Global Health Care Services Dr. Ali Hojjati MD, MPH My name is Ali Hojjati I am here from Accreditation Canada International to talk to you today about how international accreditation can help organizations improve quality and safety for international patients December 18 , 2012 3

The Third Conference on Health Tourism in Islamic Countries We are here because of the third conference on health tourism in Islamic countries

Global Healthcare – A Reality Medical Tourism Wellness Travel Medical Travel Health Tourism Travelling patient International Patient QUALITY SAFETY Animated; click on , each line by one clock We are all here because global healthcare is a reality, & has been the case for many decades and is now a growing concern Again as we have reviewed, many terms come into play: (click) Medical Tourism Wellness Travel (click) Medical Travel Health Travel (click) Travelling patient International Patient And there are many reasons why people travel for health care: for economy, for urgency, for emergency, for accessibility, for familial/cultural comfort, for expertise, NO matter what the term, what is common is that all patients local or international are looking for (click) QUALITY & SAFETY (last click) Health Tourism

Global Healthcare – A Reality Medical Tourism Wellness Travel Medical Travel Health Tourism Travelling patient International Patient QUALITY SAFETY Animated; click on From all these words I chose Health Tourism which is match with the title of conference. Regarding the tourism part we will had and will have a lot of discussion like hotel, visa, transportation and . . . I just want to focus on health part of this topics.

Health

Risks Medical information Travel, transfer points Referrals, continuum of care, follow-up Language, cultural differences Assurance of expertise Insurance coverage Legal rights Privacy and access to information Of course as we have been speaking about, and will continue to speak about, there are many special issues and risks associated with medical travel, such as: Incomplete medical information or history provided by patient Special requirements for travel Multiple transfer points associated with patient referrals Continuum of Care & follow up & care post treatment procedures for working with medical professionals in other countries (and possible different kinds of professionals) Language or cultural differences; real or or perceived barriers Assurance of expertise: licensing, certification, accreditation Insurance coverage, costs Legal issues/rights in foreign countries And the Risks not just for the patient but for the Provider Health care providers want to minimize risks & maximize positive outcomes for patients and their own organization’s ongoing success

Need for Standardization Processes & Standards are needed to Mitigate Risk and ensure Quality Animated; click on As one can see (click) Processes & (click) Standards are needed to (click) mitigate risk and (click) ensure quality

Standards , Quality and Errors State of Health High Quality of Care Disease Animation: Highly Animated. Practice required. This is explain what is the different level of quality and harm during delivering healthcare services. It explain why patients looking for high quality standards and looking for safety. Harm Adopted from Donabedian 2003 Time

Standards – Do we still need them??? National Standards International Standards We have different kinds of standards in healthcare which all categorized in national or international. National one might be very good one but the level of quality is not well clear for all. With international one you have the chance to compare the level of quality to the other services around the world.

Standards – Do we still need them???

Accreditation and Standards What is Accreditation? Accreditation and Standards We have different kinds of standards in healthcare which all categorized in national or international. National one might be very good one but the level of quality is not well clear for all. With international one you have the chance to compare the level of quality to the other services around the world.

Defining Accreditation A measure of an organization’s services compared against international standards of excellence Content : Accreditation provides a measure of how organization’s services compare to national and international standards of excellence. Accreditation is also a powerful quality improvement tool that helps an organization to identify areas for improvement, and to plan for how these improvements can be made. Accreditation is – a cooperative, client centered, effective and proven process for health services organizations to regularly and consistently examine and improve the quality of their services. Regularly implies that accreditation is an ongoing process of constant quality improvement. Consistently means that there is a common set of standards against which all organizations are measuring the quality of their services. A tool to identify areas for improvement A process for organizations to regularly and consistently examine and improve their services 14 Digitalart, Master Isolated Images, Renjith Krishnan/FreeDigitalPhotos.net 14 14

Accreditation helps to… Increase credibility and demonstrate accountability Show commitment to quality and patient safety Increase capacity and lead to quality improvement Animation: Minimal. Squares with content appear on a click. Instructions: You may choose to discuss the benefits of accreditation with the group. Next slide focuses on benefits to individuals working in an organization undergoing accreditation. Content: In discussions with our member organizations, we have asked them why they go through the accreditation process. Here are some more of the benefits they’ve identified. Increase credibility and demonstrate accountability Show commitment to quality and patient safety Increase capacity for managing quality improvement. This means an increased capability of staff to pursue structured quality improvement initiatives.

