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Accreditation Guide.pdf

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Accreditation Guide.pdf

  1. 1. Hospital Orientation Program
  2. 2. Outline The Hospital Accreditation Process Guide contains: • Registration with CBAHI • Scoring Methodology • Hospital Responsibilities • CBAHI Survey Process • Pre-Survey Activities • Resources to assist the hospital • Survey Team Composition • Survey Scheduling and Survey Agenda • Off-site Survey Activities • On-site Survey Activities • Post Survey Activities
  3. 3. Registration with CBAHI
  4. 4. How to Register with CBAHI • Open your web browser e.g. Internet Explorer • Type in the address bar • Choose "Health Care Facility" and click Login. • You will be directed to other web page. Click on the icon "register to become a CBAHI Accredited Healthcare Facility" and you will again be directed to other web page. • Start entering your hospital information. • After completing all required information, you are required to: • Type the security numbers as they appear on the left bottom of the page. • A message about completion of registration will be displayed specifying the Username and Password. • Use the specified Username and Password to access the CBAHI portal Page 3
  5. 5. How to Register with CBAHI • Open your web browser e.g. Internet Explorer • Type in the address bar • Choose "Health Care Facility" and click Login. • You will be directed to other web page. Click on the icon "register to become a CBAHI Accredited Healthcare Facility" and you will again be directed to other web page. • Start entering your hospital information. • After completing all required information, you are required to: • Type the security numbers as they appear on the left bottom of the page. • A message about completion of registration will be displayed specifying the Username and Password. • Use the specified Username and Password to access the CBAHI portal Page 3
  6. 6. Scoring Methodology
  7. 7. • Each sub-standard has equal weight and is scored on a three point scale as follows: 0 = < 50% Compliance 1 = >= 50% - < 80% Compliance 2 = >= 80% Compliance N/A = Not Applicable • The overall score of the hospital is automatically calculated by the software application using the average (arithmetic mean) score of all applicable sub-standards, i.e. as the sum of all values divided by the number of values added. • 3,588 scorable sub-standards. • There is no chapter score 10 Scoring Guidelines
  8. 8. Scoring Guidelines Special scoring considerations • All ESRs should be in full compliance. If more than 25% of ESRs are partially or not met, the hospital will get Conditional Accreditation. The hospital is required then to develop a “Standards Compliance Progress Report”, followed by a “follow up Focused Survey” if required before changing the accreditation status. • Criticality of a non-compliant standard. o Criticality has several levels, the most serious of which is when the surveyor notices an immediate threat to safety or quality of care. Such as: Healthcare provider is entering an isolation room without proper Personal Protective Equipment (PPE). o The criticality of non-compliant standards affects the accreditation decision.
  9. 9. Hospital Responsibilities
  10. 10. Responsibilities of Participating Hospitals Survey Visit Coordinator • The survey visit coordinator designated by the hospital will serve as the liaison with the Healthcare Accreditation Department (HAD) and the survey team leader about the survey visit arrangements. Survey Team Biographies • A list of survey team members, with their biographies, will be sent to the hospital prior to the survey visit. • The hospital should contact the Healthcare Accreditation Department promptly if any surveyor is deemed to be inappropriate due to conflict of interest or other valid reasons. • Note: CBAHI cannot honor requests for specific surveyors for the purpose of objectivity. • Page 6
  11. 11. Responsibilities of participating hospitals Travel Arrangements • The hotel and flight reservations will be arranged by CBAHI. A list of assigned surveyors together with their flights’ details and mobile numbers will be sent to the hospital’s survey coordinator prior to the survey. • The hospital should arrange ground transportation from the airport to the hotel. • The hospital should decide how to transport the team members each day between their hotel and the hospital and to any remote sites they will visit as part of the survey. • Additionally, the hospital should arrange transportation from the hotel to the airport according to the departure time of surveyors Gifts to Survey Team Members
  12. 12. Responsibilities of participating hospitals Survey Logistics • Hospitals should provide appropriate logistics that include the following: • A workroom that is large enough for the survey team members to review documents and leave computers and binders. The workroom needs to be furnished with a desk or table, access to electrical outlets, and internet access, if available. • Workrooms for group meetings and interviews with staff as specified in the survey agenda. • Assigning a counterpart for each surveyor who is a responsible person for the same specialty during the survey. Survey Observers • One or more observers or mentors may join the CBAHI survey team as part of the surveyors’ training process. • Observers and mentors from CBAHI side will be included in the list of the surveyors sent by hospital accreditation department prior to the survey.
