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National vs. International Accreditation ‘A Kuwaiti Experience in private and public sector’ Ahmad Nasrallah, MPH. Chief Operating Officer Dar Al Shifa Hospital (DASH) Kuwait 1 Content 1. National (Kuwaiti) Vs. International Accreditation (similarities & differences) 2. A glance at Kuwaiti Accreditation System 3. CCHSA Accreditation (as an international sample) 4. DASH Real Life Experience 2 National Vs. International Accreditation “similarities” • Both aim at achieving QUALITY & PATIENT SAFETY • Both utilize certain set of standards to compare actual practice against • Both use surveyors to accomplish them • Both utilize a multidisciplinary approach (with differences) • Self Assessment is one of the process cornerstone elements • Top management COMMITMENT is a necessity • Clients’ involvement and education is elaborated • Closing the LOOP is a MUST 3 Kuwaiti National Accreditation vs. International Accreditation ‘Differences’ • • • • • • • National For governmental hospitals and clinics only Mandatory Mainly structure-focus Few indicators are utilized (administrative, outcome) Free of charge Limited resources 2-year cycle (theoretically) • • • • • • • • International For governmental and private health organizations Voluntary Mainly process& outcome – focus Comprehensive process is identified to go through starting from assessment to final survey Many indicators are utilized (structure, process, outcome) Relatively expensive More resources are available 3-year cycle 4 National Accreditation As A Tool for Adopting International Quality Standards • Introduces the local clients and organizations to the concepts of accreditation & quality in an incremental way therefore; buying in and committing to it will be easier • Facilitates building the infrastructure for quality, hence becomes more sustainable • Helps to transform the current punitive culture into a learning culture which is considered a primary yet crucial step farther 5 Content 1. National vs. International Accreditation (similarities & differences) 2. A glance at Kuwaiti Accreditation System 3. CCHSA Accreditation (as an international sample) 4. DASH Real Life Experience 6 Kuwait National Accreditation “History” • Commenced in the year 2000, Guided by the M.O.H Quality Department. • Started by a gap analysis conducted to the 15 governmental hospitals • Implementation was divided into two phases: 1. Preparation Phase: during which the basic requirements’ draft was prepared (based on the M.O.H circulars) & implemented by the hospitals 2. Adoption Phase: during which the established standards were adopted by the hospitals to evaluate their performance against them and identify opportunities for improvement • First External Survey was conducted in 2004 7 Kuwait National Standards: • A Total of 266 basic requirements • Involved the work processes of the different committees and sections Aspects covered by the requirements: • Hospital’s Top Management (Hospital’s Director, Deputy Director, Assistant Director for Administrative Affairs) • Heads of Clinical and Non Clinical Units & Departments • Hospital wide committees(Hospital Administrative Board,Morbidity & Mortality Committee,Medical Record Review Committee,Infection Control Committee,Code Blue Committee (ER),Accreditation Preparation Committee… 8 Dimensions of Kuwait National Accreditation 1. 2. 3. 4. Compliance Coordination Communication Client-Centered 9 Evolved around Patient Safety: • Coordination of services (amongst the different specialties and units) • • • • • • • Standardization of clinical practices Integrated Medical Records Continuous education & training Fire Safety Program Emergency Preparedness Plan Infection Control Program Risk Management 10 Client-Centered: • Involvement of patients and their families in their care & treatment therefore; they can make informed decisions • Patients & Families’ Rights and education. • Patient Satisfaction Survey • Staff Satisfaction Survey • Orientation Programs • Home Care 11 Tools • • • • • • • Periodic Clinical Audits including clinical guidelines Medical Records’ Review Indicators Policies & Procedures Review Quality Improvement Projects Feedback Surveys Self assessment : A continuous review and follow up of implementation progress. • External Survey: Independent Surveyors are sent by MOH for external evaluation 12 Kuwaiti Accreditation Cycle Report on Quality Improvement Initiatives to MOH Higher Accreditation Committee Report on Recommendation Back to the Hospital’s Accreditation committee 2-year Cycle Self Assessment by Hospital’s Accreditation Committee External survey by ( Independent surveyors ) Implementation of Recommendation By the Hospital 13 National Accreditation as a Tool to Adopting International Accreditation International Accreditation Quality