Development of National Hospital Accreditation System 37-year - - PDF document

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Development of National Hospital Accreditation System 37-year - - PDF document

Oct 24, 2022 390 likes •628 views

2015/9/23 Development of National Hospital Accreditation System 37-year Experience of Taiwan Dr. Wui-Chiang Lee, MD, PhD, MHS President, Asian Society for Quality in Healthcare (ASQua) Former CEO, Joint Commission of Taiwan Former

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2015/9/23 1

  • Dr. Wui-Chiang Lee, MD, PhD, MHS

President, Asian Society for Quality in Healthcare (ASQua) Former CEO, Joint Commission of Taiwan Former Director-General, Department of Medical Affairs, Ministry

  • f Health and Welfare

1

Development of National Hospital Accreditation System ─ 37-year Experience of Taiwan

李偉強博士

  • Dr. Wui-Chiang Lee

Agenda

 Development of accreditation system  Characteristics of hospital accreditation  Performance and impacts  Continuous improvement  Lessons sharing  Conclusions

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  • Dr. Wui-Chiang Lee

Objectives of Accreditation

 Assuring quality and safety care  Patient-centered medical services and management  Addressing risk management  Protecting patient right  Assuring infection control after SARS  Continuous quality improvement  Capabilities as a teaching hospital  Compliance to government policies

3 李偉強博士

  • Dr. Wui-Chiang Lee

Evolution of Accreditation System

 1978 Accreditation launched by Ministry of

Education and Department of Health

 1986 Medical Care Act  1995 Linked to NHI contract and reimbursement  1999 Entrust accreditation program to Taiwan Joint

Commission on Hospital Accreditation

 2003 Accreditation reform after SARS  2007 New accreditation standards (version 1)  2011 Standard revision (version2)  2014 Patient-focused methods (version 3)

4

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  • Dr. Wui-Chiang Lee

Characteristics

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Government’s responsibility by law Hospital grading and classification Linked to NHI contract and reimbursement Tender plan to professional accrediting organization Uniform accreditation standard Reasonable cost and public disclosure

李偉強博士

  • Dr. Wui-Chiang Lee

Granted by Law

 Medical Care Act

 Article 28: The central competent authority shall conduct

accreditation of hospitals

 Article 121: The central competent authority shall collect

accreditation fee for the accreditation of hospitals

 Regulations Governing Contracting and

Management of National Health Insurance Medical Care Institutions

 Article 9: for hospitals or clinics to apply for in-patient

reimbursement, they shall be accredited by the central competent authority

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  • Dr. Wui-Chiang Lee

Government Responsibilities

 Ministry of Health and Welfare:

 to make sure quality of care, patient safety, and policy

compliance

 to certify training capability for post-graduation (PGY) and

specialty trainings

 Ministry of Education:

 to certify teaching facilities and capabilities for internship

and pre-graduation trainings

 Local Healthcare Bureaus:

 to audit facilities and manpower sufficiency and policy

compliance

7 李偉強博士

  • Dr. Wui-Chiang Lee

Hospital Grading and Classification

Classifications Medical service grading Teaching & research grading Special mission grading Medial Center ++ ++ ++ Regional Hospital + +

  • District Hospital

+

  • Psychiatric

Hospital ++/+ +/-

  • Children Center

++ ++ ++

8

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  • Dr. Wui-Chiang Lee

The Main Criteria of Hospital Classification

 Hospital Structure  Professional discipline  Manpower  Clinical teaching facilities and capability  Clinical and basic research capacity  Care process, results and continuous improvement  Patient safety and risk management  Effective administration  Emergency/Critical/Cancer care  Effective medical policy

9 李偉強博士

  • Dr. Wui-Chiang Lee

Linked to NHI Contract and Reimbursement

 Fundamental requirement to NHI contract  Medical center is reimbursed higher than regional

and district hospitals

 A certain high-risk procedures and high-tech

facilities are only allowed at medical centers

 Good reputation attracts more patients  Large-scale hospitals attract and retain medical

staffs and specialists

10

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MOHW Entrusts TJCHA to Conduct Hospital Accreditation Program

