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Proposal for Establishment of the National Healthcare Accreditation Organization in Afghanistan

Draft

May 2017

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Table of Contents

Acknowledgements.....................................................................................................................................4

Executive Summary.....................................................................................................................................5

Background..................................................................................................................................................6

Introduction and Overview......................................................................................................................6

Background and Foundational Work.......................................................................................................6

Proposed Model for National Healthcare Accreditation and Quality Improvement Organization in Afghanistan.................................................................................................................................................9

Preferred Model for National Healthcare Accreditation.........................................................................9

Vision...................................................................................................................................................9

Mission................................................................................................................................................9

Core Values..........................................................................................................................................9

Goal...................................................................................................................................................10

Proposed Key Functions of the National Healthcare Accreditation Organization..............................12

Proposed Model for the Governance Structure....................................................................................14

Explanation of the Proposed Governance Model..............................................................................15

Key Specifications and Comparative Analysis of the Governance Functions of the Organization......16

Legal Basis for Establishment of the National Healthcare Accreditation Organization and Implications for Other Laws, Regulations, and Administrative Documents...............................................................18

Proposed Governance...........................................................................................................................20

Proposed Organizational Structure and Key Staff..................................................................................21

Executive Management.....................................................................................................................21

Divisional Management Structure.....................................................................................................21

Required Funding and Business and Sustainability Plan............................................................................22

Funding Considerations and Approaches..............................................................................................22

Incentives for Accreditation and Impact on Sustainability....................................................................24

Estimated Funding Requirements for National Healthcare Accreditation Organization in Afghanistan 26

Implementation Plan.................................................................................................................................27

Phase One: Collation of past activities and building the foundation of the accreditation organization 27

Phase Two – Establishing the Accreditation Organization.....................................................................28

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Phase Three – Scaling up from Kabul to the entire country and strengthening the system for sustainability..........................................................................................................................................30

Monitoring and Evaluation Plan................................................................................................................32

References.................................................................................................................................................33

Annex A: Work Plan (2016-2022)..............................................................................................................35

Annex B: Terms of Reference for Key Staff of the Accreditation Organization.........................................36

Chief Executive Officer...........................................................................................................................36

Director of Standards and Surveys........................................................................................................38

Director of Education and Consultation................................................................................................39

Director of Finance and Administration.................................................................................................40

Annex C: Detailed Budget..........................................................................................................................42

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Acknowledgements

This proposal is the outcome of the hard work, dedication and contribution of a significant number of experts that represented various stakeholders. Under the overall leadership of Deputy Minister for Policy and Planning, Dr. Ahmad Jan Naeem, this proposal on establishment of a National Healthcare Accreditation System in Afghanistan was developed through a participatory and collaborative process that involved the Accreditation Steering Committee and the Accreditation technical working group.

We acknowledge great contribution of the Accreditation Steering Committee and the technical working group, which consisted of representatives of MoPH and other line Ministries, including the Ministry of Higher Education (MoHEd), Ministry of Defense (MoD), Ministry of Interior (MoI), National Security Department, academia and the private health sector. We are thankful to Dr. Abdul Qadir Qadir, General Director of Policy and Planning, who provided leadership to the technical working group. Special thanks go to USAID Health Sector Resiliency (HSR) project which provided technical support in the proposal development.

I look forward to endorsement and effective implementation of this proposal for improving the quality of health services and improving health for all Afghans.

Sincerely,

Ferozuddin Feroz, MD, MScHSM

Minister of Public Health

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Executive Summary

Improvement in the quality and safety of health services in Afghanistan has been a strategic initiative for at least the past decade, and is now reflected as a national priority in the National Health Strategy 2016-2020. Over the past several years, the Ministry of Public Health (MoPH) has explored the feasibility of establishing a national healthcare accreditation organization as the key mechanism by which this priority could be advanced by hospitals and other healthcare organizations at a coordinated national level.

Healthcare accreditation is defined by the International Society for Quality in Health Care (ISQua) as: “A self-assessment and external peer review process used by health and social care organizations to accurately assess their level of performance in relation to established standards and to implement ways to continuously improve the health or social care system.” 1

The initial study of feasibility for an Afghan national healthcare accreditation organization included a comprehensive review of the literature on healthcare quality and accreditation. In addition, a detailed assessment and interviews with including senior government officials from the Ministry of Finance and the Ministry of Justice, senior MoPH officials, directors and senior managers of large public sector hospitals, directors and senior managers of private sector hospitals, as well as donor-funded consultants that are working on health policy initiatives, was completed. This assessment of Afghanistan’s readiness to establish a national accreditation organization demonstrated that the country is ready and would greatly benefit from an accreditation scheme.

During the past year, continued research and strategic planning has been conducted, including a continued review of the literature, the standards for accreditation organizations set by the International Society for Quality in Health Care (ISQua), and a comparative analysis of various models of accreditation around the world (e.g. governmental vs. non-governmental/independent, mixed approaches such as public/private partnerships, voluntary vs. mandatory, and not-for-profit vs. for-profit models). An in-depth benchmarking analysis was conducted with five existing accreditation organizations in the region.

This proposal outlines the background and progress made to date, as well as a proposed way forward, in order to develop and institutionalize a credible and sustainable national healthcare accreditation organization in Afghanistan, one which will serve as an overarching structure promoting the implementation of quality standards and culture. A model for governance, as well as an organizational structure and staffing plan for the accreditation organization are proposed. An analysis of the legal basis for a national accreditation organization, as well implications for other laws, regulations, and administrative documents, are considered.

Required funding, potential finding sources and considerations, business and sustainability plans, and a detailed 5-year budget and work plan are included herein. The budget is based on the experiences of other countries of a similar size and economic status. Project funding of an estimated $US 4.3 million to cover direct costs will be needed to create and run the accreditation organization for a 5-year start-up period. While external funding support is required in the initial 5-7 years, long-term sustainability of the accreditation organization will require it to generate revenues from the services it offers, including education, consultation, and accreditation services. Finally, a recommended approach to monitoring and evaluating the effectiveness of the new accreditation organization and strategy is proposed.

1 Fortune, T, O’Connor, E, and Donaldson, B. Guidance on Designing Healthcare External Evaluation Programmes including Accreditation, International Society for Quality in Healthcare (ISQua), 2015.

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Background

Introduction and Overview

For more than a decade, the Ministry of Public Health (MoPH) has embraced a strategy to improve the overall quality and safety of health services by strengthening its stewardship of the public and private health sectors. The National Health Strategy 2016-2020 now identifies the quality of healthcare services as a national policy priority:

“Health services especially improving access to, and the sustainability of, quality primary health care and public health particularly for mothers, the new born, children and adolescents, as part of a direction towards universal health coverage and improving the quality of clinical care, and more and better quality specialist tertiary care in partnership with the private sector and controlling the quality of imported pharmaceuticals.” 2

The results framework delineates several expected results related to improved quality:

SR4.1 Enhanced access to improved and updated quality BPHS and EPHS services. SR4.2 Improved quality of and increased access to a wide range of tertiary services.

The National Health Strategy 2016-2020 further defines Institutional Development as a key strategic area: “Strengthened, expanded, and sustainable health system with well-functioning institutions.”

In support of this long-term quality strategy and over the past several years, the MoPH has explored the viability of establishing a national health care accreditation organization as a mechanism by which healthcare institutions in Afghanistan can be strengthened. Establishment of a national accreditation organization would foster systems and structures for quality and patient safety at the facility level.

Unlike licensure, which is widely viewed as a government regulatory responsibility, designed to set minimum standards for public health safety, accreditation standards are considered optimal and achievable. In many countries, accreditation is a voluntary recognition program. Accreditation standards are typically more rigorous than the minimum standards of licensure, and with a stated intent to foster a culture of continuous improvement. 3

This proposal outlines the progress made to date, as well as a proposed way forward, in order to develop and institutionalize an effective, credible, and sustainable national healthcare accreditation organization in Afghanistan, one which will serve as an overarching structure promoting the implementation of quality standards and culture.

Background and Foundational Work

Since 2003, the MoPH has partnered with several organizations to improve the quality and safety of healthcare services in Afghanistan. The projects ranged from working with individual hospitals to projects that worked to improve different aspects of quality at the national and district hospitals. Several projects focused specifically the development of hospital standards. The projects included Hospital

2 Islamic Republic of Afghanistan Ministry of Public Health National Health Strategy 2016-2020, September 2016, p. 7.

3 Mate KS, Rooney AL, Supachutikul A, Gyani G. Accreditation as a path to achieving universal quality health coverage. Global Health. 2014 Oct 17; 10:68.

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Standards for Essential Package of Hospital Services 2005, Standards Based Management and Recognition 2006, and Minimum Required Standards for Private Hospitals 2009.

In 2011, the National Strategy for Improving Quality in Health Care - 2011 to 2015 was developed. The strategy pointed to the development of a national accreditation organization in Afghanistan. In 2013, many sets of standards and approaches for public health sector were harmonized into a common package called Harmonized Quality Improvement Package (HQIP).

In 2012, the government enacted a regulation that mandated minimum standards of quality for private health centers, paving the way for the development of the Minimum Required Standards (MRS). 4

From 2011 to 2013, the MoPH collaborated with the Afghan Private Hospital Association (APHA) to develop the Minimum Required Standards (MRS) for private hospitals. The intent was to standardize the regulation of quality in private hospitals, improve the culture of quality within the private health sector, and ensure patient safety.

