This document discusses accreditation in the healthcare sector. It begins with definitions of accreditation and certification. It then discusses the benefits of accreditation for hospitals, staff, and communities. These include improved quality, safety, leadership, and clinical outcomes. The document also examines important questions to consider regarding accreditation implementation. It outlines the key elements of an accreditation process, including the accrediting body, standards, and assessors. Several international accrediting organizations are described. The rest of the document focuses on barriers to implementing hospital accreditation standards in Pakistan, based on a qualitative study. Major barriers identified include lack of awareness, resources, and leadership support. Ways to overcome these barriers are also

1. Presented By:
Dr. Minhaj A. Qidwai
MBBS, MPH (USA), MBA (USA), CMC (Canada)
Program Director, Health Management
Institute of Business Administration, Karachi. Pakistan
Supported By:
Dr. Sarosh Siddiqui
Assistant Professor Jinnah Sindh Medcial University
Karachi-Pakistan
Study On Accreditation and Barriers
Of Implementation

2. •A process
•Through a Third party entity, separate and
proven, competent evaluator, distinct from
the hospital,
•Assesses the hospital to determine if it:
• Meets a set of standards designed to improve:
• Quality and
• Safety of care
Definition of Accreditation

3. Accreditation supports...
 Quality improvement
 Patient safety
 Risk management
 Strategic change and risk
Management
 Pro-activeness
 Transparent and rigorous
analysis of service
provision

4. Does accreditation make a difference?
 Better communication and collaboration
 Stronger inter-disciplinary teams
 Increased credibility and accountability
 Accredited hospitals report significant improvements in:
 Leadership and decision making
 Promotes measurement and use of indicators
improvements
 Medical records management
 Infection control
 Clinical Outcomes
 Reduction in medication errors
 Staff training and professional credentialing -----

5. What sectors of the health system should be accredited—
hospitals, ambulatory and primary care facilities, or both?
Should both public and private sectors be included?
To what extent should community representatives participate
on accreditation boards or survey teams?
Should the accrediting bodies be governmental or non-
governmental organizations?
Should accreditation surveys be scheduled or “surprise
visits” or both?
IMPORTANT QUESTIONS CONSIDERING ACCREDITATION

6. 6
ELEMENTS OF AN ACCREDITATION PROCESS
Accreditation Body
Standards
Assessors

7. Certification
• Written assurance (the certificate) by an independent external body that
processes or products conform to the requirements specified in the
standard.
Accreditation
• Is a formal recognition by an accreditation body that a person or institution
is competent to carry out the certification in specified business sectors (=
certification of the certification body)
Certification versus Accreditation
Source: www.iso.org

8. Assessment: Norms and Accreditation-Module 11 8
PROCÈS FOR ACCRÉDITATION
not one to be taken lightly
or without forethought
Requirements
Knowledge Resources
Commitment Planning

9. • Shows commitment to quality
• Improves communication and collaboration within the
organisation
• Promotes team building
• Increases credibility
• Demonstrates accountability
• Improves productivity
• Obtaining advice from surveyors (mentoring)
Benefits of Accreditation

10. • Improves professional staff development.
• Provides education on consensus standards.
• Provides leadership for quality improvement within medicine and
nursing.
• Increases satisfaction with continuous learning, good working
environment, leadership and ownership.
Benefits For The Staff

11. • Improves care.
• Stimulates continuous improvement.
• Demonstrates commitment to quality care.
• Raises community confidence.
• Opportunity to benchmark with the best.
Benefits For The Hospitals

12. • Quality revolution
• Disaster preparedness
• Epidemics
• Access to comparative database
Benefits To The Community

13. Continuity of care & Safe transport
Pain management & Focus on patient safety
Patient satisfaction is evaluated
Rights are respected and protected
Access to a quality focused organization
Credentialed and privileged medical staff
High quality of care
Understandable education and communication
BENEFITS TO THE PATIENTS

14. Accreditation
INPUT
Is a
PROCESS
Not an
event
OUTPUT
Summary-What is Accreditation?
OUTCOME

16. Accreditation
INPUT
Is a
PROCESS
Not an
event
OUTPUT
Summary-What is Accreditation?
OUTCOME IMPACT

18. Professional Accrediting Bodies
International
Professional
Bodies
National
Professional
Bodies
Regional
Professional
Bodies

19. International Quality Assurance
Bodies
Regional Quality Assurance
Bodies
National Quality Assurance
Bodies
Professional Bodies
Internal Quality Assessment

