives of accreditation project (include short- and long-term goals and objectives) Selection, prioritization, and integration of the accreditation standards Selection of the accrediting bodies Expected outputs (short- and long-term) Expected impact (short- and long-term) Timelines (short- and long-term) Strategies and action plans to achieve expected outputs and impacts (short- and long-term) Budget (short- and long-term) Monitoring and oversight plan Evaluation plan (short- and long-term)
  58. 58. What are the common problems or challenges in hospital accreditation?   Common problems and challenges (commitment, cooperation, collaboration, and integration of all stakeholders) Weakness in: Leadership Management Planning, implementation, and evaluation Integration of standards in all units Communication Education
  59. 59. Best Management Practices to Ensure Financial Viability: Manila Doctors Hospital's Experience ROJ’s Perceptions on Good-to-best Management Practices that Contributed to MDH Financial Viability to Sustainability Governance and Leadership In 2005, MDH got its ISO 9001 certificate and has maintained the accreditation up to now. Accreditation Project
  60. 60. Best Management Practices to Ensure Financial Viability: Manila Doctors Hospital's Experience ROJ’s Perceptions on Good-to-best Management Practices that Contributed to MDH Financial Viability to Sustainability Governance and Leadership In July 2010, MDH got its PhilHealth Benchbook Certification of Center of Excellence. Accreditation Project
  61. 61. Best Management Practices to Ensure Financial Viability: Manila Doctors Hospital's Experience ROJ’s Perceptions on Good-to-best Management Practices that Contributed to MDH Financial Viability to Sustainability Governance and Leadership Accreditation Project December 2010, MDH got a certification or accreditation from Accreditation Canada International for “meeting international standards of excellence in quality care and service.”
  62. 62. 2013
  63. 63. The Road To Hospital Quality Accreditation: What’s In It For Us? Is It Even Worth The Expense? Some questions and instructions to me: • What is accreditation? • What are some of the accrediting agencies? International or local? • Does it matter? • What are the benefits? • What are the disadvantages? • Give a brief background of the Manila Doctors Hospital experience.
  64. 64. The Road To Hospital Quality Accreditation: What’s In It For Us? Is It Even Worth The Expense? Does it matter? (to have a formal accreditation) It depends on your need and situation! Need - to participate in National Health Insurance Program and get benefits – go for PhilHealth Accreditation! Need - to participate in medical tourism program and get benefits – PCAHO, international accreditation (JCI / ACI / NBAH) Need – to satisfy requirement of corporate accounts – go for accreditation! Need – to satisfy expectations of the community – go for accreditation!
  65. 65. The Road To Hospital Quality Accreditation: What’s In It For Us? Is It Even Worth The Expense? Does it matter? (to have a formal accreditation) It depends on your need and situation! Situation – to be with the trend of having an international accreditation (not to be left out – strong community expectation) – go for accreditation! Situation – want to fast-track improvement of quality and safety of operations and services with accreditation – go for accreditation (assessment, training, improvement, evaluation)!
  66. 66. The Road To Hospital Quality Accreditation: What’s In It For Us? Is It Even Worth The Expense? Does it matter? (to have a formal accreditation) It depends on your need and situation! NO need; NO situation Be COMPLIANT with the standards and criteria without going for formal accreditation! (self-directed learning and improvement!)
  67. 67. Advantages of Being Compliant with Local and International Standards of Quality and Safe Patient Services • Stimulate continuous improvement in service and patient care processes and outcomes. • Improve management of health care services particularly on patient safety. • Provide staff education on better or best practices.
  68. 68. Advantages of Being Compliant with Local and International Standards of Quality and Safe Patient Services • Increase efficiency / reduce cost. • Improve organization performance. • Promote recognition for excellence. • Strengthen public and community confidence.
  69. 69. Integrating Hospital Quality and Performance Standards • Baldrige Health Care Criteria for Performance Excellence / Philippine Quality Award Criteria for Performance Excellence • ISO Quality Management System • PhilHealth Benchbook (including PH statutory and regulatory requirements) • Joint International Commission, Accreditation Canada International (either one) • Investors in People *Compliance but NOT necessarily going for accreditation to all standards, except PhilHealth Benchbook and Philippine Quality Awards for Performance Excellence Performance Excellence Use integrated checklists
  70. 70. Integrating Hospital Quality and Performance Standards • Baldrige Health Care Criteria for Performance Excellence / Philippine Quality Award Criteria for Performance Excellence • ISO Quality Management System • PhilHealth Benchbook (including PH statutory and regulatory requirements) • Joint International Commission, Accreditation Canada International (either one) • Investors in People *Compliance but NOT necessarily going for accreditation to all standards, except PhilHealth Benchbook and Philippine Quality Awards for Performance Excellence Performance Excellence •Business Development •Efficiency •Learning
  71. 71. Integrating Hospital Quality and Performance Standards • Baldrige Health Care Criteria for Performance Excellence / Philippine Quality Award Criteria for Performance Excellence • ISO Quality Management System • PhilHealth Benchbook (including PH statutory and regulatory requirements) • Joint International Commission, Accreditation Canada International (either one) • Investors in People *Compliance but NOT necessarily going for accreditation to all standards, except PhilHealth Benchbook and Philippine Quality Awards for Performance Excellence Performance Excellence Increase in utilization of services Increase in corporate accounts and patient-clients
  72. 72. The Road To Hospital Quality Accreditation: What’s In It For Us? Is It Even Worth The Expense? Reynaldo O. Joson, MD, MHA, MHPEd, MSc Surg August 16, 2013 UP College of Public Health HA 202 [Organization and Management of the Different Hospital Departments] Thank you for your kind attention. For query: rjoson2001@yahoo.com 0918-804-0304
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