The General Authority for Healthcare Accreditation & Regulation

(GAHAR)
EGYCAP Training Program

EGYCAP Program
Overview
For Egyptians to acquire optimal health & better life quality, as individuals & as
a population, they need the presence of high-quality health care services that
are effectively coordinated within an efficient public healthcare delivery
system.
This system should continuously strive hard not only to reduce the burden of
illness, injury, & disability, but also to improve the health & functionality of the
people.
Eventually, this emphasizes the role of the health care sector in assuring the
nation's health.
From this prospective, as well as from its commitment to the national vision of
purpose for an efficient & safe healthcare system as a whole, GAHAR
developed its Accreditation Standards, aiming for continuous improvement,
which can raise the quality of care to unprecedented levels.
The EGYCAP training program is particularly designed for healthcare
participants to allow them to adopt the main principles that support creating a
safe healthcare environment that drives continuous improvement through:
 Setting priorities for improvement
 Redesigning care delivery processes
 Supporting change in the care delivery system
 Creating a system that supports evidence-based practice
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  Facilitating the use of information technology
 Empowering the workforce & developing their capabilities
 Seeking for patient-centered healthcare services that fulfill the patient’s
needs & preferences
 Establishing a more equitable healthcare system for all, regardless of the
socioeconomic standard, race, or religion.
 Assuring that all patients access a safe & a high quality care
 Reducing morbidity & mortality through reducing errors
 Supporting a system of high quality, less waste, low cost, & more value

EGYCAP Participants
 Healthcare professionals working in the sector of healthcare quality who look
forward to improve & assist institutes to get GAHAR accreditation

 Healthcare professionals working in the health sector & willing to acquire the
knowledge & skills that allow them to adequately practice in the healthcare
quality sector

 Leadership of healthcare institutes, who envision their organizations to get

prepared for GAHAR accreditation

EGYCAP Program Outline

EGYCAP program comprises eight modules:

1) Module 1: Organizational Leadership

Overview:
The health care industry has recently developed greatly. Major focuses
are on management, competition, and quality. Improvement in quality over
the coming future can be achieved only by engaging the support of the
governing boards and the managers of health care organizations. Change is
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 needed at all levels, including; the structure, management, and operation of
health care organizations.
Qualified and trained healthcare leadership is essential to ensure that
healthcare services are able to keep up with the changing needs of the
customers. As more individuals become qualified to lead in the healthcare field,
more leaders will work effectively to help tackle various challenges and
problems.
Objectives:
By the end of this training module, each participants will be able to:
 Identify the main healthcare quality concepts
 Discuss the main dimensions of healthcare quality
 Define the different styles of leadership & their roles
 Develop adequate organizational strategic plan
 Describe different quality improvement activities
 Implement utilization & resource management efficiently
 Apply participative management principles adequately
 Appreciate the importance of teamwork in performance improvement
 Adopt organizational ethics to keep patient rights
 Respect the importance of proper risk management in achieving patient
safety

Outline:
 Introduction to quality management
 Organizational governance & management
 Management & quality
 Organization structure & design
 Strategic planning
 Quality improvement
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  Patient safety & risk management
 Utilization & resource management
 People management & participative management skills
 Communication, negotiation, & teamwork
 Organizational Ethics

2) Module 2: Workforce Management

Overview:
Healthcare organizations need appropriate variety of skilled, qualified
people to fulfil its mission & meet patient’s needs.

The organization’s workforce refers to the staff within the organization.

Planning for the appropriate number and skill mix of workforce is essential.

Developing clear job descriptions, strong orientation & training programs

help the staff to deliver proper healthcare.

This module is designed to provide healthcare providers & quality

professionals with essential information regarding the different aspects of
understanding, implementing and monitoring GAHAR standards of
workforce management.