Accreditation contract Entrust accreditation program

Surveyor

TJCHA

Apply and pay for accreditation Report Accreditation Processes

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  • Dr. Wui-Chiang Lee

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Taiwan Joint Commission on Hospital

Since 1999 Non-profit, non-governmental, organization Renamed: Joint Commission of Taiwan (since 2014) Fund contributors Department of Health Taiwan Medical Association Taiwan Hospital Association Taiwan nongovernmental hospitals and clinic associations

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TJCHA’s Missions

TJCHA

Accreditation & Certification Patient Safety (PS) Program Disease Prevention & Health Promotion Publication Education QI Activities health promotion in schools and pharmacies

  • PS reporting ● PS goals
  • PS culture survey ● PS awareness week
  • hospital, psychiatric hospital, teaching hospital
  • psychiatric rehabilitation institution, psychiatric

nursing home

  • infection control, hand hygiene, IRB, Chinese

Medicine

  • Emergent and Critical Care Ability Classification,

Special Care Center, Disease-Specific Care, Health Check-up Program

  • healthcare professional training programs
  • quality contest (HQIC)
  • measurement system (TCPI)
  • promotion of quality improvement tools (PDCA、RCA, TRM )

Journal, teaching guide, textbooks

  • train the trainer ●healthcare faculty ●surveyors

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Since 2006 Since 2007 Since 2013

International Recognition as a Professional Accreditation Body

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  • Dr. Wui-Chiang Lee

Asian Society for Quality in Health Care

1.

India: National Accreditation Board for Hospitals and Healthcare Providers (NABH)

2.

Indonesia: Komisi Akreditasi Rumah Sakit (KARS) Indonesian Commission on Accreditation of Hospitals (ICAHO)

3.

Japan: Japan Council for Quality Health Care (JCQHC)

4.

Korea: Korea Institute of Healthcare Accreditation (KOIHA)

5.

Malaysia: Malaysian Society for Quality in Health (MSQH)

6.

Mongolia: National Centre for Health Development of Mongolia

7.

Philippine: Philippine Council on Accreditation for Healthcare Organization (PCAHO)

8.

Thailand: The Healthcare Accreditation Institute

9.

Taiwan: Joint Commission of Taiwan (JCT)

李偉強博士

  • Dr. Wui-Chiang Lee

Evolution of Accreditation Standards

16 2011 New Hospital Accreditation Standards (2007~2010) Old Hospital Accreditation Standards ( before 2006)

Hospital Management

  • 1. Vision、Strategies and Community

Functions Administrative management

Medical Care

  • 2. Management and Operations

Surgery

  • 3. Patient Rights and Safety

Internal medicine

  • 4. Healthcare Systems and operations

Nursing

  • 5. Appropriate Healthcare Operations

Pharmaceutical

  • 6. Appropriate Nursing Care

Radiation

  • 7. Comfortable Healthcare Environment

and Care Clinical laboratory (transfusion) and pathology (add in 1990)

  • 8. Human Resources and Quality

Improvement Psychology(add in 1991) Emergency medicine(add in 1993)

Infection control(add in 1996)

2 surveyor teams (administrative, medical care) 3 surveyor teams (administrative, medical, nursing) 10 Surveyor teams

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Continuous Quality Improvement

17

PLAN DO CHECK ACT

PLAN PLAN

s

Patient- centered

Safe Efficient Timely Effective Equal

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  • Dr. Wui-Chiang Lee

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Accreditation Standards – Part 1: Hospital Management

1.1 Management strategy 1.2 Staff management and support system 1.3 Human resources management 1.4 Employee education and training 1.5 Medical records & information management 1.6 Safe environment and equipment 1.7 Patient-oriented services 1.8 Crisis management and disaster response

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Accreditation Standards – Part 2: Medical Care