Beginning in 2009, the MoPH convened a 36-member expert Task Force to develop a National Strategy for Improving Quality in Health Care (IQHC). After reviewing internationally accepted definitions of quality of health care, the Task Force agreed upon the following definition and dimensions for quality of health care in Afghanistan: "A quality health care system is client centered, equitable, available, appropriate, safe, consistent, effective, timely, and efficient; it continuously improves." 5

The National Strategy for IQHC also addressed key strategic objectives and related interventions designed to improve the capacity of the health system to provide high quality services. These strategic objectives included:

Improving patient safety; Providing client centered services; Strengthening data recording and reporting system; Improving clinical practices; and Building capacity to continuously improve.

Although these various initiatives have been underway to improve healthcare quality, there has been no unified strategy or organization that could bring these efforts together under an integrated, comprehensive approach. These various sets of healthcare standards have been developed independently of one another and need to be harmonized and brought under one system. There is a need for steps to be taken to bring quality to the forefront by building a quality management system and national accreditation organization. Although some harmonization of the standards occurred in 2014, work remains to finalize these into a single set that can be used across the country. A culture of quality and safety is still not widespread or well integrated at the facility level.

The MoPH conducted an assessment in late 2013 to determine the country’s readiness for a national accreditation organization. An external consultant with expertise in accreditation met and interviewed 44 individuals as part of this assessment, including senior government officials from the Ministry of Finance

4 Options for the Afghanistan’s Ministry of Public Health to Consider When Establishing a National Accreditation Organization, Paper, July 2016.

5 National Strategy for Improving Quality in Health Care, 2011-2015. Ministry of Public Health of Afghanistan, 2011.

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and the Ministry of Justice, senior MoPH officials, directors and senior managers of large public sector hospitals, directors and senior managers of private sector hospitals, as well as donor-funded consultants that working on health policy initiatives in Afghanistan. The consultant reviewed documents, conducted semi-structured interviews with key stakeholders, and visited private, public and non-governmental (NGO) healthcare facilities.

The findings of the assessment were presented at a two-day workshop in December 2013 that was attended by key stakeholders from relevant Government ministries, donors, the MoPH, and the private sector.

The assessment of Afghanistan’s readiness to establish a national accreditation organization demonstrated that the country was ready and would greatly benefit from such a system. The report concluded that a strong political will exists to improve healthcare quality and safety in a planned and systematic way that incorporates international best practices. Stakeholders expressed a strong belief that establishing an accreditation organization would be the most effective approach for implementing the quality improvement strategy. The report also observed that sufficient expertise was available in the country to govern and manage an accreditation organization with limited technical assistance. 6

During the past year, continued research and strategic planning has been conducted in order to explore the best way forward for an Afghan national accreditation organization. This included a review of the literature as well as a comparative analysis of various models of accreditation around the world (e.g. governmental vs. non-governmental/independent, mixed approaches such as public/private partnerships, voluntary vs. mandatory, and not-for-profit vs. for-profit models). A draft Five-Year (2016 to 2021) Strategic Plan to Develop the Afghan Healthcare Quality Management System and Accreditation Organization, initially developed in 2014 and then updated in 2016, provides a framework of the major components and activities necessary to establish a national accreditation organization. 7

On 19 December 2016, a newly formed Accreditation Steering Committee held its inaugural meeting, chaired by Dr. Ahmad Jan Naeem, Deputy Minister for Policy and Planning. The Steering Committee is comprised of stakeholders representing senior leaders from within the MoPH, MoHEd, Sardar Mohammad Daud Khan Hospital, National Security Department Hospital, Police Hospital as well as the private sector, including several hospital directors. At its first meeting, the Steering Committee reviewed an overview of international history and experience with accreditation models around the world. The Committee discussed preferred models for Afghanistan. Specific recommendations emanating from the December 2016 and January 2017 meetings of the Accreditation Steering Committee are incorporated into the section entitled Proposed Model for National Healthcare Accreditation in Afghanistan later in this proposal. The recommendations also consider the experiences and functions of several mature and/or evolving accreditation organizations in the region, specifically Jordan, India, Thailand, the Kingdom of Saudi Arabia, and Turkey.

6 USAID Health Policy Project. Assessment of Afghanistan’s Readiness to Establish a National Healthcare Accreditation System, 2014.

7 A Five-Year Strategic Plan to Develop the Afghan Healthcare Quality Management System and Accreditation Organization (DRAFT), June 2016.

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Proposed Model for National Healthcare Accreditation and Quality Improvement Organization in Afghanistan

Preferred Model for National Healthcare Accreditation

Vision

Every Afghan citizen will have access to health services that meet internationally accepted standards of care and ensure that a culture of continuous quality improvement and safety is an integral part of their day-to-day operations.

Mission

The accreditation organization’s mission is to continuously improve the delivery of safe, quality healthcare services provided to the public. This will be accomplished by working in collaboration with our stakeholders to set evidence-based standards, facilitate implementation of standards, and conduct reliable assessments.

Core Values

As reflected in the National Health Strategy 2016 – 2020, the five core values of the Ministry of Public Health (MoPH) are defined as: 8

Equity Integrity Right to Health Accountability Trust.

These overarching MoPH core values align well with those specifically proposed to guide the design of the accreditation organization. 9 These include the following:

Transparency: Transparency is defined as operating in a way that makes it easy for others to see what actions are performed. In the case of accreditation, the standards and accreditation processes will be published and made available to all interested parties. Reports of the accreditation organization‘s activities and funding will be open for review.

Confidentiality: Information considered confidential in an accreditation organization includes any that the organization has a legal duty not to disclose publicly, such as sensitive or proprietary information received from outside organizations in the course of its activities, patient-identifiable health information, or personnel files. The board, accreditation organization, surveyors, facilitators, and contractors will be held accountable for maintaining confidentiality.

Integrity: Professional integrity defines a professional as one who consistently and willingly practices within the guidelines of the mission of the organization under the obligation of a code of conduct that

8 National Strategy for Improving Quality in Health Care, 2011-2015. Ministry of Public Health of Afghanistan, 2011.


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includes honesty, appropriate use of resources, avoiding conflicts of interest, and complying with the policies and procedures of the accreditation organization.

High reliability: A high-reliability individual or organization demonstrates a high degree of accountability for decisions and work. Accreditation decisions depend on accurate collection of data and accurate scoring and reporting mechanisms. Consistency of interpretation of the standards and scoring is critical to the perceived integrity of accreditation decisions, and thus the reputation of the accreditation organization.

Quality management: All members of the accreditation organization participate in improving processes, products, services, and the culture in which they work, which includes the involvement of management, workforce, suppliers, and customers. The accreditation organization’s standards and surveyor training are designed to meet the standards of the International Society for Quality in Health Care (ISQua). 10

Collaboration/partnership: The MoPH, partners, and stakeholders work together to achieve accreditation through sharing risks, responsibilities, resources, competencies, and benefits.

Efficiency: Inasmuch as one of the major issues in Afghanistan is that it has limited resources, the design of the accreditation organization needs to respect the use of all resources to carry out its work.

Sustainability: The goal is to develop a national accreditation organization in which the processes become a standard way of functioning and the partnership of the accreditation organization is self-supporting.

Goal

The overarching goal of a national healthcare accreditation and quality improvement organization will be the improvement of the quality and safety of healthcare services for all the people of Afghanistan.11 In support of this ambitious, but ultimately achievable goal, several key objectives must be considered:

Overall Objectives:

Establish a National Healthcare Quality Management System. Such a system includes a planned and coordinated national approach to institutionalizing quality management, such as training in quality principles for healthcare leaders and staff, implementation of process improvement methods and tools, data collection and analysis of key performance measures that are linked to national priorities for quality and safety. The quality management system should also include a defined process and policy for identifying, reporting, and analyzing serious quality and safety incidents that cause harm or death to patients, in order to prevent the risk of them occurring in the future.

Strengthen institutional and individual capacity for Healthcare Accreditation. This capacity-building will include education and training for healthcare leaders and staff on the accreditation standards and approaches to implement them in practice. In addition to education, capacity-building will include technical assistance and consultation to assist hospitals to implement the

10 ISQua was initiated in 1985 in connection with the World Health Organization (WHO) Working Group on Training in Quality Assurance. ISQua sets standards and accredits healthcare accrediting agencies throughout the world.


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necessary changes to processes and policies in order to achieve the expected performance of the accreditation standards.

Consolidate, harmonize and implement standards at the national level. Currently, there are several sets of standards what have been developed for various purposes and projects over the past decade. These existing standards will be used to develop a final set of standards that will be used for accreditation of Afghanistan’s hospitals. This will require a thorough review and analysis to identify best practice and contemporary standards, as well as an identification of any gaps where new standards will need to be created. This final set of standards, once approved, will supersede any previous sets of hospital standards.

Promote evidence-based decision-making through generation of evidence and operational research. A coordinated approach to the implementation of accreditation standards, evaluation, and objective performance measurement will allow the MoPH an opportunity to analyze patterns and trends in the performance of Afghan hospitals, including “best practice” hospitals. For example, implementation of standards and safety goals related to infection prevention can be evaluated over time, in order to determine if these measures resulted in improved performance and a decrease in hospital-associated infections. The results of this analysis can then be shared with hospitals in a continuous learning process, so that future decision-making can be based on evidence and data.

Some of the strategic interventions in support of the above stated objectives are provided below:

Strategic Intervention #1: Consolidation of national laws, regulations, and policies related to quality Strategic Intervention #2: Consolidation and harmonization of previous healthcare standards Strategic Intervention #3: Establishment of a national healthcare accreditation organization Strategic Intervention #4: Integration of incentives for long-term sustainability Strategic Intervention #5: Capacity-builing in healthcare quality and safety Strategic Intervention #6: Improvement in the use of data for decision-making Strategic Intervention #7: Promoting opportunities for operational research Strategic Intervention #8: Promoting international recognition and benchmarking of best practices.

Expected Results

Some of the key outcomes that will be achieved as a result of implementation of the National Healthcare Accreditation Organization are highlighted below.

