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Hossam Elamir, MSc.HCM, TQMD, MBBCh
Quality & Accreditation Office, MKH
 Numbers, Charts and Comments on
Standards were taken from a presentation of:
Maitham Husain, MD FRCPC​
National Accredit...
• Accreditation is a QUALTIY PROCESS
• Standards are QUALITY TOOLS
• Required Organization Practices
Essential service to ...
“Quality is NEVER AN ACCIDENT;
it is always the result of HIGH
INTENTION, SINCERE EFFORT,
INTELLIGENT DIRECTION and
SKILF...
“First, do no harm” (Kohn et al. 2000)
 Perhaps the closest approximation
in the Hippocratic Corpus is in
Epidemics:
"Th...
Medicine used to be
simple, ineffective &
relatively safe… now it
is complex, effective &
potentially dangerous!
Chantler...
 Don’t kill me (no needless
deaths)
 Do help me & don’t hurt me (no
needless pain)
 Don’t make me feel helpless
 Don’t...
The seven pillars of
quality (Donabedian, 1990)
The six aims of quality
improvement (IOM, 2001)
The six dimensions of
qual...
• Standards have been reviewed by:
1. A taskforce committee
(surveyor, accreditation department, safety department)
2. Adv...
Parameter All Standards PSRA
Average Rate 2.62 2.00
Range 1.92-3.25 1.3-2.38
Median 2.72 2.29
MKH 2.21 2.00
53%
MKH
1.5
0.0
2.0
2.0
2.5
2.0
2.0
1.6
1.63
1.7
1.8
1.1
2.0
1.0
• Recommendation to the Standard of
Accreditation
Changes are being introduced to the program
that will highlight the sign...
• Each PSRA will be elevated to the criterion
level
• The rating scales and calculation of the
accreditation decisions are...
• The 3-point scale for PSRAs will be eliminated and all
criteria (including PSRAs) will be rated on the 4-
point scale ba...
Organizations must achieve a rating of 3 or 4
on the 4-point scale for all (100%) of the PSRAs
or the accreditation award ...
MKH
3.00
2.00
2.00
2.00
2.00
1.00
2.00
2.00
2.00
• The leadership section will include a standard on
Training on Patient Safety.
11.0 Training on Patient Safety
Level 1 - ...
53%
MKH
1.5
0.0
2.0
2.0
2.5
2.0
2.0
1.6
1.63
1.7
1.8
1.1
2.0
1.0
Average rating – 2.15 (range 0.8-3.0) or 54%
Area of Special concern (below national average)
•Obs./Gyn. 0.8
•Human resour...
STANDARD 8 – SAFETY PLAN
8.1 Management ensures there is an annual
written safety plan
8.2 The safety plan is regularly mo...
 Similar changes will be applicable to all
clinical and support services.
 Each PSRA will appear as criterion and
scored...
changes to the standards
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changes to the standards