Objectives:
By the end of this training module, each participant will be able to:

 Identify the main activities of advanced human resources management

 Develop adequately a workforce plan
 Design effective healthcare training programs
 Develop adequate orientation programs
 Explain clinical governance concept
 Implement performance appraisal effectively
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  Apply properly advanced organizational behavior management
 Appreciate the importance of leadership in performance improvement
 Respect the importance of proper risk management in achieving clinical
governance

Outline:
 Introduction to advanced human resources management
 Staffing plan & workforce management
 Recruitment system & training program design
 Orientation program structure & design
 Performance appraisal &measuring compliance to clinical guidelines
 Staff file & effective nursing management
 Introduction to organizational behavior management
 Clinical governance structure& design

3) Module 3: Patient Centered Care

Overview:
Providing safe & high-quality care in addition to optimizing patient
experience had been considered the global main concern of healthcare industry
for the past two decades. Many healthcare organizations all over the world are
striving to reach optimal standards of care provision as well as patient
satisfaction.

This module is designed to provide quality professionals and healthcare

providers with the essential information concerning the different aspects of
understanding, implementing and monitoring the provision of better patient
care.

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It offers real experience-based knowledge about the knowhow of national
GAHAR accreditation standards’ implementation, and sheds light on common
pitfalls affecting the quality and safety of service.

The module also provides the knowledge and necessary information on the main
relevant regulations needed to provide compliant services.

Objectives:
By the end of this training module, each participant will be able to:
 Explain the steps needed to meet standard requirements
 Identify different methods applied to meet standard requirements
 Assess compliance of provided healthcare services with relevant
laws & regulations
 Construct required policies and procedures
 Apply safety and continuity of care provision in various
departmental and cross departmental aspects
 Discuss the relevance of patient centered standards to other
domains of GAHAR accreditation standards
 Describe proper integration of safe care delivery into
departmental operational processes.
 Prioritize implementation of GAHAR patient centered standards in
relevant departments
 Appreciate the importance of standard compliance and its effect
on healthcare processes and services.

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  Adopt adequate application of various quality dimensions in
patient centered care processes

Outline:

 Patient-centeredness culture
 Access to care
 Continuity and transition of care
 Introduction to integrated care delivery
 Patient assessment
 Specialized assessment & integrated care in emergency and high-
risk areas
 Quality and safety in surgery and invasive procedures
 Implementing anesthesia and moderate sedation standards
 Quality standards in radiology services
 Laboratory and other diagnostic and ancillary services
 Quality and safety in medication management system
 Implementing accreditation standards in medication management
 Special concerns in medication management and safety

4) Module 4: Quality & Performance Improvement & Information

Management & Technology:
Overview:
It is well known that the healthcare industry is a high-risk, high-
volume, and problem-prone industry. This necessitates, from the
perspective of the responsibility and accountability of GAHAR,
developing initiatives to help provide safe, high-quality services in
healthcare organizations. This includes patients, service providers,
vendors, visitors, as well as the environment they present in.

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Safety is no longer a wish. It requires full awareness of the different
types of risks and hazards in healthcare facilities, as well as acquiring the
know-how of mitigation and even proactive prevention of these risks.
Every process in any industry should be improved in a continuous
manner, and the healthcare industry is no exception. Leadership support,
well established processes, active participation of all head of
departments and staff are essential elements to create & sustain
continuous improvement & risk management framework.
The massive evolution in information technology necessitates knowing
how to utilize data adequately to obtain useful information. Such
information will be the source for measures, which in turn will be the
guide to take right decisions on the right time.
Practically, information management process, must ensure patient
safety, continuity of care, security and confidentiality of information.
Maintaining patient confidentiality is an ethical and legal concern,
especially with the emerging technology & implementation of electronic
information systems.
Quality improvement, risk management and information management
plans, all are parts of both strategic and departmental operational plans.
This module, in a stepwise approach, is the cornerstone to enable health
care quality specialists to acquire the essential knowledge, transfer the
necessary skills, and convey a patient-oriented mindset to all the staff of
the organization, as well as its leadership structure, thus, ensure
providing safe, highly reliable, & high-quality healthcare services.

