Prod Cliff HughesA0 Jakarta 8 August 2017

ISQuas Role in the Governance of

Quality & Safety
Prof Cliff Hughes
President ISQua
 ISQua
Not for Profit Membership
Organisation

Mission is to inspire and drive

improvement in the quality and safety
of healthcare worldwide through
education and knowledge sharing,
external evaluation, supporting health
systems, and connecting people
through global networks

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 Why work with ISQua?

ISQuas mission is to:

To inspire and drive improvement in the quality

and safety of healthcare worldwide through
education and knowledge sharing, external
evaluation, supporting health systems and
connecting people through global networks
Networking events
Person Centred Care is at our core
Develop communities of practice
 The ISQua Network system

Policy Experts IAP

Development

Quality External
Improvement evaluation
Membership
and Patient Accreditation
Safety

Innovation and Accreditation

research Education Council
Fellowship
International Accreditation
Programme (IAP)
IAP Global Presence
66 Organisations in 34 Countries
IAP Global Presence
66 Organisations in 34 different countries
 Language / Terminology

Accreditation is a self-assessment and external peer

review process used by health care organisations
to accurately assess their level of performance in
relation to established standards and to
implement ways to continuously improve the
health care system.
ISQua 1998
 Codman 1913
1. There will be an organised medical staff.
2. That membership of this staff be limited to licensed
physicians who are competent and of worthy character
and who are professionally ethical.
3. That the staff develop rules and regulations governing
professional work in the hospital.
4. Each patient will have a comprehensive medical record.
5. That diagnostic and therapeutic facilities are under
competent supervision and includes, at least, laboratory
and x-ray departments.

Ernest Codman, 1913

2005 HMI 8/25/2017 12

 History of Accreditation

US 1910s JCI
Canada 1950s - AC
Australia 1980s - ACHS
UK 1980s CHI / HQS / HCC / CQC

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 Accreditation Bodies 1951-2009
45
40
35
30
25
20
15
10
5
0
1951
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1981
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1987
1989
1991
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1995
1997
1999
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2003
2005
2007
2009
Government Mixed Independent
October 2010 International survey results 14
Shaw et al, 2010 International Survey of Accreditation Organisations 2009
 ISO vs. Accreditation

Shaw et al, ISQua 2010. Accreditation and ISO certification: Do they explain differences in quality management in European
hospitals?
Sept 2010
 Benefits of Accreditation

Need more research

Difficult to measure as variables difficult to

control
 What does the evidence show?

Australia 2008
Research shows inconsistent findings but accreditation does
promote change and professional development
and may
have an organizational financial impact
improve measured quality performance
with public disclosure of outcomes, increase the
credibility of the hospital with the community
There is insufficient evidence to know if accreditation improves
patient satisfaction

Greenfield and Braithwaite, 2008. Health Sector Accreditation Research: a systematic review Greenfield
and Braithwaite. Int. Journal for Qual. in Healthcare.
 Canada 2011 (Updated 2015)

30 Benefits Listed
Risk Mitigation System
Strengthens interdisciplinary team effectiveness
Improves communication
Promotes measurement and use of indicators
Improvements needed
Does not increase patient satisfaction
Data capture
Accreditation Canada, 2015. Value and impact of accreditation: a literature review.
 Clinical benefits an example

Gratwohl et al (2011), Patient outcome was systematically better when

the transplantation centre was at a more advanced phase of JACIE
accreditation

Lichtman et al (2011), CVA accreditation resulted in reduced mortality

rate but no change in readmission rates

Menachemi et al (2008), Ambulatory care centres, patients in JCI

accredited facilities were significantly less likely to be re hospitalized after
colonoscopy
 Accreditation
Opportunities for Improvements
Reduce work load associated with accreditation
reduce burden of excessive audits
Move from structure process model to more outcomes
focused model
Strengthening data collection
More and better research non acute
Improve service user and medical involvement
Inform public and measure satisfaction
adverse events may still occur in an accredited
hospital
Promote transparency
 Recent trends
Unannounced surveys no rigorous empirical
evidence to support these surveys presumed
benefits
Patient satisfaction surveys requiring patient
satisfaction surveys as part of accreditation process.
Mandatory accreditation
Australia National Safety and Quality Health
Service (NSQS) Standards hospitals, day
procedure centres and public dental services
Canada Mandatory in Quebec and Alberta
 IAP international reach
Argentina India Philippines
Australia Indonesia Saudi Arabia
Brazil Ireland Slovenia
Canada Japan South Africa
Columbia Jordan Spain
Croatia Kazakhstan Taiwan
Czech Republic Korea Tajikistan
Denmark Kyrgyzstan Thailand
Dubai Lebanon Turkey
Egypt Malaysia UAE
France Netherlands United Kingdom
Hong Kong New Zealand United States
Norway

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 ISQua Accredited Organisations

CHKS Accreditation Unit, UK

Haute Autorit de Sant DAQSS
Accreditation Canada Canadian Accreditation Council of Human Services - CAC
Joint Commission of Taiwan JCT Global-Mark Pty Ltd, Australia
Council for Health Service Accreditation of
Southern Africa - COHSASA Health and Disability Auditing New Zealand - HDANZ
Danish Institute for Quality and Accreditation Australian Aged Care Quality Agency - AACQA
in Health Care - IKAS
The Healthcare Accreditation Institute (Public Organization),
Diagnostic Accreditation Programme, British
Thailand - HAI
Columbia
Health and Disability Auditing Australia Pty Ltd Australian General Practice Accreditation Ltd / Quality in
- HDAA Practice Pty Ltd AGPAL/QIP
Joint Commission International - JCI Japan Council for Quality Health Care - JCQHC
Malaysian Society for Quality in Health - MSQH
The Australian Council on Health Care Standards - ACHS
Quality Improvement Council, Australia - QIC
National Accreditation Board for Hospitals & Health Care Accreditation Council, Jordan - HCAC
Health Care Providers, India - NABH
DNV GL Business Assurance, Norway
DAA Group Limited, New Zealand
AABB, USA Associacao Brasileira de Acreditacao De Sistemas e Servicos
de Saude, Brazil CBA
Netherlands Institute for Accreditation in
Healthcare - NIAZ KARS Komisi Akreditasi Rumah Sakit
ICONTEC Health Accreditation Service,
Columbia
 IAP- 4 year cycle

Critical path issued

Technical review
Final Submission of Self Assessment
Surveyor Assessment (survey)
Factual Review
Report Validated by Panel
Accreditation Decision
Award Pack to Organisation
Continuous Assessment 12 and 30 months post survey
 IAP - Principles and Standards

4th Edition, V1.2 4th Edition, V1.2 3rd Edition, V1.0

Published in September 2015 Published in September 2015 Published in September 2016
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 Standards

Guidelines and Principles for the Development of

Health and Social Care Standards, 4th Edition 2014

Surveyor Training Programme, 2nd Edition 2009

Guidelines and Standards for External Evaluation

Organisations, 4th Edition 2014
Guidelines and Standards for External
Evaluation Organisations 4th Edition, 2014

8 Standards
Governance
Strategic, operational and
financial management
Risk management and
performance
Human resources management
Information management
Surveyor management
Survey and client management
Accreditation or certification
awards
Learning and Knowledge network
Membership network
Email: plachman@isqua.org

@peterlachman
Join the conversation

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