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Under the Patronage of
HH Lieutenant General
Dr. Shaikh Mohammed bin Abdullah Al Khalifa
President of the Supreme Council for Health
National Accreditation Orientation Workshop
for Health care Facilities
11-12 February 2017
Slide 2
Aim of the workshop
To inform and orient all private hospitals and effectively assist them to be prepared
for the upcoming National Accreditation surveys
11 March
9:00-9:40 Accreditation Policy Dr Mariam Al-Jalahma
9:40-10:15 Accreditation Procedures Dr Maha Alkawari
10:15-10:35 Break
10:35- 11:10 Survey Visit Dr Leena AlQasem
11:10-14:10 Standards Review NHRA surveyors
14:10:14:30 Tamkeen presentation Tamkeen
representative
Lunch
Time Session speaker
8:00-10:00 Standards Review NHRA surveyors
10:00-10:30 Break =============
10:30—12:00 Standards Review NHRA surveyors
12:00:13:30 Hospital Preparation Dr Yannis Skalkidis
13:30-14:00 Next Steps Dr. Mariam Al-Jalahma
Lunch
12 March
National Accreditation Policy
for Health care Facilities
2017
Dr. Mariam Al-Jalahma CEO
NHRA
Slide 6
Agenda
• About NHRA • The Accreditation Regulations • Benefits of Accreditation • Aim of Accreditation • Accreditation Structure • Accreditation Standards • Awards of Accreditation • Categorization of Accredited Facilities • Maintaining Accreditation • Quality Improvement Plan • Midyear Self Assessment • Annual Inspection • Withdrawal or suspension of Accreditation • Appeal Process • Re-accreditation
Slide 7
ABOUT NHRA
The National Health Regulatory Authority (NHRA) is an independent regulatory body established in 2010 under Law No. 38 of 2009.
Slide 8
Our vision
Safe and High Quality in the delivery of Health Services
Slide 9
Our Values
INTEGRITY
FAIRNESS
INDEPENDENCE
TRANSPARENCY
BEST PACTICE
ACCOUNTABILITY
OUR VALUES
Slide 10
Preserved health rights
Safe and trusted health services
Regulated and accountable
health facilities
Our Goals
Our Goals
Slide 11
Law no(21) of 2015 regarding private health care facilities: Article (19) NHRA’s responsibility for evaluating health services
provided in all facilities in order to ensure quality and high performance of those services, and ensure compliance with regulations and standards related to patient safety, infection control and other technical standards.
Article (20) specifies NHRA responsibilities for inspection to ensure compliance of private health facilities with the law and regulations issued to implement it.
Accreditation Regulations
Slide 12
The Supreme Council of Health issued: Decision no. (7) of 2016, specifying the required NHRA
standards.
Decision no. (26) of 2016, regarding accreditation processes of hospitals.
Minister of Health Issued article: Decision No. 20 of 2016, regarding fees for licensing and
Accreditation of private hospitals
Accreditation Regulations
Slide 13
The Benefits of NHRA Accreditation
• An on-going monitoring system, which supports and complements the licensing process, as accreditation will be mandatory for a license to remain in operation.
• Assurance of the good standing of a facility to all stakeholders,
especially consumers, employers, health funding organizations and public authorities, as the facilities will be evaluated against internationally accepted norms.
• Confidence of patients and their families that all areas and
parameters of the facility’s provision of care match to evidence based best practices and meet the international standards and, in case of expressed complaints, a rigorous and comprehensive process to effectively deal with them will be immediately activated
Slide 14
Aim of Accreditation
Accreditation aims at supporting and assisting healthcare facilities
NHRA adopts the peer review approach, when surveying healthcare
facilities for accreditation
NHRA embraces a blame-free culture that will encourage all healthcare
facilities to adopt this philosophy as a pivotal and essential organizational
attribute.
Slide 15
Each and every single department and unit of all healthcare
facilities in Bahrain can undoubtedly, reasonably and
feasibly make a small step ahead, towards quality
improvement, even if they are already absolutely compliant
with the minimum standards that have been set.
