The document discusses hospital accreditation and quality standards. It provides an overview of hospital accreditation, outlining that it is a voluntary process where a hospital chooses an accrediting body and set of standards to be assessed against. The benefits of accreditation include promoting business development, assessing performance, and increasing credibility. Key standards discussed for Philippines hospitals are the PhilHealth Benchbook, Joint Commission International, Accreditation Canada, ISO, and Philippine Quality Awards. Recommendations are provided for standards compliance and accreditation.
An introductory overview of the basic concepts of Healthcare Quality, a starter for beginners.
Prepared in 2014 for the new staff of the Quality Management Department in King Saud University Medical City in Riyadh as a part of their capacity building plan.
Acknowledgments:
*Dr. Magdy Gamal Yousef, MBBCh, MS, CPHQ - for his contribution in the scientific content
**Ms. Maram Baksh, MS, CPHQ - for the design of the full HCQ capacity building plan in KSUMC
Theera-Ampornpunt N. Quality and regulatory compliance in health care. Presented at: Faculty of ICT, Mahidol University; 2012 Mar 13; Bangkok, Thailand.
An introductory overview of the basic concepts of Healthcare Quality, a starter for beginners.
Prepared in 2014 for the new staff of the Quality Management Department in King Saud University Medical City in Riyadh as a part of their capacity building plan.
Acknowledgments:
*Dr. Magdy Gamal Yousef, MBBCh, MS, CPHQ - for his contribution in the scientific content
**Ms. Maram Baksh, MS, CPHQ - for the design of the full HCQ capacity building plan in KSUMC
Theera-Ampornpunt N. Quality and regulatory compliance in health care. Presented at: Faculty of ICT, Mahidol University; 2012 Mar 13; Bangkok, Thailand.
ThailandMedtourism.com is the official website for Medical Tourism in Thailand by the Tourism Authority of Thailand. ThailandMedTourism.com provides in-depth healthcare information and medical provider directory for international patients travelling to Thailand for medical treatment.
JCI Accreditation Status and way-forward in Saudi Arabia in 2013 by Mumtaz AhmedMumtaz Ahmed
The Joint Commission International (JCI) is a well know certification-body in health sector, to provide and accredit various standards of service delivery. In this presentation, author describes the situation analysis of accreditation status, in Saudi Arabia upto September, 2013, and way-forward for desired hospital setups for certification.
Professor Hakam Yaseen, Medical Director ( CMO)
Consultant Neonatologist, HOD pediatric/ Neonatal
Member of Board of Trustees, University Hospital Sharjah
JCI is the world’s leader in health care accreditation and the author and evaluator of the most rigorous international standards in quality and patient safety.
hospital_220_a
With its newly published 5th edition of JCI’s Accreditation Standards for Hospitals, JCI addresses the unique concerns of hospitals and academic medical centers, as well as the challenges of preserving quality care as patients move from inpatient to outpatient and other care providers.
Our unique tracer methodology provides the cornerstone of the JCI on-site survey, serving as a tool for surveyors and health care organizations to evaluate patients and systems in unprecedented depth. JCI separates itself from its competitors with innovations network accreditation, where similar organizations within a single system or larger entity can achieve accreditation efficiently through a single network application.
JCI is committed to keeping pace with the dynamics of global health care while remaining the standard bearer for its universally recognized Gold Seal of Approval®.
Rigorous process for developing international standards
Due to the expertise and scope of its international team, JCI is uniquely positioned to adapt leading global practices to the delivery of local care. Standards are developed and organized around important functions common to all health care organizations. In fact, the functional organization of standards is now the most widely used around the world and has been validated by scientific study, testing, and application.
Standards Advisory Panel
To maintain best practices, JCI turns to its Standards Advisory Panel, comprised of experienced physicians, nurses, administrators, and public-policy experts. The panel guides the development and revision process of the JCI accreditation standards. Panel members are from five major world regions: Latin America and the Caribbean, Asia and the Pacific Rim, the Middle East, Europe, and the United States. The panel’s recommendations are refined based on an international field review of the standards and input from experts and others with unique content knowledge.
Eat less, live longer cutting back on food can help repair the body by Dr.Ma...Healthcare consultant
Eating less can boost healthier ageing by protecting the body’s cells from harmful deterioration and the risk of cancer.
