Prof.Dr Nagwa El Hosseiny Executive Committee of Accreditation

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Prof.Dr Nagwa El HosseinyExecutive
Committee of Accreditation
EGYPTIAN HEALTHCARE ACCREDITATION
November 2007
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• INTRODUCTION
• The experience of the last decade shows that
  accreditation has been a valuable technology for
  quality improvement in many settings.
• But the effectiveness of an accreditation
  program, as well as its affordability whether
  it will be sustainable, depends ultimately on
  many variable factors in the particular
  healthcare environment of the country involved.

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• The Egyptian Ministry of Health Population
  (MOHP) is responsible for all roles of providing
  healthcare as a-
• Policy Maker. Payer. Provider.
  Regulator.

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• Recently the Egyptian Ministry of Health
  Population (MOHP) has began implementing an
  ambitious reform covering its entire healthcare
  system.

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• One of the key initiatives of the reform is
  the
• restructuring of the health insurance
  landscape, to
• cover all population, in order to import the
• responsiveness to patient needs and prevent
• impoverishment

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Quality Healthcare

• Is one of the cornerstones of Health Reform Plan
• The reform plan includes development of an
  Egyptian Accreditation Organization which will be
  independent within 5 years
• The Payors will contract only with high quality
  healthcare services ensured by accreditation and
  monitoring by an independent regulator.

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Role of the Quality in Health Reform Plan

• Quality evaluation and Improvement is involved in
  all the steps
• The Payers Level Clinical Auditing, role is to
  confirm that clinical care was satisfactory.
• The Provider Level Accreditation Program

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• The Regulatory Level
• 1- For consumer protection (quality)
• Ensuring quality of care delivered in all
  healthcare facilities.
• Registration of profesionals,
• Pharmacueticals and medical devices
• Research and development
• 2-For system effectiveness (economic)
• Financial performance,prizing..

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• Egyptian Accreditation Program

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• What is accomplished now?

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• A quality department has been established in MOHP
  in 1998. It was able to accredit about 900
  primary healthcare facilities after being
  converted to Family Medicine Units.This
  accreditation program is very successful in
  improving the quality of care provided in the
  primary care sector.

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Clear Purpose

• Our Vision
• To enable all Egyptians to receive equitable
  and quality health care. Hence, Accreditation is
  to be used by the government as a contribution
  towards regular public accountability.
• To be approved as an International
  Accreditation body.
• Our Mission
• To empower Egyptian healthcare facilities to
  deliver quality health services continuous
  quality improvement through the accreditation
  approach.
• Our Values
• Integrity, Quality, Accuracy, Transparency,
  Honesty, Cost- effectiveness.

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Philosophy

• To develop and implement standards that define
  what is needed to provide quality service in all
  types of facilities.
• To assess the starting position of services
  provided by healthcare facilities.
• To facilitate the best use of health resources
  constrained by tight budgets.
• To empower staff to provide quality healthcare by
  introducing continuous quality improvement
  methods and participatory management.
• To be seen by the public and funders as a
  hallmark of quality .

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Scope of Responsibility

• According to the Egyptian Health reform plan.
• Accreditation will be on 3 levels-
• Basic.
• Intermediate.
• Accreditation.
• Accreditation Organization Body Formation
• .
• According to the Ministerial degree in 2004, The
  structure includes-
• Survey accreditation.
• Training, education research.
• Quality monitoring risk management.

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Chairman / CEO
Governing Board Stakeholders
Community Advisory Board
President / COO

• Stakeholders
• Curative Sector
• HIO
• CCO
• Teaching Hospital
• Specialized Centers
• Military Hospitals
• University Hospitals
• Private Hospitals
• Doctors Syndicate
• Nursing Syndicate
• Others ?

• VP Education
• Training
• Surveyors
• Organizations
• Public
• Publications

• VP Quality
• Improvement
• Patient Safety
• Risk Management
• Performance Measures
• Clinical Guidelines

• VP Accreditation Program
• Hospitals
• Ambulatory Clinics
• Primary Care Clinics

• Finance
• Human Resources
• Information Technology
• Business Development Marketing
• Statistical Evaluation
• Legal / Compliance

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Scope of Responsibility

• 5- Standards has been developed revised for-
• Hospital accreditation.
• Primary healthcare accreditation.
• Ambulatory care accreditation.
• Scoring system is also settled, standards are
  subdivided into A, B C standards scoring will
  be according to the 3 levels.
• Survey Process It will be functional
  departmental.

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• The A standards
• Standards related to structure,laws and
  regulations,policies procedures
• The B standards
• Standards related to implementation of
  policies,and process of care
• The C standards
• Standards related to implementation,but are
  considered difficult to implement in the first
  stages.

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Pyramid of Excellence in HealthCare Accreditation
ABC Standards
Egypt Accreditation
AB Standards
Basic Quality Level
A Standards
Foundation Level
Pre-survey Assessment Application Validation
Application Self Assessment
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External Technical Assistance
The three types of standards are now ISQua
accreditated. Our target is to recognize
internationally the whole program of
accreditation. Experience of external
consultants in the field of accreditation.
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• Training and Education

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A. Basic Education

• How to get started?
• Standards interpretation

B. Advanced Courses

• Performance Improvement
• Infection Control

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Future Training

• Risk management patient Safety
• Strategic management leadership
• Information management
• Others

• Medication Management
• Human resources
• Environmental safety

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Performance Monitoring and Risk management

• We started by basic set of quality indicators,
  with regular follow up and assessment course of
  variance to start improvement
• In 2008. There will be increase in the indicators

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National Quality Indicators

• They include
• Inpt/outpt ratio
• Bed occupancy rate
• Gross unadjusted hospital mortality
• ICU ,NICU mortality
• Readmission rate within 72 hrs from ER
• Nosocomial infection rate,surgical site infection
  rate
• Financial revenue

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• Yet There are Challenges to face

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Quality Culture

• We still need to orient and encourage the care
• providers and patients about the
• importance of high quality of healthcare services.

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Quality Culture

• Leadership commitments and support at all levels,
  the cultural barrier can be rather
• transformed to allow organizations to integrate
  CQI practices in their everyday activities.

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Motivation
Primary healthcare According to the accreditation
continuous quality monitoring, there is a
monthly incentive (pay for performance). In the
new insurance plan, reimbursement is related to
the quality of work. Hospitals Contracting
reimbursement will depend on achieving
accreditation. Public reporting pay for
performance based on the monthly quality monitors
results.
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Independence

• The accreditation organization is better to be
  far enough from government to be credibly
  independent, why?
• Because
• government domination of program direction might
  lead to conflict of interest in assessment of
  public services.
• Demotivation of other stakeholders.
• Vulnerability to short-term political changes.

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Sustainable Resourcing(Human Financial)

• Source of funding developmental operational
  eg. government pays, funds transition HCO
  pay.
• It is expected that full pay will be needed for
  3-5 yrs.

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Clear Definition and separation of the following

• Role of Accreditation Program
• Role of Ministerial licensing and Inspection

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Conclusion

• By our Accreditation Program, we are intending
  to-
• Support healthcare reform.
• Improve the quality of organization
  management of services.
• Promote continuous quality improvement.