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

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. 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 Kuwaiti National Accreditation vs. International Accreditation‘Differences’

5. 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

6. Content • National vs. International Accreditation (similarities & differences) • A glance at Kuwaiti Accreditation System • CCHSA Accreditation (as an international sample) • 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

8. Kuwait National Standards: • A Total of 266 basic requirements • Involved the work processes of the different committees and sections Aspects covered by the requirements: • Hospital’s Top Management (Hospital’s 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…

9. Dimensions of Kuwait National Accreditation • Compliance • Coordination • Communication • Client-Centered

10. 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

11. 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

12. 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

13. Kuwaiti Accreditation Cycle 2-year Cycle

14. National Accreditation as a Tool to Adopting International Accreditation

15. Supportive Infrastructure Components

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

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

18. Self Assessment CLIENT CCHSA Accreditation Process

19. Principles of CCHSA Accreditation

20. 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.

21. 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.

22. CCHSA - Patient Safety Area 2/3 3. MEDICATION USE Goal 3: Ensure the safe use of high risk medications Goal 4: Ensure the safeadministration of parenteral medications.

23. CCHSA - Patient Safety Area 3/3 4: WORKLIFE/WORK FORCE Goal 5: Create a worklife 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.

24. 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

25. Survey Simulation Indicators Client interviews Patient Tracer Surveyor Rating Self-assessment Team interviews On-sitedocumentation Required Information Focus groups Tours

26. What should you learn from the process?

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

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

29. 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.

30. 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 52out patient clinics. • 6 operating theatres • Cardiac Catheterization Lab was launched on May 07 • A total of 776 diverse workforce • Started a massive expansion project.

31. 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

32. Turnover Trends at DASH

33. 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

34. Communication Patient safety Organization’s Culture Accreditation Self Assessment Organization wide Committees Quality Infrastructure Medical Record Education & Training DASH Approach To Achieving CCHSA Accreditation

35. 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

36. Self Assessment Teams • Service Delivery Teams • Support Services teams • Administrative Teams • Environment Care Team

37. Service Delivery Teams • Surgical Care Team • Maternal/ Child Team • Medical Care Team • Emergency Care Team

38. Support Services Teams 5. Pharmacy Team 6. Diagnostic Services’ Team 7. Laboratory Team

39. Administrative Teams 8. Leadership & Management Team 9. Human Resources Team 10.Information management Team 11.Environment Care Team

40. Accreditation Process/DASH

41. Mock Survey Results

42. Final Survey’s Results

43. 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

44. However; towards the final survey many people bought in due to…. • Continuous education and training • Open door policy and open channels of communication • Open meetings between top managers and employees • Staff satisfaction survey • Feedback mechanisms in place • Involvement in setting up the alternate strategic direction of the organization • Emphasizing important ethics of organizational justice, teamwork, recognition, and rewards • Creating positive competition through continuous internal benchmarking and role modeling • Most important: transforming the organization into a LEARNING ORGANIZATION and adopting an OPEN, NON-PUNITIVE CULTURE

45. Resistance Trend Towards the Process

46. Performance Improvement Projects & Indicators Examples for Demonstration

47. 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