Accreditation Programs

We strive to bring essential challenges to healthcare institutions in order to improve quality. We focus on our role as an accreditor through many initiatives including:

  • Development of Healthcare Standards
  • Recruitment and Certification of Surveyors
  • Accreditation of Healthcare Institutions and Programs
  • Certification Of Disease Specific Programs:

Our accreditation programs include standards development, implementation of these standards in addition to the survey process.

To date, HCAC has the following accreditation and certification programs:
  • Hospital Accreditation
  • Primary Health Care and Family Planning Centers Accreditation
  • Breast Imaging Units Certification
  • Diabetes Mellitus Program Certification
  • Cardiovascular Care Program Certification
  • Family Planning and Reproductive Health Centers of Excellence Certification Program
  • Medical Transport
Patient Centered Standards

The standards are written with a focus on the patients - not on a department or the professional who provides health care services.

Patient-centered care is based on several key principles:
  • Dignity and respect
  • Information sharing: Encouraging patients to share their perspectives and questions on one hand, and encouraging healthcare professionals to provide information regarding illness and treatment options in terms that the patient can understand, on the other.
  • Participation: Preparing and supporting patients and families to participate in care at the level they choose.
  • Continuity: Providing care across the continuum; designing systems that promote seamless transitions between home, hospital, primary health care and the community.

Are divided into clusters with measureable elements for each standard that can be used by healthcare institutions to conduct a self-assessment. It also includes the scoring mechanism that is used by the surveyors when they perform a mock or accreditation survey.

The standards are divided into:
  • Critical Standards: are those standards that address laws and regulations or, if not met, may cause death or serious harm to patients, visitors, or staff.
  • Core standards: are the standards addressing systems, processes, policies and procedures that are important for patient care. However, partially met compliance with these standards must not pose a threat of harm or death for patients, visitors or staff.
  • Stretch standards: are standards that are important, but not easy to implement due to time or resource constraints, or a need for culture change.

 

All HCAC standards are not prescriptive; this characteristic is embedded in all sets of standards. The standard statement is a general statement that provides guidance to the healthcare institution on what to do. The implementation and how to meet the standard requirements are left open to the discretion of the institution however, the healthcare institution needs to assure that evidence-base practices are always considered in the implementation of the standards to support the effectiveness of all actions and at all times.

The development of standards starts with extensive desktop research and literature review followed by international benchmarking and local sensitization. The first draft is then shared with local experts in the field to ensure comprehensiveness, applicability and usability. After that, international experts are sought to review and provide feedback to ensure that the standards are internationally acceptable and evidence-based before field testing. Every 3-4 years, the standards are updated, improved and expanded based on current evidence.

The HCAC Cardiovascular Care Program Certification was developed to recognize accredited hospitals that have developed comprehensive programs to provide high quality of care and services to patients with cardiovascular diseases.

The Health Care Accreditation Council (HCAC) has taken the initiative to produce standards that help facilitate the development of comprehensive, quality cardiovascular care programs to improve cardiovascular health. Rooted in prevention, collaboration, patient-centered care and self- management, we believe that these standards will help drive change in the way that cardiovascular care and services are provided.

Aim

To embed high quality and reliable cardiac patient care and services.

Scope and Framework

The standards are designed for organized cardiovascular care programs that are managing persons over the age of 18 who have been diagnosed with cardiovascular related diseases. In addition to acute care interventions, the standards promote community awareness, identifying individuals at risk and prevention strategies.

Eligible Institutions

Any accredited healthcare institution that offers a comprehensive cardiovascular care program and performs minimum cardiac cathertizations is eligible for seeking Cardiovascular Care Program Certification.

The Standards Manual

The Cardiovascular Care Program Certification standards are intended to provide health care providers with the components of cardiovascular care to evaluate the quality of care.

