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

The Road to Hospital Accreditation:
How Necessary and Who Cares?
Reynaldo O. Joson, MD, MHA, MHPEd, MSc Surg
UP Manila College of Public Health

Hospital Accreditation
All graduates of hospital administration (master,
diploma, certificate courses) should have at least a
basic knowledge and proper attitude on hospital
accreditation.

All members of the Board of Director of a hospital
should have at least a basic knowledge and proper
attitude on hospital accreditation.
All chief of hospitals and chief executive officers of a
hospital should have at least an in-depth knowledge
and proper attitude on hospital accreditation.

All managers of a quality management office of a
hospital should have in-depth knowledge, skill and
proper attitude on hospital accreditation.
All managers of an operation department in a
hospital should have in-depth knowledge, skill and
proper attitude on accreditation for their respective
departments.

Proper attitude
Welcoming attitude and being open-minded on
hospital accreditation for continuous improvement
of the quality management system of the hospital

Basic knowledge
• What is hospital accreditation?
• What is the importance of hospital accreditation?
• What are the principles and processes involved in
hospital accreditation?
• What are the different kinds of hospital
accreditation?
• How much does it cost to have a hospital
accreditation?

In-depth knowledge (in addition to the basic
knowledge)
• What are general requirements for a hospital
accreditation?
• What are specific requirements for a hospital
accreditation?
• What are the specific requirements of
accreditation in a particular department?

Skill
How to prepare for the hospital accreditation?
How to maintain the hospital accreditation?

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

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

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

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

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

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

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

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 (if there are
several).

The standards may be on
• quality management system
• quality health care and patient safety management
system
• human resource management system
• environment management system
• emergency and disaster management system
• others

Hospital accreditation almost always entails fees:
• fee for the survey or assessment
• fee for the certificate
How much the fees are is dependent on the
accrediting body.

What are the 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.

The overarching major primary benefit or goal is to promote
the business development program of the hospital so as to
make it viable and sustainable.

The secondary benefits or objectives can and should be
the following:
To use the accreditation project as an assessment tool
on hospital performance as well as a change
management tool.
To identify and institute areas of improvement towards
excellence with the help of the hospital accreditation project.
To educate the staff on performance excellence with the help
of the hospital accreditation project.

The secondary benefits or objectives can and should be
the following:
To increase the hospital’s credibility and to demonstrate
its accountability to the community using an attained
hospital accreditation.
To enhance the hospital reputation so as to attract more
clients utilizing its services.
To increase its leverage with the potential partners and
collaborators in the health care industry using the attained
hospital accreditation.

Accreditation
as a Strategy / Tool
for Hospital Quality Service /
Improvement
Use it as change agent!
• Know & fulfill requirements of
quality! (with assessment –
internal and external)
• Educate staff on quality!
• Motivate staff on quality!

What are the currently sought accreditation by hospitals in the Philippines, fees,
advantages and recommendations?
In a hospital setting in the Philippines, as of 2020,
the following local and international documented
sets of standards should guide all hospitals in
achieving a high level of quality and performance:

What are the currently sought accreditation by hospitals in the Philippines, fees,
Philippine Quality Award Criteria for Performance Excellence
ISO Quality Management System
PhilHealth Benchbook (including PH statutory and
regulatory requirements)
Joint International Commission, Accreditation Canada
International, National Accreditation Board for Hospitals
and Healthcare Providers (choose one)
Investors in People

What are the currently sought accreditation by hospitals in the Philippines?
Accreditation Standards URLs
PhilHealth Benchbook http://www.philhealth.gov.ph/providers/instit
ution/benchbook.htm
Joint Commission International (JCI)
Accreditation International (ACI)
National Accreditation Board for
Hospitals and Healthcare Providers
(NABH)
http://www.jointcommissioninternational.org
/
http://www.internationalaccreditation.ca/en/
home.aspx
http://www.nabh.co/
Philippine Quality Awards
(equivalence of Baldrige Awards of )
http://www.pqa.org.ph
http://www.dti.gov.ph/dti/index.php?p=492
http://www.nist.gov/baldrige/publications/hc
_criteria.cfm
ISO (International Organization for
Standardization)
http://www.iso.org/iso/home.html
Investors in People http://www.investorsinpeople.co.uk/Pages/H
ome.aspx

