Presented by Salma Jaouni, CEO, Health Care Accreditation Council

First Dubai Health Regulation Conferencefor the MENA region

22-23 October , 2014

Regulatory StandardsDo they promote continuous quality improvement!

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Some standards are more comprehensive others less!

HCAC StandardsHCAC Standards

MM.7.2 A system to control the use and distribution of high alert medications is in place according to laws and regulations. _ Critical Measurable Elements:

There is a policy/procedure to control the use and distribution of high alert medications, which includes::

List of high alert medications

Procedure for storing, securing of high alert medications

Safety practices have been implemented to reduce harm associated with high alert medications including removing high alert medication from patient care units or limit or standardize their numbers.

Strategies have been developed to identify and mitigate errors associated with high alert medications when they occur.

The policy has been communicated to relevant staff members.

The policy/procedure is carried out

JFDAJFDA

Article (74):The pharmacist in charge, who is licenced to dispense narcotics and hallucinators, may dispense those items prepared for medical use to the following persons:-

Article (75):A -It is prohibited to dispense any special medical prescription containing any narcotics or hallucinators unless such prescription has met the following terms:

B - Taking into consideration the provisions of clause (8) of paragraph (A) of this article, the pharmacist in charge must not dispense any prescriptions containing any narcotics and hallucinators to cancer patients except when the following terms are fulfilled:-

Article (76):In case any special medical prescription does not fulfill any of the provisions specified in article (75) of this law, or in case the pharmacist is doubtful of its authenticity, he then must not dispense the same and must

Article 77-87

High Alert Medication

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Some standards are more comprehensive others less!

HCAC Standards related to a regulationHCAC Standards related to a regulation

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

MM.1 Pharmacy services and medication management processes within the hospital comply with applicable laws and regulations.

IP.1.3 Infection prevention and control activities are in compliance with laws and regulations.

Additional standards on the same topicAdditional standards on the same topic

IPC.7    Isolation precautions are in place when indicated.  IPC 6.6    The surveillance data results and reports are disseminated to senior management and concerned department or units to be utilized for improving the quality of care.  ST.1     The hospital has a central sterilization supply department (CSSD).  ST 1.1    Sterilization processes are managed by individual who is qualified by training and experience.

Infection Control

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Quality improvement is an activity that requires a continuous cycle of assessment re-asseessment checking double checking implementing feedback and updating

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In any type of standard development, there should be room for revision, growth and raising the bar

Review of

literature to

develop first draft

Step 2 Step 3 Step 4 Step 5 Step 6 Step 7

Review first draft by a local experts

Task Force to determine:

• Appropriateness for Jordan & the region

• Clarity and correctness of wording

• Classification of standards (critical, core, stretch)

Review second draft

by an external

committee of experts to ensure that

the standards are

internationally acceptable

Review fourth draft by the

HCAC Board Technical

Committee and recommend

approval to the full board

Translate into

Arabic and send for ISQua accredita

tion

Field test the third

draft by to ensure

applicability and

smoothness

Collect feedback, Q&A, and assess implementation - review and update every 3 years

Needs Assessment

Step 1

HCAC Standards Development

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In accreditation standards, there is a consultative process that ensures many qualities to the standards

Standards reflect legislative requirements, safety and good practiceStandards should be relevant, understandable, measurable, beneficial and achievable.

Standards reflect legislative requirements, safety and good practiceStandards should be relevant, understandable, measurable, beneficial and achievable.

Reviewing other accreditation and certification organization standards

Incorporating legislative, technical and safety requirements

Incorporating best practice where evidence is available

Ensuring the standards are client focused, cover the functions or systems of a whole organization or service, address the dimensions of quality and support quality improvement

Consulting stakeholder groups, including and consumer groups

Involving stakeholders in standards development committees and working groups

Developing the measurement system for measuring compliance with/achievement of the standards

Testing the standards and the way they are rated through self-assessment, pilot surveys

Using feedback from testing to improve the standards and rating system

Developing guidelines to assist users to interpret and apply standards

Get standards approved by accreditation organization governing body

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Accreditation standards differ from regulatory ones in referencing criteria and measurement systems

Measurable Elements

Requirements of the standard that will be reviewed and assigned a score

during the accreditation survey process

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

Classification Critical (24 Standards):

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

or staff

Core (98 standards):Address systems, processes, policies and

procedures that are important for patient care

Stretch (7 standards):Important standards, but not easy to implement

due to time or resource constraints, or a need for culture change

Standards Statements

Survey Process

HCAC PRIMARY HEALTH CARE STANDARDS

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Accreditation standards also have characteristics that are at the core of their aim

Dignity and respect: Values, beliefs and cultural backgrounds

Information sharing:Share perspectives & questions

Participation:Patients and families

Continuity: Continuum; designing systems that promote seamless transitions

Characteristics of Standards

Characteristics of Standards

Provide guidelines for quality patient care

Are not prescriptive in nature

Are Patient centered

Are educational in aim

What is Patient Centered Care?What is Patient Centered Care?

HCAC STANDARDS

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Accreditation Standards also have dimensions that are crucial to their applicability

Characteristics of Good Standards

Based on scientific evidence or other acceptable experience, expert consensus at a minimum

Valid

Leads to the same result each time it is applied by anyone who uses it.Reliable

Understood in the same way by everyone; not

subject to misinterpretationClear

Can be achieved with existing resources, suited

to the settingRealistic

Can be quantified or countMeasurable

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This is what makes accreditation a continuous quality improvement process

New standards every other

year

Contiguous engagementUn-announced

midpoint assessment

Mystery client

Continued reporting

HCAC Accreditation Model

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This does not mean that regulatory standards can not promote continuous improvement!

Ireland: http://www.hiqa.ie/

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As long as the standards follow the characteristics, but more importantly continue to progress in a process!

Consult-ative

Evidence based

implement-ed

measured

Needs assess-

ment

Developed based on evidence based practice in both clinical and managerial aspects

Updated frequently and when needed

There is a system that ensure the implementation that:

enforce the development of organizational P&P that translate the requirements into practice

include active monitoring system of implementation by auditing or frequent submission of related indicators

The intent of the regulatory system foster quality improvement and patients safety:

promote the quality cycle component (PDSA: plan, do, study, act)

Covered all quality principles and aspects requirements

Questions and Comments

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Thank You