  • Cluster 1: Program Management
  • Cluster 2: Clinical Management
  • Cluster 3: Self-Management
  • Cluster 4: Ancillary Services
  • Cluster 5: Staff Performance
  • Cluster 6: Quality and Safety
Program Management
  • Program Structure and Management
  • Community Mobilization
  • Patient rights
Clinical Management
  • Patient assessment
  • Patient care
Self-Management
Ancillary Services
  • Pharmaceutical services
  • Laboratory services
  • Cardiac diagnostic tests
  • Radiology services
Staff Performance
Quality and Safety
  • Quality improvement and patient safety
  • Information management

All men and women have the right to be informed of and have access to family planning services that are provided in a way that enables clients to rationalize effective contraception methods that match their individual needs and preferences. This ensures safe, effective, affordable, and acceptable methods of fertility regulation of their choice.

Aim
Scope the Framework

HCAC has established a Family Planning and Reproductive Health Centers of Excellence Certification Program that recognizes organizations that provide exceptional quality of services in family planning and reproductive health services. All health care organizations that provide these services are encouraged to meet the criteria and are eligible for certification.

Eligible Institutions:

Any healthcare institution that offers family planning and reproductive health (FP/RH) services in the private, public (Ministry of Health and Royal Medical Service) and university sector and provides exceptional quality of services in family planning and reproductive health services.

Family Planning and Reproductive Health Programs cover, but are not limited to, the following:
  • Contraceptive services
  • Reproductive health services
    1. Reproductive health screening and assessment services (including cervical cancer screening)
    2. Sexually transmitted infections (STIs) screening and assessment, diagnosis and treatment, and disease intervention services
    3. Pregnancy testing, risk assessment, and early pregnancy care services, timely appropriate care and follow-up
    4. Client education and anticipatory guidance.

Institutions must have attained HCAC or another recognized institution accreditation prior to applying for centers of excellence certification.

The Certification Manual
The certification manual has been organized into four sections to be user-friendly. The sections and their content are as follows:

  • Section 1: Description of the Certification Program
  • Section 2: Domains and Criteria
  • Section 3: Assessment and Scoring Guide
  • Section 4: Glossary, Required Document

The first section provides information about the criteria and certification development process. The scope and eligibility of the program is defined (section four) along with an overview of the certification process. The center of excellence model is presented that was designed based on seven guiding principles, with a focus on client and family-centered care.

The second section outlines each of the eight domains and their corresponding criteria. Criteria represent an outcome expectation. Using domains from various excellence models within the mindset of family planning and reproductive health, /HCAC began to shape the criteria. The CoE model designed by HCAC focuses on the following eight domains:

  • Leadership
  • Service Providers
  • Process Management
  • Environment of Care
  • Community Involvement
  • Exemplary Practices
  • Outcomes
  • Knowledge Management

The Assessment and Scoring Guide provides guidance and examples of how each criterion could be met. These elements support self-assessment, provide a consistent assessment process and guide the institution towards reflective thinking about their processes and outcomes. The Assessment and Scoring Guide is organized by domain and criteria. The table is structured to list the criteria under each domain, the types of assessment processes that will be used to determine the level at which the criterion is met, and the examples of how to achieve the criteria. Unlike the accreditation survey process, these examples are not intended to be scored as measurable elements. Achievement of a criterion is assessed on the basis of whether the institution has taken steps that conform to the intent of the criterion.

The institution is encouraged to be creative in finding ways to meet the criteria.

The levels range from zero to four, with zero indicating that there is no evidence that the criterion has been met, while the level of four demonstrates the level of achievement of an exceptional institution. Level 2, being the mid-point, include elements that would be expected in an accredited primary health care center. Levels 3 and 4 both represent categories of exemplary practices.

Centers of excellence recognition is based on an institution achieving an overall score of 2.5 – 3.5 (Silver Award of Best Practice) and those receiving a score of >3.5 (Centers of excellence Gold Award).

Section four is composed of three appendices. A glossary of terms defines the words for which the institution will need to be familiar when preparing to meet the criteria. A list of documents that are required to provide evidence of meeting various criteria is provided to assist the institution to gather the necessary materials for the assessment process.

The HCAC Diabetes Mellitus Program Certification Program is designed for organized diabetes mellitus programs that are managing persons of all ages who have been diagnosed with diabetes mellitus (type 1 and 2). The focus includes community awareness, identifying individuals at risk and prevention strategies. The program may be provided within a primary health care center, hospital or other setting that provides a comprehensive, multidisciplinary approach to diabetes care.

