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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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