Quality and Accreditation

1. Quality and Accreditation Dalal Abu AL Rob , RN, MSc, HCAC certified surveyor & Consultant Senior Specialist , Education and Consultation, HCAC 29 January 2014

2. Outlines • History of improving quality • Quality and cost • accreditation preparedness process • leadership role in quality and accreditation • Assessment of accreditation readiness by leaders

3. The History of Improving Get rid of the bad apples! Total Quality Management We are perfect! Patient Safety Process Improvement Quality Assurance Continuous Quality Improvement NO ACTION PROACTIVE REACTIVE

4. What is Quality? The Institute of Medicine defines quality as: "The degree to which health care services for individuals and populations increase the probability of desired health outcomes and are consistent with current professional knowledge of best practice."

5. Principles of Quality Improvement Population & Clients Know who we serve Quality Continuous Improvement Keep making it better Process & Outcome Look at what we do & what results we reach Teams With those who do the work Leadership & Partnership Who we work with

6. Quality and Cost

8. Facts • Quality can be improved by utilizing available resources and even decrease required resources • Quality not luxury, its essential to improve services and utilization of resources

9. Health care advancement in the last century

10. Health care advancement in the last century

11. Condition • Hip Fracture • Urinary Tract Infection • Headaches • Diabetes Mellitus • Hyperlipidemia • Benign Prostatic Hypertrophy • Asthma • Colorectal Cancer • Orthopedic Conditions • Depression • Hypertension • Coronary Artery Disease % Recommended Care Received 22.8 40.7 45.2 45.4 48.6 53.0 53.5 53.9 57.2 57.7 64.7 68.0 The Quality Gap McGlynnet al., NEJM; 2003

12. “Knowing is not enough; we must apply. Willing is not enough; we must do.” — Goethe

13. Key International Concerns • 3.5-16.6% of hospital patients suffer some sort of preventable harm • 25% of medical errors occur when medications are prescribed • 50% of all medical equipments in developing countries are unsafe • 77% of reported cases of counterfeit and substandard drugs occur in developing countries

14. Key International Concerns • Staggering costs associated with additional hospitalizations, litigation claims, nosocomial infections, lost income, disability and medical expenses • Issues seen in developing countries include unsafe blood transfusions, counterfeit and substandard drugs, and overall unreliable practices within poor work conditions • Adverse medical events affect every country, hospital, and health clinic “round the world,” as well as, all healthcare disciplines (Sources: World Health Professions Alliance Fact Sheet, 2002; Bulletin of the World Health Organization 11 Nov 2004)

15. Quality to Performance الجودة ------- الاداء Measurement to Improvement القياس من أجل التحسين www.qualitytools.ahrq.gov

16. To Err is human….. • In NY, adverse events* occurred in 2.9% of hospitalizations • In Colorado and Utah the number was 3.7% • Of the above 13.6% resulted in deaths in NY and 6.6% in the other states • At least 44,000 and up to 98,000 deaths occur per year in the US due to medical errors • What is the number in the rest of the world? IOM (2000)

19. Health Care Errors • Medication Errors • Nosocomial infections • Patients falls • Pressure sores • Phlebitis associated with intravenous lines • Restraint related strangulation • Preventable suicides • Failure to provide prophylaxis

20. DOCUMENTATION of the care process is CRUCIAL… • ACCURATELY • COMPREHENSIVELY • TIMELY • CONTINUOUSLY

21. Documentation… التوثيق “People lie, people die, but the medical record lives forever.” Author unknown

22. Legibility…

30. You know John! hospitals are the greatest harm…. to health!?

31. Accreditation Journey

32. The Accreditation Journey:leadership Involvement • The importance of leadership commitment: Board, CEO, and clinical leaders • Leadership’s responsibility to assuring systems are designed for quality and safety • Allocation of resources: may include facility enhancement, training, recruitment of new staff, and redesign of systems

33. The Accreditation Journey:Begin with Education • Education for organizational leaders and managers • Introduction to accreditation philosophy and approach • Accreditation as a quality improvement and risk reduction strategy • Review of the standards and measurable elements • Discussion of the survey process and what to expect • Project planning and next steps

34. The Accreditation Journey:Baseline Assessment • Conduct a detailed baseline assessment of the organization’s current adherence to the standards and each measurable element • Priority focus on the critical standards • Include all areas of the organization in the assessment

35. The Accreditation Journey:Baseline Assessment • collect and analyze baseline quality data as required by the quality monitoring standards • Examples: medication errors, hospital-associated infection rates, antibiotic usage, surgical complications, etc. • Establish an ongoing monitoring system for data collection (e.g. monthly, with quarterly data analysis) to identify problem areas and track progress in improvement

36. The Accreditation Journey:Action Planning • Using the findings of the baseline assessment, develop a detailed project plan with assigned responsibilities, deliverables, and timeframes • Start first with priority areas of the critical standards • Example: Revise informed consent policy, develop a new informed consent statement, educate staff --- in the next two month time period • Hold leaders and staff accountable to plan

37. The Accreditation Journey:Team Approach • Assign oversight of each cluster of standards to a respected champion/leader who will identify team members from throughout the hospital • Involve those who may also be skeptical of the process • Look for good people skills, time management skills, and consensus building skills • Be prepared to change as new champions emerge, and some leaders drop out

38. The Accreditation Journey:Policies and Procedures • compile a list of all required policies and procedures that will need development and revision • These may take some time to get revise or develop, undergo organizational review, and obtain final approval • The policy need to reflect actualpractice, as this is what the surveyors will evaluate your organization against

39. The Accreditation Journey:Mid-Point Strategies • Monitor progress in meeting the standards, such as through a mini-evaluation of each cluster at regular intervals (e.g quarterly) • Adjust project plan to be more realistic --- change often takes longer than one expects • Involve as many staff as possible in the process --- make it an organizational quality goal that together you are wishing to achieve

40. Strategies that have Worked • Importance of physician commitment to the accreditation process • Must see accreditation standards as a framework by which organizational processes will be improved • Care will ultimately be of higher quality and safer for their patients • Reassure physicians that accreditation is not intended to tell them how to practice medicine!

41. Strategies that have Worked • Learn from what others have done well and adapt the experience to the needs of your organization

42. Pitfalls to Avoid • Top leaders give “lip service” to the process, but are totally unrealistic in what it will take to achieve it in terms of time and resources • Staff end up feeling that accreditation is extra work for which they are not rewarded or recognized • Over-eager managers use the standards as a stick rather than as a carrot --- can make entire accreditation process feel punitive and inspecting rather than motivating

43. Accreditation- readiness assessment tool

44. Accreditation- readiness assessment tool

45. Accreditation- readiness assessment tool

46. Is the juice worth the squeeze? Concentrate your efforts where they will do the most good!

47. Thank You.