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National Hospital Survey

Process
  • All hospitals that are contracted to the MOPH for treatment of MOPH patients in 2001will be included in the First National Hospital Survey and the main purpose is to assess all contracted hospitals against the Basic and Accreditation standards, for bench marking purposes.
  • The First National Hospital Survey will be undertaken by the OPCV Project Team under the supervision of the Ministry of Public Health (MOPH) and the Health Sector Rehabilitation Project (HSRP). The Project is financed by the World Bank.
 
Resources
  • The attached forms cover all acute hospital Departments/ Services for Basic and Accreditation standards.
  • The forms should be considered in conjunction with the relevant section of the (a) Hospital Accreditation Manual, and (b) Guidelines. Both these publications are included in the kit.
  • The forms will be used by the visiting Hospital Survey Team to assess each Department/Service of your hospital against the standards.
  • Your hospital may utilise these forms in your preparation for the survey, by photocopying as many as required for self-assessment purposes. However, in the First National Hospital Survey your self-assessment is not included as a part of the official result.
 
Survey
  • A schedule of visits by the Survey Teams is currently being compiled. It is vitally important that once the survey dates are arranged that your hospital does not alter the dates. There are some 134 hospitals involved in the survey that will take place over a 12 month period. Any hospitals reneging on the survey dates without very advanced negotiation will either go to the back of the queue or be relegated from the survey altogether. Your cooperation in regard to the scheduling is crucial to the success of the exercise.
  • For the majority of hospital surveys there will be three surveyors per team, consisting of a general hospital Administrator, a Nurse with clinical and administrative experience, and a Physician with clinical and administrative experience. There will be an extra clinical team member for hospitals over 150 beds in total.
  • For some surveys there will be an observer with the team. This will be a person from either the MOPH or the HSRP. The observer will be undergoing training as a surveyor through the OPCV so that skills can be transferred for future surveys in Lebanon. The observer will not have any executive, advisory or reporting responsibilities during his/her training period with OPCV. All aspects of confidentiality in regard to individual hospital information and results will be respected.
  • The survey team will be on site at the hospital for a varying number of days depending on hospital size in terms of total bed numbers as per official MOPH lists:
 
Hospital size On site survey days
49 beds or less One day (1)
50-99 beds Two days (2)
100-149 beds Two days (2)
150 + beds Three Days (3)
 
 
Scoring
The scoring system to be used for surveys will be as follows:
 
Basic standards Yes: One point
No: Zero points
Not Applicable: Excluded from calculation
Accreditation standards Yes: One point
No: Zero points
Needs improvement: 0.5 points
Not applicable: Excluded from calculation
 
  • Needs improvement.This category has been developed for the Accreditation standards so that the survey team can allot some credit where the hospital is making demonstrated progress on a particular standard. The category is not used for the Basic standards because these are lower level standards that are expected to be fully implemented
  • The Survey Team will calculate the Department/ Service results, and the overall result and advise the MOPH and your hospital at the completion of the First National Hospital Survey. All hospitals will be measured against both the Basic and the Accreditation standards
 
Results
  • The overall percentage required for the various assessments are:
% Basic % Accreditation Result Acronym
85% Basic Standards  65% + Accreditation Standards Full Accreditation Status  BFA
65% - 84% Basic Standards 65% + Accreditation Standards Partial Accreditation Status  BPA
65% + Basic Standards < 65% Accreditation Standards No Accreditation Award but passed Basic  BNA
50% - 64% Basic Standards < 65% Accreditation Standards No Accreditation award, Partial pass on Basic  PB
< 50% Basic Standards < 65% Accreditation Standards No Accreditation Award and Failed on Basic Standards NB
 
  • After the on site visit the OPCV Team will be involved in writing up the survey in the OPCV office. A detailed survey assessment report will be completed and Forworded to the MOPH and your Hospital.
  • During the First National Hospital Survey the opportunity will also be taken by the OPCV Team to recommend any changes to the Hospital Accreditation Manual and/or the processes adopted for surveys.
  • Beyond that there will be an interim period in which hospitals can prepare for actual Accreditation Assessment, based on the Survey results.
 
