Quality Assurance and Accreditation
in Healthcare
Standards and Processes Layout
By Farheen Iqbal
MBA-HSM
Quality
“It defined as the degree to which health services for the individuals and populations increase the
likelihood of the desired health outcomes and are consistent with current professional knowledge”.
Joint Commission on Accreditation of Healthcare Organizations (2002)
“Health care services that produce desired health outcomes and fulfill consumer’s needs, with optimum use
of available resources, provided by trained and competent providers as per the national norms and standards
with minimizing risk for service providers as well as consumers.”
Quality Assurance
“Quality Assurance is a continuous process which includes series of activities for
improving and maintaining optimum level of quality of health care services that
includes mainly; setting standards and protocols, communicating standards,
developing indicators, monitoring compliance with standard and solving
problems by team approach.” (GoN, Ministry of Health and Population 2007)
“A process of measuring quality, analyzing the deficiencies discovered, and
taking action to improve performance followed by measuring quality again to
determine whether improvement has been achieved. It is a systematic, cyclic
activity using standards of measurement. ((Palmer, Heather, 1983 )
OBJECTIVES OF QUALITY ASSURANCE
Promoting
Ensuring Enhancing
Continuous
Patient Patient Improving
Safety Satisfaction Improvement Productivity
Improvin Monitoring and Regulator
g Quality Measuring y
of Care Performance Complian
ce
Components of QA
Availability and quality of resources, management
Structure system, policy guidelines, No. of qualified staff,
evaluation training programs, available capital facilities
Overall end results of healthcare Outcome Process
The outputs and healthcare status evaluation evaluation Proper monitoring systems. Process
measures includes waiting time,
Measures includes mortality,
correct diagnosis, proper
mobility, satisfaction level,
examination of patients
coverage, attendance levels
The Quality Assurance Process
5.
3. 7.
2. 4. Solution
1. 6. Documentati
Standardizati Monitoring Problem Development
Planning and Continuous on and
on and and Identification and
Goal Setting Improvement Communicati
Guidelines Evaluation and Analysis Implementati
on
on
TOOLS FOR QUALITY ASSURANCE –
Quantitative and Qualitative
Checklists can be prepared for various parameters based on Inputs/Structure, Process/Services and Outcome (Health benefits/client
satisfaction) indicators
Qualitative methods such as in depth interviews, focus group discussions can be used to assess quality of services provided, training
and proficiency of health workers etc
Both methods can be used in combination as tools for quality assurance
FACILITY CHECKLIST (Input)
Clinic Timings properly displayed
Availability of Service Provider
Presence of adequate and sheltered waiting area
MODELS OF QUALITY ASSURANCE
MODELS OF QUALITY ASSURANCE
Benefits of Quality Assurance
ACCREDITATION
• A formal process by which a recognized body,
usually a non-governmental organization (NGO),
assesses and recognizes that a healthcare
organization meets pre- determined standards.
• Accreditation standards are usually regarded as
optimal and achievable and are designed to
encourage continuous improvement in delivery
of healthcare within accredited organizations.
Accreditation cont….
An accreditation decision about a specific healthcare organization is made following a periodic
on-site evaluation by a team of peer reviewers, typically conducted every two to three years. •
It is usually a voluntary process in which organizations choose to participate, rather than one
required by law and regulation.
Components of accreditation
It is based on written and published standards.
Reviews are conducted by professional peers.
The accreditation process is administered by an independent body.
The aim of accreditation is to encourage organizational development.
Accreditation Standards
They can provide an integrated and structured framework for managing an organization's performance
and its quality program.
Address a
recognized need
Evidence based (as
Measurable far as practicable)
Developed
through a
Achievable transparent and
consultative
process
Outcome focused
ACCREDITATION PROCEDURE
Self- On-Site Decision and Maintaining
Application
Assessment Survey Awarding Accreditation
Accreditation Bodies
Global Accreditation Bodies
Joint Commission International (JCI)-1951
International Society for Quality in Health Care (ISQua)-1985
Global Healthcare Accreditation (GHA)
The International Standards Organization (ISO)-1947
Accreditation Bodies
Accreditation Bodies in Pakistan
Pakistan Medical and Dental Council (PMDC)
Pakistan Nursing Council (PNC)
Pakistan National Accreditation Council (PNAC)
Ministry of National Health Services Regulations and Coordination (MoNSR)
College of Physicians and Surgeons Pakistan (CPSP)
ADVANTAGES OF ACCREDITATION
Benefits to the Hospital
• It Improves delivery of medical care and enhances the image
of the hospital. Thus, for private healthcare organizations it
also results in more business.
• It stimulates a process of continuous improvement in delivery
of medical care
• Demonstrates commitment to quality care
• Raises community confidence.
• Opportunity to benchmark with the best.
ADVANTAGES OF ACCREDITATION
Benefits for the employees
• It helps in education, training and development of professional
staff
• Provides leadership for quality improvement within medical
profession and nursing
• Increases satisfaction of employees with working conditions and
leadership
• It aims for improved employee safety and security
• It promotes team work
ADVANTAGES OF ACCREDITATION
Benefits to the Patients
• Provides access to organizations providing quality medical care
• Patient’s rights are respected and protected
• It increases patient’s Involvement in medical care decisions
• Focuses on patient safety
Challenges of quality assurance and
accreditation
Limited Resources
Administrative Burden
Resistance to Change
Access to Expertise
Sustaining Continuous Improvement
Financial Considerations
Evolving Educational Landscape