Accreditation Defining Healthcare Excellence Accreditation helps organizations achieve excellence: A proactive and continuous process to regularly and consistently examine and improve services A strategic change and risk management tool to identify strengths and areas for improvement A measure of success against standards of excellence Animated; click on How can accreditation Canada help? Accreditation helps health care organizations to establish and improve the standards of operation in their organizations; facilitating ongoing quality improvement Accreditation with Accreditation Canada: (click) Firstly Accreditation is an effective and proven, proactive and continuous, process for health services organizations to regularly and consistently examine and improve the quality of services they offer. Regularly implies that accreditation is an ongoing process of constant quality improvement. Consistently means that there is a common set of standards against which all organizations are measuring the quality of their services. This ensures a consistent level of quality For this reason, accreditation is highly valued and recognized internationally (click) Accreditation with ACI is also a powerful Strategic change and risk management quality improvement tool to help organizations to identify areas/opportunities for improvement, and to systematically plan for how these improvements can be made. Accreditation also helps an organization to identify its strengths and possibly leading practices to promote its reputation among its publics & stakeholders, present & future (click) Finally, accreditation provides a measure of Achievement of success against standards of excellence (not minimum/ licensing standards), a measure of how an organization compares to international standards of excellence Accreditation provided an assurance to the public & all stakeholders, national & international, of expertise, quality and safety In short, Accreditation helps organizations to define and achieve healthcare excellence

Accreditation is credible when…. Engages all stakeholders ex: clients, staff More than a checklist Based on best practice and evidence About sharing experience Internationally recognized Appropriate methodology is used to assess compliance Program overseen by independent body ex: ISQua

The believe to quality improver met is very important. Just looking for a certificate never help patients and never end to quality improvement and safety. We should try to embed quality improvement believe in all daily activates of all staff from leadership to lower level of organization. Unfortunately some accreditation bodies just delivering onsite survey like an exam and then based on their checklist issue certificate.

Surveyors Independent, impartial peer reviewers removed from outside influence and interest Experienced and trained to look for and identify organization strengths, areas for improvement, and risks Recommend actions for quality improvement

GLOBAL HEALTHCARE SPECIFIC STANDARDS One of the Qmentum standards is Global Healthcare Specific Standards

International Client Standard Participant manual: p. 17 Documentation: p. 47 Planning for Care and Treatment Preparation Care and Treatment Discharge And Follow-up Monitoring And Quality Improvement Each care group of standards is organized so that it corresponds to particular episodes of care and treatment The standards are sequenced to go from anticipating, planning, providing and evaluating services to populations that need short-term care for a specific acute illness or injury in an institutional setting. Each subsection includes one or more standards. Monitoring and Quality Improvement

Planning for Care and Treatment Assessment of international client needs Development of services according to the needs Ensuring the team’s staff are educated, trained, qualified, and competent Enhancing wellbeing and worklife balance of staff

International Client Standard Participant manual: p. 17 Documentation: p. 47 Planning for Care and Treatment Preparation Care and Treatment Discharge And Follow-up Monitoring And Quality Improvement Each care group of standards is organized so that it corresponds to particular episodes of care and treatment The standards are sequenced to go from anticipating, planning, providing and evaluating services to populations that need short-term care for a specific acute illness or injury in an institutional setting. Each subsection includes one or more standards. Monitoring and Quality Improvement

Preparation Providing clients information on services offered Communicating with the client’s primary physician Gathering information on client’s history and current medical condition Pre-operative instructions and timelines Travel, accommodation and transportation services Pre-travel screening

