National vs. International Accreditation

1
National vs. International Accreditation A
Kuwaiti Experience in private and public sector

• Ahmad Nasrallah, MPH.
• Chief Operating Officer
• Dar Al Shifa Hospital (DASH)
• Kuwait

2
Content

• National (Kuwaiti) Vs. International
  Accreditation (similarities differences)
• A glance at Kuwaiti Accreditation System
• CCHSA Accreditation (as an international sample)
• DASH Real Life Experience

3
National Vs. International Accreditation
similarities

• Both aim at achieving QUALITY PATIENT SAFETY
• Both utilize certain set of standards to compare
  actual practice against
• Both use surveyors to accomplish them
• Both utilize a multidisciplinary approach (with
  differences)
• Self Assessment is one of the process cornerstone
  elements
• Top management COMMITMENT is a necessity
• Clients involvement and education is elaborated
• Closing the LOOP is a MUST

4
Kuwaiti National Accreditation vs. International
AccreditationDifferences

• National
• For governmental hospitals and clinics only
• Mandatory
• Mainly structure-focus
• Few indicators are utilized (administrative,
  outcome)
• Free of charge
• Limited resources
• 2-year cycle (theoretically)

• International
• For governmental and private health organizations
• Voluntary
• Mainly process outcome focus
• Comprehensive process is identified to go through
  starting from assessment to final survey
• Many indicators are utilized (structure, process,
  outcome)
• Relatively expensive
• More resources are available
• 3-year cycle

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National Accreditation As A Tool for Adopting
International Quality Standards

• Introduces the local clients and organizations to
  the concepts of accreditation quality in an
  incremental way therefore buying in and
  committing to it will be easier
• Facilitates building the infrastructure for
  quality, hence becomes more sustainable
• Helps to transform the current punitive culture
  into a learning culture which is considered a
  primary yet crucial step farther

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Content

1. National vs. International Accreditation
   (similarities differences)
2. A glance at Kuwaiti Accreditation System
3. CCHSA Accreditation (as an international sample)
4. DASH Real Life Experience

7
Kuwait National Accreditation History

• Commenced in the year 2000, Guided by the M.O.H
  Quality Department.
• Started by a gap analysis conducted to the 15
  governmental hospitals
• Implementation was divided into two phases
• Preparation Phase during which the basic
  requirements draft was prepared (based on the
  M.O.H circulars) implemented by the hospitals
• Adoption Phase during which the established
  standards were adopted by the hospitals to
  evaluate their performance against them and
  identify opportunities for improvement
• First External Survey was conducted in 2004

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Kuwait National Standards

• A Total of 266 basic requirements
• Involved the work processes of the different
• committees and sections
• Aspects covered by the requirements
• Hospitals Top Management (Hospitals Director,
  Deputy Director, Assistant Director for
  Administrative Affairs)
• Heads of Clinical and Non Clinical Units
  Departments
• Hospital wide committees(Hospital Administrative
  Board,Morbidity Mortality Committee,Medical
  Record Review Committee,Infection Control
  Committee,Code Blue Committee (ER),Accreditation
  Preparation Committee

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Dimensions of Kuwait National Accreditation

• Compliance
• Coordination
• Communication
• Client-Centered

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Evolved around Patient Safety

• Coordination of services (amongst the different
  specialties and units)
• Standardization of clinical practices
• Integrated Medical Records
• Continuous education training
• Fire Safety Program
• Emergency Preparedness Plan
• Infection Control Program
• Risk Management

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Client-Centered

• Involvement of patients and their families in
  their care treatment therefore they can make
  informed decisions
• Patients Families Rights and education.
• Patient Satisfaction Survey
• Staff Satisfaction Survey
• Orientation Programs
• Home Care

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Tools

• Periodic Clinical Audits including clinical
  guidelines
• Medical Records Review
• Indicators
• Policies Procedures Review
• Quality Improvement Projects
• Feedback Surveys
• Self assessment A continuous review and follow
  up of implementation progress.
• External Survey Independent Surveyors are sent
  by MOH for external evaluation

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Kuwaiti Accreditation Cycle
2-year Cycle
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National Accreditation as a Tool to Adopting
International Accreditation
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Supportive Infrastructure Components
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Next Move

• An Integrated contract has been prepared with
  the Canadian Council On Health Services
  Accreditation ( CCHSA). Final steps

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Content

1. National vs. International Accreditation
   (similarities differences)
2. A glance at Kuwaiti Accreditation System
3. CCHSA Accreditation (as an international sample)
4. DASH Real Life experience

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CCHSA Accreditation Process
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Principles of CCHSA Accreditation
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CCHSA Standards

• A total of 473 criteria falls under 178
  standards.
• Scored the standards within 4 parameters
  compliance, communication, coordination,
  client-focus
• Emphasized the vitality of clients safety
  (internal external customers) in all standards.
• Created 21 Required Organizational Practices
  (ROPs) that supports patient safety. By January
  2006, compliance with these ROPs became a
  requirement of accreditation surveys.
• Developed five patients safety areas and six
  patients safety goals.

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CCHSA - Patient Safety Area 1/3

• The 6 patient safety goals are organized into
  five areas
• 1. CULTURE
• Goal 1 Create a culture of safety within
  the organization.
• 2 COMMUNICATION
• Goal 2 Improve the effectiveness and
  coordination of communication among care/service
  providers and with the recipients of care/service
  across the continuum.