20. Selected Systems:
• International Organization for Standardization – ISO
• European Foundation for Quality Management – EFQM
• Joint Commission International – JCI
• The Accreditation Commission for Health Care (ACHC)
Quality Management Systems used in
health care organizations

21. • World's largest developer and publisher of international standard
• Standards are applicable to many kinds of organizations including clinical and
public health laboratories
• 1947: Creating the International Organization for Standardization
• 2012: ISO is a network of national standards institutes from 163 countries
• 2012: Over 19 000 International Standards covering almost every aspects of
technology and manufacturing
International Organization for
Standardization (ISO)
Source: www.iso.org

22. European Foundation for Quality
Management – EFQM
» Founded in 1989 by 14 European organisations, in order to increase the
competitiveness of European organisations
» Not-for-profit membership foundation based in Brussels
» Creator of „The EFQM Excellence Model“
» The aim of the Model is to improve performance in order to reach
„Excellence“
» 2012: more than 30 000 organisations in Europe use the Model
» Provide training, assessment tools and recognition for high performing
organisations  EFQM Excellence Award
Source: http://www.efqm.org

23. • Founded in 1951
• Independent, not-for-profit organization
• Define quality standards specially tailored for health care facilities
• focuses on safety quality of medical services, patient and employee satisfaction
• All processes are assessed (from patient registration, examination, treatment up to the
transfer and discharge of a patient)
• Accredits and certifies more than 19,000 health care organizations and programs in the
United States
• The whole organization, not just individual departments are being evaluated
Joint Commission on Accreditation of
Healthcare Organizations - JCAHO
Source: www.jointcommissioninternational.org
www.jointcommission.org

24. Joint Commission International – JCI
• Created in 1994
• Implements the goals of the JCAHO at an international
level
• Supports health care organizations through accreditation,
education and technical assistance
• Accreditation of an organization: Is a recognition given to
the healthcare organization, which meet the
JCI standards
• JCI has a presence in organizations in
more than 90 countries
Joint Commission International - JCI
Source: www.jointcommissioninternational.org
www.jointcommission.org

25. Has developed several standards for disease-
specific diagnostic laboratories, such as polio,
tuberculosis, influenza, measles
25
World Health Organization

26. • Canadian Commission On Hospital Accreditation 1952
• Monopoly
• Including mental health and rehabilitation facilities as well as general
hospitals
• Recently outcome measures
• 94% of hospital beds
Canada

27. • Though NHS had an agenda for accreditation but there was not
any response
• Patient’s Charter (department of health’s standards for patient
services)
• Investors in people (department of trade and industry)
• King’s Fund Organizational Audit
• Eventually accreditation as an integrate system (King Edward’s
Hospital Fund for London (mission: quality improvement in
NHS)
• Resemble to U.S ,Canada and especially Australia
U.K.

28. • Australian Council On Hospital Standards 1974
• Utilization of resources
• Quality of care
• Clinical outcome
• Fully accredited 3 years and partially accredited 1 year
• Newly a 5 year has been introduced
Australia

29. • Formal Accreditation by Ministry of Public Health (MOPH)
• Three levels of hospitals
-Neighborhood or township level
-District, country, industrial complex level
-Large municipal and teaching level
• Four areas of treatment :
-Prevention
-Healthcare reconstruction
-Support and participation in disease prevention and care
-Healthcare activities
• Every 3 years, only accredited hospitals get license to operate
• Challenge :the number of trained surveyors necessary (120000 surveyor)
China

30. • The Pakistan Standards and Quality Control Authority, under the Ministry of
Science and Technology, is the national standardization body.
• In performing its duties and functions, PSQCA came into operation in Dec. 2000.
• It has been given the task of not only formulation of Pakistan Standards, but is
also responsible for promulgation thereof.
• A technical committee comprising of multidisciplinary representation from public
and private healthcare sector of Pakistan worked under the auspices of (PSQCA)
to develop the first edition of Pakistan’s Hospital Accreditation Standards.
Pakistan

31. • Pakistan’s Hospital Standards and their criteria were specifically developed in
2013 in the context of Pakistan’s “
• National culture,
• Healthcare infrastructure, and
• Availability of resources.
• Any hospital may use this standard framework for continual improvement of its
structures, processes and outcomes.
• Quality Improvement will proceed most efficiently and effectively if the
structures and processes chosen have been demonstrated to be associated with
the desired outcomes of care. It comprised of following sections:
Development of Hospital Standards

32. • These set of standards expects hospitals to define:
• Its objectives and mission statement,
• Establish governing boards and leadership responsibilities,
• Develop risk management and QI plans,
• Financial management procedures,
• Human resource management procedures,
• Promote patient rights and complaints management, and
• Respect patient’s privacy.
Sections of The Pakistan Hospital Standards
Part A: Management Standards