  13. 13. CBAHI Survey Process
  14. 14. Pre-Survey Activities
  15. 15. Pre-survey Activities Enrollment for Survey • The accreditation process begins with selection of the hospitals to be surveyed. • Each year, CBAHI selects the hospitals to be enrolled in the accreditation program. • CBAHI sends a letter of enrollment to the selected hospitals to start their application process. Application for Survey • After completion of the enrollment process, hospitals selected for the accreditation process must complete an applicationform (demographic questionnaire) available on the CBAHI website which include: o Hospital Information o Leadership Contacts o In-patient Units o Specialty Units o Out-patient services o Top 5 diagnosis Page 7 o Site demographics
  16. 16. Pre-survey activities Update of Application Information • If a hospital experiences significant changes after it submits its application, the changes must be made in the application form within five (5) business days of this change. • The requirement of updating the application information includes updates of the main contact persons of the hospital to ensure an ongoing communication channel Update for Reaccreditation Survey • The update for a re-accreditation survey should be completed by accredited hospitals. This update for re-survey must be completed and submitted to CBAHI twelve (12) weeks prior to the accreditation expiration.
  17. 17. Resources to Assist the Hospital
  18. 18. Resources to Assist Hospitals • CBAHI accreditation coordinator • Assigned by CBAHI • Coordinate survey planning • CBAHI Standards Manual • Introduction • Accreditation policies • CBAHI standards • Accreditation Process Guide • Survey Preparation • Self-assessment guide • On-going standards compliance • Continuous quality improvement. Page 9
  19. 19. Resources to Assist Hospitals • Self-Assessment Tool (SAT) • Critical and integral part of CBAHI accreditation process • Valuable information for improvement • Hospital Orientation Program (HOP) • Standard introduction and implementation • Accreditation policies • Survey process preparation • Mock Survey • Recommended but not mandatory • Consultative Visit • Upon request • Optional • One or more selected area(s) • Requests for Interpretation of Accreditation Standards and Policies • CBAHI website “contact us” Page 9
  20. 20. Survey Team Composition
  21. 21. Survey Team Composition • The survey team size and composition is based on a careful review of:  Size of the facility to be surveyed, based on average daily census.  Complexity of services offered, including surgical and anesthesia services.  Whether the facility has special care units or off-site clinics or locations. Page 11
  22. 22. Survey Team Composition • A typical full survey of a hospital, the survey team would include seven (7) surveyors who will be at the facility for three (3) or more days: • Main (Core) Team • Leadership & Quality Management Surveyor • Medical Surveyor • Nursing Surveyor • Specialty Team • Medication Management Surveyor • Infection Control Surveyor • Laboratory Surveyor • Facility Management and Safety Surveyor Page 11
  23. 23. Off-Site Survey Activities On-Site Survey Activities Survey Scheduling and Survey Agenda
  24. 24. Off-Site Survey Activities • The hospital scheduled for the onsite survey shall send a list of the off-site required documents, for the off-site review by the surveyors at least two (2) weeks prior to the date of the onsite survey. • The list shall be communicated, as a signed and scanned PDF document, with the scheduling coordinator in the HAD department. • Sample of off-site documents: Page 14
  25. 25. Role of the Visit Team Leader: • Review the uploaded hospital demographic data. • Review hospital website (if any) for any additional information related to the survey. • Deal with any conflicts arising between surveyors and/or with the hospital. • Communicate with hospital visit coordinator the required medical records to be selected. • Communicate with hospital visit coordinator to ensure that the requested personnel files ready prior to the personnel files review session. • Coordinate and arrange a new session “if needed”.
  26. 26. On-Site Survey Activities • The survey visit will last for 3 days. • The survey commences with: - Opening conference - Closed document session. - Facility tour - Observation/staff interview - Open medical record - Closed medical record - Personnel files - Multiple committees meetings:  Quality management  Environmental safety  P&T committee  Medical executive  Executive leadership  Infection control  Contract review committee
  27. 27. Sample Survey Agenda P.49 – 52
  28. 28. On-Site Survey Activities Surveyor Planning Session P.16 • Only surveyors attend this session Opening Conference P.17 • Greeting on behalf of the team members & CBAHI. • Introduction of survey team members. • Call hospital leader to start the hospital presentation. The hospital leadership shall introduce: o The hospital structure oThe hospital scope of services o Highlight the hospital improvement initiatives. o The surveyors' counterpart to facilitate the smooth flow of the survey process.
