ACCREDITATION

Presented by
NIZEYIMANA Emmanuel

Director of Nursing and Midwifery

/RULI DH
 Definition of Accreditation

Accreditation has been defined as "A self-

assessment and external peer assessment process
used by health care organizations, to accurately
assess their level of performance in relation to
established standards and to implement ways to
continuously improve.
Fundamentally, healthcare and hospital
accreditation is about improving how care is
delivered to patients and the quality of the care
they receive.
Steps toward Accreditation
1. Leaders embrace the concept

2. Concept and value of accreditation is

communicated to all staff

3. Quality structure established

4. Staff educated about the accreditation

standards

5. Baseline assessment conducted

Steps Toward Accreditation (cont’d)
6. Gaps identified and work plans developed

7. Standards implement through quality

improvement activities

8. Impartial external evaluation

 Progress surveys by external surveyors

 Final accreditation survey

9. Accreditation decision
 Accreditation -
Does it make a difference?

 Leadership
 Medical records management
 Infection control
 Reduction in medication errors
 Staff training and professional credentialing
 Clinical outcomes
 Background

 1995.Adopted AFR/RC45/R3 of WHO for the African

Region Resolution – strategies for improving quality of
health care
 2006 .The Rwandan Government introduced accreditation
program in three university teaching hospitals.
 2009.Lab accreditation launched: Using Strengthening
Laboratory Management Towards Accreditation (SLMTA)
program.
 Background….
 2012.Developed and officially launched national
healthcare accreditation system in all
Referral/Provincial &District Hospitals
 202016-2018. Development and dissemination of
PHC
 2019: Licensing standards of new private
facilities Standards, for health post, RHCs &
QOC for MNCH
 2021 Dissemination of revised standards
 Accreditation Process in Rwanda
In 2013:

 Conducted accreditation baseline assessment in all 42

hospitals.
 Linked PBF to accreditation
 Harmonized assessment tools (One tool-One Team)
 Assessments are done now every year at all 42 districts
 In June 2018: Dissemination of Rwandan Primary
Health Care standards to all health centers.
 Implementation Process Cont’

PBF link to accreditation to reward quality through PBF:

Rationale:

Both aim for CQI, avoid duplication of efforts and resources

and to stimulate harmonization of tools to one standardized
assessment tool and team.

PBF remunerations are based on accreditation

assessment results
PBF link to accreditation
 Why hospital Accreditation
 Standardizing systems and practices: Evidence-based
standards for key processes and clinical practices to improve
quality and safety of care and services.
 Measurement of performance: Implementing a structured
system for measuring compliance to standards with the aim
of improving health outcomes.
 Institutionalization of a culture of quality and safety:
using quality management, continuous quality improvement
methods and the accreditation process.
 Improved accountability: holding health care organizations
accountable to patient health care and regulatory agencies.
 Standard
What is a standard?

A statement of the quality expected

It includes:
• Policies
• Procedures
• Protocols
• Algorithms (process, systems, rules)
 Why are standards important?
Importance of Standards:

 Inform Healthcare providers of expectations

 Guide monitoring and evaluation of care

 Patients receive same level of care regardless of

where they receive treatment.
 Policy / Politiques

 Policy: Is a principle or rule to guide decisions and

achieve rational outcomes. A policy is a statement of
intent, and is implemented as a procedure.
 Procedures : Are step-by-step instructions on how to
perform a technical skill. This format often involves the use
of equipment, medication, or treatment.
 Implementation Process of accreditation program
Development of national healthcare accreditation standards organized in a
framework of 5 Domains/Risk areas:

Risk Area 1 Risk Area 2 Risk Area 3 Risk Area 4 Risk Area 5
Safe Clinical
Leadership Competent Environment Care of Improvement of
Process and and Capable for Staff & Patients Quality and
Accountabilit Workforce Patients # 23 Safety
y #12 # 15 #9
#16
Three levels of efforts are defined:
 Level I: Developing and communicating policies, procedures and plans for quality in
all areas within the facility
 Level II: Implementing policies, procedures and plans that were developed in Level
I
 Level III: Monitoring the effectiveness of the processes evidence based data for
continous improvement
 Organisation des standards (cont’)

In each Risk Area, there are different standards that represent

the risk reduction strategies for that area. These standards
have been developed according to the standards of the
International Society for Quality in Healthcare (ISQua)..

Likewise, the standards were developed from the International

Standards for Health Quality and Safety by the Joint
Commission International (JCI) and adapted to the needs of
health care and services in Rwandan HFs.
 Classification of standards

 Core standards are the standards addressing systems

and processes that are important for patient care.

