Rabab Diab, RN, MSN, CPHQHCAC, Deputy CEO and Director of Education & Consultation

Iraqi Health Conference – ErbilMonday, 28 May 2013

Accreditation Standards for Medical Staff Management

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 upper-

middle income countries with 38 percent under the age of 14

Healthcare Providersby Sector

Public Sector

Royal medical services

Ministry of health (primary

healthcare centers and hospitals)

University hospitals

Private Sector

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 Population2005 – 2010

Wor

ld

Algeria

Bahra

in

Djibou

ti

Egypt

Iran

(Islam

ic Rep

ublic

of)

Iraq

Isra

el

Jord

an

Kuwait

Leba

non

Libya

n Ara

b Ja

mah

iriya

Malt

a

Mor

occo

Oman

Qatar

Saudi

Arabia

Syrian

Ara

b Rep

ublic

Tunisi

a

United

Ara

b Em

irate

s

United

King

dom

United

Sta

tes

of A

mer

ica

Yemen

0

5

10

15

20

25

30

35

40

45

50

14.212.1

14.4

2.3

28.3

8.96.9

36.5

24.5

17.9

35.4

19

31.1

6.2

19

27.6

9.4

15

11.9

19.3

27.4

24.2

3

Number of Physicians/10,000 Population

WHO, World Health Statistics 2012, 2012. See also, WHO, Global Health Observatory.

Medical staff management in Jordan have different strengths but face several challenges

Strengths Strengths

Established education programs

Qualified medical staff Good health out come

indictors in terms of communicable diseases, infant and maternal health

Challenges 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

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Quality improvement for Jordan started with a visionary Minister who took a leap for accreditation…

2003

2004

2005

2007

2008

2009

2010

2011

2012

2013

12 members from a

National Accreditation Committee

was approved

USAID Agrees to support initiative of Minister of

Health

Pilot Hospitals

HCAC registered as a non-profit

private sector company

ISQUA accredits hospital

standards

ISQua accredits Surveyor

Certification Course

1st edition Primary Health Care Standard

ISQua accredits HCAC

First Regional Conference

NQSGs launched

Cardiac Standards

Patient Safety Center

/ Institute

Diabetes Standards

Second Regional

Conference

Public Awareness

Medical Transport Standards

Breast imaging Units

Standards

Centers of Excellence

Pilot Hospitals and

First draft of Jordanian Hospital

standards

First Surveyor Certification

course started

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So HCAC was established in 2007 as a nonprofit private shareholding company with the aim to raise the quality of health services…

HCAC

MissionMission

VisionVision

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

ValuesValues

Continuous Improvement

Customer Focus

Impartiality

Integrity

Learning

Teamwork

Transparency

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…Through a range of different services stemming out of two separate arms of the organization

FunctionsFunctions

Accreditor

Enabler

Consultant Development

Training and Certified Courses

Preparedness

Consulting for Government

Mock Surveys

Accreditation

Surveyor Development

Standards Development

Education and ConsultationDepartment

Education and ConsultationDepartment

Surveys and Standards

Development Department

Surveys and Standards

Development Department

“A Comprehensive Model of Quality Improvement Services”

Fir

ewal

l

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HCAC can now showcase a multitude of successes…

StandardsStandards

Hospital Accreditation Standards - 3rd edition

Primary Health Care & Family Planning Accreditation Standards– 2nd edition

Medical Transport Services Certification Standards- 1st edition

Breast Imaging Units Certification Standards- 1st edition

Diabetes Care standards 1st edition

Cardiac Care standards being developed 2012-2013

National Quality and Safety Goals 2009, 2010, 2011, 2012, 2013

Family Planning & Reproductive Health Centers of Excellence Program- 1st edition

AccreditationAccreditation Education & ConsultationEducation & Consultation

41 certified hospital surveyors

31 certified PHC surveyors

17 hospitals accredited – four in the pipeline

45 PHC accredited – 60 in the pipeline

4 Certified Breast Imaging Unit

Preparing 8 hospitals for Accreditation, 5 breast imaging units

Graduated groups from :

q Certified Consultant Training program

q Certified Quality professionals

q Certified Infection Control professionals

q Certified Risk Management

q Leadership & Management

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Measurable ElementsRequirements of the standard that will be reviewed and assigned a score during the accreditation survey process

The HCAC Hospital Standards Manual (3rd ed.) is divided into 14 clusters entailing 347 standards and 1238 measurable elements

The ClustersThe Clusters

Cluster 1: Ethics and Patients’ Rights

Cluster 2: Access and Continuity of Care

Cluster 3: Patient Care

Cluster 4: Diagnostic Services

Cluster 5: Medication Management

Cluster 6: Infection Prevention and Control

Cluster 7: Environmental Safety

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

Each Cluster is composed of 4 line itemsEach Cluster is composed of 4 line items

Classification Critical (57 Standards):

Address laws and regulations and, if not met, may cause death or serious harm to patients, visitors, or staff

Core (257 standards):Address systems, processes, policies and procedures that are important for patient care

Stretch (33 standards):Important standards, but not easy to implement due to time or resource constraints, or a need for culture change

Standards Statements

Survey Process

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

chemical exposure

Lack of radiation safety

Absence of basic hygiene

Violation of human rights

Flies in operating rooms

Open sewage systems within hospitals

Lack of privacy

No fire safety procedures and systems

Untrained staff on basic resuscitation

Lack of medical staff management systems

Competency of healthcare providers

No documented policies, procedures, plans,

No clinical guidelines

Not in compliance with laws and regulations regarding fire safety, radiation safety, staff qualifications, and medication management processes.

Quality and Patient safety still faces many challenges in Jordan

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

19

Medical staff

management standards

Human Resources

Education and

Training

Quality Improvement and Patient

Safety

Patient Care

Medical Record Documentation

Management and

Leadership

The standards of medical staff management are integrated in all clusters

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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””

HRM.7 The hospital has a process, defined in writing for verification of the license, education, experience, and certification for all licensed professional staff.

21

21

Current licensure

Relevant training and experience

Current competence

Peer recommendations

Clinical privilege delineation

Essential Data in the Credentialing Process

22

22

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.

23

23

Granting Clinical Privileges

Delineation of clinical privileges

Delineation of admitting privileges

Categories of privileges

Limitations of privileges

Practicing within scope

24

24

Other Data

Ability to perform

Challenges to licensure/registration

Voluntary/involuntary terminations or restrictions

Professional liability

25

Medical Staff Management Standards

Credentialing and privileging

Medical staff file

Medical staff governance system

Medical graduate program

Performance appraisal

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- Documents related to license- Education - Experience- Certification

HRM.9 a personnel file is maintained for each employee

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 • Privileging

Medical staff bylaws

• Medical staff issues• Quality improvement

activities

Medical staff committee

• Role of medical staff members in committees

• Quality improvement initiatives

Hospital-wide quality improvement

program

Medical Executive Committee

Bylaws Rules and regulations

Organization structure Developing policies

and procedures

Medical staff committee

29

Medical Staff Bylaws

Medical staff structureMedical 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

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35

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.

Other Related Standards

Medical Record

Documentation

All patient medical record entries are legible, complete, dated, timed, and authenticated .

Clinical Practice Guidelines

CPGs are adopted/developed

and implemented for priority clinical

services.

Individual healthcare providers’

compliance with the clinical practice

guidelines.

Anesthesia Standards

Current anesthesia evidence-based

guidelines.

Patients are managed by a qualified

physician.

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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

38

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

…HCAC is in continuous improvement itself…

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