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Accreditation Standards for Medical Staff Management Rabab Diab, RN, MSN, CPHQ HCAC, Deputy CEO and Director of Education & Consultation Iraqi Health Conference – Erbil Monday, 28 May 2013 Outline • • • • • Healthcare System in Jordan Medical Staff in Jordan and Challenges Quality and Patient Safety Journey in Jordan Quality and Patient Safety Challenges Accreditation Standards for Medical Staff Management • Conclusion Outline • • • • • Healthcare System in Jordan Medical Staff in Jordan and Challenges Quality and Patient Safety Journey in Jordan Quality and Patient Safety Challenges Accreditation Standards for Medical Staff Management • Conclusion Introduction • Upper middle-income country • Population of 6.2 million • Per-capita GNI of US$4,340 • Youngest among uppermiddle income countries with 38 percent under the age of 14 Healthcare Providers by Sector Public Sector Private Sector Ministry of health (primary healthcare centers and hospitals) Hospitals Royal medical services University hospitals Private clinics Diagnostic and treatment centers International Sector UNRWA Outline • • • • • Healthcare System in Jordan Medical Staff in Jordan and Challenges Quality and Patient Safety Journey in Jordan Quality and Patient Safety Challenges Accreditation Standards for Medical Staff Management • Conclusion Number of Physicians/10,000 Population 2005 – 2010 Number of Physicians/10,000 Population 50 45 40 36.5 35.4 35 31.1 28.3 30 27.6 25 20 15 24.2 17.9 19 19.3 19 15 14.4 14.2 12.1 11.9 9.4 8.9 10 5 27.4 24.5 6.9 6.2 2.3 0 WHO, World Health Statistics 2012, 2012. See also, WHO, Global Health Observatory. 3 Medical staff management in Jordan have different strengths but face several challenges Strengths Established education programs Qualified medical staff Good health out come indictors in terms of communicable diseases, infant and maternal health Challenges Lack of leadership competency Lack of regulations No policies, procedures, clinical guidelines Lack of credentialing and privileging system for medical staff No relicensing system Continuous education No medical liability laws Outline • • • • • Healthcare System in Jordan Medical Staff in Jordan and Challenges Quality and Patient Safety Journey in Jordan Quality and Patient Safety Challenges Accreditation Standards for Medical Staff Management • Conclusion Quality improvement for Jordan started with a visionary Minister who took a leap for accreditation… USAID Agrees to support initiative of Minister of Health HCAC registered as a non-profit private sector company NQSGs launched 1st edition Primary Health Care Standard ISQua accredits Surveyor Certification Course 2004 2007 2009 2003 12 members from a National Accreditation Committee was approved 2005 Pilot Hospitals Pilot Hospitals and First draft of Jordanian Hospital standards 2008 ISQUA accredits hospital standards First Surveyor Certification course started Medical Transport Standards Public Awareness Centers of Excellence Patient Safety Center / Institute Breast imaging Units Standards 2011 Cardiac Standards 2010 2013 2012 ISQua accredits HCAC Diabetes Standards First Regional Conference Second Regional Conference 10 So HCAC was established in 2007 as a nonprofit private shareholding company with the aim to raise the quality of health services… HCAC Mission Vision Values To foster the continuous improvement of the quality and safety of health care facilities, services and programs through developing internationally accepted standards, capacity building and awarding accreditation HCAC services and accreditation will be the primary choice of healthcare facilities and organizations in Jordan and the region Continuous Improvement Learning Customer Focus Teamwork Impartiality Transparency Integrity 11 …Through a range of different services stemming out of two separate arms of the organization “A Comprehensive Model of Quality Improvement Services” Standards Development Surveyor Development Accreditor Accreditation Surveys and Standards Development Department Functions Firewall Mock Surveys Consulting for Government Preparedness Enabler Training and Certified Courses Education and Consultation Department Consultant Development 12 HCAC can now showcase a multitude of successes… Standards Hospital Accreditation Standards - 3rd edition Primary Health Care & Family Planning Accreditation Standards– 2nd edition Accreditation Diabetes Care standards 1st edition 41 certified hospital surveyors Cardiac Care standards being developed 20122013 17 hospitals accredited – four in the pipeline National Quality and Safety Goals 2009, 2010, 2011, Medical Transport 2012, 2013 Services Certification Family Planning & Standards- 1st Reproductive edition Health Centers of Excellence Breast Imaging Program- 1st Units Certification edition Standards- 1st edition 31 certified PHC surveyors 45 PHC accredited – 60 in the pipeline 4 Certified Breast Imaging Unit Education & Consultation Preparing 8 hospitals for Accreditation, 5 breast imaging units Graduated groups from : Certified Consultant Training program Certified Quality professionals Certified Infection Control professionals Certified Risk Management Leadership & Management 13 The HCAC Hospital Standards Manual (3rd ed.) is divided into 14 clusters entailing 347 standards and 1238 measurable elements The Clusters Each Cluster is composed of 4 line items Cluster 1: Ethics and Patients’ Rights Cluster 2: Access and Continuity of Care Cluster 3: Patient Care Standards Statements Survey Process Cluster 4: Diagnostic Services Cluster 5: Medication Management Cluster 6: Infection Prevention and Control Classification Cluster 7: Environmental Safety Critical (57 Standards): Address laws and regulations and, if not met, may cause death or serious harm to patients, visitors, or staff Cluster 8: Support Services Cluster 9: Quality Improvement and Patient Safety Cluster 10: Medical Records Cluster 11: Information Management Cluster 12: Human Resources Management Cluster 13: Management and Leadership Cluster 14: Education and Training Core (257 standards): Address systems, processes, policies and procedures that are important for patient care Measurable Elements Requirements of the standard that will be reviewed and assigned a score during the