Slide 16
Accreditation Structure
Surveyors
Accreditation Committee
CEO
Slide 17
Hospital Standards
1 Governance, Management and Leadership 15 Emergency Care
2 Human Resource 16 Operating Theatre and Surgery Provision
3 Patient and Family Rights 17 Anesthesia and Sedation
4 Quality Management and Patient Safety 18 Intensive Care Units
5 Management of Information and Medical Records 19 Labour and delivery standard
6 Infection Prevention and Control 20 Outpatient Standards
7 Facility Management and Safety 21 Clinical Support Services
8 Health Promotion and Education 22 Fertility and Assisted Reproductive Technology
9 Provision of Care 23 Dental services
10 Medical 24 Optometry
11 Nursing 25 Hemodialysis
12 Radiology 26 Burns Care
13 Laboratory 27 Psychiatry
14 Pharmacy
Slide 18
Awarding the Accreditation
• The Accreditation Committee can recommend the: • award of accreditation, • conditional accreditation, • defer • refusal of accreditation. • The facility will be informed of the NHRA decision within one calendar
month of the decision being made. NHRA will send to the facility a copy of the report, along with the Accreditation Certificate, as long as accreditation or re-accreditation has been awarded.
Slide 19
Categorization of accredited Health Care Facilities
Diamond: for facilities which achieve 95% or more of standards evaluation.
Platinum: for facilities, which achieve from 90% up to 95% of standards evaluation.
Gold: for facilities, which achieve from 80% up to 90% of standards evaluation
Silver: for facilities, which achieve from 70% up to 80% of standards evaluation
Slide 20
Conditional Accreditation
• The Accreditation Committee may recommend conditional accreditation if the results of the visit report indicates that the facility’s overall score ranges between 70% to 80%, and that the outstanding issues are such that they can be resolved easily within a short period of time.
Slide 21
Deferred Accreditation
• A decision can be deferred for up to six months, if the surveyor team has concerns
about issues of medium priority, namely, those that can be actioned in a longer time-frame. These action points could result in a recommendation to defer the decision on the award of accreditation.
• During that period of time the facility must effectively address the action points
identified in the report and specifically raised by the Accreditation Committee. • The Accreditation Committee will require that, before the end of the deferral time
period, the facility may either undergo a supplementary visit or may submit adequate documentary evidence, showing that the outstanding requirements have been met or the relevant issues have been resolved.
Slide 22
• The supplementary visit report or documentary submission will be considered by the Accreditation Committee before the end of the deferral time period and a recommendation on accreditation will then be made.
• If the supplementary visit report indicates significant concerns other than those
that led to the deferral, the Accreditation Committee may require an additional full visit before making a recommendation on accreditation. If necessary, the deferral time period may be extended to allow for this to successfully take place.
• If the facility fails either to submit satisfactory documentary evidence or to undergo
a supplementary visit before the end of the deferral time period, the Accreditation Committee may recommend refusal or withdrawal of accreditation.
Deferred Accreditation
Slide 23
Refusal, suspension or withdrawal of accreditation
• The Accreditation Committee may recommend the refusal, suspension or withdrawal of accreditation, if the survey report indicates that the facility has failed to meet or maintain the standards required for accreditation and the overall scoring is less than 70%.
• If accreditation is refused or withdrawn, the reasons will be clearly and comprehensively explained in the report and the accompanying letter.
• Failing to achieve accreditation after expiry of the deferred time period will
result in withdrawing the accreditation from the facility. • The facility has obviously the right to appeal against NHRA decision.
Slide 24
Statement of Accreditation
Following the award of accreditation, the facility is : • permitted to use the statement of accreditation, • listed in the NHRA directory of accredited health care facilities on the
NHRA website. Acceptable forms of the statement are:
“Accredited by the National Health Regulatory Authority, Kingdom of
Bahrain”
“NHRA accredited”.
Slide 25
Maintaining accreditation
The accredited facility has a continuing responsibility both to maintain the standards required for NHRA accreditation and to fully cooperate with NHRA in continuous monitoring of those standards. Specific duties arising from these responsibilities are :
• Continue to comply with all relevant laws and regulations, including those
pertaining to licensing • Continue to maintain all the standards required for NHRA accreditation • Work to meet the requirements set out in previous NHRA reports and implement
the additional specific recommendations on the basis of the agreed upon timeframe
• Pay on the pre-agreed timeline the required annual fees • Submit an application for re-accreditation and undergo a full re-accreditation visit
before the expiry date of the facility’s current accreditation. Failure of the facility to meet any of the above requirements may lead to the suspension or withdrawal of its accreditation.
.
Slide 26
Quality improvement plan
• The facility develops a quality improvement plan template, which summarizes the action plan for all the standards that do not comply with the NHRA requirement and the subsequent recommendations that were made.
• The facility is expected to fill in the template, stating the proposed action and
expected date to implement and the responsible personnel that will follow up and complete implementation.
