ACCREDITATION

THIS ARTICLE IS IN THE PROCESS OF BEING WRITTEN

1. THE ROLE OF ACCREDITATION

Society demands that  health care is provided in a safe, effective and acceptable manner. These limits are expressed in statutes, rules and regulations. The health care professions establishes procedural and ethical guidelines in response to the above demands and in part to justify their role in society. To provide proof of conformance to the above limits, the mechanism of accreditation is established.

Accreditation is the award of recognition of the ability or potential to deliver health care services in accordance with the above limits. The government has the choice to make accreditation mandatory or to let health care service providers (individuals, groups or organizations) subject themselves to it voluntarily. Hence the establishment of the body to award the accreditation status can be spearheaded by the government or the health care professional bodies.

2. AWARD OF ACCREDITATION STATUS

Preferably, the body that sets the criteria and standards should be different from the body that determines the compliance to them and awards the accreditation. However, in many countries both functions are taken up by the same organization. In fact, in Malaysia the same body i.e. Malaysian Society for Quality in Health (MSQH) sets the criteria and standards, does the training, perform the compliance audit/survey and awards the accreditation certificate.

3. CRITERIA FOR AWARD

The criteria used for determining compliance is derived from proof of ability to deliver services in a safe, effective and acceptable manner. The focus of accreditation is on the patient and on quality. Accreditation in health care is less concerned about efficiency, profitability, competitiveness or affordability.

Proof of ability is based on the premise that a system is in place (at the time of survey/audit) to deliver services with those outcome characteristics. The method of ascertaining this is the Accreditation Audit or Survey which comprises two main activities i.e.

  • an examination of documents supplied by the institution
  • a visit by a audit/survey team to the institution

3.1  Aspects Considered

The aspects that are looked at include the entire service delivery system.

  • Governance (Management)
  • Environment
  • Input
  • Policies (regulatory framework)
  • Processes

As far as possible these aspects are assessed in all functional units of the service and physical areas of the facility.

3.2  Functions Included

The ability to deliver services in a safe, effective and acceptable manner is dependent on the interplay between various functions that include:

  • Management / Administration
  • Delivery of Clinical Service
  • Delivery of Clinical Support Service
  • Provision Ancillary Service
  • Provision of Facility Support Services
  • Adherence to relevant laws, rules, regulations and ethical standards
  • Establishment of a Cultural Environment

3.3 Physical Areas Surveyed

  • Facilities including Equipment
  • Physical Environment

components of the system is discussed in the article ‘Quality through Design and Planning’.

4. STANDARDS

For each of the aspects, functions and physical areas forming the compliance criteria, assessment is made by comparing with standards set by the accreditation body. Standards in accreditation is based on:

  • laws and regulations
  • professional standards
  • societal norms

These are minimal standards. The hospital may set higher standards especially with regards to aspects not considered in accreditation such as business excellence, community services etc., but the achievement or failure in these areas shall not affect decisions regarding compliance. Standards with regards comfort, respect for human dignity and privacy, though important, should take into consideration societal values and expectations. What is acceptable may be different for different cultures. Their importance should not overshadow the primary goal of health service i.e. to provide effective and safe care.

There are broad overall standards and standards specific to a particular, service, function or location. In some respect the overall standard sets the broad limits that would apply to each specific area.

5. BREAKDOWN OF ASPECTS, SERVICES, AND AREAS

In general, the various functions and services that can be facilitated by information systems can be divided into two main group of activities:

    1. The core business of care of patients
    2. Managing the hospital as a business entity, a provider of hospitality services and a physical facility

5.1 SERVICES

Clinical services (direct care)

  • Complementary clinical services

Clinical Support Systems (indirect care)

  • Laboratory Information System
  • Blood Banking Information System
  • Radiology Information System
  • Pharmacy Information System
  • Food and Beverage Supply System
  • Operation Theatre / Suite Information System
  • Sterilization and Sterile Inventory & Supplies System
  • Other support systems

Facility Support Services

  • engineering
  • environmental
  • hospitality services
    • rooms, comfort
    • food beverage
    • communications

6. THE AUDIT PROCESS

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