Further Contact
Please contact the OPCV Team Leader or the HSRP if you have any comments or queries about this Accreditation Survey Kit:
  • OPCV: Telephone 1 747 263/64
  • HSRP: Telephone 1 616 601 Mr. Roy Wakim
 
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ATC Name B/G Ingredients Dosage Form Price
N02BA51 ASPIRINE C EFFERVESCENT B Acetylsalicylic acid - 400mg, Vitamin C - 240mg Tablet, effervescent 162,605 L.L
D10AD01 RETACNYL - 0.05 % G Tretinoin - 0.05% Cream 584,571 L.L
J07BD52 M-M-R II (MEASLES, MUMPS AND RUBELLA VIRUS VACCINE LIVE) B Rubella virus live attenuated - , Mumps virus live attenuated - , Measles virus live attenuated - Injectable solution+diluent 12,924,401 L.L
N02BA51 ASPRIVIT G Acetylsalicylic acid - 500mg, Caffeine - 50mg, Vitamin B1 - 2mg Tablet 186,794 L.L
A11A BEBE-VIT G Vitamin A - 1500IU/ml, Vitamin D3 - 400IU/ml, Vitamin E - 5mg/ml, Vitamin C - 40mg/ml, Vitamin B1 - 0.5mg/ml, Vitamin B2 - 0.6mg/ml, Vitamin B6 - 0.6mg/ml, Nicotinamide - 8mg/ml Drops 287,582 L.L
B05CX01 DEXTROSE INJECTION 5% G Dextrose, H2O - 5g/100ml Injectable solution 212,797 L.L
J07BD52 MEASLES, MUMPS AND RUBELLA VACCINE LIVE ATTENUATED (FREEZE-DRIED) MMR G Rubella virus live attenuated - ?1000CCID50 /0.5ml, Mumps virus live attenuated - ?5000CCID50 /0.5ml, Measles virus live attenuated - ?1000CCID50 /0.5ml Injectable freeze dried powder + diluent 739,113 L.L
A11AA PHARMATON KIDDI B Vitamin E - 15mg/15ml, Phosphorous - 200mg/15ml, Calcium - 130mg/15ml, Vitamin D3 - 600IU/15ml, D Panthenol - 10mg/15ml, Nicotinamide - 20mg/15ml Syrup 417,935 L.L
J07BF03 POLIOMYELITIS VACCINE INACTIVATED B Poliomyelitis virus type 1 inactivated - 40D.U, Poliomyelitis virus type 2 inactivated - 8D.U, Poliomyelitis virus type 3 inactivated - 32D.U Injectable suspension 1,206,771 L.L
A11AA PANTOGAR B P-aminobenzoic acid - 20mg, Keratine - 20mg, Medical yeast - 100mg, Thiamine mononitrate - 60mg, L-Cystine - 20mg, Calcium D-pantothenate - 60mg Capsule 2,005,013 L.L
B02BD06 HAEMATE P BioHuman Von Willebrand Factor - 600IU, Blood Coagulation Factor VIII - 250IU Injectable lyophilised powder for solution+diluent 14,117,737 L.L
C03EA01 MODURETIC B Hydrochlorothiazide - 50mg, Amiloride HCl - 5mg Tablet 767,985 L.L
J07BG01 RABIVAX-S (RABIES VACCINE INACTIVATED) BioTech Freeze dried inactivated purified rabies antigen (Pitman Moore PM3218 as virus strain) - Injectable freeze dried material 1,552,138 L.L
R03AK06 SERETIDE DISKUS 100 B Salmeterol (xinafoate) - 50mcg/inhalation, Fluticasone propionate - 100mcg/inhalation Inhalation powder 2,276,469 L.L