accreditation survey process Stretch (33 standards): Important standards, but not easy to implement due to time or resource constraints, or a need for culture change 14 Outline • • • • • Healthcare System in Jordan Medical Staff in Jordan and Challenges Quality and Patient Safety Journey in Jordan Quality and Patient Safety Challenges Accreditation Standards for Medical Staff Management • Conclusion Quality and Patient safety still faces many challenges in Jordan chemical exposure Lack of medical staff management systems Lack of radiation safety Competency of healthcare providers Absence of basic hygiene Violation of human rights No documented policies, procedures, plans, Flies in operating rooms No clinical guidelines Open sewage systems within hospitals Lack of privacy No fire safety procedures and systems Untrained staff on basic resuscitation Not in compliance with laws and regulations regarding fire safety, radiation safety, staff qualifications, and medication management processes. Outline • • • • • Healthcare System in Jordan Medical Staff in Jordan and Challenges Quality and Patient Safety Journey in Jordan Quality and Patient Safety Challenges Accreditation Standards for Medical Staff Management • Conclusion Medical Staff Management Standards • • • • • Credentialing and privileging Medical staff file Medical staff governance system Medical graduate program Performance appraisal The standards of medical staff management are integrated in all clusters Quality Improvement and Patient Safety Medical staff management standards Human Resources Education and Training Management and Leadership Patient Care Medical Record Documentation 19 HRM.7 The hospital has a process, defined in writing for verification of the license, education, experience, and certification for all licensed professional staff. The process of obtaining, verifying, and assessing the qualifications of a licensed independent practitioner Why? To determine whether he/she is qualified and able to provide patient care services and to participate on the medical staff”” 20 Essential Data in the Credentialing Process Current licensure Relevant training and experience Current competence Peer recommendations Clinical privilege delineation 21 21 Privileging The process of evaluation of an individual’s performance to determine if he/she is qualified and able to perform specific patient care services related to his/her specialty Privileging of medical staff accompanies credentialing process. 22 22 Granting Clinical Privileges Delineation of clinical privileges Delineation of admitting privileges Categories of privileges Limitations of privileges Practicing within scope 23 23 Other Data Ability to perform Challenges to licensure/registration Voluntary/involuntary terminations or restrictions Professional liability 24 24 Medical Staff Management Standards Credentialing and privileging Medical staff file Medical staff governance system Medical graduate program Performance appraisal 25 HRM.9 a personnel file is maintained for each employee - Documents related to license Education Experience Certification 26 Medical Staff Management Standards • • • • • Credentialing and privileging Medical staff file Medical staff governance system Medical graduate program Performance appraisal HRM.13 A governance system is in place for the medical staff to ensure the quality of patient care. • Categories of medical staff Medical staff bylaws • Privileging Medical staff committee • Medical staff issues • Quality improvement activities • Role of medical staff Hospital-wide members in committees quality improvement • Quality improvement program initiatives Medical Executive Committee 29 Medical Staff Bylaws Medical staff structure Medical executive committee Credentialing and privileges processes Membership, delineation of clinical privileges, and termination Participation in organization improvement activities 30 ML.8 Each Administrative and Clinical Department has an assigned department head with specific responsibilities • Each clinical department has a designated medical staff head who is board certified in a relevant specialty. • The assigned department head responsibilities include: - Ensuring and overseeing the development and implementation of the departmental policies and procedures - Ensuring that quality improvement and patient safety activities are carried out (PDSA) 31 Medical Staff Management Standards • • • • • Credentialing and privileging Medical staff file Medical staff governance system Medical staff graduate training program Performance appraisal 32 HRM.15 Hospitals that participate in professional under graduate education programs have a well-defined system for training. • Supervision of trainees by qualified members and their relationship with the hospital • Clear process for trainee orientation 33 Medical Staff Management Standards • • • • • Credentialing and privileging Medical staff file Medical staff governance system Medical graduate program Performance appraisal 34 HRM.8.1 Performance appraisals measure the performance of the employee against criteria related to evidence-based practice, innovation and/or research. • Performance criteria are written supporting evidence-based practice, innovation and/or research for each category of employee including medical staff. • Performance criteria are measurable, understandable, verifiable, equitable, and achievable. 35 Other Related Standards Medical Record Documentation All patient medical record entries are legible, complete, dated, timed, and authenticated . Clinical Practice Guidelines Anesthesia Standards CPGs are adopted/developed and implemented for priority clinical services. Current anesthesia evidence-based guidelines. Individual healthcare providers’ compliance with the clinical practice guidelines. Patients are managed by a qualified physician. 36 Outline • • • • • Healthcare System in Jordan Medical Staff in Jordan and Challenges Quality and Patient Safety Journey in Jordan Quality and Patient Safety Challenges Accreditation Standards for Medical Staff Management • Conclusion …HCAC is in continuous improvement itself… The future of Quality Improvement is full of commitments Commitment to the QUALITY Commitment to PATIENT SAFETY Commitment to CAPACITY BUILDING Commitment to RESEARCH and POLICY 38 39 39