Philippines
Certifying Bodies
• DOH
• PhilHealth
• Accrediting Bodies
• Philippine Council on Accreditation of Healthcare
Organizations (PCAHO)
• Hospital Accreditation Commission
Standards
• PhilHealth Benchbook

Philippine Council on Accreditation of Healthcare Organizations
(PCAHO)
- established in 1998
- founded by the Philippine Department of Health and is
financially supported by the Asian Development Bank
- goal is to improve the hospitals in the Philippines
- responsible for the certification of hospitals
- works closely with the Confirmatory Drug Testing Laboratories
(CDTLS)
- works closely with industrial clinics
- focus on medical tourism
- giving workshops to medical staff dealing with quality
standards of different systems and their implementation in
hospitals

AO No. 2013-0002 Establishment of the Hospital
Accreditation Commission as the National Accrediting
Body for Hospitals in the Philippines
The new accreditation process under HAC will involve two levels of
participation: basic and advanced.
With basic participation, licensed hospitals will automatically be
classified by PhilHealth as Centers of Safety.
HAC will accredit hospitals for advanced participation.

Membership of HAC
DOH
PhilHealth
Philippine Council on Accreditation for Healthcare
Organizations
Philippine Hospital Association
Philippine Medical Association
Philippine College of Hospital Administrators
Private Hospitals Association of the Philippines
Philippine Nurses Association

What are the similarities and differences between and among the currently
sought accreditation standards?
ISO / PQA JCIA / ACI / NABH / PhilHealth
Benchbook
Origin manufacturing
industry
hospital industry
Language manufacturing health care
Product easily defined, tangible
item
clinical aspects of health care,
not easily defined, not readily
tangible

What are the currently sought accreditation by hospitals in the Philippines
and their accreditation fees?
Accreditation Standards Accreditation Fees (Assessment
and Certification)
As of 2020 (may change anytime)
PhilHealth Benchbook PhP 10T
JCI
ACI
NABH
JCI – PhP 14 M
ACI – PhP 8 M
NABH – PhP 3 M
(equivalence of Baldrige Awards
of )
PhP 30T – small organizations
PhP 50T– medium to big
organizations
Standardization)
PhP 300T
Investors in People PhP 1M

What are the currently sought accreditation by hospitals in the Philippines,
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 Canada
International (ACI)
National Accreditation Board
for Hospitals and Healthcare
Providers (NABH)
Designed to improve quality and safe
patient care
Designed to assess and improve
organization performance based on
internationally agreed standards and
stimulating continuous improvement to
achieve optimum outcomes on
healthcare

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
 Individual Client /
Patient Care
Groups (14)
 Information
Management
 Human Resources
Development and
Management
 Environmental
Management
 Leadership and
Partnerships

Accreditation
Canada
Joint Commission International National Accreditation Board
for Hospitals
 Individual
Client / Patient
Care Groups
(14)
 Information
Management
 Human
Resources
Development
and
Management
 Environmental
Management
 Leadership
and
Partnerships
Patient-centered Standards
•Access to Care and Continuity of Care
•Patient and Family Rights
•Assessment of Patients
•Care of Patients
•Anesthesia and Surgical Care
•Medication Management and Use
•Patient and Family Education
Health Care Organization Management
Standards
•Quality Improvement and Patient
Safety
•Prevention and Control of Infections
•Governance, Leadership, and
Direction
•Facility Management and Safety
•Staff Qualifications and Education
•Management of Communication and
Information
• Access and Planning of
Services
• Customer Rights and
Education
• Care of Customers
• Management of
Medication,
Consumables and
Equipments (including
Instruments)
• Infection Control
• Continual Quality
Improvement
• Responsibilities of
Management
• Facility Management and
Safety
• Human Resource
Management
• Information Management
System

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

(equivalence of Baldrige Awards of US )
Designed to help provide hospitals with an
integrated approach to organizational
performance that results in
Delivery of ever-improving value to
customers and stakeholders, contributing
to organizational sustainability
Improvement of overall organizational
effectiveness and capabilities
organizational and personal learning
Standardization)
ISO 9001: Quality Management
System
Designed to help organizations ensure that
they meet the needs of customers and other
stakeholders while meeting statutory and
regulatory requirements related to the product.