Objectives:
By the end of this training module, each participants will be able to:
 Define different terminologies related to quality improvement
and risk management
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  Design performance improvement and risk management
programs based on priorities of the organization
 Assess the current situation of the organization as regarding
quality & performance improvement standards as well as
those of information management & technology
 Analyze the gap between a current situation and the optimal
one
 Design a corrective action plan for full compliance with quality
& performance improvement & information management &
technology standards
 Facilitate the selection and design of different types of
indicators needed for performance improvement
 Differentiate between different types of incidents and the
related reporting processes
 Appreciate the importance of security and information
confidentiality
 Collect and analyze data using different statistical tools
 Differentiate between different types of quality reviews
 Facilitate the roles of medical record team regarding
initiation, organization, and dissemination of the unique MR
of the organization
 Appreciate the importance of creating and institutionalizing
the culture of safety

Outline:
 Quality and Performance improvement concepts
 Organizations’ committees
 Quality planning
 Measurements in quality (indicators)
 Information management
 Data collection, validity & reliability
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  Statistics and data presentation tools
 Quality tools/data processing
 Medical records & health information system
 Quality reviews
 Reporting (incidence reports, significant events& sentinel events)
 Risk management & Failure Mode & Effect Analysis (FMEA)
 FOCUS PDCA & Lean- 6 Sigma; as performance improvement
methodologies
 Designing & reviewing a medical file as well as data management
approaches
 Demonstrating performance improvement as well as risk
management projects
 Safety culture
 Developing policies and procedures

Module 5: Patient Safety

Overview:
This module is designed to provide healthcare professionals with an
overview on the different aspects of patient safety regarding specifically
GAHAR accreditation standards for hospitals. It concentrates on how to
provide a safe, functional, and supportive facility for patients, families,
staff, and visitors.
The module provides an overview of various safety issues that need to be
addressed by each organization. It offers adequate knowledge and
necessary information, as well as essential tools and techniques that
enable participants to possess a comprehensive understanding of patient
safety principles. The module uses a competency based approach, which
focuses on transferring the adequate skills needed to engrain patient
safety in all aspects of healthcare.

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 Objectives:
By the end of this training module, each participant will be able to:
 Describe the fundamental concepts of patient safety
 Explain the magnitude of patient safety challenges
 Identify and monitor threats to patient safety towards a sustainable
positive safety culture
 Determine the characteristics that support efforts to prevent harm
to patients
 Identify and evaluate effective patient safety practices
 Define infrastructure components of the patient safety program
 Integrate patient safety concepts & activities within the
organization's strategic goals
 Promote long-term gains on a journey to zero harm
 Apply the best evidence for the collaborative healthcare choices of
each patient and provider
 Discuss new, evidence-based estimates of patient harms associated
with hospital care
 Implement patient safety systems within daily work
 Analyze collected data for continuous improvement
 Adopt prevention plan and implement response steps
 Discuss the burden of unsafe care
 Appreciate the importance of patient’s safety program
 Construct a hospital patient safety system

Outline:
 Scope and oversight of the patient safety program
 GAHAR patient safety: from standards to practice
 Safe and appropriate consultation during access, continuity, and
transition of care
 Safe provision of surgery, anesthesia, and sedation
 Diagnostic and ancillary services competencies
 Continuity of medication management services
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  Role of the patient safety committee
 Malpractice claims analysis
 Risk detection, assessment, prioritization, reporting, and
management tools
 Infection prevention and control sustainability
 Tips to prevent facility environmental hazards- creating and
sustaining a culture of safety
 The facility burden of unsafe medical care
 Organization governance and management integration
 Workforce management verification and evaluation
 Using quality and performance improvement towards development
 Information management and safe technology implementation
 Patients’ roles in reducing errors: a guide for patients
 Organization-wide integrated care delivery
 Principles of patient safety research
 Healthcare staff continuous education, training, and awareness of
patient safety

Module 6: Infection Prevention & Control (IPC)

Overview:
Clean, safe care is one of the patient’s rights, and should be the
slogan of all health care workers. Infection prevention and control (IPC) is
a cross-cutting issue in all health care services. IPC is a scientific approach
and practical solution designed to provide safe and high quality care
aiming to prevent harm caused by infection to both patients as well as
healthcare providers. IPC provides an environment and system of care
which minimizes the risk of infection to patients, staff and visitors.

