Accreditation and other alternative models in Healthcare Seval Akgün, MD, PhD Professor of Public Health and Medicine October 26-27,2010 54th EOQ Congress, İzmir, TURKEY 1
quality assurance patient satisfaction quality improvement total quality management continuous quality improvement clinical audit clinical effectiveness process management evidence-based medicine clinical governance Patient safety 2 2
The 80 s Peer review Consensus based guidelines Visitatie Transparancy and standardisation vs. Professional autonomy EOQ CONGRESS, 2010 3
The 90 s National and systemic approaches (Leidschendam conferences) Quality vs. Cost containment Accountability Quality regulation Process orientation and multidisciplinarity 4
The present decade Result orientation Performance measurement Market and products (choice, price, quality, service) Self management Accreditation 5
Which One?? Licensure Certification Credentialing Accreditation 6
Licensure A Definition A government administered mandatory program requiring Health care institutions to meet minimal standards for operation Health care professionals to meet certain minimal education, training, skills, criteria to practice their profession 7
Licensure A Definition Licensure is usually a government-sponsored activity that is put in place to control the practice of a profession or an act that has the potential of risk to the recipient or the beneficiary. For example, if an organization is licensed as a mental health center then it may function only as a mental health center unless it has another license PROF.DR.SEVAL that specifies AKGUN, 54TH otherwise. 8
Licensure A Definition Licensure is also limited by time and is usually renewable annually and may only require the payment of dues and maintenance of good standing in the community. 9
Certification A Definition Certification can be defined as a process of assessing the degree by which a facility, product, unit or professional attains minimum standards. It is specific to the nature of the assessment, and the entity is certified as a special agency for the purpose of providing a specific service or activity. (ISO, EFQM etc.) 10
What is Accreditation? It is a process of evaluation against specific standards. 12
What is accreditation? Accreditation is a process in which an entity, separate and distinct from the health care organization, usually nongovernmental, assesses the health care organization to determine if it meets a set of requirements designed to improve quality of care. 13
Accreditation A Definition Usually a voluntary process by which a government or non-government agency grants recognition to health care institutions which meet certain standards that require continuous improvement in structures, processes, and outcomes. 14
What is accreditation? Accreditation standards are usually regarded as optimal and achievable. Accreditation provides a visible commitment by an organization to improve the quality of patient care, ensure a safe environment, and continually work to reduce risks to patients and staff. Accreditation has gained worldwide attention as an effective quality evaluation and management tool. 15
Philosophy of Accreditation Evaluates the entire health care organization as a complex interaction of many clinical and management processes Uses published consensus standards in conducting an evaluation Engages health professionals and key stakeholders in creating the standards Represents an objective and transparent evaluation of quality standards using pre-determined decision rules Stimulates a quality culture that supports continuous improvement 16
The major purposes of accreditation Improve the quality of health care by establishing optimal achievement goals in meeting standards for health care organizations Stimulate and improve the integration and management of health services Establish a comparative database of health care organizations able to meet selected structure, process, and outcome standards or criteria 17
The major purposes of accreditation Reduce health care costs by focusing on increased efficiency and effectiveness of services Provide education and consultation to health care organizations, managers, and health professionals on quality improvement strategies and best practices in health care 18
The major purposes of accreditation Strengthen the public s confidence in the quality of health care, and Reduce risks associated with injury and infections for patients and staff 19
The Accreditation Process The accreditation process consists of a combination of self and external organizational assessments based on pre-established standards. Accreditation differs from certification in that it is typically awarded to organizations and not to individuals 20
The Accreditation Process Accreditation focuses on continuous improvement strategies and achievement of optimal quality standards rather than adherence to minimal standards intended to assure public safety. 21
Strengths Of Accreditation External, objective evaluation Proactive not reactive Organization wide Focus on systems not individuals Stimulates continuous improvement Periodic re-evaluation against standards 22
Scope of Accreditation Hospital Ambulatory Care Facilities PHC Centers Clinics Medical Groups Surgical-Centers, ER, Centers Rehabilitation Facilities Psychiatric Care Facilities 23
