Importance of Hospital Quality Accreditation - ROJoson

Importance of Hospital Quality Accreditation
Reynaldo O. Joson, MD, MHA, MHPEd, MScSurg
2020

Course Number and Title: HA 202
(Organization and Management of the Different
Departments and Services of a Hospital)
Course Description:
The course deals with the major concepts, principles,
and considerations in the management of various
hospital services and departments.

Prescribed Learning Outcomes:
After studying this topic, you should be able to:
1. Understand the importance and value of adhering to quality control
standards when it comes to managing the hospital and its different
departments and services.
2. Discuss the philosophy, objectives, structure, staffing, policies,
systems, and methods of Hospital Quality Accreditation.
3. Develop the ability to pinpoint and isolate management and
administrative problem(s) in the hospital Quality Control Program and
offer relevant solutions.
4. Draft a hospital quality management system framework patterned
after ISO 9001:2015 framework that can be used as a guide for
developing a hospital-wide governance and operations manual.

1. Understand the importance and value of adhering
to quality control standards when it comes to
managing the hospital and its different departments
and services.
2. ……..
3. ……..
4. ……..

Importance and value of adhering to quality control standards when it comes to
managing the hospital and its different departments and services
A patient-client tends to go to a particular hospital because
of known quality services in this hospital.
A physician-client tends to send his/her patients to a
particular hospital because of known quality services in this
hospital.
A hospital wants to attract patient-clients and physician-
clients to its hospital through its quality services.
These three primordial realities and practices constitute the
first general driving force why a hospital and its
departments and services should promote and offer quality
services to its clients.

Promoting and offering quality services to patient-clients
and physician-clients should be part of the business
development program of the hospital and its departments
and services in attaining financial viability and sustainability.
The hospital and all its departments and services should
have a quality management system in place as part of its
business development program.

The quality management system includes defining first the
quality expectations of the patient-clients and physician-
clients then finding ways on how to meet these
expectations.
After the quality management system has been developed,
it should be institutionalized by continually doing quality
control (continually fulfilling the requirements of the clients)
and documenting it on a manual that contains the quality
control standards which all staff should know, adhere to and
make decisions according to them.

Aside from making the patient-clients and physician-clients
experience and appreciate the quality services,
the hospital can go for external accreditation not only to
have affirmation and validation of its quality management
system but to utilize external accreditation for marketing.

Importance and value of adhering to quality control
standards when it comes to managing the hospital
and its different departments and services
Attract patient-clients and physician-clients
to utilize the services of the hospital
because of a reputation of quality services
that results from adherence to quality control
standards.

1. ……..
2. Discuss the philosophy, objectives, structure,
staffing, policies, systems, and methods of Hospital
Quality Accreditation.
3. ……..
4. ……..

Philosophy of Hospital Quality Accreditation
Philosophy of a Hospital Quality Accreditation
- group of theories and ideas related to the understanding of the
Hospital Quality Accreditation
ROJoson will present
• Theories and ideas
• Information on Hospital Quality Accreditation as
being practiced in the Philippines
• Personal thoughts, perceptions, opinions and
recommendations on Hospital Quality
Accreditation

What is the difference between hospital licensure and
hospital accreditation?

What is the difference between hospital licensure and hospital
accreditation?
Hospital licensure means obtaining an official and legal
permit to operate a hospital from the Department of Health.
A permit is granted after the hospital fulfills certain
minimum requirements imposed by the Department of
Health.
These requirements usually include those that ensure
structural and operational safety and human resource
among other things.
Furthermore, they may include imposition of the presence
of a quality management system.

accreditation?
Hospital accreditation is the processes by which a hospital
voluntarily applies for recognition or attestation of
compliance to certain set of standards by a third-party.
The standards may be anything that the hospital wants to
have an external recognition of compliance and wants to use
it for business development purpose.
The standards may be hospital management system, quality
management system, environmental management system,
disaster response, recovery and business continuity, etc.

accreditation?
Main difference between hospital licensure and
hospital accreditation:
required legal permit to operate (for licensure)
voluntary seeking for recognition or attestation of
compliance to certain standards to be used for
business development (for accreditation)

What is the difference between hospital accreditation and hospital
quality accreditation?
Hospital accreditation is the process by which a
hospital voluntarily applies for recognition or
attestation of compliance to certain set of standards
by a third-party.
Hospital quality accreditation is the process by which
a hospital voluntarily applies for recognition or
attestation of compliance to quality management
system standards by a third-party.