A national quality management system is established, including educating and mentoring leaders and professionals in concepts of quality, collection and use of data, problem-solving, change management, and building a culture of quality and safety.

National laws, regulations, and policies related to healthcare quality are reviewed, consolidated, updated as needed, and harmonized through a formal process.

Previously developed healthcare standards are reviewed, updated, maintained, and disseminated through a formal process that includes participation by individuals with expertise in the content areas addressed in the standards. A final set of consolidated and harmonized accreditation standards is developed and published.

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With assistance of initial funding by the Government of Afghanistan and/or donors, a national accreditation organization is designed and launched. The organization supports the appointment of a Steering Committee, Board of Directors, executive staff, administrative staff, surveyors, and consultants. Operating policies and procedures are developed and implemented. International benchmarking and best practices are used when possible.

The national accreditation organization is designed to include incentives that will support its adoption by hospitals and other healthcare organizations in Afghanistan. Wide-scale adoption will in turn promote not only improved healthcare quality and safety, but sustainability and financial independence of the accreditation organization . After its start-up (e.g. first 7-10 years), the accreditation organization will eventually be supported, partially or in full, from the fees related to accreditation services, education, and consultation.

Proposed Key Functions of the National Healthcare Accreditation Organization

The design and key functions of the proposed national healthcare accreditation and quality improvement organization for Afghanistan are based on a careful literature reviews as well as a comparative analysis of the key functions of other national accreditation organizations in the region that have existed for at least several years. This comparative analysis is reflected in Table 1 below. Although this regional analysis is useful for benchmarking purposes, ultimately each country designs and evolves its accreditation organization to best suit the national healthcare structure and priorities for quality and safety, as well as its economics and market realities.

The key functions of the national healthcare accreditation organization proposed for Afghanistan include:

1. Setting evidence-based and internationally-recognized quality standards for hospitals, and eventually, other healthcare provider organizations, such as clinics, primary care centers, and diagnostic laboratories;

2. Facilitating adoption of a quality and safety culture, as well as implementation of accreditation standards, by hospitals and other healthcare provider organizations through technical assistance, education, and the provisions of tools and resources;

3. Assessing a hospital’s or healthcare provider organization’s adherence to the standards through a rigorous, reliable, valid, and objective on-site evaluation by trained evaluators or surveyors;

4. Providing official recognition to a hospital or healthcare provider for its performance in achieving the standards through the award of an accreditation decision (which is typically valid from two to four years);

5. Providing key stakeholders, such as the Government of Afghanistan, the MoPH, health professionals, insurers, donors, and the public with objective data about the quality performance of hospitals and other provider organizations in Afghanistan;

6. Serving as a repository of data about the quality and safety of hospitals and other healthcare provider organizations in Afghanistan;

7. Providing opportunities for operational research about healthcare quality and safety in Afghanistan; and;8. Participating in international exchanges and benchmarking of best practices with other national

accreditation organizations and achievement of International Society for Quality in Health Care (ISQua) accreditation status.

Table 1 below represents a high-level comparative analysis of the key functions of five other mature or evolving accreditation systems in the region as well as for those function proposed for Afghanistan.

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Table 1: Key Functions of Accreditation Organizations in the Region

Key Functions of the Accreditation Organization

Afghanistan

(Proposed)

Jordan India Thailand Saudi Arabia

Turkey(new in2017)

Setting evidence-based standards for hospitals and other healthcare provider organizations

Yes* X X X X X

Facilitating adoption of a quality culture and adherence to the accreditation standards through technical assistance and education

Yes* X X X X Still very new

On-site evaluations of hospitals and other healthcare provider organizations to determine adherence to the standards

Yes* X X X X Yes*

(planned)

Providing official recognition through an accreditation award (for those organizations meeting threshold of standards performance)

Yes* X X X X

None yet, as program just announced in Feb 2017; testing in several hospitals

Providing key stakeholders with objective data and conclusions about the quality performance of hospitals and other provider organizations

Yes* X X X X

Too early, new program

Serving as a repository of data about the quality and safety of hospitals and other healthcare providers

Yes* X X X X


Providing opportunities for operational research Yes* X X X X


Achieving ISQua Accreditation and participating in international benchmarking and best practices

Yes*

(in 5-7 years)

X X X X


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Key Functions of the Accreditation Organization

Afghanistan

(Proposed)

Jordan India Thailand Saudi Arabia

Turkey(new in2017)

2007: Standards

2009: Surveyor Training Program

2010: HCAC

Proposed Model for the Governance Structure

Based on the 2013 assessment of Afghanistan’s readiness for a healthcare accreditation organization as well as a literature review and analysis of five mature and/or evolving healthcare accreditation organizations in the region, a public-private partnership model for an accreditation organization is recommended for Afghanistan. A newly-developed accreditation organization will serve as the chief mechanism to achieve the strategic objectives of a national accreditation system in Afghanistan.

A public-private partnership (PPP) represents a contract between a government institution and private party, under which the private party performs an institutional function to produce specified outputs. For example, the institutional functions performed by the accreditation organization on behalf of the Afghan government would include setting and promulgating standards; recruiting, training, and managing consultants and surveyors; providing education and consultation to healthcare organizations seeking accreditation; all aspects of financial management, including collecting fees for services; managing marketing and business development to engage healthcare organizations in the accreditation approach. In essence, the private party (accreditation organization) is responsible for designing, implementing, and managing all of the operational aspects of national accreditation.

The government, through the MoPH, remains involved in setting strategic direction in accordance with national priorities and plans. Such a model, especially in the first 5-7 years of the accreditation organization, will allow for strong government representation and close guidance and support from the Ministry of Public Health, while still maintaining a critical “arms-length,” from the government where necessary. The “arms-length” approach supports objectivity and credibility in the evaluation process and is a model that is used in many other countries.12

A regional example of such a public-private partnership can be seen in Thailand, where for the past seven years the hospital accreditation system has been administered by a formal independent government organization, Healthcare Accreditation Institute (HAI), which is nonetheless accountable to the Minister

12 Shaw, C. Quality and accreditation in health care services: a global review. World Health Organization, 2003 (data updated 2010).

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of Health. Also reflective of the relationship between the Healthcare Accreditation Institute (HAI) and the Ministry of Health is that the HAI Board signs a Performance Agreement with the Minister of Health.13

The participation of the Government of Afghanistan and the MoPH in the accreditation organization will also provide financial support to the new entity in its first 7-10 years – from the government and/or international donors − until such time as the accreditation organization can be financially self-sustaining through the collection of revenues from accreditation survey fees and education and consultation.

Explanation of the Proposed Governance Model

Supporting legislation incorporating the accreditation organization as a non-profit legal entity is proposed. While this is not always done in other countries, especially if the accreditation organization is a unit of the Ministry of Health, international experience has shown that a formal legal status supports long-term sustainability of the accreditation organization, even though changes in governments, administrations, donors, and funding support. In a 2013 survey of 44 healthcare accreditation organizations from around the world, two-thirds of organizations (29 out of 44) were formally authorized by national legislation, official decree, or both.14

An example of such supporting legislation can be seen in Thailand, generally viewed among global healthcare accreditation as a successful model that has evolved from quality improvement initiatives to full accreditation over the past twenty years. The Institute of Hospital Quality Improvement and Accreditation played a crucial role in promoting standard and quality of healthcare in Thailand for many years. Being recognized by its roles, the institute became a public organization in 2009. Objectives of HAI which are promulgated in the Royal Decree on the Establishment of The Healthcare Accreditation Institute or HAI (Public Organization) B.E. 2552 (2009) are as follows:15

1. To assess work systems and accredit healthcare organizations. These activities include setting up standards of healthcare organizations that will be used as a framework for assessing quality improvement and accrediting healthcare organizations.

2. To collect, study and analyze data and make recommendations which aim to promote, support and improve quality of healthcare organizations.

3. To promote and support the establishment of mechanisms which systematically improves quality and safety of healthcare services.

4. To generate and disseminate knowledge and provide access to knowledge on quality assessment, quality improvement and accreditation of healthcare organizations.

5. To collaborate with state agencies, national and international organizations, and private sector that are interested in quality assessment, quality improvement and accreditation of healthcare organizations.

6. To formulate curricula and train healthcare personnel in order to escalate understanding on tools for quality assessment, quality improvement and accreditation of healthcare organizations.

A governing organization or Board of Directors (BoD) should be established, one that represents government, military and private hospitals as well as other related stakeholders, such as insurers or professional societies. Specific composition for the BoD has been proposed in the later section of this

13 Personal communication with Dr. Anuwat Supachutikul on behalf of the Healthcare Accreditation Institute of Thailand, 2017.

14 Shaw, C, Braithwaite, J, Moldovan, M, Nicklin, W, Grgic, I, Fortune, T, Whittaker, S. Profiling health-care accreditation organizations: an international survey. International Journal for Quality in Health Care 2013; 25 (3): 222-231

15 Web site of Healthcare Accreditation Institute of Thailand (HAI). https://www.ha.or.th/EN/AboutUs/History

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https://www.ha.or.th/EN/AboutUs/History

proposal. In order for the accreditation organization to optimize the public component of its structure and governance, it is proposed that the Board and the accreditation organization report to H.E. the Minister of Public Health.

As noted above, there will be a need for government financial support in the initial stages and first at least 7-10 years, until the accreditation organization can become self-sustaining. External funding support will be actively explored and sought, including both government and donor support in the initial stages of the accreditation organization’s implementation.

It is recommended that accreditation be voluntary in the initial stages (e.g. for at least 7-10 years), which will help to build a commitment to the change management process from hospital leaders across Afghanistan. A package of incentives should be developed for those organizations that achieve accreditation. Specific suggestions for the incentives package have been provided later in the proposal. Eventually (after at least 7-10 years), Afghanistan may want to consider phasing in a mandatory accreditation process. By that time, all hospitals in the country will have had sufficient exposure to the standards as well as to education and consultation about the standards. A mandatory process helps to maintain more standardization among hospitals across the country and also helps to ensure that the accreditation organization remains financially viable and self-sustaining.