Benefits Improving Quality of Care Patients are in Good Hands Promoting Patient Safety Culture Accreditation System Standardization Of Care Staff Satisfaction Reputation Building Integrity & Trust 24
Accreditation Standards Accreditation standards are typically developed by a consensus of health care experts Standards are published and reviewed and revised periodically in order to stay current with the state-of-the-art thinking about health care quality, advances in technology and treatments, and changes in health policy. 25
Accreditation Standards Depending on the scope and philosophy of the individual accreditation program, accreditation standards may take a systems approach that is organized around key patient and organizational functions and processes, such as: Patient assessment, Infection control, Quality assurance, and Information management. 26
Standards - Types Structure: Resources E.g. adequate staff, supplies, building Process: Activities E.g. patient education, nursing assessment Outcomes: Results E.g. infection rates, maternal mortality 27
Patient-Centered Standards Access to Care and Continuity of Care Care of Patients Patient and Family Rights Patient and Family Education Assessment of Patients 28
Health Care Organization Management Standards Quality Improvement and Patient Safety Facility Management and Safety Prevention and Control of Infections Staff Qualifications and Education Governance, Leadership, and Direction Management of Information 29
Disease or Condition- Specific Program Organizations may seek certification for the comprehensive clinical management of virtually any chronic disease or condition 30
Disease or Condition-Specific Care Examples Acute coronary syndrome Alzheimer s disease Arthritis Asthma Cancer Chronic obstructive pulmonary disease Chronic kidney disease Coronary artery disease Depression Emphysema Epilepsy Heart failure Hemophilia High-risk pregnancy HIV/AIDS Hypertension Inpatient diabetes Ischemic heart disease Low back pain Migraines Multiple sclerosis Obesity/bariatric surgery Osteoporosis Parkinson s disease Primary stroke centers Sickle cell disease 31
35 Growth of accreditation 1951-01 30 25 20 15 10 5 0 February 2009 32 32
European accreditation growth 1990-2004 February 2009 33 33
The EFQM (European Foundation for Quality Management) Excellence Model 34
The inside look at the Model Value of the Excellence Model Fundamental Concepts Dimensions Structure Measurement Success Stories Improves Process & Customer Satisfaction Results Award-winning companies have consistently better business results than their competitors in the same industry 35
What is the Excellence Model? Set of organisational beliefs or values Basis for thinking about, discussing and improving your organisation Framework for analysing an organisation and benchmarking with others Basis for a management system Framework to make sense of the vast range of initiatives we all have 36
Why use the Model? To give a realistic view of how good your organisation is To identify where to focus improvement effort To bring initiatives together into a single framework To encourage the sharing of internal and external good practices To provide a common language To understand the drivers behind business results 37
Most widely used Framework 38
Dimensions to the Model Concepts = foundations Content = structure Comparison = measurement 39
The Concepts The eight fundamental concepts which underpin the model are: Customer focus Partnership Development People development and involvement Management by processes and facts Continuous learning, innovation and improvement Leadership and constancy of purpose Corporate social responsibility Results orientation 40
Structure of the Enablers 1 Leadership 1a 1b 1c 1d 1e Criteria parts Areas to consider 5 Processes 5a 1998 EFQM 11 41
Structure of the Results Criterion 6 Customer Results 6a (75%) Perception data Criteria parts 8 in total 6b (25%) Performance Indicators 7 People Results 7a (75%) Perception data 7b (25%) Performance Indicators 8 Society Results 8a (25%) Perception data 8b (75%) Performance Indicators 9 Key Performance Results 9a (50%) Key Performance Outcomes 9b (50%) Key Performance Indicators 42
Measurement System Enablers 7 Attributes Results 5 Attributes 43
Use of the Model Mergers, Investment Evaluation 15% Supplier management Project management Visioning 37% 37% 45% Strategy formulation 66% Self-Assessment 80% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 44
The Model is used by more than 35000 organisations across Europe 60% of Europe s largest 25 companies 9 of the 13 European companies in the FT s 50 World s Most Respected Companies at least 15000 SMEs 45
Malcolm Baldrige National Quality Award- Program Health Care Criteria For Performance Excellence 46
The inside look at the Model Since 1995, healthcare organizations have used the Baldrige Health Care Criteria to help them address challenges such as; focusing on core competencies, introducing new technologies, reducing costs, communicating sharing information electronically, establishing new alliances with health care providers, or just maintaining market advantage 47
Value of the Model The Baldrige Health Care Criteria have three important roles in strengthening competitiveness: 1. They help improve organizational performance practices, capabilities, and results; 2. They facilitate communication and sharing of best practices information among health care organizations and among U.S. organizations of all types; and 3. They serve as working tool for understanding and managing performance and for guiding organizational planning and opportunities for learning. 48
