Assessing Regional Blood Assessing Regional Blood CentersCenters
Using Foreign Using Foreign or International Standards or International Standards
Abdulla A. Alkhashan MS, ASCP, NCAAbdulla A. Alkhashan MS, ASCP, NCA
King Abdulaziz Medical City-RiyadhKing Abdulaziz Medical City-Riyadh
For the 10For the 10thth Arab Transfusion Medicine Course Arab Transfusion Medicine Course Kuwait City, KuwaitKuwait City, Kuwait
2929thth November to 1 November to 1stst December, 2012 December, 2012
Presentation Outline•Nature of Modern Health Care SystemNature of Modern Health Care System
•History of Accreditation in Health History of Accreditation in Health
Care Care
•The Value and Impact of AccreditationThe Value and Impact of Accreditation
•Accreditation in the Developing Accreditation in the Developing
CountriesCountries
•The Pitfalls of SurveyingThe Pitfalls of Surveying
•Accreditation in the KSAAccreditation in the KSA
Nature of Modern Health Care Nature of Modern Health Care SystemSystem 44,000–98,000 annual deaths occur as a result 44,000–98,000 annual deaths occur as a result
of errorsof errors
National Institute of Medicine report published in1999
2,956,351 Transfusions2,956,351 Transfusions
8 Mortalities (1:370,000 Transfusions )8 Mortalities (1:370,000 Transfusions )
117 Morbidities (1:25,000 Transfusions 117 Morbidities (1:25,000 Transfusions
))
SHOT Report 2011
Nature of Modern Health Care Nature of Modern Health Care SystemSystem
Nature of Modern Health Care Nature of Modern Health Care SystemSystem
Not Monitored (Don’t Have Any)Not Monitored (Don’t Have Any)
Nature of Modern Health Care Nature of Modern Health Care SystemSystem
Facts patients need to live with it !Facts patients need to live with it !
Nature of Modern Health Care Nature of Modern Health Care SystemSystem Investigated individually (case-by-Investigated individually (case-by-
case)case)
Nature of Modern Health Care Nature of Modern Health Care SystemSystem Investigated individually (case-by-Investigated individually (case-by-
case)case)What is wrong with this approach? Reactive
Focus on individuals
Focus on corrective measures and may be taken ineffective preventive measures
No long term gains (such event may occur in the future)
Nature of Modern Health Care Nature of Modern Health Care SystemSystem
Excellen
ce
Quality ball on the Hill; Koch, 1991
Nature of Modern Health Care Nature of Modern Health Care SystemSystem
Excellen
ce
Standards and Accreditation
Nature of Modern Health Care Nature of Modern Health Care SystemSystem
Excellen
ce
Standards and Accreditation
Proactive Approach
Nature of Modern Health Care Nature of Modern Health Care SystemSystem
Excellen
ce
Standards and Accreditation Proactive Approach
Risk Reduction
Nature of Modern Health Care Nature of Modern Health Care SystemSystem
Excellen
ce
Standards and Accreditation Proactive Approach
Risk Reduction
Organization Wide
Nature of Modern Health Care Nature of Modern Health Care SystemSystem
Excellen
ce
Standards and Accreditation Proactive Approach
Risk Reduction Organization Wide
System Focus
Nature of Modern Health Care Nature of Modern Health Care SystemSystem
Excellen
ce
Standards and Accreditation Proactive Approach
Risk Reduction Organization Wide System Focus
Stimulate Continuous Improvements
History of AccreditationHistory of AccreditationAccreditation is a voluntary Accreditation is a voluntary
program, in which authorized program, in which authorized
external peer reviewers evaluate external peer reviewers evaluate
the compliance of a health care the compliance of a health care
organization with pre-organization with pre-
established performance established performance
standards.standards.
History of AccreditationHistory of Accreditation
Licensure is a process by which Licensure is a process by which
a government authority grants a government authority grants
permission to an individual permission to an individual
practitioner or healthcare practitioner or healthcare
organization to operate in an organization to operate in an
occupation or profession.occupation or profession.