Hospital accreditation – no specified standards
Hospital quality accreditation – accreditation on quality
management system standards
What is the difference between hospital accreditation and hospital
quality accreditation?
Examples of standards to be selected for accreditation:
• quality management system
• quality health care and patient safety management
system
• human resource management system
• environment management system
• emergency and disaster management system
Types /
Subsets of
Quality
management
systems

ISO (International Organization for Standardization)
headquartered in Switzerland
defines rules and standards to aid in tasks for virtually all
products and services that people use, including rules and
standards about how products are made and services to be
done and how quality control tests should be performed

ISO (International Organization for Standardization)
has about 300 standards that organizations can seek
certification from
Some examples of ISO standards:
• ISO 9001 - Quality Management
• ISO / IEC 27000 - Information Security Management Systems
• ISO 14000 – Environmental Management
• ISO 31000: 2018 - Risk Management
• ISO 50001: 2018 - Energy Management
• ISO 26000: 2010 - Social Responsibility

Accreditations / certifications sought by Philippines
Hospitals
ISO 9001 (quality management)
ISO 14000 (environmental management)
Quality healthcare and patient safety management
• Joint Commission International
• Accreditation Canada International
• PhilHealth Benchbook
Philippine Quality Award (total quality management)
Investors in People (human resource management )

What is hospital QUALITY accreditation?
hospital’s voluntary application for recognition or
attestation of compliance to certain QUALITY
management system standards set up by an external
organization to be used as part of the business
development program of the hospital.
QUALITY MANAGEMENT SYSTEM STANDARDS
ISO 9000 (quality management)
Philippine Quality Award (total quality management)
Quality healthcare and patient safety management
• Joint Commission International
• Accreditation Canada International
• PhilHealth Benchbook

What is QUALITY management system?
ISO 9001 – management system that pertains to quality.
What is QUALITY?
ISO 9001 - degree to which an object or entity (e.g. process,
product, or service) satisfies a specified set of attributes or
requirements.

PQA Business Criteria for Performance Excellence
*PQA Health Care Criteria for Performance Excellence Framework

Quality healthcare and patient safety management standards
PhilHealth
Benchbook
Joint Commission International (JCI) Accreditation Canada
International (ACI)
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

Accreditation Fees
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.

Various Hospital Accreditation Fees
Accreditation Standards Accreditation Fees (Assessment
and Certification)
As of 2020 (may change anytime)
PhilHealth Benchbook PhP 10T
JCI
ACI
JCI – PhP 14 M
ACI – PhP 8 M
Philippine Quality Awards PhP 30T – small organizations
PhP 50T– medium to big
organizations
ISO (International Organization for
Standardization)
PhP 300T

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 Canada
International (ACI)
International standards directly related to
hospitals, recognized globally, and prestigious
*Go for one, if hospital has a medical
tourism project and needs leverage
with international collaborators and
partners.

What are the currently sought accreditation by hospitals in the
Philippines, advantages and recommendations?
Accreditation Standards Advantages and *Recommendations
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.
Philippine Quality Awards
(PQA Health Care Criteria for
Performance Excellence)
Local standards that covers all kinds of industry
and there is a specific set of standards in health
care
*Recommended if hospital wants to
have highest most prestigious quality
award in the Philippines as this is
awarded by President of the Philippines

Objectives of Hospital Quality Accreditation
General and Overarching Objective:
Hospital quality accreditations are used for
business development program of hospitals
to enhance their reputation so as
to attract more patient-clients and physician-clients
to utilize their services thereby
promoting financial viability and sustainability.

Specific Objectives:
• To increase the hospital’s credibility and to demonstrate
its accountability to the community using an attained
hospital accreditation.
• To increase its leverage with the potential partners and
collaborators in the health care industry using the
attained hospital accreditation.

Specific Objectives:
• 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.

Structure of Hospital Quality Accreditation
Hospital Quality Accreditation
Program or project - temporary or permanent
Permanent –
- duration of accreditation – limited – usually every 3
years
- Need to continually train staff on quality management
system and to continually monitor conformance to
standards
Committee if program is short-termed.
Office if program is long-termed.

Staffing of Hospital Quality Accreditation
Strictly speaking, staffing of hospital quality accreditation
program involve all staff of the hospital, from top
management to rank and file,
all working in an aligned and integrated fashion towards
attainment of the external recognition or attestation of
compliance by a third party.

To orchestrate or direct the hospital quality accreditation
program,
committee or office may be created.
Staff in this committee or office will be those
- knowledgeable on hospital accreditation processes
- can teach the rest of the hospital staff on quality
management system particularly on how to fulfill the
requirements of the required standards
- have leadership and managership skills.

Since Hospital Quality Accreditation Program is hospital
program and hospital-wide,
all staff should be engaged, aligned, coordinating,
collaborating and integrating with each other
to promote success of program.
STEERING COMMITTEE should have multi-sectoral
membership.

