Hospital Accreditation Benefits, Goals and Objectives

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]

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.

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 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)

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)

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)

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)
Internal
Auditors
with Checklists-
Rating Scales
External
Auditors
PQA
PhilHealth
DOH
Others (Int’l)

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)
Internal
Auditors
with Checklists-
Rating Scales
External
Auditors
PQA
PhilHealth
DOH
Others (Int’l)

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)
Internal
Auditors
with Checklists-
Rating Scales
External
Auditors
PQA
PhilHealth
DOH
Others (Int’l)
Accreditation
Certification
External Award of Excellence

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

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

MDH Journey towards Excellence - 2013

2013
Certification
Accreditation
Award

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.”

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

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

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

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

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

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

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

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?


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?

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?

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.


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.


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


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.

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.


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.


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.


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.

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

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:

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

What are the recommendations on compliance and accreditation?
• Baldrige Health Care Criteria for Performance Excellence /
Philippine Quality Award Criteria for Performance
Excellence
• PhilHealth Benchbook (including PH statutory and
regulatory requirements)
• Joint International Commission, Accreditation Canada
International (either one)
*RED – go for accreditation / compliance
** BLACK – go for compliance

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

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)
JCI – PhP 14 M
ACI – PhP 8 M
(equivalence of Baldrige Awards
of )
PhP 30T – small organizations
PhP 50 – medium to big
organizations
Standardization)
PhP 300T
Investors in People PhP 1M


Accreditation Standards Advantages
PhilHealth Benchbook Designed to encourage Philippine hospitals
improve on their quality management system
and to improve quality and safe patient care
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


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.
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.


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
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.

Baldrige Health Care Criteria for Performance Excellence

PQA Business Criteria for Performance Excellence


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.
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


Investors in People Designed to transform business performance
through people


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.

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

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

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

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.

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.)

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

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.

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)

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

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

In July 2010,
MDH got its PhilHealth
Benchbook Certification of
Center of Excellence.

December 2010,
MDH got a certification or
accreditation from
Accreditation Canada
International for
“meeting international
standards of excellence in
quality care and service.”

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!

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)!

NO need; NO situation
Be COMPLIANT with the standards and criteria without
going for formal accreditation!
(self-directed learning and improvement!)

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.

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.

Integrating Hospital Quality and Performance
Standards
• Baldrige Health Care Criteria for
Performance Excellence / Philippine
Quality Award Criteria for Performance
Excellence
• PhilHealth Benchbook (including PH
statutory and regulatory requirements)
• Joint International Commission,
Accreditation Canada International (either
one)
*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

Standards
Excellence
one)
Performance
Excellence
•Business
Development
•Efficiency
•Learning

Standards
Excellence
one)
Performance
Excellence
Increase in
utilization of
services
Increase in
corporate
accounts and
patient-clients

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

Hospital Accreditation Benefits, Goals and Objectives

Recommended

Recommended

More Related Content

What's hot

What's hot (20)

Viewers also liked

Viewers also liked (20)

Similar to Hospital Accreditation Benefits, Goals and Objectives

Similar to Hospital Accreditation Benefits, Goals and Objectives (20)

More from Reynaldo Joson

More from Reynaldo Joson (20)

Recently uploaded

Recently uploaded (20)

Hospital Accreditation Benefits, Goals and Objectives