infrastructure & Culture Adaptation National Accreditation 14 Supportive Infrastructure Components Information Management Learning Culture Competent Committed Reward System Human Resources Recognition & Motivation Education & Training Benchmarking Quality Infrastructure Measurements & Monitoring Activities Documentation P&P Practice Guidelines Performance Standards Top Management Commitment Supportive Committees 15 Next Move An Integrated contract has been prepared with the Canadian Council On Health Services Accreditation ( CCHSA). Final steps 16 Content 1. National vs. International Accreditation (similarities & differences) 2. A glance at Kuwaiti Accreditation System 3. CCHSA Accreditation (as an international sample) 4. DASH Real Life experience 17 CCHSA Accreditation Process Self Assessment CLIENT 18 Principles of CCHSA Accreditation 19 CCHSA Standards A total of 473 criteria falls under 178 standards. Scored the standards within 4 parameters; compliance, communication, coordination, & client-focus Emphasized the vitality of clients’ safety (internal & external customers) in all standards. Created 21 Required Organizational Practices (ROPs) that supports patient safety. By January 2006, compliance with these ROPs became a requirement of accreditation surveys. Developed five patients’ safety areas and six patients’ safety goals. 20 CCHSA - Patient Safety Area 1/3 The 6 patient safety goals are organized into five areas: 1. CULTURE Goal 1: Create a culture of safety within the organization. 2: COMMUNICATION Goal 2: Improve the effectiveness and coordination of communication among care/service providers and with the recipients of care/service across the continuum. 21 CCHSA - Patient Safety Area 2/3 3. MEDICATION USE Goal 3: Ensure the safe use of high risk medications Goal 4: Ensure the safe administration of parenteral medications. 22 CCHSA - Patient Safety Area 3/3 4: WORKLIFE/WORK FORCE Goal 5: Create a work life and physical environment that supports the safe delivery of care/service 5: INFECTION CONTROL Goal 6: Reduce the risk of health service organization-acquired infections, and their impact across the continuum of care/service. 23 Client/Patient and Family Care Preparing for Care and Treatment Assessment Care and Treatment Planning Implementation and Evaluation of Care and Treatment Discharge And Follow-up Quality Monitoring And Improvement Quality Monitoring and Improvement 24 Canadian Council on Health Services Accreditation Survey Simulation Client interviews Indicators Patient Tracer Self-assessment Team interviews Surveyor Rating On-site documentation Focus groups Required Information Tours 25 What should you learn from the process? 26 Self assessment Vision Mission Values Communicatio n Process Co-ordination Structure Client input 27 Content 1. National vs. International Accreditation (similarities & differences) 2. A glance at Kuwaiti Accreditation System 3. CCHSA Accreditation (as an international sample) 4. DASH Real Life experience 28 History of DASH The first Private Hospital in Kuwait that was established in 1961. It began with Maternity department only (30 beds). In 1995, it evolved into a hospital that provides a broader scope of services. Various departments were launched; Dentistry , Pediatrics , Internal Medicine , Plastic Surgery, ENT , Dermatology , General Surgery , Orthopedics , Ophthalmology , in addition to Cardiac Sonar & Radiology, Laboratory and Pharmacy. 2004: Transferred to the new building in the District of Hawally. 29 Nowadays: A total of 100 in-patient beds including SCBU, NICU, ICU, CCU, and Day Case Surgery. A total of 23 medical specialities and 12 subspecialities. A total of 52 out patient clinics. 6 operating theatres Cardiac Catheterization Lab was launched on May 07 A total of 776 diverse workforce Started a massive expansion project. 30 DASH; A Month In Life…. 20217 1041 500 5500 5289 475 40 18 20048 1020 253 1244 Outpatient visits People are admitted Deliveries Patients are seen in Emergency Room New patients are accepted in all specialties Patients have surgical procedures IVF cycles Total Knee Replacements Performed Laboratory tests are analyzed Routine radiological studies are performed CT/MRI studies are done Ultrasound studies are performed 31 Turnover Trends at DASH 25000 20000 OP.Visits Emergency Pts 15000 Deliveries Admitted Pts 10000 New Patients 5000 0 2004 2005 2006 2007 32 DASH The first hospital in Kuwait that signed up for accreditation with a world-wide recognized accrediting body, and… The first hospital in Kuwait that was granted the accreditation certificate on Dec.2007 By The Canadian Council On Health Services Accreditation CCHSA 33 DASH Approach To Achieving CCHSA Accreditation Communication Organization’s Culture Organization wide Committees Patient safety Accreditation Quality Infrastructure