2. HOSPITAL ACCREDITATION NUR 781, SPECIAL TOPICS IN NURSING PRESENTED BY: HUSNI ROUSAN SUPERVISED BY DR. ARWA OWIES JUST, 2002 / 2003

3. OUT LINE  INTRODUCTION  DEFINITION OF ACCREDITATION  BENEFITS OF ACCREDITATION  ACCREDITATION PROCESS  ACCREDITATION LEVELS  THE PERFORMANCE AREAS  ACCREDITATION IN JORDANIAN HOSPITALS

4. INTRODUCTION  QUALITY OF CARE  COST  AHCPR, HHS  JCAHO, JCI

5. PURPOSE OF ACCREDITATION The Main Purpose Is to Continuously Improve the Safety and the Quality of Care Provided to Public Through the Provision of Health Care Accreditation and Related Services That Support Performance Improvement in the Health Care Organization. (JCAHO, 1997)

6. DEFINITION OF ACCREDITATION it’s a formal process by which a recognized body, usualy a non-govermental organization assesses and recognizes that a health care organization meets applicable pre-determined and published standards. Accreditation standards are usually regarded as optimal and achievable designed to encourage continuous improvement efforts within accredited organization its made following a periodic on-site evaluation by a team of reviewers.

7. BENEFITS  Improve quality of care  Public confidence  Meet Medicare certification  Provide educational tool  Enhance recruitment  Influence the insurance  Care contracts  Access to financial markets

8. ACCREDITATION PROCESS  Accreditation team  Survey every three years. (JCAHO, 1997)  Quality-related performance evaluation  Observe activities, interview nurses, patients, families & review documents  Specific scoring guideline

9. OVERALL EVALUATION SCORE  Comprehensive Accreditation Manual for Hospitals ( 500 standards )  Performance area scores are combined  Scores are based on a scale of ( 1 - 5 )  1 = Substantial compliance  2 = Significant compliance  3 = Partial compliance  4 = Minimal compliance  5 = Noncompliance

10. ACCREDITATION LEVELS  Accreditation with Commendation  Accreditation without recommendations  Accreditation with recommendation for improvement  Provisional Accreditation  Conditional Accreditation  Preliminary Denial of Accreditation  Accreditation Denial (JCAHO, 2001)

11. THE PERFORMANCE ARES  PATIENT’S RIGHTS AND ORGANIZATION ETHICS  ASSESSMENT OF PATIENTS  CARE OF PATIENTS  PATIENT AND FAMILY EDUCATION  CONTINUITY OF CARE  IMPROVING ORGANIZATION PERFORMANCE  LEADERSHIP  MANAGEMENT OF THE ENVIRONMENT OF CARE

12. CON.  MANAGEMENT OF INFORMATION  INFECTION CONTROL  GOVERNANCE  MANAGEMENT  MEDICAL STAFF

13. ACCREDITATION MODELS  PARTNERSHIP MODEL  INTEGRATED MODEL  PHASED MODEL

14. MAJOR MILESTONES OF ACCREDITATION  Recognize the need to improve quality  Choose the appropriate model  Setting up the formal structure of accreditation  Develop and test standards & design the process  Recruiting, hiring & training surveyors  Conducting surveys  Refining policies, procedures and rules for Acc.  Developing accreditation database format  Conducting full accreditation surveys  Interpreting data and make decisions

16. THANK YOU FOR YOUR TIME AND INTEREST