Accreditation Standards for Medical Staff Management

Accreditation Standards for Medical Staff Management Rabab Diab, RN, MSN, CPHQHCAC, Deputy CEO and Director of Education & ConsultationIraqi Health Conference – ErbilMonday, 28 May 2013

Outline • Healthcare System in Jordan • Medical Staff in Jordan and Challenges • Quality and Patient Safety Journey in Jordan • Quality and Patient Safety Challenges • Accreditation Standards for Medical Staff Management • Conclusion

Introduction • Upper middle-income country • Population of 6.2 million • Per-capita GNI of US$4,340 • Youngest among upper-middle income countries with 38 percent under the age of 14

Public Sector • Private Sector • International Sector Healthcare Providersby Sector • Ministry of health (primary healthcare centers and hospitals) • Hospitals • UNRWA • Private clinics • Royal medical services • Diagnostic and treatment centers • University hospitals

Number of Physicians/10,000 Population2005 – 2010 WHO, World Health Statistics 2012, 2012. See also, WHO, Global Health Observatory.

Medical staff management in Jordan have different strengths but face several challenges Strengths Challenges • Lack of leadership competency • Lack of regulations • No policies, procedures, clinical guidelines • Lack of credentialing and privileging system for medical staff • No relicensing system • Continuous education • No medical liability laws • Established education programs • Qualified medical staff • Good health out come indictors in terms of communicable diseases, infant and maternal health

Quality improvement for Jordan started with a visionary Minister who took a leap for accreditation… NQSGs launched Public Awareness Medical Transport Standards Centers of Excellence 1st edition Primary Health Care Standard Patient Safety Center / Institute USAID Agrees to support initiative of Minister of Health HCAC registered as a non-profit private sector company Breast imaging Units Standards ISQua accredits Surveyor Certification Course Cardiac Standards 2004 2007 2009 2011 2013 2003 2005 2008 2010 2012 12 members from a National Accreditation Committee was approved Pilot Hospitals ISQUA accredits hospital standards ISQua accredits HCAC Diabetes Standards Pilot Hospitals and First draft of Jordanian Hospital standards First Regional Conference Second Regional Conference First Surveyor Certification course started

So HCAC was established in 2007 as a nonprofit private shareholding company with the aim to raise the quality of health services… HCAC To foster the continuous improvement of the quality and safety of health care facilities, services and programs through developing internationally accepted standards, capacity building and awarding accreditation Mission Vision HCAC services and accreditation will be the primary choice of healthcare facilities and organizations in Jordan and the region • Continuous Improvement • Customer Focus • Impartiality • Integrity • Learning • Teamwork • Transparency Values

…Through a range of different services stemming out of two separate arms of the organization “A Comprehensive Model of Quality Improvement Services” Standards Development Surveys and Standards Development Department Surveyor Development Accreditor Accreditation Mock Surveys Functions Firewall Consulting for Government Education and Consultation Department Preparedness Training and Certified Courses Enabler Consultant Development

HCAC can now showcase a multitude of successes… Standards Accreditation Education & Consultation • Hospital Accreditation Standards - 3rd edition • Primary Health Care & Family Planning Accreditation Standards– 2nd edition • Medical Transport Services Certification Standards- 1st edition • Breast Imaging Units Certification Standards- 1st edition • Diabetes Care standards 1st edition • Cardiac Care standards being developed 2012-2013 • National Quality and Safety Goals 2009, 2010, 2011, 2012, 2013 • Family Planning & Reproductive Health Centers of Excellence Program- 1st edition • 41 certified hospital surveyors • 31 certified PHC surveyors • 17 hospitals accredited – four in the pipeline • 45 PHC accredited – 60 in the pipeline • 4 Certified Breast Imaging Unit • Preparing 8 hospitals for Accreditation, 5 breast imaging units • Graduated groups from : • Certified Consultant Training program • Certified Quality professionals • Certified Infection Control professionals • Certified Risk Management • Leadership & Management