Self Assessment Medical Record Education & Training 34 DASH Self Assessment Teams A Total of 11 multidisciplinary teams were made up to : 1. Conduct periodic self assessment of the organization 2. Liaise between the departments and the Quality Management Office 3. Identify opportunities for improvement and define quality improvement projects in collaboration with the relevant departments/units and guided by the Quality Management Department 35 Self Assessment Teams • Service Delivery Teams • Support Services teams • Administrative Teams • Environment Care Team 36 Service Delivery Teams 1. Surgical Care Team 2. Maternal/ Child Team 3. Medical Care Team 4. Emergency Care Team 37 Support Services Teams 5. Pharmacy Team 6. Diagnostic Services’ Team 7. Laboratory Team 38 Administrative Teams 8. Leadership & Management Team 9. Human Resources Team 10.Information management Team 11. Environment Care Team 39 Accreditation Process/DASH 60% 50% 40% 30% 20% 10% 0% Not in Place In Development Implemented 40 Mock Survey Results Adequate Standards Improvement Required Not in Place 63% 36% 1% 70% 60% 50% 40% 30% 20% 10% 0% Adequate Improvement Required Not in Place 41 Final Survey’s Results Substantial Compliance Partial Compliance Minimal Compliance 65% 35% 0% 70% 60% 50% 40% 30% 20% 10% 0% Substantial Compliance Partial Compliance Minimal Compliance 42 Challenges Faced During The Process 1. Resistance: it was dependant on employees characteristics most resistance had come from physicians 2. Inconsistency between the strategic direction of the top management and subordinates 3. Culture : both patients and employees 4. Compliance to documentations’ standards was crucial 5. Lack of understanding of the main purpose for as such process by the employees 6. Absence of Teamwork 7. Communication 8. Politics 9. Lack of employees’ involvement in major decision making 10. Lack of feedback activities 11. Multidisciplinary Approach 43 However; towards the final survey many people bought in due to…. 1. 2. 3. 4. 5. 6. 7. 8. 9. Continuous education and training Open door policy and open channels of communication Open meetings between top managers and employees Staff satisfaction survey Feedback mechanisms in place Involvement in setting up the alternate strategic direction of the organization Emphasizing important ethics of organizational justice, teamwork, recognition, and rewards Creating positive competition through continuous internal benchmarking and role modeling Most important: transforming the organization into a LEARNING ORGANIZATION and adopting an OPEN, NON-PUNITIVE CULTURE 44 Resistance Trend Towards the Process 80% 60% PRO 40% CON Passive 20% 0% Initially 3 Months later 6 Months later Nov-07 45 Performance Improvement Projects & Indicators Examples for Demonstration 46 Compliance Rate with Proper Documentation within the Patients’ Medical Records- 2007 70% 60% 50% 40% 30% 20% 10% 0% 1st Quarter 2nd Quarter 3rd Quarter 4th Quarter 47 Falls’ Preventive Programs year 2007 3.5 3 2.5 2 1.5 1 0.5 December November October September August July June May April 0 Num ber of falls 48 Pressure/Bed Sores Preventive Program year 2007. 2.5 2 1.5 1 0.5 December November October September August July June May April 0 No. Bedsores 49 Thrombo-phlebitis incidence Rates At DASH2007 12% 10% 8% 6% 4% 2% 0% December November October September August July June May April 50 Proper Hand Washing Rates vs. Infection Rates 66% decline in the infection rate was directly correlated to improvements in hand washing practices: 80% 70% 60% 50% 40% 30% 20% 10% Rate of Proper Handwashing December November October September Augu st July June May April March 0% Rate of Infections 51 Morbidity Report 1/2 Morbidity Report - 2007 Fever Post-Wound Infection Neonatal - Jaundice 6 Umblical Infection 5 Birth Asphyxia Anaemia (After Surgery) 4 Intravenous Infiltration Blood Transfusion Reaction 3 Pulmonary Embolism(After Surgery) 2 Neonatal Seizures after Vac.Delivery Allergic Reaction To Inj.Rocephin/Inj.Mesporin 1 Anaphylactic Shock 0 Postpartum Haemorrhage Ju l Au g Se p O ct N ov D ec Ja n Fe b M ar Ap r M ay Ju n Pulmonary Edema Abscess Formation after Intramuscular Injection 52 Morbidity Rates 2/2 Anaemia (Af ter Surgery) 6 Intravenous Inf iltration 5 Abdominal Distention (Af ter Surgery) 4 Blood Transf usion Reaction Pulmonary Embolism(Af ter Surgery) 3 Aspiration Pneumonia 2 Ovarian Hyperstimulation Syndrome Secondary Post-Tonsillectomy Haemorrhage 1 Scalp Injury w ith Erb's Palsy af ter Vac.Delivery N ov S ep Ju l ay M ar Birth Encephalopathy M Ja n 0 Neonatal Seizures af ter Vac.Delivery Allergic Reaction To Inj.Rocephin/Inj.Mesporin 53 Patient Satisfaction Rate 2007 62% 60% 58% 56% 54% 52% 50% 48% 2nd Quarter 3rd Quarter 4th Quarter 54 “Thank You” www.daralshifa.com [email protected] phone: (Office): (965) 223-1111 55