• The facility should develop and present the quality plan within 6 weeks of
submitting accreditation report. This plan will be monitored during the annual follow up, support visits.
Slide 27
Annual self-assessment report
• The facility should submit a follow up annual self-assessment report, documenting the achievements made in the partially met or un-met standards, as well as the progress pertaining to the recommendations made.
• The facility should submit the supporting documents or proof of those
achievements. • A delay in submitting report by more than 60 days from due date without a
justification acceptable to NHRA, may result in temporary suspension of accreditation, followed by revocation of accreditation if the total delay exceeds 90 days
Slide 28
Annual inspections
• All accredited facilities are scheduled to undergo an annual follow up visit as part of NHRA’s quality monitoring process.
• The annual visit will be conducted by NHRA surveyors over one day. This follow up
will focus on areas that were partially achieved and/or un-met standards to ensure that the action plan related to the specific recommendations progresses satisfactorily and according to pre-agreed plan.
• The annual report of the facility will be considered by the NHRA and will
recommend either that accreditation should continue or that there are areas of concern, which require further action. The findings of the visit will be discussed and agreed with facility’s management.
• The final report of the follow up visit with all the essential details of the
recommendations and any further action, if required, will be sent to the facility.
Slide 29
Withdrawal and suspension of accreditation
Reasons for suspension or withdrawal of accreditation: Following a follow up, support visit: • NHRA may recommend withdrawing accreditation, if the support visit report
shows that the facility is failing to meet the standards required for accreditation.
Slide 30
Withdrawal and suspension of accreditation
Additional grounds for immediate suspension or withdrawal
• Failure to comply with all relevant laws and regulations of NHRA
• Failure to apply for re-accreditation within the deadline given
• Failure to undergo the process of re-accreditation before the accreditation expiry date
• The submission of false or intentionally misleading statements on the forms or in associated documents of the application.
• Non-payment of required annual fees
Slide 31
Appeals
A surveyed facility can appeal against the following accreditation decision: 1. Not accredited (denial of accreditation). 2. When the overall score is between 70-79%. 3. Suspension/revocation of accreditation. • The appeal should be raised within 15 days from receiving the report. • The right of appeal is granted solely to provide the facility with the means of
challenging either the assessment of the surveyor team in the course of the visit or the judgement of the Accreditation Committee and its proposed recommendations.
• A facility has no right within this appeals procedure to challenge either the criteria assessed or standards required for accreditation or the general regulations that accredited facilities must follow.
• The right of the facility within this procedure is rather to challenge the appropriateness of the application of those criteria, standards and regulations in its individual case.
Slide 32
Grounds for an appeal
The appeal submission against the accreditation decision must clearly state the grounds for the appeal, selecting one of the following:
• Relevant and significant information, which was available to the survey team was not considered in making of the accreditation decision.
• The report of the surveyors was inconsistent with the information presented to the survey team.
• Perceived bias of the surveyor team
• Information provided to the survey team was not duly considered in the survey report.
• The Accreditation Committee did not have all the relevant information available to it at the time .
• The decision was not made in accordance with the procedures or criteria set out in the NHRA accreditation policy.
Slide 33
The appeals process
An appeal will be heard in 2 weeks’ time by the Appeal Committee, which is an unbiased body comprising an independent Chair and surveyors, who did not vote in the original recommendation of the Accreditation Committee. The Appeal Committee shall:
1. Consider the grounds for the appeal as alleged by the health care facility;
2. Study the evidence submitted by the facility in support of its allegation;
3. Consider the report of the survey team and other supporting statements and documents;
4. Consider whether the survey team and Accreditation Committee substantially followed stated NHRA policies and procedures;
5. Consider whether the survey team made substantial errors or omissions, which affected the decision of the Accreditation Committee;
6. Consider whether the evidence at the time the accreditation decision was made, was wrongly assessed.
Slide 34
Recommendations on appeals
At the end of the hearing, the Appeal Committee may make one of the following recommendations: • Dismiss the appeal • Recommend a new visit • Recommend that NHRA award or reinstate accreditation or re-
accreditation.
NHRA will inform the facility of its decision within 2 weeks. Upon completion of the process, the appealing facility will have no further recourse to the appeals process.
Slide 35
Accreditation is awarded for three years. To remain accredited, the facility must submit an application for re-accreditation and undergo a full re-accreditation visit before the facility’s accreditation expires.
Should the facility fail to undergo a re-accreditation visit before its current accreditation expiry date, the facility’s accreditation will be withdrawn.
