hospital quality accreditation - upcph - rojoson - 2013-08-16

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 SurgAugust 16, 2013

UP College of Public HealthHA 202 [Organization and Management of the Different Hospital

Departments]


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.

Q. When does one say that a hospital is delivering service excellence? What makes a hospital excellent?

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)

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


3 Macro-indicators of Excellent Hospital:





Formal - Objective - Stringent Assessment(Internal & External)

3 Macro-indicators of Excellent Hospital:






Internal Auditors

with Checklists-Rating Scales

External AuditorsPQA

PhilHealthDOH

Others (Int’l)

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



Internal Auditors



PhilHealthDOH

Others (Int’l)

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



Internal Auditors



PhilHealthDOH

Others (Int’l)

AccreditationCertification

External Award of Excellence

Hospital’s Steadfast Strategic Objectives

STRATEGIC OBJECTIVES

PERSPECTIVES OBJECTIVESGovernance, 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 delightProcess 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 organizationCSR 10 CSR program with tangible social impact

Hospital’s Steadfast Strategic Objectives

STRATEGIC OBJECTIVES

PERSPECTIVES OBJECTIVESGovernance, 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 delightProcess 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 organizationCSR 10 CSR program with tangible social impact

AccreditationCertification

External Award of Excellence

MDH Journey towards Excellence - 2013

2013

CertificationAccreditation

Award

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.”


Compliance

Accredited certifying body

Certification

Accreditation

Award (recognition)

Certifying / awarding body


Compliance


Certification

Accreditation

Award (recognition)


PQA

DTI


Compliance


Certification

Accreditation

Award (recognition)


PhilHealthPhilHealth


Compliance


Certification

Accreditation

Award (recognition)


JCI / ACI / NABH

ISQUA

JCI / ACI / NABH


Compliance


Certification

Accreditation

Award (recognition)


ISO 9001 / 14000ISO

AJA / TUV

Compliance, Accreditation, Certification, AwardHospital

SetStandards

CriteriaIndicators

Satisfactorydegree of compliance /

achievement

Certification AwardAccreditation

Third-partyAssessor/ Auditor

Philippine Quality Award

ISO 9001

ISO 14000

PhilHealth / Benchbook

PCAHO

JCI

ACI

NABH

Compliance, Accreditation, Certification, AwardHospital

SetStandards

CriteriaIndicators

Satisfactorydegree of compliance /

achievement

Certification AwardAccreditation

Third-partyAssessor/ Auditor

Philippine Quality Award

ISO 9001

ISO 14000

PhilHealth / Benchbook

PCAHO

JCI

ACI

NABH

Levels

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?

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?

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?

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.


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.


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.

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


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:


• 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

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

What are the currently sought accreditation by hospitals in the Philippines?

Accreditation Standards URLs

PhilHealth Benchbook http://www.philhealth.gov.ph/providers/institution/benchbook.htm

Joint Commission International (JCI)Accreditation International (ACI)

http://www.jointcommissioninternational.org/http://www.internationalaccreditation.ca/en/home.aspx

Philippine Quality Awards (equivalence of Baldrige Awards of )

http://www.pqa.org.phhttp://www.dti.gov.ph/dti/index.php?p=492http://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/Home.aspx

http://www.philhealth.gov.ph/providers/institution/benchbook.htm

http://www.philhealth.gov.ph/providers/institution/benchbook.htm

http://www.jointcommissioninternational.org/

http://www.internationalaccreditation.ca/en/home.aspx

http://www.internationalaccreditation.ca/en/home.aspx

http://www.pqa.org.ph/

http://www.dti.gov.ph/dti/index.php?p=492

http://www.nist.gov/baldrige/publications/hc_criteria.cfm

http://www.nist.gov/baldrige/publications/hc_criteria.cfm

http://www.iso.org/iso/home.html

http://www.investorsinpeople.co.uk/Pages/Home.aspx

http://www.investorsinpeople.co.uk/Pages/Home.aspx

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 10TJoint Commission International (JCI)Accreditation International (ACI)

JCI – PhP 14 M

ACI – PhP 8 MPhilippine Quality Awards (equivalence of Baldrige Awards of )

PhP 30T – small organizationsPhP 50 – medium to big organizations

ISO (International Organization for Standardization)

PhP 300T

Investors in People PhP 1M

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


Designed to improve quality and safe patient careDesigned to assess and improve organization performance based on internationally agreed standards and stimulating continuous improvement to achieve optimum outcomes on healthcare


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.


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.




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 sustainabilityImprovement of overall organizational effectiveness and capabilitiesorganizational 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.

Baldrige Health Care Criteria for Performance Excellence

PQA Business Criteria for Performance Excellence

ISO 9000 QMS




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



Investors in People Designed to transform business performance through people



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.

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

Comparison of StandardsPhilHealth 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

Comparison of StandardsBaldrige 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

PlanDo Review1. Business Strategy2. Learning and development strategy3. People management strategy4. Leadership and management strategy5. Management effectiveness6. Recognition and reward7. Involvement and Empowerment8. Learning and development9. Performance Measurement10. Continuous improvement


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.


Top management creates a Steering Team / Committee for Hospital Accreditation Project with clear functions and authority.

Membership of Steering Team / CommitteeSenior Management Representative if not the Hospital DirectorChair (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 sectorNursing service sectorAncillary medical service sectorAdministrative or support service sectorHuman resource development sectorBusiness development sectorFinance sectorSecretariat


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.


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 bodiesExpected 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 planEvaluation plan (short- and long-term)

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 evaluationIntegration of standards in all units

CommunicationEducation

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



Governance and Leadership

In July 2010,

MDH got its PhilHealth Benchbook Certification of Center of Excellence.

Accreditation Project



Governance and LeadershipAccreditation Project

December 2010,

MDH got a certification or accreditation from Accreditation Canada International for “meeting international standards of excellence in quality care and service.”


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.


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!




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!)

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.

Integrating Hospital Quality and Performance Standards


• ISO Quality Management System• PhilHealth Benchbook (including PH

statutory and regulatory requirements)• Joint International Commission,

Accreditation Canada International (either one)


*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









•Business Development•Efficiency•Learning









Increase in utilization of

services

Increase in corporate

accounts andpatient-clients


Reynaldo O. Joson, MD, MHA, MHPEd, MSc SurgAugust 16, 2013

UP College of Public HealthHA 202 [Organization and Management of the Different Hospital

Departments]

Thank you for your kind attention.For query:

[email protected]

mailto:[email protected]

hospital quality accreditation - upcph - rojoson - 2013-08-16

Health & Medicine