Accreditation as a Strategy / Tool for Hospital Quality Service Improvement

1. Accreditation
as a Strategy / Tool
for Hospital Quality Service /
Improvement
Reynaldo O. Joson, MD, MHA, MHPEd, MSc Surg
Short Course on Total Quality Management
June 23 - 27, 2014
UP Manila College of Public Health

2. Accreditation
as a Strategy / Tool
for Hospital Quality Service /
Improvement
Outline of Contents of Talk:
•Definition of Terms
•Why the Strategy
•How to Go About It (The Tool)

3. Accreditation
as a Strategy / Tool
for Hospital Quality Service /
Improvement
Outline of Contents of Talk:
•Definition of Terms
•Why the Strategy
•How to Go About It (The Tool)

4. Accreditation as a Strategy and Tool for Hospital
Quality Service Improvement
Definition of Terms:
•Accreditation = Hospital* Accreditation = A
Hospital Unit Accreditation
•Accreditation
•Certification
•Award

5. Processes by which a hospital voluntarily applies for
recognition or attestation of compliance to certain set of
standards by a third-party
What is Hospital Accreditation?
Accredited /
Accreditation
Certified / Certification
Compliance
Demonstration of
competency /
consistency
Products
Processes
Systems
Persons

6. 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

7. Compliance, Certification, Accreditation, Award
Compliance
Accredited
certifying body
Certification
Accreditation
Award
(recognition)
Certifying /
awarding body

8. Compliance, Certification, Accreditation, Award
Compliance
Accredited
certifying body
Certification
Accreditation
Award
(recognition)
Certifying /
awarding body
PQA
DTI

9. Compliance, Certification, Accreditation, Award
Compliance
Accredited
certifying body
Certification
Accreditation
Award
(recognition)
Certifying /
awarding body
PhilHealth
PhilHealth

10. Compliance, Certification, Accreditation, Award
Compliance
Accredited
certifying body
Certification
Accreditation
Award
(recognition)
Certifying /
awarding body
JCI / ACI / NABH
ISQUA
JCI / ACI / NABH

11. Compliance, Certification, Accreditation, Award
Compliance
Accredited
certifying body
Certification
Accreditation
Award
(recognition)
Certifying /
awarding body
ISO 9001 / 14000ISO
AJA / TUV

12. 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.

13. 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

14. 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.

15. 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.

16. Accreditation
as a Strategy / Tool
for Hospital Quality Service /
Improvement
Outline of Contents of Talk:
•Definition of Terms
•Why the Strategy
•How to Go About It (The Tool)

17. 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.

18. 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.

19. 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.

20. 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.

21. Accreditation
as a Strategy / Tool
for Hospital Quality Service /
Improvement
Outline of Contents of Talk:
•Definition of Terms
•Why the Strategy
•How to Go About It (The Tool)
Use it as change agent!
•Know & fulfill requirements of
quality! (with assessment –
internal and external)
•Educate staff on quality!
•Motivate staff on quality!

23. What are the currently sought accreditation by hospitals in the Philippines, fees,
advantages and recommendations?
In a hospital setting in the Philippines, as of 2014,
the following local and international documented
sets of standards should guide all hospitals in
achieving a high level of quality and performance:

24. What are the currently sought accreditation by hospitals in the Philippines, fees,
advantages and recommendations?
• 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, National Accreditation Board for Hospitals
and Healthcare Providers (choose one)
• Investors in People

25. 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)
National Accreditation Board for
Hospitals and Healthcare Providers
(NABH)
http://www.jointcommissioninternational.org/
http://www.internationalaccreditation.ca/en/h
http://www.nabh.co/
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

26. What are the similarities and differences between and among the currently
sought accreditation standards?
ISO / PQA JCIA / ACI / NABH / 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