History of AccreditationHistory of Accreditation
American College of Surgeons in American College of Surgeons in 19171917
History of AccreditationHistory of Accreditation
International Standards International Standards Organization (ISO) in 1947Organization (ISO) in 1947
1917 - ACS
History of AccreditationHistory of Accreditation
American Association of Blood American Association of Blood Banks (AABB) 1947Banks (AABB) 1947
1917 - ACS 1947 - ISO
History of AccreditationHistory of Accreditation
Joint Commission on Accreditation Joint Commission on Accreditation of Healthcare Organizations of Healthcare Organizations
(JCAHO) 1951(JCAHO) 1951
1917 - ACS 1947 - ISO 1947 - AABB
History of AccreditationHistory of Accreditation
AABB Accreditation Program -1957AABB Accreditation Program -1957
1917 - ACS 1947 - ISO 1947 - AABB 1951 - JCAHO
History of AccreditationHistory of Accreditation
CAP Accreditation Program (1961)CAP Accreditation Program (1961)
1917 - ACS 1947 - ISO 1947 - AABB 1951 - JCAHO 1957 - AABB AP
History of AccreditationHistory of Accreditation
Accreditation modules exported Accreditation modules exported (1960s)(1960s)
1917 - ACS 1947 - ISO 1947 - AABB 1951 - JCAHO 1957 - AABB AP 1961 - CAP AP
History of AccreditationHistory of Accreditation
ISQua’s International Accreditation Program(1985)(1985)
1917 - ACS 1947 - ISO 1947 - AABB 1951 - JCAHO 1957 - AABB AP 1961 - CAP AP 1960s – Export of AP
The Value and Impact of The Value and Impact of AccreditationAccreditation
Helps set national standards forHelps set national standards for
health care health care
Improves patient careImproves patient care
Helps set national standards for health care
The Value and Impact of The Value and Impact of AccreditationAccreditation
Makes information available to Makes information available to
the publicthe public
Helps set national standards for health care Improves patient care
The Value and Impact of The Value and Impact of AccreditationAccreditation
Lenient accreditation Lenient accreditation
requirementsrequirements
Helps set national standards for health care Improves patient care Makes information available to the public
The Value and Impact of The Value and Impact of AccreditationAccreditation
Makes health care more Makes health care more
expensiveexpensive
Helps set national standards for health care Improves patient care Makes information available to the public Lenient accreditation requirements
The Value and Impact of The Value and Impact of AccreditationAccreditation
Accreditation in the Developing Accreditation in the Developing CountriesCountries
Absence of strong regulatory Absence of strong regulatory
and local accreditation bodiesand local accreditation bodies
Accreditation in the Developing Accreditation in the Developing CountriesCountries
Used as a term for contracting Used as a term for contracting
with hospital's operating with hospital's operating
companiescompanies
Absence of strong regulatory and local accreditation bodies
Accreditation in the Developing Accreditation in the Developing CountriesCountries
Business owners recognized Business owners recognized
accreditation a powerful accreditation a powerful
marketing toolmarketing tool
Absence of strong regulatory and local accreditation bodies
Term for contracting with hospital's operating companies
Accreditation in the Developing Accreditation in the Developing CountriesCountries
Skeptical about the impact of Skeptical about the impact of foreign or international foreign or international
accreditation on the quality of accreditation on the quality of healthcare services providedhealthcare services provided
Absence of strong regulatory and local accreditation bodies.
Term for contracting with hospital's operating companies
Powerful marketing tool
Accreditation in the Developing Accreditation in the Developing CountriesCountries
Prohibitively expensive and Prohibitively expensive and unjustifiedunjustified
Absence of strong regulatory and local accreditation bodies.
Term for contracting with hospital's operating companies
Powerful marketing tool Skeptical about the impact
Accreditation in the Developing Accreditation in the Developing CountriesCountries
Improve efficiency and clinical Improve efficiency and clinical outcomes of a wide spectrum of outcomes of a wide spectrum of
clinical conditionsclinical conditions
Absence of strong regulatory and local accreditation bodies.
