Accreditation As A Strategy / Tool For Hospital Quality Service / Improvement

Accreditation
as a Strategy / Tool
for Hospital Quality
Service /
Improvement
Reynaldo O. Joson, MD, MHA, MHPEd, MSc
Surg
Short Course on Total Quality Management
June 23 - 27, 2014
Accreditation
Service /
Improvement
Outline of Contents of Talk:
Definition of Terms
Why the Strategy
How to Go About It (The Tool)
Accreditation
Service /
Improvement
Definition of Terms
Why the Strategy
Accreditation as a Strategy and Tool

for Hospital Quality Service
Improvement
Definition of Terms:
Accreditation = Hospital*
Accreditation = A Hospital Unit
Accreditation
Accreditation
Certification
Award
What is Hospital
Accreditation?
Processes by which a hospital voluntarily
applies for recognition or attestation of
compliance to certain set of standards by
a third-party
Accredited /
Accreditation
Certified /
Product
s
Process
es
Systems
Persons
Compliance
Demonstration
of competency /
consistency
Compliance, Accreditation,
Certification,
Hospit Award
Third-party
Assessor
/ Auditor
Certificatio
n
ISO 9001
ISO 14000
al
Satisfactory
degree of
compliance /
achievement
Set
Standards
Criteria
Indicators
Accreditati
on
PhilHealth /
Benchbook
PCAHO
JCI
ACI
NABH
Levels
Award
Philippine
Quality Award
Compliance, Certification,
Accreditation, Award
Certifying /
awarding body
Certification
Compliance
Accredited
certifying body
Accreditation
Award
(recognition)
Certifying /
awarding body
Certification
DTI
Compliance
Accreditation
PQA
Accredited
certifying body
Award
(recognition)
Certifying /
awarding body
Certification
PhilHealth
PhilHealth
Compliance
Accredited
certifying body
Accreditation
Award
(recognition)
ISQUA
Certifying /
awarding body
Certification
JCI / ACI / NABH
Compliance
Accredited
certifying body
JCI / ACI / NABH
Accreditation
Award
(recognition)
ISO
Certifying /
awarding body
ISO 9001 / 14000

Certification
Compliance
Accredited
certifying body
AJA / TUV
Accreditation
Award
(recognition)
What is the concept of hospital accreditation?
A hospital seeking accreditation from

an accrediting body is done on a
voluntary basis.
The hospital has the freedom to
choose the set of standards it wants
to be assessed or evaluated on by an
accrediting body.
It also has the liberty to choose the
accrediting body to do the assessment
The standards may be on

quality management system
quality health care and patient safety
management system
human resource management system
environment management system
emergency and disaster management
system
others
Hospital accreditation almost always

entails fees:
fee for the survey or assessment
fee for the certificate
How much the fees are is dependent
on the accrediting body.
Hospital accreditation almost always

entails fees:
fee for the survey or assessment
fee for the certificate
How much the fees are is dependent
on the accrediting body.
Accreditation
Service /
Improvement
Definition of Terms
Why the Strategy
What are the benefits of hospital accreditation?

What are the goals and objectives of having a hospital
accreditation?
There are a lot of benefits that can be

derived from hospital accreditation.
Some can be considered as major benefits
and some, as minor benefits.
Some can be considered as primary benefits
and others, as off-shoots of the primary, or
secondary.
These benefits are translatable to goals and
objectives of having a hospital

accreditation?
The overarching major primary benefit or

goal is to promote the business
development program of the hospital so as
to make it viable and sustainable.

accreditation?
The secondary benefits or objectives can

and should be the following:
To use the accreditation project as an

assessment tool on hospital performance
as well as a change management tool.
To identify and institute areas of
improvement towards excellence with the
help of the hospital accreditation project.
To educate the staff on performance
excellence with the help of the hospital

accreditation?
The secondary benefits or objectives can

and should be the following:
To increase the hospitals credibility and

to demonstrate its accountability to the
community using an attained hospital
accreditation.
To enhance the hospital reputation so as to
attract more clients utilizing its services.
To increase its leverage with the potential
partners and collaborators in the health care
industry using the attained hospital
accreditation.
Accreditation
Service
Use/it as change
agent!
Improvement
Know & fulfill
requirements of quality!
(with assessment
Definition of Terms
internal and external)
Educate staff on
Why the Strategy
quality!
Motivate staff on
quality!
What are the currently sought accreditation by hospitals in

the Philippines, fees, advantages and recommendations?
In a hospital setting in the Philippines,

as of 2014,
the following local and international
documented sets of standards should
guide all hospitals in achieving a high
level of quality and performance:

the Philippines, fees, advantages and recommendations?
Philippine Quality Award Criteria for