International Client Standard Participant manual: p. 17 Documentation: p. 47 Planning for Care and Treatment Preparation Care and Treatment Discharge And Follow-up Monitoring And Quality Improvement Each care group of standards is organized so that it corresponds to particular episodes of care and treatment The standards are sequenced to go from anticipating, planning, providing and evaluating services to populations that need short-term care for a specific acute illness or injury in an institutional setting. Each subsection includes one or more standards. Monitoring and Quality Improvement

Care and Treatment Team coordinates services on client arrival Assessment Procedure Discharge planning Transition to retreat area Monitoring medical condition Preparation for client’s return

International Client Standard Participant manual: p. 17 Documentation: p. 47 Planning for Care and Treatment Preparation Care and Treatment Discharge And Follow-up Monitoring And Quality Improvement Each care group of standards is organized so that it corresponds to particular episodes of care and treatment The standards are sequenced to go from anticipating, planning, providing and evaluating services to populations that need short-term care for a specific acute illness or injury in an institutional setting. Each subsection includes one or more standards. Monitoring and Quality Improvement

Discharge and Follow-up Evaluating and addressing client’s medical and support needs for traveling after the procedure Communicating with clients on their return home Monitoring compliance with discharge plan Follow-up with client’s primary physician

International Client Standard Participant manual: p. 17 Documentation: p. 47 Planning for Care and Treatment Preparation Care and Treatment Discharge And Follow-up Monitoring And Quality Improvement Each care group of standards is organized so that it corresponds to particular episodes of care and treatment The standards are sequenced to go from anticipating, planning, providing and evaluating services to populations that need short-term care for a specific acute illness or injury in an institutional setting. Each subsection includes one or more standards. Monitoring and Quality Improvement

Monitoring and Quality Improvement Quality improvement program to enhance service delivery Performance management Client feedback Benchmarking Animation: Highly Animated. Practice required.

Accreditation standards enhance quality and safety related to: Planning Preparation Treatment Follow-up Monitoring and quality improvement

Accreditation Canada International Objective, independent, 3rd party, peer evaluation Transparent and rigorous analysis Performance measurement & management Client and patient safety Quality improvement Risk prevention Governance Education ACI’s accreditation programs involves: Objective, independent, third party, expert peer evaluation & coaching Transparent and rigorous analysis of service provision & organizational performance focused on: Performance measurement & management Including efficiency & effectiveness, change management Client and patient safety Quality improvement Risk prevention Effective Governance It Addresses current and future client needs & contains educational components to build and sustain Quality Improvement capacity within the organization 32

Accreditation Canada International CANADIAN TRADITION OF QUALITY HEALTH CARE 5000+ 54 years 1000+ Animation: Highly Animated. Practice required. instructions: The key messages for this slide are: Working with Accreditation Canada International, you get access to expertise that has helped building recognized high quality service of the Canadian health care system. Accreditation Canada works globally (Europe, Asia, South America, Africa) and has experience working with a variety of international clients. ACI understands client needs and is able to tailor solutions to clients individual needs. Accreditation Canada International delivers high quality work. ACI is accredited by ISQUA, who accredits the accreditors. Content: In 50 years Accreditation Canada moved from offering a limited institution based program focusing on acute care to Qmentum - a comprehensive program covering a wide range of health care areas. 1958 Canadian Council on Hospital Accreditation is incorporated. The Council's purpose is to set standards for Canadian hospitals and evaluate their compliance. The accreditation program is voluntary, free from government intervention, national, bilingual, and not-for-profit. 2012 Accreditation Canada is a non-profit and independent organization that is recognized as a leader in supporting quality health care. Its mission is to drive quality in health services through accreditation. Accreditation Canada works with over 1000 clients (5700 sites) in Canada and internationally. Among its clients there are both small and big organizations representing different health care sectors. Accreditation Canada is working in 30 countries and has the ability to understand international clients and provide tailored solutions and support (for example advisory services and education) Accreditation Canada is accredited by the International Society for Quality in Health Care, who “accredits the accreditors”. This means that Accreditation Canada undergoes an impartial and independent review and adheres to international standards that are designed for health care external evaluation bodies. More information on Accreditation Canada: www.accredition.ca , on ISQUA accreditation http://www.isqua.org/accreditations.htm Bermuda Hospital First International Hospital 45 years ago ACCREDITED BY ISQUA GLOBAL PRESENCE LOCAL SOLUTIONS 1958 1967 2012 Master isolated images / FreeDigitalPhotos.net jscreationzs / FreeDigitalPhotos.net