It is recommended that the new accreditation approach be piloted in ten hospitals, including public, private and military hospitals, and the results of the pilots then be evaluated in order to inform the next steps, including a determination of whether accreditation should be mandatory or voluntary. As noted above, many national accreditation organizations begin with voluntary systems; then depending on the successful adoption of the program by hospitals and health care provider organizations, may eventually phase-in a mandatory process.

Key Specifications and Comparative Analysis of the Governance Functions of the Organization

At its December 2016 meeting, the Accreditation Steering Committee suggested that more accreditation models from within the region should be reviewed, particularly for those countries similar to Afghanistan. Lessons learned should then be applied in Afghanistan context.

Table 2 below represents a comparative analysis of the governance functions of five other national accreditation organizations from within the region.

Table 2: Comparative Analysis of Key Specifications of Other Accreditation Organizations

Specifications Afghanistan(proposed)

Jordan(HCAC)

India(NABH)

Thailand(HAI)

Saudi Arabia

(CBAHI)

Turkey(TUSEB)

Legal Structure and Reporting Line

Propose a public-private partnership model, with accreditation organization CEO reporting to Board or Directors with govt representation,

The Health Care Accreditation Council (HCAC) is a private, nonprofit, share holding company, registered with the Jordanian

NABH is one of five Boards under the Quality Council of India, each having functional autonomy. The MOH is one of the

HAI-Thailand began as a program under the Health Services Research Institute in 1997; in 2009 was incorporated as HAI. It

CBAHI has emerged from the Saudi Health Council as a non-profit organization. Governed by a Director General who reports to a

All healthcare accreditation activities are supported by the Ministry of Health and carried out by TUSEB, which is a related organization

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Jordan(HCAC)

India(NABH)

Thailand(HAI)

Saudi Arabia

(CBAHI)

Turkey(TUSEB)

which in turn reports to HE the Minister of MoPH.

Ministry of Industry and Trade since 2007. Governed by a Board of Directors representing public and private health sectors, including insurers and professional associations (e.g. Jordan Nurses and Midwives Association).

Board members of the NABH Board. The Constitution of the NABH is approved by the Governing Board of the Quality Council of India.

constitutes a public-private partnership model, Healthcare Accreditation Institute (HAI) is accountable to Minister of Health; HAI signs a Performance Agreement with the MOH.

Board of Directors.

of the MoH.

Accreditation activities are based on a law issued in 2015 describing the new organization , established as “Health Institutes of Turkey” (TUSEB); and a newer regulation detailing the responsibility of “Turkish Healthcare Services Quality & Accreditation Institution” (TUSKA – under the umbrella of TUSEB) issued in 2016.

Note: System just announced Feb 2017.

Authority in Hiring and Firing

Proposed for Board (hire CEO); CEO/ management team hire staff and surveyors

Yes, under governance of CEO and Board

Yes, CEO reports to the NABH Board of Directors; NABH maintains functional autonomy within Quality Council of India



Unknown (new system

Financial Independence

Donor and/or government support for at least the first 5 years

Donor support for initial development and launch, now self-funded through

Now self-sustaining through accreditation and education/consultation fees

Funding is 50% from Thai government(=approx $US 1.4M - $2.5M/year),

Funded by the MOH for public hospitals; private hospitals and healthcare

Not applicable; program new as of Feb 2017; Healthcare organizations

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Jordan(HCAC)

India(NABH)

Thailand(HAI)

Saudi Arabia

(CBAHI)

Turkey(TUSEB)

accreditation/ educational fees. Consultation and Training separate

and grants 50% from accreditation and education fees and other grants

providers pay an accreditation survey fee

will be charged for the survey activities. However, the amount of fee is not identified yet; Ministry of Finance’s comments are expected.

Funding Source Recommend that donor support be explored for at least the first 5 years

Initially funded by donor support for development of the accreditation organization and technical assistance and education to the public hospitals. Recommends that Afghanistan consider a similar model of support for public hospitals to build their capacity to meet the standards.

In 2005, NABH was set up as one of the Boards of the Quality Council of India (QCI), so seed money came from QCI; Now self-supported through fees, but NABH stresses importance of it getting new organizations to apply for accreditation in order to maintain this.

Initial funding (1999) from the Thai government and two research institutes = approx$US 700K; originally intended to become self-sustaining but found that since most hospitals are public, they could not afford increased accreditation fees. Now funded 50/50 from Thai govt and from survey fees

Initial funding by the MOH

MOH received donor support over past 10 years (e.g. World Bank) which included the development of national accreditation

Mandatory vs. Voluntary

Proposed voluntary to start; plan to accredit 10 hospitals within 7-10 years; may consider mandatory in future

Now has regulations that all hospitals (106 total) and primary health centers must be accredited within three years

Voluntary Voluntary but have accredited 57% of the hospitals in Thailand (mostly public sector)

Mandatory for all eligible healthcare facilities (as of late 2013)

Voluntary to start (new as of Feb 2017); will look to make mandatory in the future, depending on success of adoption

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Legal Basis for Establishment of the National Healthcare Accreditation Organization and Implications for Other Laws, Regulations, and Administrative Documents

Governments around the world have developed different legislations for facilitating healthcare reform and improving the quality of services. Legislation could be in different forms such as law, regulation and the presidential decree. The MoPH conducted a regulatory assessment in order to determine the best structure for establishment of the National Healthcare Accreditation Organization. MoPH reviewed relevant laws and regulations such as Afghanistan’s constitution, the medical council draft law, public health law, the mass media law, higher education law, PPP law, private health centers regulation and regulation of legal assistances. Government institutions in other sectors with similar mandates such as Accreditation board of higher educational institutions were also reviewed.

The review found that various legislative documents have been enacted for establishment of independent or semi-independent bodies in Afghanistan. The Interim Medical Council has been established via presidential decree and the Interim Medical Council is then mandated to draft the medical council law. The Accreditation Board of Higher Educational Institutions has been established through a regulation by Ministry of Higher Education (MoHEd). In addition, the Independent Board for Legal Assistances has been established through a regulation by Ministry of Justice and the body includes representatives from both the Government and Non-Government stakeholders including Kabul University, Human Rights Commission and NGOs providing the legal services.

Likewise, through the mass media law developed by the Ministry of Culture, Tourism and Youth, a Media High Council and Mass Media Commission has been established to manage affairs related to media across Afghanistan, draft the required policies and provide dispute settlement and resolution. The council is currently functioning well representing both the public and the private sector. The following Table 3 summarizes organizational structures and their legislative basis of a number of entities in Afghanistan:

Table 3: Summary of Organizational Structures and Legislative Basis in Afghanistan# Structure Legislative

BasisEstablished by and reportable to Status

1 Interim Medical Council and the Medical Council Organization

Presidential Decree

MoPH Independent

2 Accreditation Board of Higher Educational Institutions

Law Ministry of Higher Education (MoHEd)

Operates independently within the framework of MoHEd

3 Independent Board of Legal Assistances

Regulation Ministry of Justice (MoJ) Operates independently within the

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framework of MoJ

4 Media High Council and Mass Media Commission

Law Ministry of Culture, Tourisms and Youth (MOCTY)

Operates independently within the framework of MoCTY

In addition, review of countries such as Jordon, India, Thailand, Saudi Arabia and Turkey also demonstrates that the accreditation organizations are established through various legislative documents including law, regulation and the presidential decree.

Given the above organizational structures within Afghanistan’s administrative system, and the international lessons learned, there are a few options for establishment of the National Healthcare Accreditation Organization including through a law, a regulation or presidential decree. In addition, some of the current laws could be amended to include provisions for establishment of the Healthcare Accreditation Organization; for example, amendment of the health law, the medical council law or the private health centers regulation. As a preferred model, it is recommended to establish Afghanistan’s National Healthcare Accreditation Organization as an independent body, through a regulation, which will be reportable to the MoPH. The organization shall operate based on public-private partnership, capable of generating revenue.

Proposed Governance

The accreditation organization will be overseen by a Board of Directors, which in turn will report to the Minister of Public Health. The Board will be guided by a set of bylaws. The Board will set policy and direction, establish and monitor the budget and financial systems, and ensure that the strategic objectives are met. Responsibilities will include selecting the Chief Executive Officer (CEO); approving the strategic, business, marketing, and operational plans; approving and monitoring the annual budget; and ensuring that accepted accounting practices are employed, including annual financial audits. In addition, the Board will approve the healthcare facility standards and certification of surveyors, award accreditation, support improvements in the quality and safety of healthcare services, and represent the accreditation organization within the community.

The International Accreditation Program (IAP) standards for accreditation published by the International Society for Quality in Healthcare (ISQua) provides guidance for the structure and functions of the governing organization. 16

At its 11 January 2017 meeting, the Accreditation Steering Committee recommended that the composition of the Governing Organization or Board of Directors for the accreditation organization include the following:

Minister of Public Health Minister of Finance Minister of Higher Education Director of Health for Ministry of Defense

16 International Society for Quality in Health Care. Guidelines and Standards for External Evaluation Organisations 4th Edition Version 1.1 July 2014. Dublin: International Society for Quality in Health Care, 2014.