The re-accreditation process
Slide 36
Your success is our GOAL
Slide 37
The Accreditation Process Dr. Maha AlKawari
Chairperson. Accreditation Committee
Slide 39
Facility submit request for accreditation
6 months prior to license expiry
Accreditation Committee reviews
application within 2 weeks of submission
Further
clarification
needed from
survey team
Assign a survey team and schedule a
visit within 2 weeks
Survey team conducts the survey
Write the report
3 days
Accreditation committee reviews report
and submit decision within
2 week
Application is not
complete
Report final edit and submission to
accreditation committee within 1 week
1-2
months
Steps involved in the accreditation process
Slide 40
Facility is informed of the
decision within 1 week
Appeal Committee review the
appeal
Within 2 weeks’ time of
submission
Appeal Committee raise decision
to CEO within 4 weeks
7 weeks
Facility appeals within 15 days
of receiving decision
Appeal
Slide 41
Application for accreditation
completed application form
self -assessment report form
required supporting documentation
payment of required annual fees
Slide 42
Application form
Slide 43
Self Assessment
Facilities are required to complete and submit a self-assessment report assessing structural and procedural elements that are in place and correspond them to each of the NHRA standards prior to the actual visit of the survey team. The self-assessment report must be submitted in English.
The self-assessment report form should be completed in as much detail as possible and be completely transparent in their evaluation of their strengths, weaknesses and compliance with NHRA standards.
The self-assessment report form provides tables for the recording of the evidence and actions required.
The self-assessment report must be completed and sent to NHRA at least two months before the start of the visit.
Slide 44
The Accreditation Committee will assign a dedicated facility coordinator from NHRA who will be the main point of contact with the facility.
This member of NHRA staff will contact the facility to seek clarifications or request additional documentation.
Once all the outstanding issues have been resolved, the complete application will be considered by the NHRA Accreditation Committee that will assign a surveyor team to conduct the field survey and develop the survey report.
Assigning the Survey Team
Slide 45
Preparing for the visit
Once the survey visit has been organized, the facility will receive written confirmation from the Accreditation Committee regarding the dates, the names of the members of the survey team and the details of the visit, including a list of premises to be visited.
The facility should inform their staff that a survey will be taking place.
It is the survey team’s intention to avoid disruption of the facility’s normal activities as far as possible during the visit. All documentation, which the surveyors will require will need to be gathered and collated before the visit electronically and preferably, in hard copies, too.
Slide 46
The detailed timetable of the survey will be developed prior to the visit by the lead surveyor, in consultation with the facility through the NHRA coordinator. The facility will be required to facilitate this task by providing the right staff, detailed information, and program timetable by suggesting the right timing at which key personnel will be available to meet with the surveyors.
Scheduling the Visit
Slide 47
Making changes to the visit date or surveyors
Facilities are encouraged to adhere to the proposed date by NHRA. However, if rescheduling or postponement is needed, hospitals need to submit in writing their request, indicating their justification for the request.
NHRA reserves the right to change the date of the visit or surveyors, prior to the commencement of the visit. NHRA would only make such changes once all other options have been exhausted and where it would be impossible or disadvantageous to go ahead with the visit as planned. Those alterations will be agreed by the facility prior to the survey visit.
Slide 48
The Survey Visit Dr. Leena Alqasem
Team Leader
Slide 50
Survey Team
• Lead surveyor is responsible for: • arranging the visit timetable • managing the team • compiling the report • ensuring that the visit is carried out according to published guidelines
and covers all the standards.
• NHRA coordinator will be responsible for liaison with the facility and arranging the visit timetable.
• Specialty Team members such as Pharmacist, Infection Control Specialist,
Laboratory and / or Radiology Specialist, and Facility Management and Safety Specialist
Slide 51
Conflict of Interest: • All surveyors must disclose any circumstances that could represent a
potential conflict of interest (i.e., any interest that may affect, or may reasonably be perceived to affect, the surveyor's objectivity and independence).
• Surveyors must disclose on the Declaration of Interests (DOI) form any
conflict they may have relevant to the facility being surveyed. • The facility will be informed of the names of the surveyors before the
visit and can make recommendations to NHRA if it is felt that there could be potential for a conflict of interest.
Survey Team
Slide 52
Facilities to provid during the visit
• A dedicated room:
• available throughout the duration of the visit for the team to use.
• be located centrally in the facility, within close reach of the administration and
CEO of the facility, if possible.
• offer privacy for internal discussions between the team members
• secure so that team members may leave personal belongings
• hold meetings with staff members.