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CCHSA - Patient Safety Area 2/3
3. MEDICATION USE Goal 3 Ensure the safe use
of high risk medications Goal 4 Ensure the
safe administration of parenteral medications.
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CCHSA - Patient Safety Area 3/3
4 WORKLIFE/WORK FORCE Goal 5 Create a work
life and physical environment that supports the
safe delivery of care/service 5 INFECTION
CONTROL Goal 6 Reduce the risk of health
service organization-acquired infections, and
their impact across the continuum of care/service.
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Client/Patient and Family Care
Preparing for Care and Treatment
Assessment
Care and Treatment Planning
Implementation and Evaluation of Care
and Treatment
Discharge And Follow-up
Quality Monitoring And Improvement
Quality Monitoring and Improvement
? Canadian Council on Health Services
Accreditation
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Survey Simulation
Indicators
Client interviews
Patient Tracer
Surveyor Rating
Self-assessment
Team interviews
On-sitedocumentation
Required Information
Tours
Focus groups
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• What should you learn from the process?

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Self assessment
Vision Mission Values
Communication
Structure
Client input
Process Co-ordination
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Content

• National vs. International Accreditation
  (similarities differences)
• A glance at Kuwaiti Accreditation System
• CCHSA Accreditation (as an international sample)
• DASH Real Life experience

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History of DASH

• The first Private Hospital in Kuwait that was
  established in 1961. It began with Maternity
  department only (30 beds).
• In 1995, it evolved into a hospital that
  provides a broader scope of services. Various
  departments were launched
• Dentistry , Pediatrics , Internal Medicine ,
  Plastic Surgery, ENT , Dermatology , General
  Surgery , Orthopedics , Ophthalmology , in
  addition to Cardiac Sonar Radiology, Laboratory
  and Pharmacy.
• 2004 Transferred to the new building in the
  District of Hawally.

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Nowadays

• A total of 100 in-patient beds including SCBU,
  NICU, ICU, CCU, and Day Case Surgery.
• A total of 23 medical specialities and 12
  subspecialities.
• A total of 52 out patient clinics.
• 6 operating theatres
• Cardiac Catheterization Lab was launched on May
  07
• A total of 776 diverse workforce
• Started a massive expansion project.

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DASH A Month In Life.

• 20217 Outpatient visits
• 1041 People are admitted
• 500 Deliveries
• 5500 Patients are seen in Emergency Room
• 5289 New patients are accepted in all
  specialties
• 475 Patients have surgical procedures
• 40 IVF cycles
• 18 Total Knee Replacements Performed
• 20048 Laboratory tests are analyzed
• 1020 Routine radiological studies are
  performed
• 253 CT/MRI studies are done
• 1244 Ultrasound studies are performed

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Turnover Trends at DASH
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DASH
The first hospital in Kuwait that signed up for
accreditation with a world-wide recognized
accrediting body, and The first hospital in
Kuwait that was granted the accreditation
certificate on Dec.2007 By The Canadian Council
On Health Services Accreditation CCHSA
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DASH Approach To Achieving CCHSA Accreditation
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DASH Self Assessment Teams

• A Total of 11 multidisciplinary teams were
  made up to
• Conduct periodic self assessment of the
  organization
• Liaise between the departments and the Quality
  Management Office
• Identify opportunities for improvement and define
  quality improvement projects in collaboration
  with the relevant departments/units and guided by
  the Quality Management Department

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Self Assessment Teams

• Service Delivery Teams
• Support Services teams
• Administrative Teams
• Environment Care Team

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Service Delivery Teams

1. Surgical Care Team
2. Maternal/ Child Team
3. Medical Care Team
4. Emergency Care Team

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Support Services Teams

• 5. Pharmacy Team
• 6. Diagnostic Services Team
• 7. Laboratory Team

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Administrative Teams

• 8. Leadership Management Team
• 9. Human Resources Team
• 10.Information management Team

11. Environment Care Team
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Accreditation Process/DASH
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Mock Survey Results
Adequate Standards Improvement Required Not in Place
63 36 1

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Final Surveys Results
Substantial Compliance Partial Compliance Minimal Compliance
65 35 0
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Challenges Faced During The Process

• Resistance it was dependant on employees
  characteristics
• most resistance had come from
  physicians
• 2. Inconsistency between the strategic
  direction of the top management and subordinates
• 3. Culture both patients and employees
• 4. Compliance to documentations standards
  was crucial
• 5. Lack of understanding of the main purpose
  for as such process by the employees
• 6. Absence of Teamwork
• 7. Communication
• 8. Politics
• 9. Lack of employees involvement in major
  decision
• making
• Lack of feedback activities
• Multidisciplinary Approach

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However towards the final survey many people
bought in due to.

1. Continuous education and training
2. Open door policy and open channels of
   communication
3. Open meetings between top managers and employees
4. Staff satisfaction survey
5. Feedback mechanisms in place
6. Involvement in setting up the alternate strategic
   direction of the organization
7. Emphasizing important ethics of organizational
   justice, teamwork, recognition, and rewards
8. Creating positive competition through continuous
   internal benchmarking and role modeling
9. Most important transforming the organization
   into a LEARNING ORGANIZATION and adopting an
   OPEN, NON-PUNITIVE CULTURE

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Resistance Trend Towards the Process
46

• Performance Improvement Projects Indicators
• Examples for Demonstration

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Compliance Rate with Proper Documentation within
the Patients Medical Records- 2007
48
Falls Preventive Programs year 2007
49
Pressure/Bed Sores Preventive Program year 2007.
50
Thrombo-phlebitis incidence Rates At DASH-2007
51
Proper Hand Washing Rates vs. Infection Rates66
decline in the infection rate was directly
correlated to improvements in hand washing
practices
52
Morbidity Report 1/2
53
Morbidity Rates 2/2
54
Patient Satisfaction Rate2007
55
Thank You
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