Cross-sectoral or multisectoral membership with
representatives from key functional areas in the hospital,
such as the following:
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

Policies of Hospital Quality Accreditation
The primordial policy is that once the hospital quality
accreditations project or program is set up,
all staff of the hospital, from top management to rank and
file, should all be working in an aligned and integrated
fashion towards attainment of the external recognition or
attestation of compliance by a third party.

Policies of Hospital Quality Accreditation
The other basic policies should cover the following:
• What are the authorized functions and authority of the
hospital quality accreditation committee or office?
• What are punishments and rewards for non-conformities
and excellent conformities respectively on established
quality management standards?

Systems of Hospital Quality Accreditation
Systems Approach / Thinking
All departments and services should be involved in the
hospital quality accreditation project or program.
All departments and services should be aligned,
coordinating and collaborating and integrating with each
other in the hospital quality accreditation project or
program so to ensure attainment of external recognition or
accreditation.
It goes without saying, that all the quality management
systems of all the departments and services should be
aligned and integrated also with each other to attain the
highest degree of quality.

Methods of Hospital Quality Accreditation
Top management decides to have a Hospital Quality
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.
Top management creates a Steering Team / Committee or
Office for Hospital Quality 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)

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

Steering Team formulates a master plan for Hospital Quality
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 Quality Accreditation Project.

The Road to Hospital Quality Accreditation:
How Necessary and Who Cares?

The Road to Hospital Accreditation:
It depends on your need and situation!
NEED
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 – go for an international accreditation (ISO / JCI /
ACI)
Need – to satisfy requirement of corporate accounts – go for
an accreditation!
Need – to satisfy expectations of the community – go for an
accreditation!
Need – to be known as the best hospital with performance
excellence – go for PQA

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)!

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

Integrating Hospital Quality and Performance
Standards
• ISO Quality Management System
• PhilHealth Benchbook (including PH
statutory and regulatory requirements)
• Joint Commission International or
Accreditation Canada International
• Philippine Quality Award Criteria for
Performance Excellence
*Compliance but NOT necessarily going for accreditation to all standards
Performance
Excellence
Use
integrated
checklists

1. ……..
2. Discuss the philosophy, objectives, structure,
staffing, policies, systems, and methods of Hospital
Quality Accreditation.
3. ……..
4. ……..
5. ……..
6. ……..

1. ……..
2. ……..
3. Develop the ability to pinpoint and isolate
management and administrative problem(s) in the
hospital Quality Control Program and offer relevant
solutions.
4. ……..
5. ……..
6. ……..

Common Problems in Hospital Quality Control Program and Suggested Solutions
Pre-hospital-quality-accreditation phase
Hospital-quality-accreditation phase
Post-hospital-quality-accreditation phase

1. Varying perceptions and definitions of “quality” of
clients and hospital and department staff.
2. Established mindsets and habits of staff (top
management to managers and rank and file) where
call for change for improvement is difficult.
3. Cost of accreditation as accreditation entails cost.
4. Inherent difficulty in developing and
institutionalizing a comprehensive, aligned and
integrated quality management system in a hospital.

Problem: Varying perceptions and definitions of “quality” of
clients and hospital and department staff
• Patient-clients have their own perceptions and
definitions of quality.
• Physician-clients have own perceptions and definitions of
quality.
• Staff have their own perceptions and definitions of
quality.

In 2010, I made a survey on the perceptions of hospital
administrators, physicians, non-physician health
professionals and patients on the parameters of excellence
(or quality) in a hospital.
https://rojosonhospital.wordpress.com/category/concept-of-an-excellent-hospital-in-the-
philippines/
141 respondents (May 31, 2010) – 34 HAdm; 34 MD; 39
HStaff; and 34 Pt.
I got varied responses from one group of respondents to
another.

Collated responses revealed 58 specific parameters of excellence
which can be grouped into 11 categories.
Parameter categories Frequency of Expression
Infrastructure and facilities 244
Medical equipment and drugs 158
Governance 154
Services 147
Staff 128
Community- and patient-focused 109
Hospital / medical cost 92
Continual improvement program 55
Education and training program 48
Research program 30
Emergency room 9

On specific parameters on infrastructure and facilities, there were
varied perceptions of quality among the different groups of
respondents.
Parameters of Excellence as Perceived by
Respondents
HAdm MD HStaff Pt
With modern infrastructure and facilities 15% 6% 50% 29%
With complete and well-maintained
infrastructure and facilities
27% 30% 30% 13%
Being a safe hospital 4% 46% 29% 21%
With IT-enabled facilities and records
management
33% 50% 7% 10%

On specific parameters on services, there were varied perceptions of
quality among the different groups of respondents.
Parameters of Excellence as
Perceived by Respondents
HAdm MD HStaff Pt
With complete services 18% 32% 39% 11%
With efficient services 33% 9% 39% 18%
With appropriate services 100% 0% 0% 0%
With evaluation of outcome of
services (value-based services)
43% 29% 14% 14%
With clinical practice guidelines 67% 33% 0% 0%
With multispecialty medical services 29% 52% 10% 10%

Strategic Solutions:
Hospital should look at the perceptions and definitions of
quality of the clients (patients and physicians) and try to
meet their requirements as INDICATED AND AS
APPROPRIATE.