Global Presence Latin America Brazil Chile Colombia Costa Rica Mexico Caribbean Anguilla Barbados Bermuda St. Lucia Trinidad & Tobago Turks and Caicos Europe France Italy Ireland Eslovenia Middle East and North Africa Bahrain Egypt Iran Kuwait Lebanon Qatar Saudi Arabia Tunisia UAE Oman Asia Kazakhstan Philippines Content: In addition to Accrediting hospitals and other health services organizations in Canada, 31 organizations in more than a dozen countries participated in Accreditation Canada International’s program and you can see on this slide the wide range of continents and countries where Accreditation Canada is assisting in Quality Improvement. Accreditation Canada works in the following countries: Latin America: Costa Rica, Brazil, Colombia, Chile, Mexico Caribbean: Anguilla, St. Lucia, Trinidad & Tobago, Turks and Caicos, Bermuda Europe: Italy, France, Ireland Middle East and North Africa: United Arab Emirates, Saudi Arabia, Kuwait, Bahrain, Lebanon, Tunisia Egypt, Iran, Qatar Asia: Philippines, Khazakstan, China, India jscreationzs / FreeDigitalPhotos.net

Accreditation Canada International One third of all new accreditation programs and standards developed worldwide have taken the lead from Accreditation Canada Charles D. Shaw , ISQua

Accreditation in Canadian and international Health Care AIM – Achieving Improved Measurement Client Centered Program Qmentum/ Qmentum Intl Structure Introduced in 2010 emphasis has shifted to health system performance, risk mitigation and prevention planning, client safety, performance measure, and governance. Strong focus on structure i.e. policies, procedures, fire safety, etc. Introduced in 1995 forcing organizations to understand who were their clients, their needs & how to improve services. Introduced in 2001 requiring organizations to measure the outcomes of health care as well as other components including continuous learning and improvement cycle and are we improving the health status of the population. During the years of activity ACI has changed the standards and program. Because we believe to improvement. 1995 2001 2010 36

Accreditation in Canadian and international Health Care Why is it constantly changing? Change is necessary to remain relevant in our ever-shifting health care environment. During the years of activity ACI has changed the standards and program. Because we believe to improvement.

The leader in raising the bar for health quality ACI always try to raise the bar.

What does “Qmentum” Mean? Quality + Momentum = Qmentum Content: To start with, we are often asked the meaning of the word Qmentum. This is the name of the our current program both nationally and internationally. The “Q” in Qmentum stands for Quality, and the “mentum” part is a reference to the word “momentum” which is the kind of force of energy that keeps things rolling with little effort once the initial energy has been put into the system, so the combination of these two concepts is a good way to describe what this new accreditation process is trying to do: to create organizational momentum driven by continuous quality improvement.

Accreditation Canada International: Services Advisory Services Education Content: These are three major services: Advisory Services: Accreditation Canada International expertise and experience include but are not limited to the following areas: assessment of health care system and services (access, quality, efficiency, costing); health care policy development ; human resource management and capacity building; health care standards development and application; consultations to prepare health care institutions for accreditation, etc. Education: Training and education are delivered through on-site sessions, live videoconferences and teleconferences, and study tours. New workshops and customized sessions can be developed upon request by an organization. Although workshops are usually presented in English, Accreditation Canada International employs facilitators, surveyors, and consultants from diverse backgrounds who speak a number of languages and are capable of delivering sessions in Italian, Spanish, Portuguese, French, Farsi and Arabic, among other languages. . Ambro / FreeDigitalPhotos.net renjith krishnan / FreeDigitalPhotos.net