  29. 29. On-Site Survey Activities Review of Documents (Closed Session Sample) Annex B P.55 – 81
  30. 30. On-Site Survey Activities • Unit Document “Documented evidences” Sample Annex B P.55 – 81
  31. 31. On-Site Survey Activities Surveyors Business Lunch Only surveyors attend this meeting Surveyors End of the Day Meeting Only surveyors attend this meeting. Surveyors Debriefing oThe surveyors present their findings to their counterparts for discussion and clarification. oThis allows for direct face-to-face interaction with the surveyors. oAllows the hospital to clarify or explain possible discrepancies or compliance issues.
  32. 32. On-Site Survey Activities Medical Record Review (Closed and open) • Surveyors will use both closed and open medical records. • While closed records determine the past practice and the frequency of a deficient practice, open records reflect services provided at the time of the survey. Annex C
  33. 33. On-Site Survey Activities Annex C
  34. 34. On-Site Survey Activities Personnel Files Review • Hospitals are required to have the requested personnel files ready prior to the personnel files review session. • The surveyors will provide the hospital with the randomly selected personnel files list required to be reviewed during the session • Hospitals are encouraged to present the needed documentation in one location to ensure comprehensiveness of personnel data and the employment history in the hospital
  35. 35. Personnel Files Review On-Site Survey Activities Annex D
  36. 36. On-Site Survey Activities Facility Tour and Unit Visits • Hospitals should assign a counterpart for each surveyor to guide the surveyor to the various survey sites. • At all times during the unit visits, the surveyors gather information with minimal disruption of the daily activities of the hospital being surveyed. • During this activity, the surveyor moves through the hospital and visits all areas of the hospital that affect the delivery of care and services. • The hospital staff are interviewed, facilities are observed, and records are checked to ensure compliance with certain standards’ requirements. This activity also includes a facility tour conducted for review of infection control and facility management and safety standards.
  37. 37. On-Site Survey Activities P.27
  38. 38. On-Site Survey Activities Committee guidelines and requirements sample
  39. 39. On-Site Survey Activities Report Preparation session • Only surveyors attend this session. • To provide the hospital with the possible challenges and areas for improvement. • Provide the hospital with the list of non-compliant “ESR’s” that need immediate leadership attention. Closing Conference • At the conclusion of the on-site survey, after collection of final data, the surveyors hold a closing conference at which they present key findings and the hospital’s areas for improvement. • Exit report will be provided to the hospital director including the draft of major findings in ESRs and other standards in all specialties Note: As the surveyors are “fact finders” for the CBAHI, they do not render the final accreditation decision, but instead they report findings to the CBAHI. Therefore, during the exit conference, the surveyors will not state whether the hospital will be awarded an accreditation. P.40
  40. 40. Post Survey Activities
  41. 41. Post Survey Activities Survey Report • Within 30 days • Cover letter, detailed sub-standards by chapter, ESRs, Executive summary. • Accreditation is valid for 3 years. Accreditation Maintenance • Maintain compliance for the entire accreditation duration • Right of CBAHI to review hospital compliance • Mid-term self assessment. Page 42 - 46
  42. 42. Post Survey Activities Self-assessment Tool (SAT) • To assist hospitals measure their compliance with CBAHI standards, maintain a status of accreditation readiness and oversees the quality and safety of patient care. • It is intended for use by the hospital leadership, planners, hospital committees’ team members. • The tool is expected to provide hospitals with means of evaluating their plans, policies, procedures and capabilities against current CBAHI standards • Identify its own strengths and areas for improvement • Understand more clearly the issues that are of interest to CBAHI • Export the data for analysis and evaluation by CBAHI Page 42 - 46
  43. 43. Post Survey Activities Self-assessment tool (SAT) • Initial (prior to initial survey) • At the middle of accreditation cycle (18-month) • CBAHI reminder at 15-month • Submit SAT with action plans for non-satisfactory compliances, date, responsible staff, and measures to ensure sustainability. • 0 = insufficient compliance, • 1 = partial compliance, and • 2 = satisfactory compliance • “NA” = Not Applicable • How to access SAT (next presentation) Page 42 - 46
  44. 44. Post Survey Activities Survey Feedback • CBAHI wish to evaluate and improve its performance. • Hospital feedback. • Ensure the continuing growth and improvement of CBAHI’s accreditation program. • Email reminder • Feedback: CBAHI standards, Survey process Surveyors performance. Page 42 - 46
  45. 45. Thank you