The HCAC Diabetes Mellitus Program Certification Standards are designed to assure high quality of care is provided to those who are at risk of developing or have been diagnosed with diabetes mellitus.

Aim

To embed high quality and reliable diabetic patient care and services.

Scope and Framework

The standards are designed for organized diabetes mellitus programs that are managing persons of all ages who have been diagnosed with diabetes mellitus (type 1 & 2). The focus includes community awareness, identifying individuals at risk and prevention strategies. The program may be provided within a primary health care center, hospital or other setting that provides a comprehensive, multidisciplinary approach to diabetes care.

Eligible Organizations

Any accredited healthcare organization that offers a comprehensive diabetes mellitus program is eligible for seeking Diabetes Mellitus Program Certification.

The Standards Manual

The standards manual are grouped according to the following clusters:

  • Cluster 1: Program Management
  • Cluster 2: Clinical Management
  • Cluster 3: Self-Management
  • Cluster 4: Ancillary Services
  • Cluster 5: Staff Performance
  • Cluster 6: Quality and Safety
Program Management
  • Program Structure and Management
  • Community Mobilization
Clinical Management
  • Patient Rights
  • Patient assessment
  • Patient care
Self-Management
Ancillary Services
  • Pharmaceutical services
  • Laboratory services
Staff Performance
Quality and Safety
  • Quality improvement and patient safety
  • Information management

The Medical Transportation program is developed to create a baseline of expectations for the quality of medical transport services. It also reflects patient rights during transport, safe vehicle performance and other practices.

Aim

To embed high quality and reliable medical transportation services.

Scope and Framework

These standards have been developed for organizations that provide medical transport services, which include those responsible for emergency treatment and transport; nonemergency transport; ambulance services (public or private); land, air, and fire brigade emergency services. The service may be a free-standing organization or associated with a larger organization, such as a hospital.

Eligible Institutions
  • Any medical transport institution currently operating in Jordan.
  • Any institution willing to assume responsibilities for quality improvement.
  • Any institution addressing services that are listed in the Key Principles of Medical Transport Services standards.
The Standards Manual

The standards are grouped according to the following functions or ―clusters‖, as they are called in the Manual:

  • Cluster 1: Organization and Management (OM)
  • Cluster 2: Access and Continuity of Care (AC)
  • Cluster 3: Information Management (IM)
  • Cluster 4: Human Resources (HR)
  • Cluster 5: Patient Care (PC)
  • Cluster 6: Patient and Family Rights (PR)
  • Cluster 7: Infection Prevention and Biological Control (IC)
  • Cluster 8: Clinical and Environmental Safety (ES)
  • Cluster 9: Quality Management and Performance Improvement (QI)
Organization and Management (OM)
Access and Continuity of Care (AC)
Information Management (IM)
Human Resources (HR)
Patient Care (PC)
  • Patient Assessment and Care
  • Physician Interaction and Communication
  • Medication Use
Patient and Family Rights (PR)
Infection Prevention and Biological Control (IC)
Clinical and Environmental Safety (ES)
Quality Management and Performance Improvement (QI)
Introduction
Aim
Scope and framework
Eligible Institutions

All hospitals that offer health care services are eligible to apply for accreditation.

This manual follows the structure of the hospital standards. They are divided into 14 clusters as follows:

  • Cluster 1: Ethics and Patients’ Rights
  • Cluster 2: Access and Continuity of Care
  • Cluster 3: Patient Care
  • Cluster 4: Diagnostic Services
  • Cluster 5: Medication Management
  • Cluster 6: Infection Prevention and Control
  • Cluster 7: Environmental Safety
  • Cluster 8: Support Services
  • Cluster 9: Quality Improvement and Patient Safety
  • Cluster 10: Medical Records
  • Cluster 11: Information Management
  • Cluster 12: Human Resources Management
  • Cluster 13: Management and Leadership
  • Cluster 14: Education and Training
Ethics and Patients’ Rights
Access and Continuity of Care
Patient Care
  • Assessment
  • General Care
  • Surgical Care
  • Anesthesia and Sedation Care
  • Emergency Services
Diagnostic Services
  • Laboratory
  • Blood Bank
  • Radiology Services
Medication Management
Infection Prevention and Control
  • Sterilization
Environmental Safety
  • Employee Health
Support Services
  • Housekeeping
  • Food Service and Kitchen
  • Laundry
Quality Improvement and Patient Safety
Medical Records
Information Management
Human Resources Management
Management and Leadership
Education and Training
  • Patient and Family Education
  • Employee Training and Education

