1. Hossam Elamir, MSc.HCM, TQMD, MBBCh
Quality & Accreditation Office, MKH

2.  Numbers, Charts and Comments on
Standards were taken from a presentation of:
Maitham Husain, MD FRCPC​
National Accreditation Program​
Accreditation Department, ​
Accreditation & Quality Directorate, MOH​

3. • Accreditation is a QUALTIY PROCESS
• Standards are QUALITY TOOLS
• Required Organization Practices
Essential service to improve patient safety & minimize
risk

4. “Quality is NEVER AN ACCIDENT;
it is always the result of HIGH
INTENTION, SINCERE EFFORT,
INTELLIGENT DIRECTION and
SKILFUL EXECUTION… the WISE
CHOICE of many alternatives.”
William A. Foster, 1917-1945

5. “First, do no harm” (Kohn et al. 2000)
 Perhaps the closest approximation
in the Hippocratic Corpus is in
Epidemics:
"The physician must ... have two
special objects in view with regard
to disease, namely, to do good or
to do no harm"

6. Medicine used to be
simple, ineffective &
relatively safe… now it
is complex, effective &
potentially dangerous!
Chantler, C. (1999), The role and education
of doctors in the delivery of healthcare,
Lancet, 53(9159), 1178–1181.
Medicine used to be
simple, ineffective &
relatively safe…
Chantler, C. (1999), The role and education
of doctors in the delivery of healthcare,
Lancet, 53(9159), 1178–1181.

7.  Don’t kill me (no needless
deaths)
 Do help me & don’t hurt me (no
needless pain)
 Don’t make me feel helpless
 Don’t keep me waiting
 Don’t waste resources - mine or
anyone else’s
Berwick, D. M. (2005), My right knee, Annals of Medicine,
142 (2), 121-125.

8. The seven pillars of
quality (Donabedian, 1990)
The six aims of quality
improvement (IOM, 2001)
The six dimensions of
quality (Bengoa et al.,
2006)
Efficacy
Effectiveness Effective Effective
Efficiency Efficient Efficient
Optimality
Acceptability Acceptable / patient-centred Patient-centred
Legitimacy
(Partially covered by the
patient-centred aim)
(Partially covered by the
patient-centred dimension)
Equity Equitable Equitable
Accessible
Safe Safe
Timely

9. • Standards have been reviewed by:
1. A taskforce committee
(surveyor, accreditation department, safety department)
2. Advisory Committee, MoH
3. Higher Committee for Accreditation, MoH

11. Parameter All Standards PSRA
Average Rate 2.62 2.00
Range 1.92-3.25 1.3-2.38
Median 2.72 2.29
MKH 2.21 2.00

12. 53%
MKH
1.5
0.0
2.0
2.0
2.5
2.0
2.0
1.6
1.63
1.7
1.8
1.1
2.0
1.0

13. • Recommendation to the Standard of
Accreditation
Changes are being introduced to the program
that will highlight the significance of the
Patient Safety Required Areas as essential
practices to improve patient safety in health
care organizations.
(In Canadian Standards they are called: ROPs
Required Organisational Practices)

14. • Each PSRA will be elevated to the criterion
level
• The rating scales and calculation of the
accreditation decisions are changing for the
second cycle of accreditation
• Each individual PSRA will now be assigned its
own rating in the self-assessment and on-site
survey in a scale of 4

15. • The 3-point scale for PSRAs will be eliminated and all
criteria (including PSRAs) will be rated on the 4-
point scale based on test of compliance
Level 1 The plan and policy are developed
Level 2 The plan and policy are partially
implemented in the service area, as per the Test(s) for
Compliance
Level 3 The plan and policy are fully implemented in
the service area, as per the Test(s) for Compliance
Level 4 The service collects data and analyzes data,
and uses the results for improvement

16. Organizations must achieve a rating of 3 or 4
on the 4-point scale for all (100%) of the PSRAs
or the accreditation award will be affected
•If one or more PSRAs is unmet (below level 3 or
4), the accreditation award will be reduced by
one level

17. MKH
3.00
2.00
2.00
2.00
2.00
1.00
2.00
2.00
2.00

18. • The leadership section will include a standard on
Training on Patient Safety.
11.0 Training on Patient Safety
Level 1 - Plan and policy are developed
Level 2 - Plan and policy are partially implemented in the
service as per test of compliance
Level 3 - Plan and policy are fully implemented in the service
as per test of compliance
Level 4 - The service collects data, analyses it and uses results
for improvement

19. 53%
MKH
1.5
0.0
2.0
2.0
2.5
2.0
2.0
1.6
1.63
1.7
1.8
1.1
2.0
1.0

20. Average rating – 2.15 (range 0.8-3.0) or 54%
Area of Special concern (below national average)
•Obs./Gyn. 0.8
•Human resources 1.2
•Emergency service 1.7
•Surgical 1.8
•Information management 1.8
•Intensive care 2.0
•Environment 2.1

21. STANDARD 8 – SAFETY PLAN
8.1 Management ensures there is an annual
written safety plan
8.2 The safety plan is regularly monitored for
progress
8.3 Results from safety related activities are
reported throughout the hospital and management
reports findings to governance.
8.4 Resources are provided for quality
improvement and safety activities throughout the
hospital

22.  Similar changes will be applicable to all
clinical and support services.
 Each PSRA will appear as criterion and
scored accordingly on scale of 0,1,2,3 and 4