• An internet access, whenever possible, should be available in the room.
• All documentation, needed by the survey team must be placed in this room. This will
include all the documentation sent in with the application form, all supplementary
documentation providing evidence of the facility ability to meet the standards.
Slide 53
Survey Tasks
Task 1 – Pre-visit Preparation Task 2 – Opening Activities Task 3 – Information/Evidence Gathering Task 4 – Closing Conference Task 5 – Data Entry and Report Writing Task 6 – Reviewing the reports
Slide 54
The Survey Visit
The visit will include, in addition to a comprehensive documentation review:
an introductory meeting with staff (at least members of the management
team);
a tour of the facility;
a meeting with the CEO;
a meeting with senior management team (Chief of medical staff, Nursing
director, human resource director, quality officer);
a meeting with a representative group of doctors, nurses or pharmacists;
Field visits;
a final meeting with the CEO and senior managers;
Slide 55
Scoring the Standards
The survey team will decide on one of the following four judgments when considering the level of compliance in each element in the standard:
Not met when < 50 % compliance with the sub-standard
Partially met when ≥ 50 to < 80 % compliance with the sub-standard
Fully met when ≥ 80 % compliance with the sub-standard
Not Applicable indicates that the standard/sub-standard does not apply
to the facility
Slide 56
The concluding section of the visit report normally contains a number of action points. These are categorized as being of high, medium or low priority. High priority - those which the surveyors consider necessary to action as a matter of urgency and which will normally prevent the immediate award of accreditation Medium priority - those which the surveyors have concerns about but which can be actioned in a longer time-frame. These action points could result in a recommendation to defer the decision on the award of accreditation Low priority – those which the surveyors consider would benefit the facility and would enhance the quality of the provision and foster best practice. These action points will not, on their own, normally affect the decision of the award of accreditation
Summary of Recommendations
Slide 57
The Facility will receive in the report additional comments other than those listed in the standards The Additional comments will include further improvement recommendations aiming at achieving higher standards
Additional Comments
Slide 58
Accreditation Report
The facility report will include the following sections: • Roles and responsibilities of NHRA • Background to the facility and its scope of services • Background and context for the visit process
• Areas visited • Methodology and process • Commentary on how the facility performs against each of the accreditation
standards and key indicators
• Details of the evidence base for judgments. • An overall judgment on the facility’s achievement of the requirements for each of
the visited area reported as ‘fully met’, partially met’ or ‘not met’
• Summary of Recommendations • Additional Comments
Slide 59
Preparatory steps for
NHRA Accreditation
Dr. Yannis Skalkidis
Consultant Surveyor
Slide 61
Fundamental principles of NHRA’s National Accreditation Program
1. Support and encourage blame-free values and attitudes between NHRA and healthcare facilities, along with the application of this philosophy within each healthcare facility in Bahrain
2. Establishment of a strong, fruitful and continuous partnership with all healthcare facilities
3. NHRA approach to survey healthcare organizations for granting accreditation is not the “tick-box method of auditing/inspecting but adopts the peer review approach, that entails an in-depth discussion and exchange of views between peers.
Slide 62
4. NHRA is not limited to use a set of minimum standards but it relies on surveyor’s expertise to encompass key areas for quality improvements, aiming to recommend internationally accepted evidence-based practices *
4. NHRA is fully aware of the critical importance of the
microenvironment in each facility under scrutiny, so, the added-value recommendations that will be made will be contextual, appropriate, patient-centered, feasible and cost-effective for the facility.
* Activities that may not directly correspond to the description of the NHRA elements but are relevant to the domain under scrutiny, will be also examined and assessed
Fundamental principles of NHRA’s National Accreditation Program
Slide 63
Self-assessment / Pre-survey Report *
Make sure that you are familiar with all NHRA standards. Facilities are expected to clearly and meticulously respond to each and every NHRA standard and sub-standard. Healthcare facility’s response means: To ensure that they have adequately met the
requirements of NHRA standards and sub-standards To provide relevant, sufficient and sound documentation To state that specific NHRA standards are Not Applicable
for the facility. * The Self-Assessment Report is called Pre-Survey Report, whenever it is developed in the frame of the preparation for the on-site NHRA survey visit
Slide 64
NHRA methodological approach to analyse facility’s activities
NHRA surveyors are expected to confirm and document a “spiralling” PDCA sequence of events : have in place comprehensive policies, referenced to national legislation,
regulations and accepted international standards
develop guidelines and/or derived procedures that cover satisfactorily all aspects of those policies
implement and monitor on a systematic basis the described procedures
analyze and interpret results and communicate them to relevant professionals
take corrective action, whenever needed, monitor and analyze its effect
make the required changes at system level, whenever needed.
