Accreditation - Dubai Health Regulation Conference

January 30, 2018 | Author: Anonymous | Category: Science, Health Science, Immunology
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Accreditation vs Regulation: It’s that difference that makes a difference!

First Dubai Health Regulation Conference for the MENA region 22-23 October , 2014

Today, regulation is an encompassing term for three different potential regulatory activities...


Regulation—any standard that is mandated by a governmental agency or authoritative body

• Licensing implies meeting minimal standards


• Certification: Procedure by which a third party gives written assurance that a product, process or service conforms to specific requirements • Credentialing means that an individual has demonstrated the capabilities necessary for successful participation in that profession

• Accreditation

Accreditation implies performing at a higher level and are meeting additional standards beyond the licensing standards


Definitions have been unified to a certain extent…  usually a voluntary program,



 sponsored by a non-governmental agency  trained external peer reviewers evaluate a health care organization's compliance with pre-established performance standards  addresses organizational rather than individual practitioner capability or performance  is an internationally recognized evaluation process  used to assess and improve the quality, efficiency and effectiveness of health care organisations. ISQua definition of accreditation: “Act of granting credit or recognition by an external evaluation organization of the achievement of accreditation standards, demonstrated through an independent external peer assessment of that organisation’s level of performance in relation to the standards.”

Licensure: “Licensure: process by which a government authority grants permission to an individual practitioner or health care organisation to operate or to engage in an occupation or profession.” ISQua Accreditation Council 2002

*Unlike licensure, accreditation focuses on continuous improvement strategies and achievement of optimal quality standards rather than adherence to minimal standards intended to assure public safety.“ - Simply put, accreditation is based on the premise that adherence to evidence-based standards will produce higher quality health care services in an increasingly safe environment. It is also a way to publicly recognize that a health care organization has met national quality standards”. (Pomey, 2005) 3

… And the USA-based Quality Assurance Program and Joint Commission Resources have proposed a table of definitions Process

Accreditation (voluntary or mandatory)

Licensure (mandatory)

Object of Evaluation


Uses recognised tools, often an NGO but may be part of government or funded by government

Organization e.g. hospital, clinic, community service, network of health services and facilities

Compliance with or achievement of published standards, on-site evaluation, compliance usually not required by law and/or regulations but a developing trend of becoming required by governments

Governmental authority

Individual Organization


Certification (voluntary or mandatory)


Issuing Organization

Authorized body, either government or NGO Organization or component


Regulations to ensure minimum standards, exam, or proof of education/competence Regulations to ensure minimum standards, on-site inspection Evaluation of predetermined requirements, additional education/training, demonstrated competence in specialty area

Set at a maximum achievable level to stimulate improvement over time, often with different levels of achievement for different levels of accreditation

Set at a minimum level to ensure an environment with minimum risk to health and safety

Set by national professional or specialty boards

Industry standards (e.g. ISO 9000 Compliance with set standards, on- standards) evaluate conformance to site evaluation design specifications, or specific health standards


But there is a crucial need to differentiate health service accreditation from both certification and licensing, especially when we are looking at institutional competence. Do we need accreditation?


Licensure Which standards should we use?


How does that differ from regulation?


Regulation seems to be more stringent on accountability


While accreditation seems to focus on growth ! Benefits (Nicklin2011)  A framework systems and processes to improve operations and health outcomes

 Decreases variances in practice among healthcare providers and decision –makers

 Improves communication and collaboration

 Stimulates continuous raising of the bar

 Strengthen interdisciplinary team effectiveness

 Leads to the improvement of internal practices

 Demonstrates credibility and a commitment to quality and accountability

 Increases health care organisations’ compliance with quality and safety standards

 Decreases liability costs:

 Improves patients’ health outcomes

 Mitigates the risk of adverse events

 Provides a team-building opportunity for staff and improves their understanding of their co-workers’ functions

 Sustains quality and organisational performance

 Enables on-going self-analysis  Ensures an acceptable level of quality among healthcare providers  Enhances the understanding of continuum of care  Improves the organisation’s reputation among end-users and enhances their awareness & perceptions  Promotes capacity-building, professional development and organisational learning  Codifies policies and procedures

 Promotes an understanding of how each person’s job contributes to the healthcare organisation mission & services  Contributes to increased job satisfaction among physicians, nurses and other providers  Engenders a spill-over effect, whereby the accreditation of one service helps to improve the performance of other service  Highlights practices that are working well

 Promotes the sharing of policies, procedures and best practices among health care organisations.


Can this diagram summarize it? Or is it too easy?


Accreditation, unlike regulation, seems to have the essence of self assessment and self growth Continued reporting Mystery client

Un-announced midpoint assessment

Contiguous engagement

New standards every other year


Many approaches look at accreditation as a developmental approach where as licensing as a regulatory one Developmental



Dynamic, organisational improvement

Static, control


Accreditation, certification

Licensing, regulation


Non-governmental organisation, stakeholders

National, regional government agency

Primary Customers

Healthcare providers


Secondary customers

Patients, professions, health care insurers

Population, politicians, public finance

Incentives for healthcare organisations to participate

Ethical, commercial

Legal, mandatory


Voluntary self-selection to available programs

All institutions in all sectors


Defined by non-governmental organisation, optimal achievable

Defined by regulation, minimal acceptable

Funding Cross-border mobility

Self-financing Limited by language, culture

State Limited by political borders


In simple terms, accreditation is to educate and elevate while regulation/licensing is to investigate and enforce

Licensure • Building safety • Physical space • provider-to-beneficiary ratios • Staff qualifications • Transportation • Compliance to regulation •

Accreditation • Access ,Assessment and continuity of care • Patient Right and Education . • Care of Patients . • Management of Medication . • Hospital Infection Control . • Continuous Quality Improvement • Responsibility of Management . • Facility Management and Safety . • Human Resource Management • Information Management System .


Sanctions, fines

Patient decision, pay for performance


Inspectors, Auditors

Assessors, Surveyors

Areas of Focus


Accreditation also seems to be more in depth! infection Policies & procedur es

hazardous material

resuscita tion

maintena nce

medical equipme nt privacy

continuit y of care

basic hygiene fire safety

radiation safety


Plans and guidelines

sterilizati on waste manageme nt

laws and regulatio ns

human rights

emergency care Medicati on referral system

lack of privacy Chemical exposure

Qualified staff


In summary, we may be able to simplify it with that licensure can be a starting point while certification and accreditation can be the continuous way forward

Heath Institution

Heath Institution

Heath Institution


Certification Licensure 13

To end with another layer of questions: What is after accreditation?

Excellence? Continuous readiness?

Heath Institution

Heath Institution

Heath Institution

Accreditation Certification



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