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Director of Health for Ministry of Interior Health Advisor to the Presidential Office Head of Health Committee of Parliament APHA President Representative of the medical or nursing council Represntative of Academic Institutions, and Director of Accreditation Organization as Non-voting Member

Some national accreditation organizations include a representative of the insurance industry and/or a public advocate. Benchmarking with the Jordanian national accrediting organization (HCAC) reflects a successful model of twelve Board members that includes not only representatives from the public sector, but the private as well; this includes a representative from the pharmaceutical field, a private equity investor, academia, the medical council, a social entrepreneur, and the association of nurses and midwives.17

Proposed Organizational Structure and Key Staff

Executive Management

Once the legal structure determined, a Board of Directors appointed, and bylaws approved, the first priority will be for the Board to hire and appoint a Chief Executive Officer (CEO). This individual will report directly to the Board of Directors and is responsible for all of the operations of the Afghanistan healthcare accreditation organization.

Divisional Management Structure

The draft Five-Year (2016 to 2021) Strategic Plan to Develop the Afghan Healthcare Quality Management System and Accreditation Organization recommends that the accreditation organization be structured into two technical divisions as well as a division focused on finance and administration. 18 The scope of work of each division is highlighted below. Detailed Terms of Reference or job descriptions for the Chief Executive Officer and the Directors of the two technical divisions and finance and administration are included as Annex B to this proposal.

The Standard and Survey Division will be responsible for standards development, maintenance, and dissemination, as well as the conduct of the external accreditation surveys, including surveyor management and determinations about accreditation awards.

The Education and Consultation Division will be responsible for consultation and education, which will focus on assisting healthcare facilities to meet the standards; capacity building of healthcare professionals to meet the standards; and internal and external training, including certification courses. Experience from other countries shows that hospitals and other healthcare organizations require significant educational support and technical assistance in order to be able to build a culture of quality and safety, understand the intent of the accreditation standards, and fully implement the standards in policy and practice.

17 Web site of the Jordanian Health Care Accreditation Council (HCAC), http://hcac.jo/en-us/About-Us/Board-of-Directors


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http://hcac.jo/en-us/About-Us/Board-of-Directors

The Finance and Administration Division will oversee business development and public relations, information technology, accounting, finance, internal and external auditing, contracting, human resources management, including staffing plans and staff development planning, housekeeping, maintenance, fire safety, health and safety, and transportation.

Figure 1 below illustrates the overall organizational structure of the accreditation organization. Additional staff will be hired for each of the three divisions as the organization grows; however, some functions may be contracted with external vendors (e.g. housekeeping, public relations, and research). The organizational structure of the accreditation organization will begin with the CEO recruiting and appointing the three directors.

Figure 1: Initial Afghan Accreditation System Organizational Chart

Required Funding and Business and Sustainability Plan

Funding Considerations and Approaches

The costs associated with establishing a national healthcare accreditation organization vary greatly from country to country, and are based on several factors. If the organization is an add-on to an already established organization in the government, a ministry, charity, or foundation, the costs may be less. If the people who will govern, manage, and staff the organization have the knowledge and skills to do the work, less funding needs to be used for capacity building. If there is a well-established quality improvement

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CEO

Director of Standards & Surveys

Surveyors

Director of Education & Consultation

Consultants and Faculty

Director of Finance & Administration

Administrative Staff (IT, Finance, Office

Management)

Executive Secretary

Board of Directors

system in the country, such that healthcare facilities already have established a culture of quality and safety, fewer resources are needed to prepare organizations for accreditation.19

The latter consideration − how ready hospitals and healthcare organizations actually are to implement the accreditation standards − will make a great difference in terms of the level and amount of education, consulting, and technical assistance that will be needed. Although Afghanistan has been working toward the establishment of a quality and safety culture within its healthcare organizations for the past decade, there is still much work to be done. Therefore, it is anticipated that the hospitals seeking accreditation will need considerable upfront help throughout a quality journey that can take 3-5 years, depending on the size and complexity of the hospital.

Accreditation organizations around the world sustain themselves through many different means, depending on the way the accreditation organization in the country operates. For example, if the legal structure is a public-private partnership with a close relationship to the government through the MoPH, it is typical that partial financial support for the organization be included in the MoPH budget.

Initially, it is anticipated that the establishment of the national healthcare accreditation organization will need government and/or donors’ support. The MoPH may consider including the establishment of the national healthcare accreditation organization in government’s National Priority Program (NPP). The Afghanistan government may also contribute funds from its national budget to demonstrate its commitment to the organization. Donor support will be required for at least the first five years for Kabul, and additional funding may be needed to roll out and scale up the program countrywide. All indications gleaned from interviewees during the initial assessment show that some public, private, and military hospitals may be ready to contribute funding to the process of training and moving toward accreditation.

For benchmarking, we can look to a mature regional example in Thailand for some insights. Its quality improvement and accreditation organization, the Healthcare Accreditation Institute (HAI) was launched in 1999 with grants from two research institutes for the first three years of its operation. Total funding from the two grants equaled 25M Baht, or approximately $US 710,000. Over time, HAI attempted to become self-sustaining through accreditation fees and education; however, the public hospitals complained that the fees were too high, so when HAI became a public organization seven years ago, it looked to the government to supplement its revenues from fees and education alone.

The HAI fee structure is calculated as number of man-days used for accreditation survey, i.e. 15,000 Baht per man-day (equivalent to $US 425/man-day), and is inclusive of all travel costs. The number of man-days per survey range from four to fifteen, depending on the size of the hospital. Today the Thai government provides annual funding to HAI of 50-90M Baht, equivalent to approximately $US 1.4M to $US 2.5M/year. The remaining 50% of HAI’s annual budget comes from accreditation fees, educational revenues, and other grants. To date, HAI has accredited 57% of the hospitals in the country (796 out of a total universe of 1,379 hospitals); the vast majority of these are public hospitals. Financial incentives are provided by the National Health Security Office and the Social Security Office.

Table 4 includes a range of accreditation survey fees currently employed in the benchmark countries. Turkey is not included in this analysis, since the accreditation organization was recently launched in February 2017 and the official fee structure has not yet been formalized or announced. However, it is


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helpful to compare the revenue from survey fees for the national healthcare accreditation organizations described below.

Table 4: Accreditation Survey Fee Structure by Country (in $USD for comparison, rounded)

National Accreditatio

n by Country

Jordan

(HCAC)

India

(NABH)20

Thailand

(HAI)21

Saudi Arabia

(CBAHI)22

Survey Fees (for one-time accreditation

survey)

<50 Beds = $15,000

50 -150 beds = $26,000

150 – 300 beds = $32,000

300 – 500 beds = $41,000

>500 beds = $49,000

*Inclusive of travel costs, 2010 data

<100 beds = $25,000

101-300 beds = $37,000

301-500 beds = $54,000

>500 beds = $66,000

*Inclusive of travel costs

Fees are based on size of hospital and number of surveyor man-days @$425/man-day

Range of surveyor man-days is 4-15 days, depending on hospital bed size. Thus range of accreditation fees = $1700 to $6375.


Fees for private hospitals:

<100 beds = $40,000

>100 beds = $66,000


Incentives for Accreditation and Impact on Sustainability

Having an incentive system in the country will greatly improve financial sustainability. An important component to ensure uptake and eventual long-term sustainability is to build-in rewards and incentives for hospitals to participate in the accreditation scheme, beyond the obvious benefits of improved quality, safety, and patient satisfaction. This will attract hospitals to want to participate in the program and on a long-term basis, remain accredited. Many countries find that financial incentives for participation can be very attractive, thus helping to build hospitals’ interest in and commitment to the accreditation organization. The more hospitals are actively engaged in accreditation, the more opportunity for the accreditation organization to sustain and grow from resulting accreditation, consultation, and education revenues. Conversely, if there is little “uptake” in accreditation among eligible hospitals, the organization is not likely to succeed long-term, both financially and from a quality impact perspective.

For example, in the Indian National Accreditation Board for Hospitals and Healthcare Providers (NABH), incentives have proven very helpful in supporting this voluntary accreditation organization in the past ten

20 Web site of National Accreditation Board for Hospitals and Healthcare Providers (NABH), 2017. http://nabh.co/Images/pdf/FeeStructure_Revision2016.pdf

21 Personal communication with Dr. Anuwat Supachutikul on behalf of the Healthcare Accreditation Institute of Thailand, 2017.

22 Personal communication with Saudi Central Board for Accreditation of Healthcare Institutions (CBAHI), 2017.

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http://nabh.co/Images/pdf/FeeStructure_Revision2016.pdf

years. The central government, under its Central Government Insurance Scheme (CGHS) provides an additional 15% reimbursement to those hospitals accredited by NABH. Many state government health insurance schemes provide incentives to NABH-accredited hospitals, and recently the insurance regulatory organization issued a directive that within two years private hospitals providing care under insurance must achieve NABH Pre-Accreditation Entry Level Certification.23

Although the Turkish national accreditation organization is quite new, already discussions are on the table with respect to a variety of incentives for accreditation, such as exemption from the MoH quality audits or a higher reimbursement from the National Social Security Institution.

Figure 2 shows a chart of accreditation organizations around the world that employ some type of incentive for hospitals and healthcare organizations to participate in accreditation.24

Figure 2: Examples of Incentives for Accreditation around the World

Note: Results reflect survey date from 44 accreditation organizations

Examples of potential financial as well as non-financial incentives include:

Less on-site monitoring by the MoPH; Government to activley promote referall of patients to accredited hospitals; Providing license to the accredited hospitals; e.g. the MoPH grants license based on the external review

findings by the accreditation organization; The renewal of license will be exempted for accredited private hospitals; Public recognition of accreditation status, such as National Quality Awards that are given to accredited

hospitals; Only the accredited hospitals can provide insurance services or sign contract for providing insurance; Higher rate of funding by the government or by insurance if a hospital is accredited;

23 Personal communication with Dr. B.K. Rana and Dr. Girdhar Gyani on behalf of NABH, 2017.

24 Shaw, C. Quality and accreditation in health care services: a global review. World Health Organization, 2003 (data updated 2010).