33. • These set of standards expects hospitals to improve:
• Accessibility of services,
• Continuity of care,
• Assessments,
• Care planning,
• Monitoring and evaluations,
• Treatments,
• Care documentation,
• Discharge,
• Specific Processes for: referral, operation theatre. ER,
Intensive care, resuscitative and maternity.
Part B: Service Delivery Standards

34. These set of standards expects hospitals to:
• Improve clinical laboratory services,
• diagnostic radiology services,
• and pharmacy services.
These set of standards expects hospitals to Improve health and safety
of all by:
Development and implementation of life safety,
Health safety,
fire safety/emergency preparedness, equipment safety and environment
safety
Part C: Auxiliary (Support) Services Standards

35. These set of standards expects hospitals to :
Develop and implement hospital infection control program,
Handling of sterile supplies,
Cleanliness and sanitation and waste management
Part D: Infection Control, Hygiene and Waste
Management Standards

36. • Healthcare organizations opt for accreditation to:
• Become part of a recognized entity,
• Meet its standards in order to, achieve excellence, strategic
management and improvement in operational processes,
• Stand out among the competitors.
• Raising their own standards,
• Better market share, and other benefits.
Qualitative Study on Barriers to PSQCA set
Hospital Standards

37. • With all the inherent benefits of accreditation, what are the barriers, which
prevent organizations from getting Accreditation?
• A research was undertaken recently, to study the barriers of implementing
“Hospital Standards” developed by Pakistan Standards and Quality Control
Authority (PSQCA).
• It used semi-structured qualitative questionnaire, for data collection from
hospital administrators in Karachi-Pakistan.
• Total 200 forms were distributed to hospital administrators and CEOs’ and
analysis was undertaken on the received 82 forms.
Qualitative Study on Barriers to PSQCA set
Hospital Standards

38. • Majority of the respondent were unaware of the PSQCA standards for
hospitals.
Table 1 - Aware of PSQCA documentation for Hospital Standards
Qualitative Study on Barriers To PSQCA set
Hospital Standards-Results

39. Respondents were aware of international accreditation organizations
for such a process .
• Table 2 - Aware of any International Accreditation Organization
for setting Hospital Standards:
Qualitative Study on PSQCA set Hospital
Standards-Results

40. • Leadership not interested in change
• Organizational politics, culture and
policies,
• Financial constraints,
• Lack of infrastructure,
• Bureaucracy
• Status Quo
Qualitative Study on PSQCA set Hospital
Standards-Results
 Lack of supportive environment,
 Ill equipped workforce,
 Unsure of ROI
 Compliance and
 Regular monitoring.
Study highlighted barriers included

41. • Understanding of Accreditation Process by Top Leadership.
• Capacity building of all concerned.
• Organize training on a national level on Quality, Patient
Safety and change management,
• Ensuring adequate resources for Accreditation.
• Make separate standards for Public and Private hospitals.
• Bringing the quality conscious hospitals’ on one platform.
Qualitative Study on PSQCA set Hospital
Standards-Results-Overcoming Barriers

42. • Start in a step by step manner.
• Initiate Quality Improvement Programs as a first step.
• Develop and implement SOPs’.
• Business Oriented Management.
• Ensure job security.
• Transparency.
Qualitative Study on PSQCA set Hospital
Standards-Results-Overcoming Barriers

43. 43
Conclusion
Standards developed by Accreditation Entities provide guidelines that
form the basis for quality practices and patient safety.
The model of Input, Processes, Output, Outcome and Impact can be
incorporated for the desired results.
Accreditation and certification are processes which recognize that an
entity is meeting the designated standards.
An active quality management program can be the first step in towards
creating an aura of “accreditation-readiness”.
43

45. 45
Accreditation does not guarantee success,
it is only one step along the quality journey
CONTINUAL
IMPROVEMENT
QUALITY
MANAGEMENT
CUSTOMER
SATISFACTION
ACCREDITATION
ERROR
REDUCTION

46.  Without change there is no innovation, creativity, or
incentive for improvement.
 Those who initiate and measure the change will have a
better opportunity to manage and lead the change
that is inevitable.
We are on a journey!

47. “A journey that will take enormous efforts to change. It is clear that improvement
in patient safety and quality will take time, but the time for change is now. Our
patients, residents, families and communities depend on providers to start now
and commit to the difficult yet achievable work ahead”
(Hassen & Dingwall, 2008)
We are on a journey!
Lead a change towards Accreditation of Your Institution.
You can’t manage, what you can’t measure