 Critical standards are those standards that address laws

and regulations or, if not met, may cause death or
serious harm to patients, visitors, or staff.

 To achieve accreditation, these standards must be met

100%.
 Example of Standard
RISK AREA #3. SAFE ENVIRONMENT FOR STAFF AND PATIENTS

j
 Progressive Achievement:
Three Levels Toward Accreditation

Level 3
Improving
Level 2 quality based on
Implementing data
Level 1 quality standards
Defining quality

Continuous
quality
improvement

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 Risk Area 1
Leadership Process and Accountability
# of Total Policies/Procedures: 15
Standard Procedure Code Status
S.02 Strategic and operational planning Visitors LM1-01 Completed
S.02 Strategic and operational planning Smoking in Hospital Premises LM1-02 Completed
S.03 Management of health information Health Information Management LM1-03 Completed
S.04 Mentorship and oversight of healthcare facilities in catchment
Mentorshipareaand Oversight of HFs LM1-04 Completed
S.05 Financial management Authorization and approval of expenditures LM1-05 Completed
S.05 Financial management Accounting controls in place LM1-06 Completed
S.05 Financial management Financial reporting LM1-07 Completed
S.05 Financial management Control of financial documents LM1-08 Completed
S.05 Financial management Internal and external audit processes LM1-09 Completed
S.05 Financial management Management oversight on financial management LM1-10 Completed
S.05 Financial management Budgeting LM1-11 Completed
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S.08 Quality requirements in contract management Contract Management LM1-12 Completed
S.10 Compliance with national laws and regulations Communication of laws and regulations LM1-13 Completed
S.11 Commitment to patient and family rights Identification of patient cultural and spiritual beliefs LM1-14 Completed
S.13 Efficient admission and registration processes Patient Admission and Registration LM1-15 Completed
S.14 Efficient inventory management Inventory and Asset Management LM1-16 Completed
S.15 Effective medical record management Medical Records Archiving, Confidentiality and DestructionLM1-17 Completed
S.15 Effective medical record management Medical Records Completion, Retrieval and Tracking System LM1-18 Completed
 Risk Area 2
Competent and Capable Workforce

# of Total Policies/Procedures: 12

Standard Procedure Code Status

S.01 Personnel files available, complete, up-to-date Personnel File Management HR2-01 Completed
S.02 Credentials of physicians Credentials of Clinical Staff HR2-02 Completed
S.06 Orientation to hospital and jobs Staff Orientation HR2-03 Completed
S.08 Sufficient staff to meet patient needs Staffing Reassignment HR2-04 Completed
S.09 Oversight of students/trainees Student Oversight HR2-05 Completed
S.10 Training in resuscitative techniques CPR Training HR2-06 Completed
S.11 Staff performance management Staff Performance Management HR2-07
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Completed
S.12 Staff health and safety program Management of Staff Illness and Injuries HR2-08 Completed
 Risk Area 3
Safe Environment for Staff and Patients
# of Total Policies/Procedures: 17
Standard Procedure Code Status
S.02 Management of hazardous materials Management of Hazardous Materials ES3-01 Completed
S.04 Biomedical equipment safety Management of Biomedical Equipment ES3-02 Completed
S.08 Reduction of health care associated infections throughHand
handHygiene
hygiene ES3-03 Completed
S.09 Effective sterilization processes Decontamination and Disinfection of Medical Equipment ES3-04 Completed
S.09 Effective sterilization processes Decontamination and Disinfection of Patient Care Units and
ES3-05
Housekeeping
Completed
S.09 Effective sterilization processes Sterlization ES3-06 Completed
S.10 Effective laundry and linen services Management of Laundry ES3-07 Completed
S.11 Reduction of health care-associated infections Hospital Staff Immunization ES3-08 Completed
S.11 Reduction of health care-associated infections Patient Isolation ES3-09 Completed
S.11 Reduction of health care-associated infections Intravenous and Tubing Maintenance ES3-10 Completed
S.11 Reduction of health care-associated infections Pre-operative Skin Preparation ES3-11 Completed
S.11 Reduction of health care-associated infections Urinary Catheterization 23 ES3-12 Completed
S.11 Reduction of health care-associated infections Management of Mortuary Services ES3-13 Completed
S.12 Barrier techniques available and used PPE Use ES3-14 Completed
S.13 Proper disposal of sharps and needles Disposal of Sharps and Needles ES3-15 Completed
S.14 Proper disposal of infectious medical waste Disposal of Infectious Medical Waste ES3-16 Completed
S.15 Prevention, control & monitoring of communicable diseases
Outbreak Management ES3-17 Completed
 Risk Area 4 # of Total Policies/Procedures: 20
Clinical Care of Patients
Standard Procedure Code Status
S.01 Correct patient identification Patient Identification CS4-01 Completed
S.02 Informed consent Patient Informed Consent CS4-02 Completed
S.03 Medical assessments complete and timely
Medical Assessments CS4-03 Completed
S.03 Medical assessments complete and timely
Nursing Assessments CS4-04 Completed
S.06 Diagnostic imaging services available, safe,
Radiology
and reliable
Examination Orders CS4-05 Completed
S.06 Diagnostic imaging services available, safe,
Radiation
and reliable
Safety Procautions CS4-06 Completed
S.06 Diagnostic imaging services available, safe,
Radiation
and reliable
Examinations for Females CS4-07 Completed
S.06 Diagnostic imaging services available, safe,
Radiation
and reliable
Monitoring CS4-08 Completed
S.06 Diagnostic imaging services available, safe,
Radiation
and reliable
Repeat Analysis CS4-09 Completed
S.07 Written plan of care Written Plan of Care CS4-10 Completed
S.08 Clinical protocols available and used Clinical Protocol Adoption CS4-11 Completed
S.14 Anesthesia and sedation are used appropriately
Anesthesia and Sedation CS4-12 Completed
S.15 Surgical services are appropriate to patient
Management
needs of Surgical Services CS4-13 Completed
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S.16 Effective emergency triage Management of Emergency Triage CS4-14 Completed