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

Baldrige Health Care Criteria for Performance Excellence

PQA Criteria for
Performance Excellence
ISO 9001:2015
 Leadership
 Strategic Planning
 Customer Focus
 Measurement,
Analysis, and
Knowledge
Management
 Workforce Focus
 Operations Focus
 Results
4. Context of Organization
5. Leadership
6. Planning
7. Support
8. Operation
9. Performance evaluation
10. Improvement

(equivalence of Baldrige Awards of US)
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 PQA Health
Care Criteria for Performance Excellence as
complementary guide.
Standardization)
ISO 9001: Quality Management
System
International standards on basic quality
management system that are applicable to all
kinds of industry including hospitals and health
care
*Recommended if an international
accreditation is deemed needed and cannot
afford ACI / JCI / NABH

Investors in People Designed to transform business
performance through people

PQA Criteria for
ISO 9001:2015 Investors in People
 Leadership
 Strategic Planning
 Customer Focus
 Measurement,
Analysis, and
Knowledge
Management
 Workforce Focus
 Operations Focus
 Results
4. Context of Organization
5. Leadership
6. Planning
7. Support
8. Operation
9. Performance evaluation
10. 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

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.

Advantages of Being Compliant with Local and International
Standards of Quality and Safe Patient Services
• Stimulate continuous improvement in service and patient
care processes and outcomes.
• Improve management of health care services particularly
on patient safety.
• Provide staff education on better or best practices.

Advantages of Being Compliant with Local and International
Standards of Quality and Safe Patient Services
Increase efficiency / reduce cost.
Improve organization performance.
Promote recognition for excellence.
Strengthen public and community confidence.

What are the recommended processes in going for hospital accreditation?
Starting point:
Top management decides to have a Hospital
Accreditation Project
• To promote the business development program of
the hospital so as to make it viable and
sustainable.
• To use it as a change agent to fast-track quality
improvement.

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.)

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

Steering Team formulates a master plan for Hospital
Accreditation Project.
Steering Team decides on set of standards to be assessed or
evaluated on by an accrediting body.
Steering Team seeks commitment for support and
collaboration from top, senior, middle, and lower
management on Hospital Accreditation Project.

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)
• ………..

Contents of master plan for Hospital Accreditation Project
• ..........
• Timelines (short- and long-term)
• Strategies and action plans to achieve expected outputs
and impacts (short- and long-term)
• Budget (short- and long-term)
• Monitoring and oversight plan
• Evaluation plan (short- and long-term)

It depends on your need and situation!
Need - to participate in National Health Insurance Program and get
benefits – go for PhilHealth Accreditation!
Need - to participate in medical tourism program and get benefits –
PCAHO, international accreditation (JCI / ACI / NBAH)
Need – to satisfy requirement of corporate accounts – go for
accreditation!
Need – to satisfy expectations of the community – go for
accreditation!

Situation – to be with the trend of having an international
accreditation (not to be left out – strong community expectation) –
go for accreditation!
Situation – want to fast-track improvement of quality and safety of
operations and services with accreditation – go for accreditation
(assessment, training, improvement, evaluation)!

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

Integrating Hospital Quality and Performance
Standards
• Philippine Quality Award Criteria for
• 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
Performance
Excellence
Use
integrated
checklists

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

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

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

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

Reynaldo O. Joson, MD, MHA, MHPEd, MSc Surg
UP Manila College of Public Health
Thank you for your kind attention.
For queries and feedback:
rjoson2001@yahoo.com
0918-804-0304

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

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