Why Hospital Accreditation?

IMPLEMENTATION OF HOSPITAL ACCREDITATION
PROGRAM
SHARING OF EXPERIENCES
THE PANTAI & GLENEAGLES EXPERIENCE
Dr Nik Fawaz Aziz
Head of Medical Affairs & Quality
Accreditation
• It is a voluntary process where organizations agreed
to meet the required standards by the accreditation
body
• It provides a visible commitment by an organization
to improve the quality of patient care, to ensure a
safe environment and to continually work to reduce
risks to patients and staff.
• It is an effective quality evaluation and management
tool of the internal processes
Accreditation
• The focus of accreditation is on continuous
improvement in the organizational and clinical
performance of health services, not just the
achievement of a certificate or award or merely
assuring compliance with minimum acceptable
standards.
• Accreditation focuses on learning, self development,
improved performance and reducing risk
Why Hospital Accreditation?
• Ensures a Quality Index for Health Consumers.
• It is a Public Recognition of the achievement of
accreditation standards by a healthcare organization
• It helps organization to have a good internal system
and create a culture for improvement in maintaining
good and safe care to patients (eg. Vision and
mission, strengthening policy, manpower planning)
Why Hospital Accreditation?
• The process of accreditation may lead to result in a
process of fundamental change in the technical
procedures of service delivery to improve patient
safety
• It helps to improve effectiveness, efficiency and in
cost containment, and accountability and the need
to reduce errors and increase safety in the system
OUR JOURNEY
Successful Accreditation
• Strong commitment by the governance body of the
organization (leadership, budget, etc)
• All stakeholders work as a team
• Commitment by the organization to meet the
required standards by the accreditation body
MSQH PREPARATION ROAD MAP
Identify Champion
(18 months ahead)
Apply for
Accreditation
Standards &
Requirements
Training by MSQH
Steering
Committee at
Group Level
Monthly Internal
Audit
Closure of Gaps
Gaps Analysis &
Recommendation
Initial Mock Audit
(6 months ahead)
Closure of Gaps
Actual Survey by
MSQH Team
(3 months ahead)
Submission of Self
Assessment
Questionnaire
Mock Audit
(3 months ahead)
2015 Pantai & Gleneagles Audit Schedule
2014
HOSPITAL
DEC
PHSP
1st Cycle
MSQH Focus
Survey
(1-2 DEC)
PHA
1st Cycle
MSQH Survey
(15-17 DEC)
2015
JAN
GPG
PHC
PHP
MAR
APR
MAY
JUN
JUL
AUG
5th Cycle
MSQH Survey
(2-4 MAR)
3rd Cycle
MSQH Survey
(5-7 MAY)
5th Cycle
MSQH Survey
(5 JUL)
5th Cycle
MSQH Survey
(10-12 AUG)
PHKL
4th Cycle
MSQH Survey
(24-26 AUG)
PHBP
PHM
OCT
2nd Cycle
MSQH Focus
Survey
(19-20 JAN)
GKL
PHI
SEP
3rd Cycle
MSQH Focus
Survey
(9-10 FEB)
PHAK
PHK
FEB
JCI SURVEY
(19-23 OCT)
2nd Cycle
MSQH Survey
(28-30 SEPT)
2nd Cycle
MSQH Survey
(5-7 OCT)
NOV
DEC
Strategic Improvement Plan
• Formation of Internal Survey Team
• Identify the champions for MSQH standards and
formation of Steering Committee in each hospital
to drive the accreditation process
• Early Preparation for Hospital Survey – Mock audits
at 6 months, 3 months and closing gap during last
one month prior to actual survey
Formation of internal Survey Team
Identify Champions for each standard at group
level and hospital level
Champions training by MSQH team
Formation of Multi Disciplinary Internal Audit
Team made up of members from corporate
MAQ, Nursing and Facilities team, as well as
champions from the hospitals
Training on the MSQH Standard by MSQH
Roles of Internal Survey Team
Conduct gap analysis and mock audit based on
MSQH standards requirement
Provide recommendation and guidance for
closure of gaps identified.
Share good practices between sister Hospitals as
internal auditors and observers are able to bring
back new practices to their own Hospitals
Mock Audit
by Internal
Survey Team
Preparation Process
• Standard Champions being guided and trained to
understand Accreditation Standards and Survey Process
• Champions to conduct self assessment against standards
requirement
• Initial assessment / gap analysis by Internal Audit Team
• Regular steering committee to address and formulate
action plans & fine tune work processes
• Upgrade facility & make structural change if necessary
Preparation Process
• Staff awareness campaign and training
• Update policies and procedures within the given time line
• Set practical time line and target for improvement
activities
• Assess readiness by mock audit / compliance audit
• Evaluate and Refine Process as necessary
• Pre-survey inspection to assess overall readiness
CHALLENGES
The hospital accreditation process faces at least three
sets of challenges to its acceptability, implementation,
and usefulness:
• Attitude of all stakeholders in acquiring hospital
accreditation;
• Uncertainty over the effectiveness
effectiveness of hospital accreditation;
and
cost
• To manage concerns about erosion of professional
autonomy
CHALLENGES
• To get the buy in of all stakeholders and
change in practice to meet to the required
standard
• Readiness of the hospital in going through the
actual survey
• Consistency in interpretation of standards
requirement by the surveyors
• Surveyor awareness of the need to be ‘reliable and
credible’
Final Process for accreditation
Success Factors
Top management support – CEO, COO
Interdepartmental task force
Multi disciplinary approach to internal audit
Team work
Culture to ensure patient safety
Pantai Hospital Ampang
Pantai Hospital Batu Pahat
Pantai Hospital Kuala Lumpur
Pantai Hospital Ayer Keroh
Pantai Hospital Ipoh
Pantai Hospital Sungai
Penang
Pantai Hospital Cheras
Pantai Hospital Klang
Pantai Hospital Sungai Petani
Gleneagles Kuala Lumpur
Gleneagles Penang
Other Hospitals to be accredited in 18 months
Gleneagles Medini,
Q3 2015
Gleneagles Kota Kinabalu, Q2
2015
Pantai Hospital Manjung
THANK YOU
Main Requirement before MSQH
To be eligible for an accreditation survey by MSQH, a healthcare organisation
shall:
•Be a member of MSQH;
•Be a healthcare organization operating in Malaysia, either in the public or private
sector;
•Be a provider of services for which the MSQH have applicable Accreditation Standards;
•Have a current and valid "license" as required by the Ministry of Health, or any other
relevant healthcare regulating body;
•Have been in full operations for a minimum of twelve (12) months prior to the survey
date;
•Ensure the availability of all services necessary to fulfill the organisation's mission and
objectives. (These services may be provided on site, or may be provided off-site by
partnerships with acceptable community or regional resources);
•Complete and return a "Survey Application Form" to MSQH. The application must be
signed by the Person-in-charge of the Hospital or an equivalent person with overall
authority and responsibility for the healthcare facility.
(Source from MSQH)