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Hospital accreditation cannot stand-alone and is not therefore "a panacea to cure all ills" within the hospital system. The OPCV Team has identified and documented other "Opportunities for Improvement" within the system, not the least of which are the following:
- Hospital role delineation
- A regional approach to planning of hospital services
- The uniform collection of morbidity and mortality data through the establishment of a national health data bank
- A tertiary education approach to medical records administration training
- National health workforce planning in relation to key clinical groups such as physicians, nurses and pharmacists
- A national approach to identified deficiencies in safety standards for hospital buildings, hospital waste management, and blood banking services
- Strategic planning in relation to the medical technology and its dissemination throughout the country.
- Creation of the national Accreditation structure, particularly the National Health Care Quality Council
The Accreditation Manual and Guidelines
The OPCV Team maintains that the entire Manual and Guidelines form the quality approach. No standards should be read in isolation, as there are interlocking standards and related services/departments across the system. However the following principles extracted from the Accreditation standards documentation (as opposed to Basic standards) illustrate some of the key areas, and code numbers have been indicated for easy cross-reference to the Accreditation manual.
Quality Systems
The Hospital Accreditation Manual and Guidelines place the accent clearly on quality by the inclusion of a Quality Systems chapter (QS).
The presence of a Quality Department that is established and funded is integral to a hospital and it must be understood that while quality activities and staffing do involve cost, quality improvement activities do save money over a period of time. Hospitals save funds through efficiencies, reduced re-admission rates, and more effective lengths of stay, improvement in hospital image, increased throughput of patients, and many other measures that accrue as part of the emphasis of a quality approach.
A hospital will increase its reputation by the development of quality hotel services, but only in conjunction with the quality systems it implements and through the development of quality plans. Within quality improvement plans (QS1), key functions should include:
The presence of a Quality Department that is established and funded is integral to a hospital and it must be understood that while quality activities and staffing do involve cost, quality improvement activities do save money over a period of time. Hospitals save funds through efficiencies, reduced re-admission rates, and more effective lengths of stay, improvement in hospital image, increased throughput of patients, and many other measures that accrue as part of the emphasis of a quality approach.
A hospital will increase its reputation by the development of quality hotel services, but only in conjunction with the quality systems it implements and through the development of quality plans. Within quality improvement plans (QS1), key functions should include:
- Patient focused care. (QS)
- Organizational improvements. (GB-14 )
- Management of the hospital environment.(ES-2-5-8-14)
- Management of the resources - human, infrastructural, financial and equipment.(ES-8-9-13)
- Infection control management. (IC-7)
- Collection and utilisation of data to improve the hospitals performance. (MR-19)
- Accurate documentation. (CN-2-10-4)
Patients Rights and Responsibilities. (QS-10-15-16)
A patient complaint process should be an integral part of the hospital administration systems, and should be contained in the general information given to patients on their admission to hospital .(QS-15)The patients right to make a complaint should be enshrined in hospital policies and procedures, and that includes feedback to the patient on what action, if any the hospital intends to take concerning the complaint. Patients complaints when considered objectively can lead to significant improvements in hospital processes and the quality of care, and therefore the image of the hospital. Patients should not be afraid to make complaints, particularly about the standards of treatment a hospital provides.
Part of the customer focus that is adopted by countries to improve the image of hospitals is to develop a questionnaire (QS-9-14) that is utilised by the patients and staff to ensure that the service the hospital is providing to the public is consistent and safe. The patients and staff provide information on any and every service within the hospital. The survey is sent on to the quality department for collation, evaluation and action. As indicated above the implementation of this standard, can significantly improve the process a hospital may utilise for excellent patient care.
A written patients charter (QS-15) is a convenient means of advising patients of their rights when entering hospital. The hospital will expect patients to make complaints through the designated procedures available. Patient's rights and responsibilities can be encapsulated within one patient's charter. The adoption of this process ensures that the customer, that is the patient, is included in the decisions that are made within the hospital through the patient feedback process. Quality standards have embedded within them such outcomes as ethics committees (QS-16 ) to consider ethical matters, confidentiality issues (QS-16-17-18 ), and the right to have a second medical opinion and the right to privacy for the patient and relatives (QS-17-18 ).
Part of the customer focus that is adopted by countries to improve the image of hospitals is to develop a questionnaire (QS-9-14) that is utilised by the patients and staff to ensure that the service the hospital is providing to the public is consistent and safe. The patients and staff provide information on any and every service within the hospital. The survey is sent on to the quality department for collation, evaluation and action. As indicated above the implementation of this standard, can significantly improve the process a hospital may utilise for excellent patient care.
