1. Quality and Accreditation in Health care setting

2. Learning Objectives:
After completing this lecture, students will be able to:
Define accreditation
Understand the elements of accreditation system
Explain benefits of accreditation
Discuss the objectives of accreditation
Describe the various chapters of Saudi hospital standards mandated by CBAHI
Know the different healthcare accreditation organizations
Understand the role of nurses when providing or recommending complementary and alternative practices to clients

3. What is quality of care?
Consistent delivery of a product or service according to expected standards
Quality is defined as „the degree to which a set of inherent characteristics fulfills requirements
The level of attainment of health systems‟ intrinsic goals for health improvement and responsiveness to expectations of the population (WHO definition)

4. Quality of care is: Doing the right things (what)
To the right people (to whom)
At the right time (when)
And doing things right first time

5. Standards and Health Care
The ISO 9000 standards approach may be useful to consider in designing quality control systems for certain health care “production” services, such as laboratory, radiology, and food services
The primary ISO standards deal with manufactured products and set basic rules for quality systems

6. Hospital Accreditation
" is a concept and practice that yields beneficial results to patients, customers, hospital personnel, the hospital, the society and the country as a whole.
“Self-assessment and external peer review process used by healthcare organizations to accurately assess their level of performance in relation to established standards and to implement ways to continuously improve the healthcare system” (CBAHI, 2006)

7. History
In 1917, the American College of Surgeons established a set of minimum standards for hospitals
In 1951, the American College of Surgeons form the Joint Commission on Accreditation of Hospitals
In addition to hospitals, the body evaluated long-term care facilities lik home health agencies, hospices, clinics, pharmacies

8. JOINT COMMISSION INTERNATIONAL ACCREDITATION (JCIA)
Accrediting health care organizations in U.S
Initiated the development of an international accreditation program in 1998

9. What are the objectives of Accreditation?
“To ensure the quality of health care through the application of quality concepts”
“To foster a culture of patient safety and minimize the risk of medical errors”
“To achieve optimum organizational results with available resources”
“To increase accountability to patients and identified stakeholders”

10. BENEFITS OF ACCREDITATION FOR PATIENTS:-
Continuity of care & Safe transport
Pain management & Focus on patient safety
Patient satisfaction is evaluated
Rights are respected and protected
Access to a quality focused organization
Credentialed and privileged medical staff
High quality of care
Understandable education and communication

11. BENEFITS TO ACCREDITATION FOR STAFF
Improves professional staff development.
Provides education on consensus standards.
Provides leadership for quality improvement within medicine and
nursing.
Increases satisfaction with continuous learning, good workin environment, leadership and ownership.

12. BENEFITS FOR THE HOSPITAL
Improves care.
Stimulates continuous improvement.
Demonstrates commitment to quality care.
Raises community confidence.
Opportunity to benchmark with the best.

13. Five key elements of accreditation:
1. Governance or stewardship function
2. A standards-setting process
3. A process of external evaluation of compliance against those standards
4. A remediation or improvement process following the review
5. Promotion of continuous quality improvement.

14. Benefits of Accreditation (Nicklin, Dickson, Accreditation Canada, 2008)
Enhancing patient safety by effectively managing and mitigating clinical and safety-related risks
Ensuring an acceptable level of quality among health care providers
Stimulating sustainable quality improvement (QI) and continuously raising the bar with regards to QI initiatives
Enhancing organizations’ understanding of the continuum of care by focusing on performance improvement and outcomes of care
Increasing reputation among end-users and enhancing their awareness of quality care
Providing a framework that enhance positive health outcomes

15. IN SAUDI ARABIA……………………………………………………

16. The CBAHI Accreditation Standards
CBAHI: المركز السعودي لاعتماد المنشآت الصحية (Saudi Central Board for Accreditation of Healthcare Institutions)
The CBAHI Accreditation Standards were developed by health care experts representing:
MOH
National Guards Hospitals
KFSH&RC
University Hospitals
Private Hospitals
Security Forces Hospital
Saudi Council for Health Specialties
The standards have been approved on May 2006.

18. Why We Create This List ECRI Institute creates this annual list of
Top 10 patient safety concerns to support
healthcare organizations in their efforts to
proactively identify and respond to threats
to patient safety

19. Emergency Care Research Institute

20. References
NURSING in TODAY’S WORLD Trends, Issues, and Management by Janice Rider Ellis, Celia Love Hartley.

21. Thank you