HCAC Medhealth Conference: Leading with Quality Improvement in Cairo

1. To Lead is to Start: the HCAC experience Medhealth Conference Tuesday, March 12 th , 2013 Cairo Marriott - Egypt

2. 2 Quality improvement for Jordan started with a visionary Minister who took a leap for accreditation… 2003 2004 2005 2007 2008 2009 2010 2011 2012 2013 12 members from a National Accreditation Committee was approved USAID Agrees to support initiative of Minister of Health Pilot Hospitals HCAC registered as a non-profit private sector company ISQUA accredits hospital standards ISQua accredits Surveyor Certification Course 1st edition Primary Health Care Standard ISQua accredits HCAC First Regional Conference NQSGs launched Cardiac Standards Patient Safety Center / Institute Diabetes Standards Second Regional Conference Public Awareness Medical Transport Standards Breast imaging Units Standards Centers of Excellence Pilot Hospitals and First draft of Jordanian Hospital standards First Surveyor Certification course started

3. 3 So HCAC was established in 2007 as a nonprofit private shareholding company with the aim to raise the quality of health services… HCAC Mission Mission Vision Vision To foster the continuous improvement of the quality and safety of health care facilities, services and programs through developing internationally accepted standards, capacity building and awarding accreditation HCAC services and accreditation will be the primary choice of healthcare facilities and organizations in Jordan and the region Values Values  Continuous Improvement  Customer Focus  Impartiality  Integrity  Learning  Teamwork  Transparency

4. 4 …Through a range of different services stemming out of two separate arms of the organization Functions Functions Accreditor Enabler Consultant Development Training and Certified Courses Preparedness Consulting for Government Mock Surveys Accreditation Surveyor Development Standards Development Education and Education and Consultation Consultation Department Department Education and Education and Consultation Consultation Department Department Surveys and Surveys and Standards Development Department Standards Development Department Surveys and Surveys and Standards Development Department Standards Development Department “A Comprehensive Model of Quality Improvement Services” Firewall

5. 5 HCAC can now showcase a multitude of successes… Standards Standards  Hospital Accreditation Standards - 3rd edition  Primary Health Care & Family Planning Accreditation Standards– 2nd edition  Medical Transport Services Certification Standards- 1st edition  Breast Imaging Units Certification Standards- 1st edition  Diabetes Care standards 1st edition  Cardiac Care standards being developed 2011- 2012  National Quality and Safety Goals 2009, 2010, 2011, 2012  Family Planning & Reproductive Health Centers of Excellence Program- 1st edition Accreditation Accreditation Education & Consultation Education & Consultation  37 certified hospital surveyors  30 certified PHC surveyors  12 hospitals accredited – four in the pipeline  34 PHC accredited – 60 in the pipeline  Preparing 6 hospitals for Accreditation, 5 breast imaging units and 14 primary healthcare centers of excellence in reproductive health and family planning  Graduated groups from :  Certified Consultant Training program  Certified Quality professionals  Certified Infection Control professionals  Certified Risk Management  Leadership & Management

6. 6 …Achieved through our rigorous and scientific approach … Review of literature to develop first draft Step 1 Step 2 Step 3 Step 4 Step 5 Step 6 Review first draft by a local experts Task Force to determine: • Appropriatenes s for Jordan & the region • Clarity and correctness of wording • Classification of standards (critical, core, stretch) Review second draft by an external committee of experts to ensure that the standards are internationally acceptable Review fourth draft by the HCAC Board Technical Committee and recommend approval to the full board Translate into Arabic and send for ISQua accreditation Field test the third draft by to ensure applicability and smoothness Collect feedback, Q&A, and assess implementation - review and update every 2 years Standards Development System

7. 7 …which fits the needs of our cultures and challenges… Accreditation Accreditation  HCAC accreditation is given only for 2 years  It includes a rigorous mid point assessment at 1 year mark  Follows strict policies and procedures for scoring, conflict of interest…etc.  Is conducted over a number of days by a number of surveyors based on the healthcare institutions size  All surveyors’ training is accredited by ISQua