Performance Excellence
ISO Quality Management System
PhilHealth Benchbook (including PH
statutory and regulatory requirements)
Joint International Commission,
Accreditation Canada International,
National Accreditation Board for Hospitals
and Healthcare Providers (choose one)
Investors in People
What are the currently sought accreditation by hospitals

in the Philippines?
Accreditation Standards
PhilHealth Benchbook
Joint Commission
International (JCI)
Accreditation International
(ACI)
National Accreditation
Board for Hospitals and
Healthcare Providers
(NABH)
Philippine Quality Awards
(equivalence of Baldrige
Awards of )
ISO (International
Organization for
Standardization)
Investors in People
URLs
http://www.philhealth.gov.ph/prov
iders/institution/benchbook.htm
http://www.jointcommissioninterna
tional.org/
http://www.internationalaccredita
tion.ca/en/home.aspx
http://www.nabh.co/
http://www.pqa.org.ph
http://www.dti.gov.ph/dti/index.
php?p=492
http://www.nist.gov/baldrige/publi
http://www.iso.org/iso/home.html
cations/hc_criteria.cfm
http://www.investorsinpeople.co.
uk/Pages/Home.aspx
What are the similarities and differences between and

among the currently sought accreditation standards?
ISO / PQA
Origin
Language
Product
manufacturing
industry
manufacturing
easily defined,
tangible item
JCIA / ACI / NABH /

hospital industry
health care
clinical aspects of
health care, not easily
defined, not readily
tangible
What are the currently sought accreditation by hospitals

in the Philippines and their accreditation fees?
JCI
ACI
NABH
Philippine Quality
Awards (equivalence of
Baldrige Awards of )
ISO (International
Accreditation Fees
(Assessment and
Certification)
As of 2014 (may change
anytime)
PhP 10T
JCI PhP 14 M
ACI PhP 8 M
NABH PhP 3 M
PhP 30T small
organizations
PhP 50 medium to big
organizations
PhP 300T

the Philippines, advantages and recommendations?
Joint Commission
International (JCI)
Accreditation
International (ACI)
Board for Hospitals and
Healthcare Providers
(NABH)
Advantages
Designed to encourage Philippine
hospitals improve on their quality
management system and to
improve quality and safe patient
care
Designed to improve quality and
safe patient care
Designed to assess and improve
organization performance based
on internationally agreed
standards and stimulating
continuous improvement to
achieve optimum outcomes on
healthcare
Comparison of Standards
Patient Rights and

Organizational
Ethics
Patient Care
Leadership and
Management
Human Resource
Management
Information
Management
Safe Practice and

Environment
Performance
Improvement
Joint Commission International

Patient-centered Standards
Access to Care and Continuity of Care
Patient and Family Rights
Assessment of Patients
Care of Patients
Anesthesia and Surgical Care
Medication Management and Use
Patient and Family Education
Health Care Organization Management
Standards
Quality Improvement and Patient Safety
Prevention and Control of Infections
Governance, Leadership, and Direction
Facility Management and Safety
Staff Qualifications and Education
Management of Communication and
Information
Accreditation Canada
Individual Client /
Patient Care
Groups (14)
Information
Management
Human Resources
Development and
Management
Environmental
Management
Leadership and
Partnerships
Accreditation
Canada
Individual Client
/ Patient Care
Groups (14)
Information
Management
Human
Resources
Development
and
Management
Environmental
Management
Leadership and
Partnerships
Joint Commission International

Patient-centered Standards
Access to Care and Continuity of Care
Patient and Family Rights
Assessment of Patients
Care of Patients
Anesthesia and Surgical Care
Medication Management and Use
Patient and Family Education
Health Care Organization Management
Standards
National Accreditation Board

for Hospitals
Access and Planning of
Services
Customer Rights and
Education
Care of Customers
Management of
Medication, Consumables
and Equipments (including
Instruments)
Infection Control
Quality Improvement and Patient Safety
Prevention and Control of Infections

Governance, Leadership, and Direction
Facility Management and Safety

Staff Qualifications and Education
Management of Communication and

Information
Continual Quality
Improvement
Responsibilities of
Management
Facility Management and
Safety
Human Resource
Management
Information Management
System

Joint Commission
International (JCI)
Accreditation
International (ACI)
Advantages and
*Recommendations
Local standards directly related to
PH hospitals; will be needed for
licensure with DOH.
*All PH hospitals must have, for
viability and sustainability;
establish complete and
sustainable compliance to serve
as a foundation for other hospital
accreditations, if needed.
International standards directly
related to hospitals all over the
world.
*Go for one, if hospital has a
medical tourism project and needs

Awards of )
ISO (International
Organization for
Advantages
Designed to help provide hospitals
with an integrated approach to
organizational performance that
results in
Delivery of ever-improving
value to customers and
stakeholders, contributing to
organizational sustainability
Improvement of overall
organizational effectiveness
and capabilities
organizational and personal
learning
Designed to help organizations

ensure that they meet the needs
PQA Business Criteria for Performance Excellence
Baldrige Health Care Criteria for Performance Excellence
ISO 9000 QMS
PQA Criteria for Performance