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Opportunity for accredited hospitals to be preferred providers with businesses, multi-national corporations, embassies, etc.; and

Opportunity to obtain loans from local or international development banks, including the International Finance Corporation (Note: IFC loans apply only to private institutions).

Estimated Funding Requirements for National Healthcare Accreditation Organization in Afghanistan

The detailed budget included in Annex C estimate the funding need at approximately $US 4.3 million for the over five years, in order to establish the national healthcare quality management and accreditation organization and prepare the first ten hospitals to become accredited within 5 to 7 years. The healthcare accreditation strategic plan/roadmap, however, can be implemented in phases and therefore funding can be allocated incrementally based on the results achieved; for example, funding maybe allocated for the first two years and the rest of the funding tied to the results and outcomes of the initial stages. The dollar estimate is based on the experiences of other countries of a similar size and economic status. Project funding of an estimated $US 4.3 million to cover direct costs will be needed to create and run the accreditation organization for a 5-year start-up period.

The obvious question regarding the long-term sustainability of the Afghan healthcare accreditation organization relates to the cost to run the organization after the full establishment and operation in the initial start-up period of 5-7 years. The answer depends on several factors, including the eventual scope of work of the organization, the cost of personnel, and the overhead expenses in Afghanistan, which can only be estimated at this time. The exercise to determine annual running costs, however, must be done early in the development of the organization so that the business plan clearly includes products and services that generate the revenues to cover the costs when external funds to establish the organization stop. The cost of running the accreditation organization, after full establishment, in a country with similar salaries for professionals and similar overhead expenses for a staff of fifteen is approximately $US 750,000/year.25

In addition to any government or donor financial support, as a public-private partnership the accreditation organization will need to generate revenues from services offered, including education, consultation, and accreditation services. Stakeholders in a voluntary system will need to see a return on investment (RoI) − the value brought to the hospital or healthcare organization if the leaders and staff are going to commit to undergoing a rigorous and often stressful process of change required to meet the standards and become accredited.

The accreditation organization will need a strong business development and marketing arm to generate new business and keep current customers. As noted above, factors that will create a higher probability of financial stability include mandatory accreditation and payments for services by insurance companies and the government.


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Implementation Plan26

This strategy focuses on the establishment of the Afghanistan national quality management system and a national accreditation organization to sustain it. Implementation can be done in three major phases over a 5-year period. Until the organization is formed and governed by a Board of Directors, the initial oversight will be by the Accreditation Steering Committee appointed by the Minister of Public Health.

These phases are (1) collation of past activities and building the foundation of the system and the accreditation organization, (2) establishing the accreditation organization, and (3) scaling up from Kabul to the entire country and strengthening the system for sustainability. The phases have no definitive beginnings because some activities will begin in one phase and continue in another. One way to look at the phases is that they do not follow one after another; rather, each has a focus area and is done in order of its priority.

Phase One: Collation of past activities and building the foundation of the accreditation organization

The process of consolidating those past achievements that have moved Afghanistan toward building its national healthcare quality management system is the first step in Phase One. This phase will take approximately one year to initiate and continue during the other two phases; it also will lay the foundation for the system and for moving into the next two phases. The objectives of Phase One are as follows:

Objective 1. Establish a national healthcare quality management system.

Key Result 1.1: The Steering Committee has been appointed and is currently functioning.

Key Result 1.2: The capacity of MoPH staff is built regarding quality management systems, including their leadership role in building a culture of quality and safety, a learning culture, a just culture, and change management.

Objective 2. Consolidate the standards and combine previous work done to build the quality management system.

Key Result: 2.1 A model to update and integrate existing standards is developed and agreed upon.

Key Result: 2.2 Task forces of local experts are appointed to use the model, provide feedback and help consolidate the standards.

Key Result: 2.3 The standards for licensure and leveled accreditation are approved and made available to all hospitals.

Key Result: 2.4 Licensure standards are linked with the existing licensure regulations and structure.

Key Result: 2.5 Ten pilot hospitals from the public, private, and military sectors are prepared to meet the standards while piloting the new hospital standards and as a means for baseline data collection.

Key Result 2.6 A communication plan is developed to inform all key stakeholders of the accreditation system.

26 Ibid.

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Activities

Several activities take place during this phase. The first task will be to advocate for and obtain support of the relevant stakeholders for development of a national healthcare quality management system and healthcare accreditation organization.

The intent of Phase One is to engage the people at the top and all staff of the MoPH in quality improvement. They will need to know about change management; culture change; and building quality, learning, and just cultures. This phase will require capacity building in the form of workshops, seminars, and other learning methodologies, as well as changes in systems in the MoPH regarding strategic planning for quality, job descriptions that require behaviors and that improve quality, and an evaluation system that rewards quality improvement efforts.

In this phase, the ground work for the standards will be achieved by developing a model and consolidating the already developed sets of standards into a unified set for pre-licensure through accreditation. The standards will need to be field tested; during this phase, ten hospitals will be identified from the public, private, and military sectors as pilot hospitals to prepare them to meet the standards. Preparing the hospitals may carry on through the next two phases, depending on the motivation and incentives offered to the hospitals to achieve them.

Measures of Achievement

1. The Afghanistan government and key stakeholders including donors are supporting the development of the national quality management system and the development of the accreditation organization.

2. The Steering Committee is appointed and meets monthly.3. Workshops are held for the management and staff of the MoPH on quality management systems; change

management; and developing quality, learning, and just cultures.4. Changes are made in the systems and processes of the MoPH, including job descriptions containing

statements regarding the leadership’s responsibility for quality, and evaluation systems that assess the staff members’ competency in quality management and improvement.

5. Standards sets are developed for pre-licensure, licensure, and accreditation.6. Ten pilot hospitals are identified to pilot the standards and are working toward meeting the standards.

Phase Two – Establishing the Accreditation Organization

Phase Two will begin the process of building the accreditation organization. This process will start in Phase One (2017) and continue through Phase Three. Objectives and key results for phase two are provided as below:

Objective 3. Develop the national healthcare accreditation organization.

Key Result 3.1: The decision is made regarding where the organization will reside in the country.

Key Result 3.2: Bylaws are developed for the national healthcare accreditation organization.

Key Result 3.3: The accreditation organization is established within a legal framework.

Key Result 3.4: The office of the accreditation organization is opened and staff hired.

Key Result 3.5: The accreditation organization’s strategic, business, marketing, operational, risk management, quality improvement, and Monitoring and Evaluation (M&E) plans, as well as operational policies and procedures, are completed.

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Key Result 3.6: An incentive scheme is in place to encourage healthcare facilities to be accredited.

Objective 3.8 National Quality and Patient Safety Goals are launched annually and are being met by hospitals in Kabul.

Objective 4. Build capacity of the accreditation organization’s governing board, management, technical staff, surveyors and facilitators to fulfill their roles and responsibilities.

Key Result 4.1: The accreditation organization’s Board and CEO are appointed and oriented to their roles and responsibilities.

Key Result 4.2: Technical and administrative staff are hired and oriented, and a staff development plan is written and implemented.

Key Result 4.3: Surveyors, facilitators, quality improvement coordinators, and infection preventionists are trained and certified to carry out their specific roles and responsibilities.

Objective: 5. Develop an information management system for better decision making.

Key Result 5.1: An information management plan is developed, includingmonitoring and evaluation of key indicators.

Key Result 5.2: Databases are established to aggregate and analyze the data.

Key Result 5.3: Targeted staff are trained to manage the databases.

Key Result 5.4: Data are being collected from Kabul hospitals.

Key Result 5.5: Data are being used by leaders, managers, and quality improvement teams to make decisions.

Activities

This phase will overlap with Phases One and Three and focuses on establishing the accreditation organization. The foundation may be built in Phase One through appointing the Steering Committee and writing the bylaws. During this phase, the organization will be designed and established according to the ISQua International Accreditation Program standards. The Board will be appointed and oriented, as will the CEO and technical staff. The management staff will complete the plans and operational policies and procedures required to run the organization.

Work will begin on how to create incentives for accreditation through exploring several means, including legislation to link it with licensure, thus making it mandatory; payments by insurance or government based on having an accreditation award; or other means. Hospitals will receive technical assistance to develop credentialing and privileging systems as well as design ways to provide continuing education for their physicians and nurses.

To encourage healthcare facilities to experience how accreditation works and improve patient safety, many countries establish two or three national patient safety goals annually, which include criteria to be met, and hospitals sign up to achieve the goals. The hospitals are surveyed; if they achieve the goals, they are awarded a certification for one or two years. The system encourages hospitals to begin the quality improvement process without being overwhelmed. The accreditation organization will approve and communicate the goals every year in the 4th Quarter, or at least two month before the end of the year,

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giving healthcare facilities a year to develop the systems to meet the goals. An annual event will be held to launch new goals and recognize those hospitals that have achieved success.

A task force needs to evaluate information management needs and develop an information management plan to support the accreditation system. Databases need to be developed and staff trained on how to manage and use them for decision making.


1. Bylaws are developed and the organization legally established. 2. Board members are appointed.3. The CEO and directors hired, oriented to their roles and responsibilities. 4. Plans and operational policies and procedures are developed. 5. Incentives for accreditation are in place.6. There is a re-licensing, credentialing, and privileging system applied to all physicians, nurses, and other

healthcare professionals.7. National Quality and Patient Safety Goals are established, and hospitals are working toward achieving

them.8. Certification curricula are developed for surveyors, facilitators, QI coordinators, and infection

preventionists; and risk manager courses are offered and participants certified.9. An information management system plan is developed and being implemented.10. The accreditation organization’s hospital standards are accredited by ISQua.