The HCAC Hospital Standards Manual (3rd ed.) is divided into 14 clusters entailing 347 standards and 1238 measurable elements The Clusters Each Cluster is composed of 4 line items • Cluster 1: Ethics and Patients’ Rights • Cluster 2: Access and Continuity of Care • Cluster 3: Patient Care • Cluster 4: Diagnostic Services • Cluster 5: Medication Management • Cluster 6: Infection Prevention and Control • Cluster 7: Environmental Safety • Cluster 8: Support Services • Cluster 9: Quality Improvement and Patient Safety • Cluster 10: Medical Records • Cluster 11: Information Management • Cluster 12: Human Resources Management • Cluster 13: Management and Leadership • Cluster 14: Education and Training Survey Process Standards Statements • Classification • Critical (57 Standards):Address laws and regulations and, if not met, may cause death or serious harm to patients, visitors, or staff • Core (257 standards):Address systems, processes, policies and procedures that are important for patient care • Stretch (33 standards):Important standards, but not easy to implement due to time or resource constraints, or a need for culture change Measurable Elements Requirements of the standard that will be reviewed and assigned a score during the accreditation survey process

Quality and Patient safety still faces many challenges in Jordan • chemical exposure • Lack of radiation safety • Absence of basic hygiene • Violation of human rights • Flies in operating rooms • Open sewage systems within hospitals • Lack of privacy • No fire safety procedures and systems • Untrained staff on basic resuscitation • Lack of medical staff management systems • Competency of healthcare providers • No documented policies, procedures, plans, • No clinical guidelines • Not in compliance with laws and regulations regarding fire safety, radiation safety, staff qualifications, and medication management processes.

Medical Staff Management Standards • Credentialing and privileging • Medical staff file • Medical staff governance system • Medical graduate program • Performance appraisal

The standards of medical staff management are integrated in all clusters

HRM.7 The hospital has a process, defined in writing for verification of the license, education, experience, and certification for all licensed professional staff. The process of obtaining, verifying, and assessing the qualifications of a licensed independent practitioner Why? To determine whether he/she is qualified and able to provide patient care services and to participate on the medical staff””

Current licensure Relevant training and experience Current competence Peer recommendations Clinical privilege delineation Essential Data in the Credentialing Process

Privileging • The process of evaluation of an individual’s performance to determine if he/she is qualified and able to perform specific patient care services related to his/her specialty • Privileging of medical staff accompanies credentialing process.

Granting Clinical Privileges Delineation of clinical privileges Delineation of admitting privileges Categories of privileges Limitations of privileges Practicing within scope

Other Data Ability to perform Challenges to licensure/registration Voluntary/involuntary terminations or restrictions Professional liability

HRM.9 a personnel file is maintained for each employee • Documents related to license • Education • Experience • Certification

HRM.13 A governance system is in place for the medical staff to ensure the quality of patient care. • Medical staff bylaws • Categories of medical staff • Privileging • Medical staff issues • Quality improvement activities • Medical staff committee • Hospital-wide quality improvement program • Role of medical staff members in committees • Quality improvement initiatives

Medical Executive Committee

Medical Staff Bylaws

ML.8 Each Administrative and Clinical Department has an assigned department head with specific responsibilities • Each clinical department has a designated medical staff head who is board certified in a relevant specialty. • The assigned department head responsibilities include: • Ensuring and overseeing the development and implementation of the departmental policies and procedures • Ensuring that quality improvement and patient safety activities are carried out (PDSA)

Medical Staff Management Standards • Credentialing and privileging • Medical staff file • Medical staff governance system • Medical staff graduate training program • Performance appraisal

HRM.15 Hospitals that participate in professional under graduate education programs have a well-defined system for training. • Supervision of trainees by qualified members and their relationship with the hospital • Clear process for trainee orientation

HRM.8.1 Performance appraisals measure the performance of the employee against criteria related to evidence-based practice, innovation and/or research. • Performance criteria are written supporting evidence-based practice, innovation and/or research for each category of employee including medical staff. • Performance criteria are measurable, understandable, verifiable, equitable, and achievable.

Other Related Standards

…HCAC is in continuous improvement itself… The future of Quality Improvement is full of commitments Commitment to the QUALITY Commitment to PATIENT SAFETY Commitment to CAPACITY BUILDING Commitment to RESEARCH and POLICY

Accreditation Standards for Medical Staff Management