Excellence
Leadership
Strategic Planning
Customer Focus
Measurement, Analysis, and
Knowledge Management
Workforce Focus
Operations Focus
Results
ISO 9001:2008
4 Quality management system
4.1 General requirements
4.2 Documentation requirements
5 Management responsibility
5.1 Management commitment
5.2 Customer focus
5.3 Quality policy
5.4 Planning
5.5 Responsibility, authority and communication
5.6 Management review
6 Resource management
6.1 Provision of resources
6.2 Human resources
6.3 Infrastructure
6.4 Work environment
7 Product realization
8 Measurement, analysis and improvement
8.1 General
8.2 Monitoring and measurement
8.3 Control of nonconforming product
8.4 Analysis of data
8.5 Improvement

Awards of )
ISO (International
Organization for
Standardization)
ISO 9001: Quality
Advantages and
*Recommendations
Local standards that covers all
kinds of industry and there is a
specific set of standards in health
care
*Recommended after PhilHealth
Benchbook accreditation; may use
the latest US Baldrige Health Care
Criteria for Performance
Excellence as complementary
guide.
International standards on basic
quality management system that
are applicable to all kinds of
industry including hospitals and

Accreditation
Standards
Investors in People
Advantages
Designed to transform business

performance through people
PQA Criteria for

Performance Excellence
Leadership
Strategic Planning
Customer Focus
Measurement, Analysis,
and Knowledge
Management
Workforce Focus
Operations Focus
Results
ISO 9001:2008
4 Quality management system

4.1 General requirements
4.2 Documentation requirements
5 Management responsibility
5.1 Management commitment
5.2 Customer focus
5.3 Quality policy
5.4 Planning
5.5 Responsibility, authority and
communication
5.6 Management review
6 Resource management
6.1 Provision of resources
6.2 Human resources
6.3 Infrastructure
6.4 Work environment
7 Product realization
8 Measurement, analysis and
improvement
8.1 General
8.2 Monitoring and measurement
8.3 Control of nonconforming product
8.4 Analysis of data
Investors in People
Plan
Do
Review
1. Business Strategy
2. Learning and
development strategy
3. People management
strategy
4. Leadership and
management strategy
5. Management
effectiveness
6. Recognition and reward
7. Involvement and
Empowerment
8. Learning and
development
9. Performance
Measurement
10. Continuous
improvement

Accreditation
Standards
Investors in People
Advantages and
*Recommendations
International standards on
people development to
promote hospital viability
and sustainability
*Use the IiP standards to
support and complement
accreditation and Philippine
Quality Awards as well as
other accreditations; nice to
have the IiP accreditation.
Advantages of Being Compliant with Local

and International Standards of Quality and
Safe Patient Services
Stimulate continuous improvement in
service and patient care processes and
outcomes.
Improve management of health care
services particularly on patient safety.
Provide staff education on better or best
practices.
Advantages of Being Compliant with Local

and International Standards of Quality and
Safe Patient Services
Increase efficiency / reduce cost.

Improve organization performance.
Promote recognition for excellence.
Strengthen public and community
confidence.
Accreditation
Service /
Improvement
Definition of Terms
Why the Strategy
What are the recommended processes in going for

hospital accreditation?
Starting point:
Top management decides to have a

Hospital Accreditation Project
To promote the business development
program of the hospital so as to make
it viable and sustainable.
To use it as a change agent to fasttrack quality improvement.

Top management creates a Steering Team /

Committee for Hospital Accreditation Project
with clear functions and authority.
Membership of Steering Team / Committee
Senior Management Representative if not
the Hospital Director
Chair (with competency in hospital
accreditation and leadership)
Cross-sectoral or multisectoral
membership with representatives from
key functional areas in the hospital, such
as the following:
(Note: the senior management team
members may constitute the Steering

Cross-sectoral or multisectoral membership with

representatives from key functional areas in the
hospital, such as the following:
(Note: the senior management team members
may constitute the Steering Team / Committee.)
sector
Medical service sector

Nursing service sector
Ancillary medical service sector
Administrative or support service
Human resource development sector
Business development sector
Finance sector

Steering Team formulates

a master plan for
Hospital Accreditation Project.

Steering Team decides on set of standards
to be assessed or evaluated on by an
accrediting body.
Steering Team seeks commitment for
support and collaboration from top, senior,
middle, and lower management on Hospital
Accreditation Project.

Contents of master plan for Hospital Accreditation

Project
Goals and objectives of accreditation

project (include short- and long-term goals
and objectives)
Selection, prioritization, and integration of
the accreditation standards
Selection of the accrediting bodies
Expected outputs (short- and long-term)
Expected impact (short- and long-term)
..