Slide 65
Specifics of the Self-assessment/Pre-survey
Report
The Self-Assessment Report is an integral part of the NHRA accreditation cycle. It is planned to be completed by all Bahraini healthcare facilities on an annual basis. The Self-Assessment Report aims to: 1. identify potential gaps against all NHRA requirements and
standards 2. deploy in a detailed manner the work that is needed for the
upcoming accreditation survey 3. record developments by trending relevant results
Slide 66
4. monitor progress of the implemented corrective actions, in response to pending recommendations from the previous NHRA survey
5. help develop and list the corpus of the evidence, which surveyors will verify and further elaborate during the on-site survey
6. assist NHRA surveyors to apprehend the current situation, in terms of achievements and difficulties faced in the facility.
Specifics of the Self-assessment/Pre-survey
Report
Slide 67
Recruits the appropriate QI tools within the facility Increases staff awareness, training and participation in QI
activities Encourages blame-free culture within the organization Develops a transparent and clear plan for Quality
improvements Improves patients’ as well as societal satisfaction by
achieving accreditation status Satisfies the demand of public authorities, consumer
associations and health funding bodies for delivering high quality services
Sets in a documented way new targets and monitors its implementation for further improvements
Benefits of the Self Assessment
Slide 68
Objectives of the NHRA accreditation survey
1. to ensure that the evidence, as described in facility’s Self-Assessment Report, was relevant and accurate
1. to carry out a peer review of facility’s performance 1. To offer advice for amending potential inefficiencies and to
further improve facility’s performance 1. to evaluate all aspects of facility’s performance and based on
this to award the appropriate accreditation category
Slide 69
What should be in place to ensure success
Support and commitment from the leadership of the organization should be strong, continuous and largely evident among all staff
A blame free culture should prevail within the organization Adequate resources, in terms of financing, allotted time and
expertise should be available A quality team, as well as a quality network throughout all
departments and units of the facility should be established to enable efficient coordination of quality activities
Staff education should be provided to effectively implement quality improvements
All staff should actively participate in this effort.
Slide 70
Organize your work effectively!
Start as early as possible (you will not regret it!) Anticipate for the worse scenarios It is imperative that key people should be part of the core
teams Involve as many people as possible (a potentially useful hint : appoint one person, preferably your “champion” to be responsible for each NHRA element) Try to follow a single, basic pattern to work in each unit Be as detailed as possible!
Slide 71
Please, also keep in mind …
Make sure that your monitoring system, namely the reporting of “events”, is systematic, relevant and accurate.
Make sure that the “evidence” that you report in the Pre-Assessment Report can be readily verified by the survey team during the on-site visit.
NHRA surveyors will ask what are your most recent achievements in improving your performance. So, please be ready to present your “achievement reports” for validation by the survey team.
NHRA surveyors will also ask what are your current plans for specific improvements. So, please be ready to present your future plans for improvements.
Slide 72
They say that: “starting is already half of the whole”! Others say that: “you have to reach half way to claim that you have started”! Nevertheless, whatever it is closer to the reality, I am sure we all agree that the right message is:
“START and you will MAKE IT”!
When should you start?
Next Steps Dr. Mariam Al-Jalahma
CEO
Slide 74
1. Implementation will start in May 2017 until July 2018 ( 2 hospitals/months)
2. Implementation will preferably start in hospitals that achieved international
accreditation
3. All hospitals should start doing the self assessment from now to identify the
gaps in achieving the standards
4. Preparatory visits will be conducted in the next 2 months by NHRA
consultant surveyor Dr. Skalkidis for the hospitals who have not passed
through accreditation process before.
5. The hospitals will be officially informed to submit the application form,
required documents, self assessment and pay the fees 6 months before the
commence of the visit.
6. Hospitals will be contacted by NHRA to schedule the visit
Slide 75
Thematic Update workshops: Proposed First week of April
Infection control
Patient Safety
Quality Management
Risk Management
Slide 76
Evaluating the workshop & Identifying the needs
Slide 77
Please contact us for any clarification you may need on
Dr. Maha Al-Kawari
Mob. 39697161
Please specify a coordinator from your facility to be the point of contact with
NHRA. Please register at the front desk.
We will hold a meeting with CEOs to respond to any further inquiries.
6th of MARCH
Announcements
Slide 78