8. 8 …And addresses the most important factor of success: Human Resources! Phase I Implementation Team Identification Phase I Implementation Team Identification Phase IV Building Capacity and Training Phase IV Building Capacity and Training Phase V Building/implementi ng quality management systems Phase V Building/implementi ng quality management systems Phase II Review hospital’s vision, mission, values and structure Phase II Review hospital’s vision, mission, values and structure Phase III Identification of Required Documents Phase III Identification of Required Documents Phase VI Monitoring and tracking system Phase VI Monitoring and tracking system 1 • Class room training 2 • Mentorship period (2 – 3 months) 3 • Presentation to the classroom 4 Final certification exam 5 Recertification every 2 years

9. But our most important achievements include our Team and the ISQUA accreditations… Team Governance Policies & Procedures Unique Services HCAC was the first in the region and the fifth worldwide to receive all three accreditations from ISQua: Organization, Standards and Surveyor Training

10. 10  chemical exposure  Lack of radiation safety  Absence of basic hygiene  Violation of human rights  Flies in operating rooms  Open sewage systems within hospitals  Lack of privacy  No fire safety procedures and systems  untrained staff on basic resuscitation  Lack of qualified medical and nursing staff  no documented policies, procedures, plans, or guidelines  Not in compliance with laws and regulations regarding fire safety, radiation safety, staff qualifications, and medication management processes. …Yet no matter how much we have achieved so far, the challenges still exist…

11. 11 …Because HCAC believes quality improvement is a journey not a destination… Understand -ing situation and needs Acquiring skills Implement -ing behavioral change Requiring change doing it over an over Doing it willingly – embedding behavioral change in day to day life

12. 12 The future of Quality Improvement is full of commitments  Commitment to the PUBLIC  Commitment to ACCREDITATION  Commitment to CAPACITY BUILDING  Commitment to RESEARCH and POLICY …HCAC is in continuous improvement itself…

13. 13 HCAC public awareness and public engagement in 2013 0 800 22 7 55

14. 14 The future of Quality Improvement is full of commitments  Commitment to the PUBLIC  Commitment to ACCREDITATION  Commitment to CAPACITY BUILDING  Commitment to RESEARCH and POLICY …so HCAC is in continuous improvement itself…

15. 15 HCAC ever strengthened accreditation system New standards every other year ISQua surveyor training Un- announced midpoint assessment Mystery client Continued reporting

16. 16 The future of Quality Improvement is full of commitments  Commitment to the PUBLIC  Commitment to ACCREDITATION  Commitment to CAPACITY BUILDING  Commitment to RESEARCH and POLICY …so HCAC is in continuous improvement itself…

17. 17 HCAC an enabler for quality improvement and patient safety Enabling Services Certification courses Certification courses Workshops and Trainings Workshops and Trainings Knowledge Transfer Knowledge Transfer Not just academic, includes practical and hands on Rich yearly schedules Walkthroughs and 1 to 1 consulting , coaching and mentoring

18. 18 The future of Quality Improvement is full of commitments  Commitment to the PUBLIC  Commitment to ACCREDITATION  Commitment to CAPACITY BUILDING  Commitment to RESEARCH and POLICY …so HCAC is in continuous improvement itself…

19.  Data for Decision Making  Continuing Education  Changing policies  Embedding into curriculums  Accountability and responsibility HCAC is developing its research and policy focus Research Research Advocacy Advocacy  Benchmarking  Identifying strengths and weakness  Pinpointing needs  Publishing Patient Safety Institute

20. 20 Un precedented Our commitment extends beyond Jordan, to the region, with one goal: Improving Quality and Patient Safety HCAC Strength Strength Commitment to Jordan Commitment to Jordan Regional Expansion Regional Expansion Un paralleled Un preventable

21. HCAC can deliver different services and different approaches based on the different Sub-Regional Clusters in the MENA Region Gulf Levant and Egypt North Africa

22. 22 To lead is to start

23. 23 Thank You