DOCUMENT: Qmentum International Cycle Part manual pg. 70 Instructions: Introduction the 3 year cycle at this point serves to give a reference point to participants when hearing about the tools and activities in this section. You should only give a briel overview of the activities at this point. Content: Lets move on to examine the activities that will take place during the three year accreditation cycle: Accreditation is a continuous process of quality improvement which involves several key phases. This graphic outlines these phases of the accreditation process that your organization will be going through as part of the Qmentum International accreditation program. We’ll discuss the different parts of the process during today’s session, and we’ll start with an overview of what the process consists of: For organizations new to accreditation, a Readiness Assessment consisting of a Readiness Assessment questionnaire begins the process. This culminates in an Initial Visit during which Accreditation Canada surveyors will visit the organization to validate the questionnaire that has been filled out online by an interdisciplinary team. At this time they will also be offering education sessions that help orient the organization to the accreditation process. The organization will then receive a Readiness Assessment report with a risk assessment and an action plan. The next phase is the Self Assessment during which, staff members complete questionnaires and submit instrument and indicator data. This will be discussed in more detail later in this session. The results from the Self Assessment will appear on the organization’s portal on what is called the Quality Performance Roadmap, where teams will be able to view identified areas for improvement and begin developing and implementing action plans. The on-site survey is the next milestone in the cycle and at this time surveyors will assess the organization’s services and report on the finding. Following the On-site survey you’ll receive a letter with your accreditation decision. The organization will have 6 months from the on-site survey to submit evidence of action taken which Accreditation Canada will review and amend the Accreditation Decision if applicable.

How Accreditation Canada International can help? Level of Quality From Current Situation to Desire level of Quality Readiness Assessment Report Self Assessment Tools Review Standards in Teams Assign an Account Manager for Each Hospital Gap Consultation Education Animation: Highly Animated. Practice required. ACI always help organization during quality improvement journey and never let them go by themselves. We help you to find your gap between current position and level of standards with different tools and services and help you to fill the gap. Advisory Services Current Situation in organization

Qmentum International Standards Public Health Acute Care Ambulatory Care Public Health Animal Health and Food Safety Ambulatory Care Blood Bank and Transfusion Biomedical Laboratory Cancer Care Critical Care Diagnostic Imaging Emergency Department Emergency and Disaster Preparedness Global Health Care Laboratory and Blood Medicine Mental Health Obstetrics/Perinatal Care Operating Rooms Rehabilitation Reprocessing and Sterilization Surgical Care Primary Care Ambulatory Care Blood Bank and Transfusion Biomedical Laboratory Cancer Care Diagnostic Imaging Laboratory and Blood Operating Rooms Rehabilitation Surgical Care STANDARD AREAS SUSTAINABLE GOVERNANCE EFFECTIVE ORGANIZATION SERVICE EXCELLENCE POSITIVE CLIENT EXPERIENCE Primary Care Public Health Primary Care Blood Bank and Transfusion Diagnostic Imaging Biomedical Laboratory Laboratory and Blood Community Care Nov 2012 Release Animation: Highly Animated. Practice required. This explain our standards. It is very important for ACI to clearly introduce standards and the structure of standards for all services. Standard and again shows our commitment for improving our services based on requests. It start with our new The slide in Highly Animated. Please click one by one and let participant see the structure and explain when it is necessary. Home Care Mental Health Developmental Disabilities Semi-Residential and Residential Substance Abuse and Addiction Independent Medical/Surgical Facilities Assisted Reproductive Technology Populations with Chronic Conditions Hospice Palliative Care Independent Laboratory Blood Bank and Transfusion Biomedical Laboratory Laboratory and Blood Medication Management – Infection Prevention and Control

Content: Accreditation Canada sees quality as multidimensional. Dimensions cover different perspectives and aspects of care. Here is Accreditation Canada’s Quality Framework, which helps to guide the focus of all of our standards. There are 8 dimensions, found here on the left hand side column, each with its own tag line to help clarify what the dimension means. For example, “Safety” has a tag line that simply states “keeping people safe”. These quality dimensions are built into the standards and how the standards are all tagged to a specific dimension of quality.