A11AA CAL-VIT G Riboflavine - 9mg/100ml, Cyanocobalamine - 570mcg/100ml, Pyridoxine HCl - 35mg/100ml, Thiamine HCl - 190mg/100ml, Inositol - 150mg/100ml, Nicotinamide - 120mg/100ml, Calcium Pantothenate - 27mg/100ml, Sodium hypophosphite - 70mg/100ml Syrup 163,821 L.L
B02BD06 HAEMATE P BioHuman Von Willebrand Factor - 2400IU, Blood Coagulation Factor VIII - 1000IU Injectable lyophilised powder for solution+diluent 49,643,758 L.L
J07BH01 ROTATEQ ROTAVIRUS VACCINE, LIVE, ORAL, PENTAVALENT B Rotavirus G1, live attenuated - ?2.2x106 IU, Rotavirus G2, live attenuated - ?2.8x106 IU, Rotavirus G3, live attenuated - ?2.2x106 IU, Rotavirus G4, live attenuated - ?2.0x106 IU, Rotavirus P1, live attenuated - ?2.3x106 IU Suspension 4,508,592 L.L
R03AK06 FLUDALT DUO G Salmeterol (xinafoate) - 50mcg, Fluticasone propionate - 100mcg Capsule, inhalation 1,709,989 L.L
A11AA COMPLEVIT G Ascorbic acid - 1.32g, Riboflavine - 0.018g, Nicotinamide - 0.264g, Cyanocobalamine - 0.9g, Pyridoxine HCl - 0.132g, Thiamine mononitrate - 0.288g, Iron Ammonium Citrate - 3.6g Syrup 218,854 L.L
B02BD06 HAEMATE P BioHuman Von Willebrand Factor - 1200IU, Blood Coagulation Factor VIII - 500IU Injectable lyophilised powder for solution+diluent 33,698,319 L.L
J07BH01 ROTARIX ORAL B Rota virus human RIX4414, live attenuated - ?106 CCID50 Suspension 5,167,074 L.L
N04BA02 SINEMET B Levodopa - 250mg, Carbidopa - 25mg Tablet, scored 1,283,690 L.L
R03AK06 PROPIONATE DE FLUTICASONE/ SALMETEROL ARROW G Salmeterol - 50mcg/dose, Fluticasone propionate - 100mcg/dose Inhalation powder 1,593,797 L.L
A07FA51 INFLORAN B Bifidobacterium infantis - 1milliard, Lactobacillus acidophilus - 1milliard Capsule 647,732 L.L
A11AA VITA-FERIN C G Manganese sulfate - 0.77mg, Copper sulfate - 0.72mg, Iron fumarate - 0.022g, Vitamin C - 0.15g, Vitamin B5 - 0.01g, Vitamin B3 - 0.022g, Vitamin B6 - 0.002g, Vitamin B2 - 0.002g, Vitamin B1 - 0.01g Capsule 1,217,521 L.L
B02BD06 WILATE 500 BioHuman Von Willebrand Factor - 500IU, Blood Coagulation Factor VIII - 500IU Injectable powder for solution+diluent 32,399,164 L.L
J07BH01 ROTASIIL, ROTAVIRUS VACCINE, LIVE ATTENUATED (ORAL FREEZE-DRIED) BioTech Rotavirus bovine-human , live attenuated - Suspension 2,822,069 L.L
N04BA02 CARLEVO G Levodopa - 250mg, Carbidopa - 25mg Tablet 796,067 L.L
R03AK06 SERETIDE DISKUS 250 B Salmeterol (xinafoate) - 50mcg/inhalation, Fluticasone propionate - 250mcg/inhalation Inhalation powder 2,830,132 L.L
A11AB CYPRO-VITA B Vitamin C - 20mg, Vitamin B3 - 5mg, Vitamin B12 - 2.5mg, Vitamin B6 - 0.6mg, Vitamin B2 - 0.75mg, Vitamin B1 - 0.6mg, Vitamin D3 - 167IU, Vitamin A - 1670IU, Cyproheptadine HCl - 4mg Tablet, film coated 409,552 L.L
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