Phase Three – Scaling up from Kabul to the entire country and strengthening the system for sustainability

This phase will focus on obtaining ISQua accreditation of the standards, the surveyor training program, and the overall accreditation organization. During this phase, an effort will be made to engage the provincial centers in the accreditation process and begin addressing operational research. Phase Three is not the end of the process — only the end of the first five years. Much more needs to be done to bring the entire country along on the journey to continuous quality improvement.

Objective 6. Obtain ISQua accreditation of the Afghan Hospital Accreditation Standards (AHAS), the surveyor training program, and the Afghan accreditation organization.

Key Result 6.1: The accreditation standards are accredited by ISQua.

Key Result 6.2: The accreditation organization’s surveyor training program is accredited by ISQua.

Key Result 6.3: The overall Afghan accreditation organization is accredited by ISQua.

Objective 7. Expand accreditation services to the provincial level.

Key Result 7.1: All provincial staff are oriented to the accreditation system and standards.

Key Result 7.2: Community awareness campaigns are begun to educate the public about the value of healthcare facility accreditation.

Objective 7.3 The strategy to implement accreditation in the country is updated and extended for additional five years and approved by the Board.

Objective 8: Conduct operational research.

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Key Result 8.1: Research studies are completed on improving the quality of the accreditation organization’s services and the results of accreditation.

Objective 9. Incorporate quality management, patient safety, and accreditation concepts into physician, nursing, and other health professionals’ pre-service training.

Key Result 9.1: Healthcare professional educational leaders are engaged in the quality management and accreditation development process.

Key Result 9.2: A course in quality management, patient safety, and accreditation for healthcare professionals is developed that can be incorporated into their pre-service training.

Activities

During this phase, an application will be submitted to ISQua to obtain the accreditation of the Afghan accreditation organization. Earlier in the project, the standards will have been submitted for accreditation because an organization cannot apply for ISQua accreditation without having its standards accredited first. ISQua currently is changing its accreditation system; by the time the Afghan accreditation organization is ready for accreditation, ISQua will have combined the surveyor training with the organizational survey.

Activities during this phase will be to engage the provincial centers in the accreditation process and begin educating the public/communities about the value of accreditation for improved healthcare services. It will also be the time to begin to use the data gathered and look to operational research to support accreditation in Afghanistan.

To strengthen the system and enhance sustainability, quality management and accreditation concepts must be taught in health professionals’ pre-service training. In addition, courses will be developed for each health professional school in Afghanistan.


1. The hospital standards are accredited by ISQua.2. The surveyor training program is accredited by ISQua.3. The accreditation organization is accredited by ISQua.4. The Board has developed a five-year strategic plan.5. Community awareness programs are initiated.6. Provincial health departments are aware of the accreditation organization and support it.7. Quality management, patient safety, and accreditation concepts are taught in all health professionals’ pre-

service training programs in the country.8. Research studies have been planned and are underway.

The proposed Implementation Plan for the national healthcare accreditation organization includes a Work Plan (Annex A) showing specific activities that must be done to achieve incremental progress over the next five years. This strategy and plan focus on developing the accreditation organization and rolling out accreditation, first in the Kabul region to a set of ten pilot hospitals. Once established, the next phase will be to scale up the system to the entire country. Activities to involve the provinces in the accreditation process can begin in tandem with other activities; for example, when standards are finalized, they can be introduced to hospitals throughout the country.

The proposed Work Plan is included as Annex A to this proposal.

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Monitoring and Evaluation Plan

The CEO and management team of the accreditation organization will need to develop a Monitoring and Evaluation (M & E) Plan that is approved by the Board of Directors. Typically M & E activities are conducted on at least a quarterly basis, and may include both qualitative and quantitative measures to evaluate the overall effectiveness of the accreditation system and organization from a variety of perspectives.

The ISQua International Accreditation Program standards require the accreditation or external evaluation organization to evaluate the performance of various functions (such as governance, human resources management, surveyor and survey management and accreditation or certification processes and outcomes), by collecting data on defined indicators and other measures of performance, analyzing it, making improvements and evaluating achievements.27

Internal audits, indicators and quality improvement projects will form part of the overall quality framework of the organization. Indicators and data routinely collected by many accreditation organizations and reported to governing boards include:28

Recruitment of organizations pursuing accreditation by number and type (e.g. public vs. private hospitals) Drop-out of participating organisations; Denial rate (proportion of organisations refused accreditation or certification); Report turnaround times (from survey date to final report or to award decision); Serious adverse events (sentinel events) occurring at accredited organizations and their root causes; Complaints are investigated, managed and completed in a timely manner, in accordance with established

policy and procedure; Nature of complaints received about accredited organizations and their resolution; Financial performance, such as actual against annual budget and various financial ratios; self-sustainability through accreditation, consultation, and education fees; Number of web site hits; Types and effectiveness of incentives available to accredited organizations; Surveyor recruitment, training and evaluation; Client satisfaction with surveyors, education services, the survey process, the survey visit and other

products provided by the program are measured on at least an annual basis and demonstrate an overall positive rating of 90% or above;

Staff and surveyor satisfaction; and Satisfaction and recommendations of other stakeholders, such as the MoPH, provincial leaders, donors,

professional societies, academic institutions, community or advocacy groups.

On at least an annual basis, the results of the monitoring and evaluation should be reflected in a written report to the Board of Directors that includes any recommended changes to overall strategy, policies, processes, or operational plans and budgets.

27 International Society for Quality in Health Care. Guidelines and Standards for External Evaluation Organisations 4th Edition Version 1.1 July 2014. Dublin: International Society for Quality in Health Care, 2014.

28 Fortune, T, O’Connor, E, and Donaldson, B. Guidance on Designing Healthcare External Evaluation Programmes including Accreditation, Dublin: International Society for Quality in Healthcare, 2015.

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References

A Five-Year Strategic Plan to Develop the Afghan Healthcare Quality Management System and Accreditation Organization (DRAFT), June 2016.

Braithwaite J, Shaw C, Moldovan M, Greenfield D, Hinchcliff R, Mumford V, et al. Comparison of health services accreditation programs in low- and middle-income countries with those in higher income countries: a cross-sectional study. International Journal for Quality in Health Care 2012:568-77.

Fortune, T, O’Connor, E, and Donaldson, B. Guidance on Designing Healthcare External Evaluation Programmes including Accreditation, International Society for Quality in Healthcare (ISQua), 2015.

International Society for Quality in Health Care. Guidelines and Standards for External Evaluation Organisations 4th Edition Version 1.1 July 2014. Dublin: International Society for Quality in Health Care, 2014.

International Society for Quality in Health Care. ISQua Checklist for the Development of New Healthcare Accreditation Programs: Guidance for governments, agencies, and other groups. 2006.

Islamic Republic of Afghanistan Ministry of Public Health National Health Strategy 2016-2020, September 2016.

Mate, K. S., Rooney, A. L., Supachutikul, A., & Gyani, G. (2014). Accreditation as a path to achieving universal quality health coverage. Globalization and Health 10(1) 68-76.

Massoud MR, Mensah-Abrampah N, Sax S, Leatherman S, Agins B, Barker P, et al. Charting the way forward to better quality health care: how do we get there and what are the next steps? Recommendations from the Salzburg Global Seminar on making health care better in low- and middle-income economies. International Jounral for Quality in Health Care 2012:558-63.

National Strategy for Improving Quality in Health Care, 2011-2015. Ministry of Public Health of Afghanistan, 2011.

Options for the Afghanistan’s Ministry of Public Health to Consider When Establishing a National Accreditation Organization, Paper, July 2016.

Personal communication: Saudi Central Board for Accreditation of Healthcare Institutions (CBAHI), 2017.

Personal communication: Dr. Edward Chappy on regarding the Jordanian Health Care Accreditation Council, 2017.

Personal communication: Dr. B.K. Rana and Dr. Girdhar Gyani on behalf of NABH, 2017.

Personal communication: Dr. Anuwat Supachutikul on behalf of the Healthcare Accreditation Institute of Thailand, 2017.

Rooney AL, vanOstenberg PR. Licensure, Accreditation, and Certification: Approaches to Health Services Quality. Washington, DC, 1999.

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Ruelas E, Gomez-Dantes O, Leatherman S, Fortune T, Gay-Molina JG. Strengthening the quality agenda in health care in low- and middle-income countries: questions to consider. International Journal for Quality in Health Care; 2012: 553-7.

Sax S, Marx M. Local perceptions on factors influencing introduction of international healthcare accreditation in Pakistan. Health Policy and Planning. 2013.

Shaw, C. Quality and accreditation in health care services: a global review. World Health Organization, 2003 (data updated 2010).

Shaw C.D. (2004a). Toolkit for accreditation programs: Some issues in the design of external assessment and improvement systems. International Society for Quality in Health Care/World Bank 2004 http://www.isqua.org/accreditation/reference-materials

Shaw, C, Braithwaite, J, Moldovan, M, Nicklin, W, Grgic, I, Fortune, T, Whittaker, S. Profiling health-care accreditation organizations: an international survey. International Journal for Quality in Health Care 2013; 25 (3): 222-231

USAID Health Policy Project. Assessment of Afghanistan’s Readiness to Establish a National Healthcare Accreditation System, 2014.

Web site of the Saudi Central Board for Accreditation of Healthcare Institutions (CBAHI), http://portal.cbahi.gov.sa/english

Web site of the Jordanian Health Care Accreditation Council (HCAC), http://hcac.jo/en-us/

Web site of Healthcare Accreditation Institute of Thailand (HAI). https://www.ha.or.th/EN/

Web site of National Accreditation Board for Hospitals and Healthcare Providers (NABH), 2017. http://nabh.co/Images/pdf/FeeStructure_Revision2016.pdf

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http://nabh.co/Images/pdf/FeeStructure_Revision2016.pdf

https://www.ha.or.th/EN/

http://hcac.jo/en-us/

http://portal.cbahi.gov.sa/english

http://www.isqua.org/accreditation/reference-materials

Annex A: Work Plan (2016-2022)

The proposed Work Plan is included as Annex A to this proposal.