Contents of master plan for Hospital Accreditation

Project
..........
Timelines (short- and long-term)
Strategies and action plans to achieve
expected outputs and impacts (short- and
long-term)
Budget (short- and long-term)
Monitoring and oversight plan
Evaluation plan (short- and long-term)
Hospital Accreditation:
Does it Matter?
It depends on your need and situation!
Need - to participate in National Health Insurance
Program and get benefits go for PhilHealth
Accreditation!
Need - to participate in medical tourism program
and get benefits PCAHO, international
accreditation (JCI / ACI / NBAH)
Need to satisfy requirement of corporate
accounts go for accreditation!
Need to satisfy expectations of the community
go for accreditation!
Does it Matter?
Situation to be with the trend of having an
international accreditation (not to be left out
strong community expectation) go for
accreditation!
Situation want to fast-track improvement of
quality and safety of operations and services
with accreditation go for accreditation
(assessment, training, improvement, evaluation)!
Does it Matter?
NO need; NO situation
Be COMPLIANT with the standards and

criteria without going for formal
accreditation!
(self-directed learning and improvement!)
Integrating Hospital Quality and

Use
Performance Standards
integrat
ed
Philippine Quality Award
checklist
s
Excellence
ISO Quality Management
Performance
System
Excellence
(including PH statutory and
regulatory requirements)
International (either one)
Investors in People
*Compliance but NOT necessarily going for accreditation to

all standards, except PhilHealth Benchbook and Philippine
Quality Awards for Performance Excellence

Excellence
System
Investors in People
Performance
Excellence
Business
Development
Efficiency
Learning


Excellence
System
Investors in People
Performance
Excellence
Increase in
utilization of
services
Increase in
corporate
accounts and
patient-clients

What are the common problems or challenges in

Common problems and challenges

(commitment, cooperation,
collaboration,
and integration of all stakeholders)

Weakness in:
Leadership
Management
Planning, implementation, and
evaluation
Integration of standards in all units
Communication
Aiming for best practices in quality and

performance excellence in hospitals
Programmed Journey of
Aiming for best practices in quality and

performance excellence in hospitals
Programmed Journey of
Accreditation
Service /
Improvement
Thank
you for your kind
attention.
For queries and
feedback:
rjoson2001@yahoo.com
0918-804-0304
Reynaldo O. Joson, MD, MHA, MHPEd, MSc
Surg
Short Course on Total Quality Management
June 23 - 27, 2014
Welcome Queries and Feedback

Anytime!
REYNALDO O. JOSON, MD, MHA, MHPEd, MSc

Surg
0918-804-03-04
rjoson2001@yahoo.com

Accreditation As A Strategy / Tool For Hospital Quality Service / Improvement

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Accreditation

Accreditation as a Strategy and Tool

ISO 9001 / 14000

What is the concept of hospital accreditation?

A hospital seeking accreditation from

What is the concept of hospital accreditation?

The standards may be on

What is the concept of hospital accreditation?

Hospital accreditation almost always

What is the concept of hospital accreditation?

Hospital accreditation almost always

What are the benefits of hospital accreditation?

There are a lot of benefits that can be

What are the benefits of hospital accreditation?

The overarching major primary benefit or

What are the benefits of hospital accreditation?

The secondary benefits or objectives can

To use the accreditation project as an

What are the benefits of hospital accreditation?

The secondary benefits or objectives can

To increase the hospitals credibility and

What are the currently sought accreditation by hospitals in

In a hospital setting in the Philippines,

What are the currently sought accreditation by hospitals in

Philippine Quality Award Criteria for

What are the currently sought accreditation by hospitals

What are the similarities and differences between and

JCIA / ACI / NABH /

What are the currently sought accreditation by hospitals

What are the currently sought accreditation by hospitals in

Patient Rights and

Safe Practice and

Joint Commission International

Joint Commission International

National Accreditation Board

Quality Improvement and Patient Safety

Prevention and Control of Infections

Facility Management and Safety

Management of Communication and

What are the currently sought accreditation by hospitals in

What are the currently sought accreditation by hospitals in

Designed to help organizations

PQA Business Criteria for Performance Excellence

Baldrige Health Care Criteria for Performance Excellence

ISO 9000 QMS

PQA Criteria for Performance

What are the currently sought accreditation by hospitals in

What are the currently sought accreditation by hospitals in

Designed to transform business

PQA Criteria for

4 Quality management system

What are the currently sought accreditation by hospitals in

Advantages of Being Compliant with Local

Advantages of Being Compliant with Local

Increase efficiency / reduce cost.

What are the recommended processes in going for

Top management decides to have a

What are the recommended processes in going for

Top management creates a Steering Team /

What are the recommended processes in going for

Cross-sectoral or multisectoral membership with

Medical service sector