A written patients charter (QS-15) is a convenient means of advising patients of their rights when entering hospital. The hospital will expect patients to make complaints through the designated procedures available. Patient's rights and responsibilities can be encapsulated within one patient's charter. The adoption of this process ensures that the customer, that is the patient, is included in the decisions that are made within the hospital through the patient feedback process. Quality standards have embedded within them such outcomes as ethics committees (QS-16 ) to consider ethical matters, confidentiality issues (QS-16-17-18 ), and the right to have a second medical opinion and the right to privacy for the patient and relatives (QS-17-18 ).
Human Resource Management. ( HR )
A comprehensive staff recruitment process (HR-3) should be the cornerstone of any human resources system and requires the recognition by the hospital that the staff are the hospitals greatest asset. The human resource component delivers the care to the patient and is an important part of any quality hospital system. Investment in continuing education (HR-8-9) ensures that staff are valued and worthy members of the hospital. Staff education improves the image of the hospital through efficient and safe care of the patient and improves the reputation for the hospital. Amongst other things, a high quality human resource department is integral to:
- The human resource strategy of the hospital (HR-10-2)
- Recruitment of all staff to the hospital. (HR-3)
- In-service and ongoing education/training processes (QS-8-19-20)
- Orientation program for all new hospital employees. (QS-8-HR-8)
- Appropriate accounting systems that are accountable and transparent (HR-11-15-16)
- Collection and analyses of utilisation statistics (sick leave, accident rates, staff qualifications, education and in-service programmes, staff appraisal). ( HR-10)
Medical Technology
There is a clear indication of a build up of medical technology in Lebanese hospitals despite under utilisation in many areas. A study by Jurjus showed that "the quantity and variety of health services are increasing almost everywhere in the country, generating new and additional costs". He concluded, "The major challenge is to develop a policy structure that can control medical technology acquisition and utilisation." There is an opportunity through hospital role definition and delineation, implementation of quality assurance and/or certificate of need legislation, for the MOPH to control the ad hoc acquisition of advanced medical technology, like many other countries have opted to do. There are standards scattered throughout the Accreditation manual that refer to appropriate levels of medical equipment (BM-3-8), properly maintained medical equipment (BM-4 ), staff familiarity with existing and new items of equipment (SC-13), and qualified staff in relation to sophisticated equipment use (SC-13-14)
Buildings, Procurement and Bio-medical.
Through standards development and implementation, quality of care to the patients and cost savings can be generated with improved management procedures regarding procurement, maintenance and utilization of building services plant and biomedical equipment.
- Procurement principles and procedures. (BM-3)
- Technical specifications. (BM-5)
- Evaluation of bids and proposals for new equipment. (BM-3)
- Equipment installation and acceptance testing. ( BU-1-2)
- Updating and retention of technical skills of engineers sufficient to ensure trouble free operation and reliability of plant and biomedical equipment. (BM-2-7- SC-13)
- The training of plant operators and users of biomedical equipment to maximise operational efficiency and mimimise the risk of clinical accidents. (BM-2-7-SC-13)
Safety
The responsibility by the hospital for a safe work environment is essential for the health of employees. It also has important follow on effects for patients- that is in the provision of a safe and secure hospital environment. Within the hospital situation this responsibility involves such area as radiation safety (RA-2-BU-2), infection control standards and education (IC-All Standards-IC-7-13-14-15), staff immunisation programs (OH-3), fire and hazardous materials and standards ( FF-4-5-7-BU-1), and hospital waste management programs ( WM-1-2-3-10-8), to name just a few.
Infrastructure development is essential for the safety of staff and patients and may be as simple as implanting smoke detectors within a hospital (BU-3). Education and training for staff in the emergency evacuation of patients is essential to preserve human life in crisis situations such fire, flood, and other disasters (FF-9-11-4).
Infrastructure development is essential for the safety of staff and patients and may be as simple as implanting smoke detectors within a hospital (BU-3). Education and training for staff in the emergency evacuation of patients is essential to preserve human life in crisis situations such fire, flood, and other disasters (FF-9-11-4).
Conclusion
This is a very brief excursion through the Accreditation Manual in an attempt to highlight quality standards and their link to a marketable hospital system. The paper places reliance on the fact that patients and health care staff, above all, want quality outcomes from health care and these outcomes are to be found in attention to all the standards, rather than merely emphasising the "hotel" standards of patient accommodation.
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