Scientists know an extreme diet does not appeal to many people but say their discovery could lead to ways of mimicking its effects and pave the way for an “anti-ageing pill.
Read and discuss the following three articles 1. ACAs Perform.pdfSALES97
Read and discuss the following three articles:
1. ACAs Performance Based Healthcare
Standards ACAsPerformanceBasedHealthCareStandards.pdf
2. Road to Accreditation RoadToAccreditation.pdf
3. JCAHO Accreditation and Quality of Care for Acute Myocardial Infarction JCAHO
accreditation and quality of care for acute myocardial infarction.pdf
Have an open discussion about these articles. Share your thoughts
For example, here are some questions to answer and discuss:
Does accreditation impact quality? Are there less errors in hospitals that are accredited? What is
the value of accreditation? Do quality concerns initiate changes in staff behavior? Should
accreditation be based on results?
Read and discuss the following three articles:
1. ACAs Performance Based Healthcare
Standards ACAsPerformanceBasedHealthCareStandards.pdf
2. Road to Accreditation RoadToAccreditation.pdf
3. JCAHO Accreditation and Quality of Care for Acute Myocardial Infarction JCAHO
accreditation and quality of care for acute myocardial infarction.pdf
Have an open discussion about these articles. Share your thoughts
For example, here are some questions to answer and discuss:
Does accreditation impact quality? Are there less errors in hospitals that are accredited? What is
the value of accreditation? Do quality concerns initiate changes in staff behavior? Should
accreditation be based on results?
Solution
ACAs Performance Based Healthcare Standards-
This booklet is intended to assist anyone dealing with or affected by Health and Employment
issues. It is one of a series of booklets and handbooks designed to give impartial advice on
employment matters to employers, employees and their representatives. Legal information is
provided for guidance only and should not be regarded as an authoritative statement of the law,
which can only be made by reference to the particular circumstances which apply. It may,
therefore, be wise to seek legal advice.
Acas is committed to building better relationships in the workplace and offers training to suit
you. From a two-hour session on the key points of new legislation or employing people to
courses specially designed for people in your organisation. Click here to find out about training
sessions in your area. We also offer hands-on practical help and support to tackleissues in your
business with you. This might be through one of our wellknown problem-solving services or a
programme we have worked out together to put your business firmly on track for effective
employment
relations.
road to accrediation -
Accreditation is usually a voluntary program, sponsored by a non-governmental organization
(NGO), in which trained external peer reviewers evaluate a healthcare organization\'s
compliance and compare it with pre-established performance standard
Accreditation is a quality assurance process designed to ensure an educational program meets a
national standard. It serves to support and encourage program responsiveness to the ra pidly
changing environmental .
Criteria for Performance Excellence to Improve Pharmacy ServicesCompleteRx
- Enhance understanding of the Performance Excellence program and the impact on Healthcare organizations
- Be able to locate Process level and Results level items and how to begin
- Identify areas in the hospital pharmacy that can be impacted by the program
While COVID-19 has consumed our lives both personally and professionally, health centers are still required to maintain compliance with Section 330 and FTCA requirements. How do we do that? By implementing an effective and cohesive credentialing and privileging process. The purpose of this webinar is to provide a better understanding of the requirements for credentialing and privileging, as well as provide tips and strategies for overcoming the challenges associated with the process during this time of crisis. Areas of focus include the following:
1. Basic Concepts
2. Understanding the difference between credentialing and privileging
3. How credentialing and privileging relates to Scope of Project
4. Where Peer Review fits in
5. Credentialing and privileging during COVID-19
Overcoming the challenges of credentialing and privilegingCompliatric
While COVID-19 has consumed our lives both personally and professionally, health centers are still required to maintain compliance with Section 330 and FTCA requirements. How do we do that? By implementing an effective and cohesive credentialing and privileging process. The purpose of this webinar is to provide a better understanding of the requirements for credentialing and privileging, as well as provide tips and strategies for overcoming the challenges associated with the process during this time of crisis. Areas of focus include the following:
1. Basic Concepts
2. Understanding the difference between credentialing and privileging
3. How credentialing and privileging relates to Scope of Project
4. Where Peer Review fits in
5. Credentialing and privileging during COVID-19
Quality and Excellence in Healthcare: Best Practices - Cebu - 14jun27Reynaldo Joson
Quality and Excellence in Healthcare: Best Practices - Lecture in Visayas Regional Seminar of Private Hospitals Association of the Philippines, Inc, - Radisson Blu Hotel, Cebu, June 27, 2014
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
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New Drug Discovery and Development .....NEHA GUPTA
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
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1. 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]
2. The Road To Hospital Quality Accreditation:
What’s In It For Us? Is It Even Worth The Expense?