Value of the Model The Baldrige Health Care Criteria are designed to help organizations use an integrated approach to organizational performance management that results in: The delivery of ever-improving value to patients and other customers, contributing to improved health care quality; Improvement of overall organizational effectiveness and capabilities as a health care provider; and Organizational and personal learning. 49
Core Values and Concepts Visionary leadership Patient-focused excellence Organizational and personal learning Valuing staff and partners Agility 50
Core Values and Concepts Focus on the future Managing for innovation Management by fact Social responsibility and community health Focus on results and creating value Systems perspective 51
Baldrige Categories 1. Leadership 2. Strategic Planning 3. Focus on Patients, Other Customers, and Markets 4. Measurement, Analysis, and Knowledge Management 5. Staff Focus 6. Process Management 7. Organizational Performance Results 52
Lessons learned Many hospitals and health care organizations have built their management systems without coverage of the clinical processes (care and prevention). There are many reasons for the difficulty in grasping the clinical process. The clinical care processes are often very complex and it is difficult to attribute them to detailed descriptions. The autonomy of professional experts, like physicians, doesn't pro mote transparency of the activities which are an essential part of the system. On another hand a management system that doesn't grab the core activity of the experts the clinical process doesn't interest the clinicians. The clinicians will never feel committed to this kind of management system. 53
France - ANAES A typical example of health care accreditation is the program of ANAES (http://www.anaes.fr) in France. The objectives of the accreditation are: To assess quality and safety of care To assess a health care organization s ability to ensure continuous improvement in quality of overall patient care To formulate explicit recommendations To involve professionals at all stages of the quality initiative To provide external recognition of the quality of care in health care organizations To improve public confidence. 54
ISQua and the Alpha Agenda ISQua was founded in 1985 by a group of health care quality professionals. Avedis Donabedian had deeply in fluenced many of the original groups. Now incorporated in Australia, ISQua has members in over sixty countries. The society is a non-profit organization, managed by an Executive Board which is elected every two years. 55
ISQua and the Alpha Agenda One of the activities of ISQua is the Alpha program, which aims to harmonize the principles of the health care accreditation schemes The objectives of the Alpha Agenda are: To demonstrate internationally that accreditation is a credible evaluation process To demonstrate that external and objective evaluation of a national accrediting organization is possible and desirable and there is a means to do this To respond to an ongoing need for a forum and organization structure through which knowledge and experience PROF.DR.SEVAL about accreditation AKGUN, 54TH could be shared. 56
The clinical audits or surveying The peer reviews done by other experts working in the same field act as an assessment of the complex and multi-sided patient care. Many countries are actively developing their clinical audit systems. An example of these clinical audit schemes is the Visitatie in the Netherlands. It has originally been developed for the selection and monitoring of special medical training. It has since been developed into a quality assessment tool. It focuses on clinical practice, professional development and service quality. Visiting teams are mostly clinical and of ten uni-disciplinary. 57
The clinical governance Clinical governance has a broader approach compared to clinical audit. The expert is asked to audit his performance, but also demonstrate how to improve the performance and maintain it. It also emphasized the responsibilities of both clinicians and managers in the delivery of care The responsibilities can be described: A clinician is responsible for providing individual patient care of high quality and for being able to demonstrate this by setting standards and monitoring acceptable standards. A health institution is responsible for providing services of high quality and for being able to demonstrate this by setting the system s standards to provide the services and by ensuring that clinicians deployed by the institution are fulfilling their individual re sponsibilities. 58
Obstacles Fear to failure. Resistance to change. Workload. No infrastructure of quality management. Information System. Financial issues. Quality Professionals. 59
Challenges Acceptance and commitment Resources (human and physical) Documentation issues Policies, plans, education, monitoring and audits, improvements, etc. Technical issues (interpreting standards and ME) Cooperation What s in it for me? Western Ideology Globalization Times and deadlines Maintaining it! 60
Questions? Comments? 61
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