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changes to the standards

  1. 1. Hossam Elamir, MSc.HCM, TQMD, MBBCh Quality & Accreditation Office, MKH
  2. 2.  Numbers, Charts and Comments on Standards were taken from a presentation of: Maitham Husain, MD FRCPC​ National Accreditation Program​ Accreditation Department, ​ Accreditation & Quality Directorate, MOH​
  3. 3. • Accreditation is a QUALTIY PROCESS • Standards are QUALITY TOOLS • Required Organization Practices Essential service to improve patient safety & minimize risk
  4. 4. “Quality is NEVER AN ACCIDENT; it is always the result of HIGH INTENTION, SINCERE EFFORT, INTELLIGENT DIRECTION and SKILFUL EXECUTION… the WISE CHOICE of many alternatives.” William A. Foster, 1917-1945
  5. 5. “First, do no harm” (Kohn et al. 2000)  Perhaps the closest approximation in the Hippocratic Corpus is in Epidemics: "The physician must ... have two special objects in view with regard to disease, namely, to do good or to do no harm"
  6. 6. Medicine used to be simple, ineffective & relatively safe… now it is complex, effective & potentially dangerous! Chantler, C. (1999), The role and education of doctors in the delivery of healthcare, Lancet, 53(9159), 1178–1181. Medicine used to be simple, ineffective & relatively safe… Chantler, C. (1999), The role and education of doctors in the delivery of healthcare, Lancet, 53(9159), 1178–1181.
  7. 7.  Don’t kill me (no needless deaths)  Do help me & don’t hurt me (no needless pain)  Don’t make me feel helpless  Don’t keep me waiting  Don’t waste resources - mine or anyone else’s Berwick, D. M. (2005), My right knee, Annals of Medicine, 142 (2), 121-125.
  8. 8. The seven pillars of quality (Donabedian, 1990) The six aims of quality improvement (IOM, 2001) The six dimensions of quality (Bengoa et al., 2006) Efficacy     Effectiveness Effective Effective Efficiency Efficient Efficient Optimality     Acceptability Acceptable / patient-centred Patient-centred Legitimacy (Partially covered by the patient-centred aim) (Partially covered by the patient-centred dimension) Equity Equitable Equitable   Accessible     Safe Safe     Timely
  9. 9. • Standards have been reviewed by: 1. A taskforce committee (surveyor, accreditation department, safety department) 2. Advisory Committee, MoH 3. Higher Committee for Accreditation, MoH
  10. 10. Parameter All Standards PSRA Average Rate 2.62 2.00 Range 1.92-3.25 1.3-2.38 Median 2.72 2.29 MKH 2.21 2.00
  11. 11. 53% MKH 1.5 0.0 2.0 2.0 2.5 2.0 2.0 1.6 1.63 1.7 1.8 1.1 2.0 1.0
  12. 12. • Recommendation to the Standard of Accreditation Changes are being introduced to the program that will highlight the significance of the Patient Safety Required Areas as essential practices to improve patient safety in health care organizations. (In Canadian Standards they are called: ROPs Required Organisational Practices)
  13. 13. • Each PSRA will be elevated to the criterion level • The rating scales and calculation of the accreditation decisions are changing for the second cycle of accreditation • Each individual PSRA will now be assigned its own rating in the self-assessment and on-site survey in a scale of 4
  14. 14. • The 3-point scale for PSRAs will be eliminated and all criteria (including PSRAs) will be rated on the 4- point scale based on test of compliance Level 1 The plan and policy are developed Level 2 The plan and policy are partially implemented in the service area, as per the Test(s) for Compliance Level 3 The plan and policy are fully implemented in the service area, as per the Test(s) for Compliance Level 4 The service collects data and analyzes data, and uses the results for improvement
  15. 15. Organizations must achieve a rating of 3 or 4 on the 4-point scale for all (100%) of the PSRAs or the accreditation award will be affected •If one or more PSRAs is unmet (below level 3 or 4), the accreditation award will be reduced by one level
  16. 16. MKH 3.00 2.00 2.00 2.00 2.00 1.00 2.00 2.00 2.00
  17. 17. • The leadership section will include a standard on Training on Patient Safety. 11.0 Training on Patient Safety Level 1 - Plan and policy are developed Level 2 - Plan and policy are partially implemented in the service as per test of compliance Level 3 - Plan and policy are fully implemented in the service as per test of compliance Level 4 - The service collects data, analyses it and uses results for improvement
  18. 18. 53% MKH 1.5 0.0 2.0 2.0 2.5 2.0 2.0 1.6 1.63 1.7 1.8 1.1 2.0 1.0
  19. 19. Average rating – 2.15 (range 0.8-3.0) or 54% Area of Special concern (below national average) •Obs./Gyn. 0.8 •Human resources 1.2 •Emergency service 1.7 •Surgical 1.8 •Information management 1.8 •Intensive care 2.0 •Environment 2.1
  20. 20. STANDARD 8 – SAFETY PLAN 8.1 Management ensures there is an annual written safety plan 8.2 The safety plan is regularly monitored for progress 8.3 Results from safety related activities are reported throughout the hospital and management reports findings to governance. 8.4 Resources are provided for quality improvement and safety activities throughout the hospital
  21. 21.  Similar changes will be applicable to all clinical and support services.  Each PSRA will appear as criterion and scored accordingly on scale of 0,1,2,3 and 4

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