S.18 Ambulance services equipped Management of Ambulance Services CS4-15 Completed
S.19 Safe medication use Management of Medications CS4-16
S.20 Patients are educated to participate in their
Patient
careand Family Education CS4-17 Completed
S.21 Communication among those caring for patients
Patient Handover Communication CS4-18 Completed
 Risk Area 5
Improvement of Quality and Safety
# of Total Policies/Procedures: 6

Standard Procedure Code Status

S.02 Effective customer care program Staff Code of Conduct QI5-01 Completed
S.03 Patient satisfaction is monitored Monitoring of Patient Satisfaction QI5-02 Completed
S.04 Complaint and suggestion process Management of Compliants and Suggestions QI5-03 Completed
S.06 Incident reporting system Management of Incidents QI5-04 Completed
S.09 Staff satisfaction monitored Monitoring of Staff Satisfaction 25
QI5-05 Completed
S.09 Staff satisfaction monitored Staff Identification and Dress Code QI5-06 Completed
 Criteria Required by Level for recognition
Level I Recognition
 Overall average score of 85% at Level I
 Average score of 75% for each risk area at Level I
 Overall average score of critical standards of 80% at Level I*
Level II Recognition
 Level I recognition must be achieved and maintained
 Level I critical standards are met at 100%
 Overall average score of 75% at Level II
 Average score of 70% for each risk area at Level II
 Overall average score of critical standards of 80% at Level II*
Level III Recognition
 Level I & II recognition must be achieved and maintained
 Overall average score of 70% at Level III
 Average score of 60% for each risk area at Level III
 Overall average score of critical standards of 100% at Level III*

*Critical standards are required by national laws and regulations and, if not met,
may cause death or serious harm to patients, visitors, or staff.
SURVEY PROCESS
 Measuring Quality

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 What to measure?

Inputs – Processes - Outcomes

 Appropriate treatment
 Correct medications
 Appropriate referrals
 Completeness of documentation
 Immunizations
 Decreased incidence of disease
 Ways to Measure Quality

 Observation
 Record reviews
 Surveys
 Interviews
 Focus groups
 Self/peer evaluations

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 Data Collection Methods

- Leadership interviews
- Staff interviews
- Patient interviews
- Document review
- Personnel file review
- Direct observation
 Document review process
 Policies and procedures, Plans, Manuals: documents organized
and available for review according to list;

 Patient Records Review : discharged (closed) patient records,

according to top diagnoses and/or procedures;

 Review of personnel files: list of staff members met during

units/departments tour.
 Visit to Facility tour

Addresses issues related to :

 Security
 Medical and other equipment
 Hazardous waste
 Fire safety
 Utility systems
 Patient and visitor safety
 Infection control
 Feedback
Findings of the progress assessment:

 PPT presentation of findings per standard;

 Report writing with scores, findings and

recommendations;

 Presentation to all stakeholders (TWG, ISMM/GSMM);

 Final report (Executive and Individual HF report);

 REFERENCES

World Health Organization. (2018). Hospital

Accreditation Guide.
•Ministry of Health, Rwanda. (2020). National Hospital
Accreditation Manual.
•USAID Rwanda. (2021). Strengthening Rwanda’s
Health System through Accreditation.
 Improving our Health System
Like a puzzle? OR Like a football game?
Questions and Comments