Qmentum International Monitoring outcomes; Using evidence and best practices to improve service Diamond level Client-centred care; Consistency of service delivery Platinum level Animation: Low. Levels of accreditation appear on a click. Content: Qmentum International is designed for three levels and allows organizations to pursue the accreditation option that is most appropriate for them at the moment If an organization is accredited at the first level (gold), it means that it has successfully built a solid foundation of quality and safety. This is achieved by addressing basic structures and processes that are linked to key elements of safety and quality improvement. These are foundational elements that must be in place for the organization to be successful in future levels of the accreditation program. An organization accredited at the second level (platinum) is at the point where they are building on the foundational elements of quality and safety, and are now focusing on key elements of client-centred care, creating consistency in the delivery of services through standardized processes, and involving clients and staff in decision-making. Finally the third level of accreditation means that the organization is focused on achieving ever higher levels of quality by monitoring outcomes, and using evidence and best practices to improve services. Gold level Foundational elements of quality and safety

Standards format Standard CRITERIA Level SUB-SECTION HEADING Standard CRITERIA Animation: Highly Animated. Practice required. Guidelines give details about what needs to be in place for the criterion to be met Level Each criterion is associated with a Quality Dimension

Accredits the Accreditors ISQua The International Society for Quality in Health Care Who accredit the accreditor Explain ISQua role Click for next slide which has the explanation regarding the ISQua role

ISQua Accredited Organisations Accredited Standards Accredited Surveyor Training Programme

Conclusion Standardization is key as global healthcare has multiple interfaces Robust, sustainable accreditation programs are urgently needed in current environment Accreditation assures the quality and safety of care to the international client

Accreditation Canada International For further information Dr. Ali Hojjati Accreditation Advisor Ali.hojjati@accreditation.ca 1-800-814-7769 www.accreditation.ca

The leader in raising the bar for health quality Le leader qui hausse la barre en matière de qualité de santé Thank you for your kind attention We look forward to further interaction to continue to advance health care quality for all.

Sample Patient Safety Requirements Client Safety Area Required Organizational Practices Communication Client verification Transfer of client information at transition points Medication reconciliation Safe surgical practices Medication Use Control of concentrated electrolytes Worklife Training on patient safety Infection Prevention and Control Hand hygiene Timely administration of prophylactic antibiotics Safe injection practices This is available at the end of presentation if somebody ask about the priority and weight of standards. Additionally there are 9 essential practices (ROPs) that client organizations must have in place to enhance patient/client safety and minimize risk. 54

Patient Safety Area Phase 1 (2013) Phase 2 (2015) Safety Culture Adverse event reporting  (G) Adverse event disclosure (G) Prospective analysis (D) Client safety quarterly reports (G) Communication Dangerous Abbreviations (G) Verification processes for high risk activities (D) Client and family role in safety (G) Medication Use High alert medications (includes former drug concentrations) (P) Infusion pump training (P) Heparin safety (P) Narcotic safety (P) Antimicrobial Stewardship (P) Worklife Preventive maintenance program (G) Client safety plan (G) Infection Control Sterilization Processes (G) Infection Control guidelines (G) Hand Hygiene Audit (P) Infection rates (D) Risk Assessment Pressure Ulcer Prevention (P) Falls Prevention (P) Venous Thromboembolism Prophylaxis (P) Home Safety Risk Assessment (P) Suicide Prevention (P) Total 11 12 This is available at the end of presentation if somebody ask about the priority and weight of standards. One example of our commitment to improvement and raising the bar. New ROPs for coming year for international.

Gold This is available at the end of presentation if somebody ask about the three level of standards. Platinum Diamond