1. International Healthcare Accreditation Why is it so important?
Aleš Semeja Ph.D.
CEO
Terme Dobrna PLC.
5th BALKAN SPA HEALTH & WELLNESS SUMMIT November

2. Structure of presentation
Terme Dobrna – short facts overview
Decision for int. accreditation
Healthcare accreditations in Slovenia
Why DIAS?
Accreditation procedure – case study
Homework and problem areas
Effect on business

3. Terme Dobrna PLC. -Who we are
Thermal SPA with longest tradition in Slovenia (over 610 years)
250 rooms in 3 hotels with categories 3* and 4*
Approx overnight stays per year
70% average occupancy rate
140 employees (approx. 1/3 in medical centre)
Specializes in diagnostic and rehabilitation services in fields of gynaecology, urology, neurology, orthopaedic and rheumatologic diseases.
Founder of the Institute for Applied Research in Medical Rehabilitation

4. Why did we decide to acquire accreditation
Further expansion in medical sector was crucial for business reconstruction;
Quality and safety
Recognition
Ambition to enter international markets
Image and brand name
The process of reorganisation was already in place

5. Most common reasons for medical errors
Underachievement - lack of awareness and knowledge
Wrong decisions in unforeseen situations
Patient data is not recorded or correctly transmitted
Equipment malfunction
3rd party influence
Standardisation of work and results measurement can eliminate deviations in medical practices.

6. International healthcare accreditations in Slovenia
AACI – International Accreditation for Healthcare Organizations
ACI – Accreditation Canada International
JCI – Joint Commission International
DIAS – DNV International Accreditation Standard for Hospitals

7. Why DIAS? High level of assessment
Emphasis on the safety of patients, visitors and employees.
Designed specifically for hospitals and medical service providers and compatible with the most important medical service providers in the public network (Slovene DNV accreditation holders: UKC Ljubljana, UKC Maribor, SB Celje, SB Jesenice, SB Novo mesto, Valdoltra Orthopaedic Hospital, SB Izola, SB Trbovlje etc.).
Easy to use and understand.
Professional practicability and applicability – clear professional demands.
Compatibility with other systems (ISO 9001:2008).

8. Accreditation procedure
Pre-evaluation – the first assessment of the evaluation committee. The committee issues a report and further recommendations for the elimination of discrepancies before the final evaluation. (17/9/2012)
Final evaluation – an evaluation of system functioning chapter by chapter in accordance with the rules of DIAS – DNV. The evaluation committee prepares a report on the discrepancies and sets deadlines for their elimination. (16/6/2014)
The accreditation is obtained after eliminating all the main discrepancies. (2/9/2014)
Periodic assessments are carried out each year after obtaining the accreditation. (6/7/2015)

9. Accreditation procedure: Hospital vs. Thermal SPA
Processes
HOSPITAL
THERMAL SPA
Accreditation cycle
Equivalent
Evaluation Committee
3 auditors
4 / 3 auditors
Course of the Assessment
Plan
(2 weeks beforehand),
management, evaluation, report
(1 week beforehand),
Duration of the Assessment
3-4 days
1 day
Language
English
Final Assessment
Final meeting
Report of the Assessment
Within 10 days
Within 30 days
After the Assessment
Corrective action plan within 30 days
Answer: within 10 days
ACCREDITATION COMPARISON
Validity of the Certificate
Certificate – 3 years

10. Accreditation procedure - chapters
Basic IDEAS standard areas or chapters:
Quality Management System,
Risk Management,
Institutional Framework and Management,
Medical Staff and Personnel Management,
Different types of services (nursing, laboratory, rehabilitation, outpatient, nutrition services and medicines),
Patient Rights,
Control of Infections,
Health Records Management,
Physical Environment (safety, hazardous substances, equipment, infrastructure).

11. Accreditation procedure – main problems
Calibration and validation of all equipment used in medical services and supporting services.
Ensuring all environmental and technical requirements, given that the services are usually not carried out in a newly constructed facility.
Assembling all the necessary documentation.
Managing medicines – very strict requirements despite the relatively small area of service in Health Resorts.

12. Acquiring the Accreditation – effect on business?
Reducing the number of complaints,
Raising the quality and safety level for patients,
Reducing liability insurance costs,
Acquisition of a new business segment – cooperation with medical equipment manufacturers, pharmaceutical companies etc.,
Improving reputation in professional public,
Easier work upon visits of regulatory inspections.
in the end…it pays out!