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Annex B: Terms of Reference for Key Staff of the Accreditation Organization

Chief Executive Officer Job Description/Terms of Reference

Ideally, the individual selected for the CEO position will hold at least a master’s or doctoral degree preferred in medicine, healthcare, business, management, or a related field. The candidate selected for Chief Executive Officer will bring solid management qualifications and experience, including:

Management experience working under the direction of a governing organization and within the government structure of Afghanistan;

Deep knowledge of the healthcare system and regulatory environment in Afghanistan; Experience in developing, implementing, and monitoring both strategic and operational policies

and plans; Experience with implementing sound financial practices, budgeting, and financial accountability

and transparency; Skills and knowledge to effectively work with various computer programs, including word

processing, spreadsheets, presentation software (e.g. Power Point), and database programs; Strong verbal and written communication skills to interact with the Board of Directors, the

Government of Afghanistan and Ministry of Public Health, healthcare organizational leaders and professionals, the media, and the public;

Recognition among the healthcare community as a leader with high standards of professional and personal integrity;

An ability to analyze and communicate data and metrics in order to monitor the effectiveness of the Afghan healthcare accreditation organization in supporting the National Health Strategy 2016-2020;

Demonstrated organizational skills, including ability to prioritize and effectively manage multiple tasks and deadlines while maintaining attention to detail; and

Demonstrated ability to exercise judgment and resolve issues in accordance with agreed parameters.

The CEO will oversee and direct the operations of the Afghan accreditation organization. The major functions of this position include:

Implementing the strategic plans and direction set forth by the Board of Directors; Developing and managing the effective implementation of the organization’s operational plans

and budgets; Managing the daily operations of the accreditation organization in accordance with international

standards and best practices for accreditation agencies, including those reflected in the standards of the International Accreditation Programme (IAP) of the International Society for Quality in Healthcare (ISQua);

Ensuring that the financial operations of the accreditation organization are implemented in accordance with accepted standards of accounting practice, including development and monitoring of an annual budget, ledgers, balance sheets, financial controls, setting of fees, and an annual external audit;

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Serving as the accreditation organization’s chief spokesperson to the Government of Afghanistan, the Ministry of Health, key stakeholders such as professional societies, academic institutions, payors, the media, the public, and the international community;

In collaboration with the management team, developing and implementing an internal quality management and risk management plan for the Afghan accreditation organization;

Recrutiting and managing the three Directors, and assuring the process for recruitment of other staff is effectively accomplished; and

Managing the process to monitor and evaluate the effectiveness of the Afghan healthcare accreditation organization in supporting the National Health Strategy 2016-2020.

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Director of Standards and Surveys

The candidate for Director of Standards and Surveys will hold at least a master’s or doctoral degree preferred in medicine, healthcare management, public health or a related field. The candidate will bring solid management qualifications and experience, including:

Management experience working in hospitals within Afghanistan; Deep knowledge and understanding of the healthcare system and regulatory environment in

Afghanistan; Knowledge of quality theories and approaches, including international standards published by the

World Health Organization and others; Strong verbal and written communication skills to develop and communicate contemporary

standards of quality and safety for hospitals and other healthcare organizations; Ability to recruit, train, certify, and manage a cadre of accreditation surveyors; Experience in developing, implementing, and monitoring operational policies and plans; Skills and knowledge to effectively work with various computer programs, including word

processing, spreadsheets, presentation software (e.g. Power Point), and database programs; Recognition among the healthcare community as a leader with high standards of professional and

personal integrity; Demonstrated organizational skills, including ability to prioritize and effectively manage multiple

tasks and deadlines while maintaining attention to detail; Demonstrated ability to exercise judgment and resolve issues in accordance with agreed

parameters.

The Director of Standards and Surveys will have responsibility for the overall management of standards and survey processes, including surveyor management. The major functions of this position include:

Developing and maintaining a comprehensive set of accreditation standards for hospitals and other healthcare organizations in Afghanistan that meet the International Accreditation Programme (IAP) of the International Society for Quality in Healthcare (ISQua);

Developing and maintaining a fair, comprehensive, and objective evaluation methodology that is used in accreditation surveys;

Recruiting, training, certifying, and managing a credible, knowledegable, and objective cadre of accreditation surveyors in accordance with the standards of the ISQua International Accreditation Programme (IAP);

Managing the daily operational unit for the accreditation survey process, including scheduling surveys, deploying survey teams to hospitals and other healthcare organizations, analyzing and maintaining accreditation data, and rendering accreditation decisions according to established criteria;

Recommending to the Board of Directors those hospitals and healthcare organizations that should be granted accreditation status, any follow-up monitoring required, and any revocations of an existing accreditation award; and

Monitoring and evaluating the effectiveness of the accreditation organization operations through established indicators.

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Director of Education and Consultation

The candidate for Director of Education and Consultation will hold at least a master’s or doctoral degree preferred in medicine or other healthcare profession, healthcare management, public health, education, or a related field. The candidate will bring solid education and consulting qualifications and experience, including:

Experience working in hospitals within Afghanistan, in order to understand hospital operations and typical challenges;

Deep knowledge and understanding of the healthcare system in Afghanistan; Knowledge and experience in working with a variety of educational modalities, from on-person

training programs to self-paced learning modules to e-Learning and video training; Knowledge of quality theories, patient safety, organizational culture, and change management; Strong verbal and written communication skills to develop and communicate educational

programs and services on standards, healthcare quality, and patient safety for hospitals and other healthcare organizations;

Ability to recruit, train, and manage a cadre of educational faculty and consultants; Experience in developing, implementing, and monitoring operational policies and plans; Skills and knowledge to effectively work with various computer programs, including word

processing, spreadsheets, presentation software (e.g. Power Point), and database programs; Recognition among the healthcare community as a leader with high standards of professional and

personal integrity; Demonstrated organizational skills, including ability to prioritize and effectively manage multiple

tasks and deadlines while maintaining attention to detail; and Demonstrated ability to exercise judgment and resolve issues in accordance with agreed

parameters.

The Director of Education and Consultation will have responsibility for building capacity among hospitals and healthcare organizations in Afghanistan to eventually meet the accreditation standards. This capacity-building will take the form of on-site consultation and technical assistance, educational programs and publications, and dissemination of best practices in meeting the standards. The Director has responsibility for recruiting and managing a cadre of quality consultants and faculty. The major functions of this position include:

Developing and maintaining a comprehensive package of educational and consultative offerings related to standards, quality, and patient safety that meet the education standards of the ISQua International Accreditation Programme (IAP);

Recruiting, training, and managing a credible and knowledegable cadre of educational faculty and consultants;

Providing on-site technical assistance to hospitals and healthcare organizations to help them fully implement and maintain the accreditation standards;

Developing and providing a variety of educational approaches, including on-site and off-site (webinars, printed publicaitons, videos, e-Learning modules, best practices examples and tools) to meet the accreditation standards; and

Monitoring and evaluating the effectiveness of the education and consultation program operations through established indicators.

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Director of Finance and Administration

The candidate for Director of Finance and Administration will hold at least a baccalaureate degree in accounting, finance, business, or a related field. The candidate will bring solid financial and office management experience, including:

Overall management experience to handle both financial as well as administrative (e.g. contracting, safety and security, housekeeping, IT) components of the role;

Certifications or credentials found to be generally acceptable for experienced accountants or finance officers in Afghanistan;

Financial management experience in Afghanistan, preferably in the health care sector or with a non-government organization (NGO);

Experience with implementing sound financial practices, including budgeting, monitoring, fee collection, preparing financial reports, auditing, assuring financial accountability and transparency;

Experience in the supervision of financial support staff, in order to assure that financial checks and balances are in place and working effectively;

Demonstrated ability to effectively develop and implement operational policies and plans, including logistics of managing an office environment;

Demonstrated interpersonal and communication skills, both oral and written, to maintain productive working relationships with a range of team members and stakeholders;

Demonstrated organizational skills, including ability to prioritize and effectively manage multiple tasks and deadlines while maintaining attention to detail; and

Demonstrated ability to exercise judgment and resolve issues in accordance with agreed parameters.

The Director of Finance and Administration will have responsibility for developing, maintaining, and overseeing the financial operations of the accreditation organization. In addition, this individual will assume responsibility for the non-technical (i.e. not accreditation-related) administrative components of the accreditation organization’s operations, such as information technology, office equipment, security, safety, risk management, human resources policies and procedures, housekeeping, and utilities. The major functions of this position include:

Developing and maintaining the overall financial operations of the organization, including policy-setting, budgeting, fee collection, financial disbursements, maintaining a general ledger and balance sheets, financial reporting, and auditing in accordance with recognized accounting principles and practices and with optimal transparency;

Ensuring that effective financial checks and balances are in place throughout all components of the organizational structure;

Ensuring that the financial operations of the organization adhere to the financial management standards of the ISQua International Accreditation Programme (IAP);

Providing complete and transparent financial reports and analyses to the Board of Directors and CEO, in order to give them sufficient information about the financial status of the organization;

Managing the financial aspects of any government-funded or donor-funded projects, in order to ensure that financial management and reporting is implemented in accordance with any standards or contract terms;

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Supervising subordinate or contracted staff who carry out finance, informational technology, public relations, human resource management, or office management functions;

Developing and maintaining quality and risk management policies and plans that adhere to the standards of the ISQua International Accreditation Programme (IAP); and

Monitoring any contracts that the accreditation organization has with outside entities or vendors are current and that the terms are being met.

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Annex C: Detailed BudgetThe detailed budget is included as Appendix C.

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