ISO 9001: 2015 QMS

PQA
3.1 Voice of the customers
a. Listening to customers
(1). Listening to current customers
(2) Listening to potential customers

Strategic Solutions:
Hospital should look at the current standards of “quality” in
hospital management, abroad and at home, and
adjust accordingly and
use these to manage the expectations of the patient-clients
and physician-clients (through education and changing their
mindsets).

Problem: Established mindsets and habits of staff (top
management to managers and rank and file) where call for
change for improvement is difficult.
“If ain’t broke, don’t fix it anymore.”
“Don’t disturb our current comfort zone.”
Situation:
• Hospital is currently financially stable regardless of QMS
• Owners / leaders not wary of threats from competing
hospitals

Problem: Established mindsets and habits of staff (top
management to managers and rank and file) where call for
change for improvement is difficult.
Strategic Solutions
Governance and Leadership
Realize the importance of an excellent hospital quality
control program in financial sustainability
Lead, convince and educate
With or without hospital quality accreditation

Problem: Cost of accreditation as accreditation entails cost.
Accreditation Standards Initial Accreditation Fees
(Assessment and Certification)
As of 2020 (may change anytime)
PhilHealth Benchbook PhP 10T
JCI
ACI
JCI – PhP 14 M
ACI – PhP 8 M
Philippine Quality Awards PhP 30T – small organizations
PhP 50T– medium to big
organizations
ISO (International Organization for
Standardization)
PhP 300T
*Maintenance and re-application of accreditation also entail costs.

Problem: Cost of accreditation as accreditation entails cost.
Strategic Solution:
Look at the indications for a hospital quality
accreditation.
One may not need it if one can do self-directed
learning and training and improvement.

Problem: Inherent difficulty in developing and
institutionalizing a comprehensive, aligned and integrated
quality management system in a hospital.
Challenges in Processes of QMS:
• Formulation of the blueprint of quality management
system (QMS) in each department and service
• Alignment and integration of all QMS of all departments
and services
• Implementation of the blueprints
• Monitoring for conformities and non-conformities to
formulated policies and procedures
• Formal evaluation of QMS at planned intervals with
continual improvement program

Challenges in Implementation of QMS:
All staff from top management to middle managers and rank
and file should be engaged (committed and trained) in
formulation of blueprints, implementation and evaluation
and continual improvement of QMS.
- A TALL ORDER (needs strong leadership and extensive
training and budget)

All staff from top management to middle managers and rank
and file should be constantly aligned, coordinating,
collaborative and integrating with each other in
accomplishing a total QMS.
training on alignment and integration)

Usual findings in hospitals (based on experiences):
Ningas Kugon or Cogon
Burning of cogon grass that only burns brightly after the first few
seconds it was lit
Initially showing great enthusiasm only for it to fade away as time
goes along.
training)

- Incomplete, incomprehensive, not aligned, not
integrated QMS
- Hiding non-conformities to stipulated policies and
procedures by staff
training)

- In those for surveillance visit after initial
accreditation, staff will work double-time to
ensure passing by covering-up on non-
conformities and catching up on fulfilling
requirements of the standards rather than doing
them on a daily basis.
training)

1. Varying perceptions and definitions of “quality” of
2. Established mindsets and habits of staff (top
management to managers and rank and file) where
call for change for improvement is difficult.
3. Cost of accreditation as accreditation entails cost.
4. Inherent difficulty in developing and
institutionalizing a comprehensive, aligned and
integrated quality management system in a hospital.

1. …….
2. …….
3. …….
4. Draft a hospital quality management system
framework patterned after ISO 9001:2015
framework that can be used as a guide for
developing a hospital-wide governance and
operations manual.
5. …….
6. …….

PhilHealth Benchbook JCI / ACI PQA

Write-ups on the Management System of Each Standards
• Client Requirements Management System
• Legal Requirements Management System
• Client Engagement Management System
• Performance Excellence Management System
• Leadership Management System
• Planning Management System
• Support Management System
• Workforce Management System
• Operations Management System
• Evaluation Management System
• Improvement Management System
• Documented Information Management System

Sample Template in Writing the Management System
• Title
• Concepts / Meanings / Definitions / Scope
• Rationale / Purpose
• Policies
• Procedures
• Work Instructions
• Review of Policies, Procedures and Work Instructions
• Non-adherence to Established Policies, Procedures and
Work Instructions
• With notations on Document Number, Version, Date
Release, Prepared by and Approved By

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