Term for contracting with hospital's operating companies
Powerful marketing tool Skeptical about the impact Prohibitively expensive and unjustified
The Pitfalls of Surveying The Pitfalls of Surveying
Interrogating and Inspecting Interrogating and Inspecting
instead of Interviewing and instead of Interviewing and
AssessingAssessing
The Pitfalls of Surveying The Pitfalls of Surveying
Consideration to the local Consideration to the local
circumstances and available circumstances and available
resourcesresources
Interrogating and Inspecting instead of Interviewing and Assessing
The Pitfalls of Surveying The Pitfalls of Surveying
Misconception of the process Misconception of the process
ownerowner
Interrogating and Inspecting instead of Interviewing and AssessingConsideration to the local circumstances and available resources
The Pitfalls of Surveying The Pitfalls of Surveying
Pressured to consider “in Pressured to consider “in
progress” as “compliance”progress” as “compliance”
Interrogating and Inspecting instead of Interviewing and AssessingConsideration to the local circumstances and available resourcesMisconception of the process owner
The Pitfalls of Surveying The Pitfalls of Surveying
The pace of developing Policies The pace of developing Policies
and Procedure faster than the and Procedure faster than the
implementationimplementation
Interrogating and Inspecting instead of Interviewing and AssessingConsideration to the local circumstances and available resourcesMisconception of the process ownerPressured to consider “in progress” as “compliance”
Licensing and Accreditation in Licensing and Accreditation in K.S.AK.S.A
370 Hospital (244 Governmental 370 Hospital (244 Governmental
and 126 Private)and 126 Private)
Licensing and Accreditation in Licensing and Accreditation in K.S.AK.S.A
13 Blood Banks and Transfusion 13 Blood Banks and Transfusion
Services Accredited by the AABB Services Accredited by the AABB
and CAPand CAP
370 Hospital (244 Governmental and 126 Private)
Licensing and Accreditation in Licensing and Accreditation in K.S.AK.S.A
21 Laboratories Accredited by 21 Laboratories Accredited by
the CAP onlythe CAP only
370 Hospital (244 Governmental and 126 Private)
13 AABB/CAP
Licensing and Accreditation in Licensing and Accreditation in K.S.AK.S.A
53 Hospitals Accredited by the 53 Hospitals Accredited by the
JCIJCI
370 Hospital (244 Governmental and 126 Private)
13 AABB21 CAP
Licensing and Accreditation in Licensing and Accreditation in K.S.AK.S.A
74 Hospitals are CBAHI 74 Hospitals are CBAHI AccreditedAccredited
6 Regional Laboratories and 6 Regional Laboratories and Central Blood BanksCentral Blood Banks
370 Hospital (244 Governmental and 126 Private)
13 AABB21 CAP53 JCI
Licensing and Accreditation in Licensing and Accreditation in K.S.AK.S.A370 Hospital (244 Governmental and 126 Private)
13 AABB21 CAP53 JCI74 CBAHI6 CBAHI-RRL
Health Care Providers in Health Care Providers in KSAKSA
1. Ministry Of Health2. Private Hospitals Sector3. National Guards Health Affairs 4. Armed Forces Medical Services Sector5. Ministry of Interior Medical Services6. University Hospitals7. King Faisal Specialized Hospital8. Saudi Aramco Medical Services
1.1. Saudi FDASaudi FDA
2.2. Council of Health ServicesCouncil of Health Services
3.3. Council for Healthcare specialtiesCouncil for Healthcare specialties
4.4. Ministry of Health (licensing)Ministry of Health (licensing)
Health Care Regulators in Health Care Regulators in KSAKSA
CBAHI Accreditation ProgramsCBAHI Accreditation Programs
HospitalsHospitals
Primary Health Care CentresPrimary Health Care Centres
Ambulatory Care CentresAmbulatory Care Centres
Reference Laboratories and Blood Reference Laboratories and Blood
BanksBanks
Central Board of Accreditation Central Board of Accreditation for Healthcare Institutions for Healthcare Institutions (CBAHI)(CBAHI)
Central Board of Accreditation Central Board of Accreditation for Healthcare Institutions for Healthcare Institutions (CBAHI)(CBAHI)
Services of CBAHIServices of CBAHI
Standards Orientation
Training/Education
Onsite Consultation
Mock Survey
Accreditation
Central Board of Accreditation Central Board of Accreditation for Healthcare Institutions for Healthcare Institutions (CBAHI)(CBAHI)
Central Board of Accreditation Central Board of Accreditation for Healthcare Institutions (CBAHI)for Healthcare Institutions (CBAHI)
الصحية المنشآت العتماد المركزي الصحية المجلس المنشآت العتماد المركزي المجلس
www.cbahi.orwww.cbahi.orgg
SummarySummaryPotential benefits of Potential benefits of
accreditation are far beyond the accreditation are far beyond the
anticipated expenses and the anticipated expenses and the
healthcare providers need to be healthcare providers need to be
educated about these benefits educated about these benefits
and convinced by conducting and convinced by conducting
cost / benefit analysis.cost / benefit analysis.