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This module provides essential IPC information for healthcare
professionals & to enable them to build up their capacity to be aligned
with GAHAR IPC standards.
The module is designed to address the most important practical
issue in infection prevention and control in different levels of health care
settings.
Participants will learn how to develop and implement
comprehensive IPC program to prevent infections, protect patients,
visitors and health care workers, and to comply with accrediting and
regulatory requirements through evidence based best practice that
reduce risks.

Objectives:
By the end of this training module, each participants will be able to:
 Define key concepts and principles of IPC.
 Describe methods to prevent the spread of infection
 Adopt general standard precautions; particularly hand hygiene
 Develop IPC risk assessment
 Design IPC plan based on risk assessment
 Apply the engineering, work practice, and environmental
controls that protect against healthcare associated infections
 Prioritize the risk of occupational exposures to infectious
diseases
 Apply different IPC methods and measures to meet GAHAR
standard requirements.
 Adopt culture of “Doing no harm”
 Appreciate an organization’s wide culture of “IPC is everybody
business”
 Respect working in homogenous coherent team to control risks,
prevent infection and improve outcome

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Outline:

 Chain of infection and epidemiological aspects of Hospital Acquired

Infections (HAIs)
 Standard and transmission based precautions& general infection
control measures.
 Processing of patient care equipment
 Aseptic techniques& bundle approach to prevent HAIs
 Blood borne pathogens
 Employee/Occupational Health program
 Central services (laundry, kitchen, central sterilization services
departments)
 IPC guidelines in special units
 CDC definitions of HAIs
 Surveillance & trends of infection
 Combating antimicrobial resistance and antimicrobial stewardship
 IPC program, IPC risk assessment & key performance indicators

Module 7: Environmental safety module

Overview:
Health care facilities are considered to be risky places due to
presence of highly complicated systems. Stakeholders are required to
work continuously to keep safety and efficiency of these systems and
processes. High-risk areas should be identified and inspected to
proactively limit risks as regards general safety and security, hazardous
materials and waste management.
Fire and non-fire internal emergencies should be critical targets for
proper handling and safe evacuation of patients and others. Disaster
preparedness is considered a big challenge for health care facilities

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This necessitates the development of a clear plan with risk assessment &
with clear responsibilities
Biomedical devices require highly competent staff, with appropriate
documented training, to be handled properly so as to keep patient and
staff safety.
Health care facilities key systems need to be under regular maintenance,
inspection and regular testing both proactively and reactively on sudden
failure, together with continuous monitoring
Heath care facilities safety module is considered the corner stone for
efficient facility management.

Objectives:
By the end of this training program, each participant will be able to:
 Identify the difference between various safety & security
plans
 Design proper and sound plans
 Implement adequately different safety programs
 Assess properly environmental safety risks
 Develop proactive workup for different health care facilities
emergencies
 Adopt staff commitment of environmental safety
implementation in their healthcare organizations

Outline:
● Introduction to health care environmental safety
● Security and hazardous material plans
● Fire safety & evacuation
● Biomedical equipment management and utility management

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 ● Disaster management

8) Module 8: Accreditation
Overview:
Accreditation is a process of review, that allows healthcare
organizations to demonstrate their ability to meet regulatory
requirements and standards established by a recognized accreditation
organization such as GAHAR. Accreditation reflects an agency’s
dedication and commitment to meet standards that demonstrate a
higher level of performance and patient care.
The main aim of the module is to enhance healthcare delivery system
and promote continuous quality improvement and patient safety.
Accreditation programs should be supported as a tool to improve the
quality of healthcare services.

Objectives:
By the end of this training module, each participants will be able to:
 Differentiate between accreditation, registration and licensure
 Discuss the needs for accreditation programs
 Describe the process of surveying
 Define the survey process steps
 Apply scoring system
 Plan for upcoming GAHAR surveys
 Adopt applying for GAHAR accreditation program
 Appreciate the importance of Accreditation

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 Outline:
 Introduction to healthcare accreditation
 Importance of registration process
 Healthcare facility registration
 GAHAR accreditation process requirements
 Standards evaluation & scoring system
 Surveying techniques
 Tracer methodology
 Accreditation process
 GAHAR accreditation decisions
 Practical training

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