1. Supervised by: Dr- Fatmah Baddar

2. 2 Health Care Service Accreditation Accreditation Accreditation is the process of assessing health institutions against a commonly accepted set of standards.

3. 3 Why Accreditation? The purpose of accreditation is to ensure and improve quality of health services. The main issue with accreditation is to ensure those providers, both institutions such as hospitals and health centers, and care givers, such as physicians and nurses, provide good quality care.

4. 4 Why Accreditation? So accreditation is an educational and evaluative process Through Which, health providers learn in an objective manner how they can improve quality.

5. 5 Accreditation Certificate The accreditation certificate is a symbol that an organization is committed to providing high-quality health care

6. 6 Benefits of Accreditation ِ Encourages professionals to continuously seek to improve quality despite resource limitations Provides sustained management of field reviewers, supervision and ongoing education of surveyors, etc.)

7. 7 Benefits of Accreditation Ensures a fair, valid, and credible evaluation process Establishes an accreditation database of information to determine compliance, pinpoint problem areas, or highlight opportunities for improvement

8. 8 Accrediting Organizations There are different accrediting organizations The Joint Commissionon Accreditation of Healthcare Organizations (JCAHO) has been accrediting hospitals for more than 40 years. Accreditation by the JCAHO is recognized nationwide as a "seal of approval" which indicates that a hospital meets certain performance standards

9. 9 Achieving accreditation means that an organization substantially complies with JCAHO standards and continuously makes efforts to improve the care and services it provides. About JCAHO Accreditation

10. 10 An overview of JCAHO Accreditation steps 1. Submit an application for initial accreditation or re-accreditation. 2. Determine a site visit date. 3. Submit a self-study report. 4. Form an Evaluation Team and determine logistics of site visit. 5. Conduct an Accreditation Site Visit. 6. Conduct an accreditation surveys

11. 11 About JCAHO Accreditation During an accreditation survey, specially trained JCAHO surveyors evaluate the level of an organization’s compliance to JCAHO standards and identify the organization’s strengths and weaknesses.

12. 12 About JCAHO Accreditation Accreditation surveys result in performance reports, which can be utilized by consumers and health care organizations to ascertain the performance of a given health care organization. The report lists: The accreditation status The date of the survey An evaluation of key areas reviewed during the accreditation survey The results of any follow-up activity Areas needing improvement

13. 13 About JCAHO Accreditation Accreditation Duration:- The time period (three-year) during which a health care organization, found to be in compliance with Joint Commission standards, is awarded accreditation. To maintain accreditation for a three-year or two-year period, satisfactory resolution of any identified issues is required

14. 14 Benefits of Joint Commission accreditation and certification Strengthens community confidence in the quality and safety of care, treatment and services Provides a competitive edge in the marketplace Improves risk management and risk reduction

15. 15 Benefits of Joint Commission accreditation and certification Provides education on good practices to improve business operations Provides professional advice and counsel, enhancing staff education Enhances staff recruitment and development

16. 16 Maintaining Accreditation Accredited organizations are required to maintain their operations in compliance with current Accreditation Association standards. In order to avoid a lapse in accreditation status, organizations must undergo full, regular surveys at least once every three years.

17. 17 Maintaining Accreditation The Accreditation Association notifies health organizations a minimum of six months prior to the expiration of their current term of accreditation. Re-accreditation surveys must occur within two months of the expiration date. Therefore it is required that all documentation be submitted to the Accreditation Association at least five months prior to expiration dates.

18. 18 Maintaining Accreditation Accredited organizations must notify the Accreditation Association in writing within 30 days of any significant organizational, operational, or financial changes. An organization's duty to provide this information continues during the entire accreditation process. Failure to notify the Accreditation Association may result in an immediate revocation of accreditation, or reduction in the term of accreditation.