2.1 Patient rights Communication, informed consent, privacy 2.2 Health care quality management 2.3 General medical care/safety 2.4 Specialized medical care/safety ER, ICU, psychiatric, dialysis, respiratory care 2.5 Medication safety 2.6 Anesthesia and surgical safety 2.7 Infection control and antibiotic use 2.8 Lab work, pathology and radiology safety

李偉強博士

  • Dr. Wui-Chiang Lee

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Accreditation Standards – Part 3: Teaching Capability

3.1 Resource, facilities, and management 3.2 Trainers’ training programs 3.3 Cross-specialty training and teamwork 3.4 Teaching and research performance 3.5 Resident, PGY and intern training programs 3.6 Other medical workers’ training programs

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Survey Methods

 A 4-year cycle  Experienced and well-trained surveyors  Self-assessment  On-site survey  Continuous quality measure (45 items)  Patient-focused methodology (PFM)

21 李偉強博士

  • Dr. Wui-Chiang Lee

Surveyor Training and Evaluation

委員制度年度計畫 Surveyor Plan 訓練 Training Program SOP：B-R-21 繼續教育訓練 Continue Education Course 實體課程 Face to face classes 通訊課程 E-learning 核心課程 Core Course 實地訓練 On-Site Simulation Training 實地觀摩 Mock On-site Accreditation Training 評核 Evaluation 共識會議 Consensus Meeting 遴選 Recommendation & Selection SOP：B-R-07、B-R-18、B-R-19 遴聘作業 Selection 排程作業 Scheduling 實地評鑑 On-site Accreditation 評核 Evaluation 申請作業 Application 評核 Evaluation

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Survey Plan

Hospital size Time Surveyors TJCHA coordinator ≦ 49 beds 1 day 3 surveyors (1 in Administration, 1 in Medicine, 1 in Nursing) 1 50 beds ~ 99 beds 1 day 6 surveyors (2 in Administration, 2 in Medicine, 2 in Nursing) 1 100 beds ~ 249 beds 1.5 days 250 beds ~ 499 beds 2 days ≧500 beds 2.5 days

李偉強博士

  • Dr. Wui-Chiang Lee

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Dual Survey

Continuous quality evaluation Feedback & Comments Quality reporting Real-time survey Performance evaluation Accreditation On-site survey Individual and systematic tracer PDCA

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Knowledge Management System

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李偉強博士

  • Dr. Wui-Chiang Lee

Public Disclosure of Accreditation Results www.mohw.gov.tw

 Basic information（beds, manpower etc.)  Service information（out/inpatient

volume, financial reports)

 Granted accreditation level  Teaching capability for different medical

disciplines

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Public Disclosure

李偉強博士

  • Dr. Wui-Chiang Lee

Follow-up Surveys

Unannounced Follow-up Surveys

First to Third year

Hospital Accreditation

Hospital Valid for 4 years Immediate Follow-up Surveys (If the Hospital happens a major sentinel event)

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126 122 150 145 7 8 1 10 33 73 55 19 12 5 2 50 100 150 200 250 2010 2011 2012 2013

Hospital Accreditation 醫院評鑑 Focus survery/ Re-evaluation 複評/複查 Unannounced Follow-up Surveys 不定時追蹤 Immediate Follow-up Surveys 即時追蹤

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  • Dr. Wui-Chiang Lee

Performance and Impacts ─ Why accreditation successes in Taiwan?

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High Participation Rate (97%)

31 Resources: ISQua Conference 2011, Hong Kong

Accreditation links to Payment

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  • Dr. Wui-Chiang Lee

Reasonable Cost (Non-for-Profit)

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Every 100 bed evaluation cost（unit：US$）

Resources: ISQua Conference 2011, Hong Kong

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Professional Accrediting Body

 Local independent organization  Profession  Non-for-profit  Transparency  Experienced surveyors  Supervision by citizen and ISQua  Listening and response to hospital feedback  Continuous improvement

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  • Dr. Wui-Chiang Lee

Hospitals Care!