27. What are the currently sought accreditation by hospitals in the Philippines
and their accreditation fees?
Accreditation Standards Accreditation Fees (Assessment
and Certification)
As of 2014 (may change anytime)
PhilHealth Benchbook PhP 10T
JCI
ACI
NABH
JCI – PhP 14 M
ACI – PhP 8 M
NABH – PhP 3 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

29. 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)
National Accreditation Board for
Hospitals and Healthcare Providers
(NABH)
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

30. 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

31. Comparison of Standards
Accreditation
Canada
Joint Commission International National Accreditation Board
for Hospitals
• Individual Client
/ Patient Care
Groups (14)
• Information
Management
• Human
Resources
Development
and
Management
• Environmental
Management
• Leadership and
Partnerships
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
• Access and Planning of
Services
• Customer Rights and
Education
• Care of Customers
• Management of
Medication, Consumables
and Equipments (including
Instruments)
• Infection Control
• Continual Quality
Improvement
• Responsibilities of
Management
• Facility Management and
Safety
• Human Resource
Management
• Information Management
System

32. 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)
National Accreditation Board for
Hospitals and Healthcare Providers
(NABH)
International standards directly related to
hospitals all over the world.
*Go for one, if hospital has a medical tourism
project and needs leverage with international
collaborators and partners.

34. 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.

35. PQA Business Criteria for Performance Excellence

36. Baldrige Health Care Criteria for Performance Excellence

37. ISO 9000 QMS

38. Comparison of Standards
PQA Criteria for Performance
Excellence
ISO 9001:2008
• Leadership
• Strategic Planning
• Customer Focus
• Measurement, Analysis, and
Knowledge Management
• Workforce Focus
• Operations Focus
• 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

39. 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 / NABH

40. 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

42. Comparison of Standards
PQA Criteria for
Performance Excellence
ISO 9001:2008 Investors in People
• Leadership
• Strategic Planning
• Customer Focus
• Measurement, Analysis,
and Knowledge
Management
• Workforce Focus
• Operations Focus
• 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

43. 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.

45. 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.

46. 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.

47. Accreditation
as a Strategy / Tool
for Hospital Quality Service /
Improvement
Outline of Contents of Talk:
•Definition of Terms
•Why the Strategy
•How to Go About It (The Tool)

48. 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.
•To use it as a change agent to fast-track quality
improvement.

49. 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.)

50. 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

51. What are the recommended processes in going for hospital accreditation?
Steering Team formulates a master plan for Hospital
Accreditation Project.
Steering Team decides on set of standards to be assessed or
evaluated on by an accrediting body.
Steering Team seeks commitment for support and
collaboration from top, senior, middle, and lower
management on Hospital Accreditation Project.

52. 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)
•………..

53. What are the recommended processes in going for hospital accreditation?
Contents of master plan for Hospital Accreditation Project
•..........
•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)

55. Hospital Accreditation:
Does it Matter?
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!

56. Hospital Accreditation:
Does it Matter?
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)!

57. Hospital Accreditation:
Does it Matter?
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!)

58. Integrating Hospital Quality and Performance
Standards
• 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

59. Integrating Hospital Quality and Performance
Standards
• 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

60. Integrating Hospital Quality and Performance
Standards
• 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

61. 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

62. Aiming for best practices in quality and performance excellence in
hospitals
ProgrammedJourneyofExcellence

63. Aiming for best practices in quality and performance excellence in
hospitals
ProgrammedJourneyofExcellence

64. Accreditation
as a Strategy / Tool
for Hospital Quality Service /
Improvement
Reynaldo O. Joson, MD, MHA, MHPEd, MSc Surg
Short Course on Total Quality Management
June 23 - 27, 2014
UP Manila College of Public Health
Thank you for your kind attention.
For queries and feedback:
rjoson2001@yahoo.com
0918-804-0304

65. Welcome Queries and Feedback Anytime!
REYNALDO O. JOSON, MD, MHA, MHPEd, MSc Surg
0918-804-03-04
rjoson2001@yahoo.com