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.
3. Q. When does one say that a hospital is delivering service
excellence? What makes a hospital excellent?
4. 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)
5. 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)
6. 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)
7. 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)
Internal
Auditors
with Checklists-
Rating Scales
External
Auditors
PQA
PhilHealth
DOH
Others (Int’l)
8. 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)
Formal - Objective -
Stringent Assessment
(Internal & External)
Internal
Auditors
with Checklists-
Rating Scales
External
Auditors
PQA
PhilHealth
DOH
Others (Int’l)
9. 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)
Formal - Objective -
Stringent Assessment
(Internal & External)
Internal
Auditors
with Checklists-
Rating Scales
External
Auditors
PQA
PhilHealth
DOH
Others (Int’l)
Accreditation
Certification
External Award of Excellence
10. 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
11. 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
18. 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.”
20. Compliance, Certification, Accreditation, Award
Compliance
Accredited
certifying body
Certification
Accreditation
Award
(recognition)
Certifying /
awarding body
PQA
DTI
21. Compliance, Certification, Accreditation, Award
Compliance
Accredited
certifying body
Certification
Accreditation
Award
(recognition)
Certifying /
awarding body
PhilHealth
PhilHealth
22. Compliance, Certification, Accreditation, Award
Compliance
Accredited
certifying body
Certification
Accreditation
Award
(recognition)
Certifying /
awarding body
JCI / ACI / NABH
ISQUA
JCI / ACI / NABH
23. Compliance, Certification, Accreditation, Award
Compliance
Accredited
certifying body
Certification
Accreditation
Award
(recognition)
Certifying /
awarding body
ISO 9001 / 14000ISO
AJA / TUV
24. 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
25. 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
26. 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?
27. Learning Issues and Contents:
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?
28. Learning Issues and Contents:
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?
29. 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.
30. 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.
31. 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
32. 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.
33. 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.
34. 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.
35. 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.
36. 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.
37. 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
38. 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:
39. What are the currently sought accreditation by hospitals in the Philippines,
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
40. What are the recommendations on compliance and accreditation?
• 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)
• Investors in People
*RED – go for accreditation / compliance
** BLACK – go for compliance
41. 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
42. 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)
Accreditation International (ACI)
JCI – PhP 14 M
ACI – PhP 8 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
43. 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)
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
44. 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)
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.
45. 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.
49. 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
50. 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
51.
52. 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.
53. 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
54. 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
55. 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
56. 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.
57. 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.)
58. 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
59. What are the recommended processes in going for hospital
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.
60. 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)
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)
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. 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
63. 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 July 2010,
MDH got its PhilHealth
Benchbook Certification of
Center of Excellence.
Accreditation Project
64. 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
Accreditation Project
December 2010,
MDH got a certification or
accreditation from
Accreditation Canada
International for
“meeting international
standards of excellence in
quality care and service.”
67. The Road To Hospital Quality Accreditation:
What’s In It For Us? Is It Even Worth The Expense?
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.
68. The Road To Hospital Quality Accreditation:
What’s In It For Us? Is It Even Worth The Expense?
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!
69. The Road To Hospital Quality Accreditation:
What’s In It For Us? Is It Even Worth The Expense?
Does it matter? (to have a formal accreditation)
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)!
70. The Road To Hospital Quality Accreditation:
What’s In It For Us? Is It Even Worth The Expense?
Does it matter? (to have a formal accreditation)
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!)
71. 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.
72. 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.
73. Integrating Hospital Quality and Performance
Standards
• 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)
• 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
74. Integrating Hospital Quality and Performance
Standards
• 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)
• 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
75. Integrating Hospital Quality and Performance
Standards
• 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)
• 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
76. 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]
Thank you for your kind attention.
For query:
rjoson2001@yahoo.com
0918-804-0304