 The #1 exam of hospital managers!

 “Oscar award” for competing medical centers  “Entrance exam” for middle level hospitals  “Survival test” for poorly-managed hospitals

 The performance in accreditation is linked to

reputation, payment, service volume and profit

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  • Dr. Wui-Chiang Lee

Better Structure and Process of Care

Accumulating evidences demonstrate that accreditation improves:

 Infrastructure, workforce, equipment  Patient-centered and safe environment  Informed consent and patient right protection  Core measures of quality in process of care  SOPs in medication safety, infection control  Safety report and risk management system

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  • Dr. Wui-Chiang Lee

The Association between Accreditation & Clinical Outcomes

 Research project sponsored by Ministry of Science and

Technology (2012~2013)

 Pre-Post comparison study of 77 hospitals  Study period: 2007~2011  Data: Indicators of Taiwan Quality Indicators Project 3M 6M 12M

  • 12M
  • 6M
  • 3M

6M accreditation

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  • Dr. Wui-Chiang Lee

Taiwan Patient Safety Culture Survey

by Chinese-version Safety Attitude Questionnaire since 2007

SAQ-C

Job Satisfaction Teamwork Climate Safety Climate

Perception of Management

Working Conditions

李偉強博士

  • Dr. Wui-Chiang Lee

Instrument and Measures

 Ten hospitals participated (2007~2011)  SAQ (Chinese version) with 30 items  5 point Likert scales:

 Strongly agree (5), Slightly Agree (4), Neutral (3),

Slightly disagree (2), Strongly disagree (1)

 Positive response rate (%)

 Percentage of caregivers strongly and slightly agree (mean

score 4, or higher) to a given safety culture dimension of a hospital

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Safety is the Core Component in Accreditation Standards

Hospital management standards Clinical Practice Standards

Hospital Operations Strategy Rights and Responsibilities of patient and family Staff Management and Support Systems Medical Care Quality Improvement Human Resource Management Care Implementation and Evaluation Staff Education and Training Care of High Risk Patients Medical Record, Information and Communication Management Medication Safety Facility and Environment Safety Anesthesia and Surgical Care Patient-focused Service and Management Infection Prevention and Control Risk Management and Emergency Response Clinical Laboratory, Pathology and Radiology Discharge / Transfer Planning and Continuity of care 李偉強博士

  • Dr. Wui-Chiang Lee

Impacts on Healthcare Authorities

 Accreditation turns to be the most efficient tool

and a “double-blade knife” in:

 Regulation compliance (or failed)  Quality improvement (at very low cost)  Manpower and staffing ratio (regardless of cost)  Special missions (public health, disease screening,

hospice care, organ donation, outreach programs to rural areas, offshore islands, and to the other countries)

 Many interest groups urge government to adopt

their requirements into accreditation elements.

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Disease-specific Certification

 AMI, ACS, CAD  High-profile physical check-up  Aesthetic medicine

 Others

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李偉強博士

  • Dr. Wui-Chiang Lee

Impacts on Hospital and Health Workers

 Over-competition: emphasis on ranking and grading,

competitiveness replaced cooperation

 Reimbursement linked to accreditation, resources

allocate to urban and large-scale hospitals

 Parts of the requirements are too difficult to achieve  Overloading by paperwork and extra workload  Shortage of nurses and critical care doctors before

accreditation

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Lessons Sharing (1)

53 李偉強博士

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Lessons Sharing (2)

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Conclusions

 Taiwan’s hospital accreditation has played important

roles in each stage of hospital development for the past 37 years in a row.

 Although some negative influence exist, accreditation

indeed improves the quality of care in infrastructure and processes of medical services

 The Taiwan model can share with Asian countries

who wish to have its own accreditation system at affordable cost

55 李偉強博士

  • Dr. Wui-Chiang Lee

ASQua ─ The Asian Accreditation Hub

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Email: leewuichiang@gmail.com