Primary health care is essential health care made accessible at a cost the country and community can afford with methods that are practical, scientifically sound and socially acceptable. Within this program, family planning is recognized as a preventive health measure, which positively impacts the health and wellbeing of women, children and families; and as such, effective family planning programs are essential health care delivery interventions. As one of the goals of primary health care is the enhancement of reproductive health services, HCAC has integrated family planning (FP) and reproductive health (RH) services into the standards for primary health care facilities.

Aim

To specify the optimal requirements for programs to ensure quality of services that are related to health promotion and disease prevention, family planning and reproductive health, client care and outcomes of care, client satisfaction, and client safety.

Scope and Framework

The standards provide facilities with a framework for addressing service delivery and coordination, planning, policy, management in addition to the relationship with other service providers and the wider community. The standards introduce the most important elements of client Primary Health Care and Family Planning Centers Accreditation Standards, 2nd Edition | 3 safety to a facility and create the capacity for the primary care center to continually improve its quality of services to benefit clients.

Eligible Institutions

The standards are comprehensive and applicable to all primary health care facilities that offer comprehensive programs; however, the HCAC recognizes that methods of achieving standards may vary according to the size, type, and resources of each facility.

The Standards Manual

The primary care standards are organized around the most important functions common to all centers. The standards are grouped according to the following functions or clusters:

  • Cluster 1: Community Integration
  • Cluster 2: Organization and Management
  • Cluster 3: Management of Information
  • Cluster 4: Continuum of Care
  • Cluster 5: Client and Family Education
  • Cluster 6: Quality Improvement and Client Safety
  • Cluster 7: Client Care Support
  • Cluster 8: Human Resources
Community Integration
Organization and Management
Management of Information
Continuum of Care
Client and Family Education
Quality Improvement and Client Safety
Client Care Support
Human Resources

HCAC’s Breast Imaging Units Certification Standards is intended to guide managers and staff in breast imaging units to design and implement safe, quality services. The Breast Imaging Units Standards promote minimizing the screening process anxiety in addition to ensuring that the services are acceptable and appropriate to women. The Certification intends to minimize possible adverse effects of screening, such as radiation exposure, over-diagnosis, under-diagnosis, and unnecessary intervention. Additionally, appropriate and equitable access should be provided for groups of women with special needs.

Aim

Ensure and promote high quality of breast imaging services.

Scope and Framework

HCAC has set standards that maintain high quality screening and diagnostic results, which are achievable by most breast imaging units. The standards have been made consistent with other nationally agreed-upon guides, where appropriate. In particular, the Breast Cancer Screening and Diagnostic Guidelines is the recommended source for all clinical practice guidelines/protocols. All units that perform mammograms are encouraged to meet the standards.

Eligible Organizations

Any unit that offers breast imaging services (screening and/or diagnostic) is eligible for seeking Breast Imaging Unit Certification Standards.

The Standards Manual

The HCAC Breast Imaging Units Certification Standards are organized around the most important functions common to all units. The standards are grouped according to the following functions or “clusters”, as they are called in the Manual:

  • Cluster 1: Professional Performance Standards
  • Cluster 2: Clinical Performance Standards
  • Cluster 3: Quality Management Standards
  • Cluster 4: Medical Records and Information Management
Professional Performance Standards
  • Organization and Leadership (OL)
  • Patient Right's (PR)
  • Professional Qualifications and Training Program (PQPT)
  • Professional Performance Evaluation (PE)
Clinical Performance Standards
  • Patient Assessment (PA)
  • Results and Reporting Management (RM)
Quality Management Standards
  • Technical Quality (TQ)
  • Quality Improvement and Patient Safety (QS)
  • Health and Safety (HS)
Medical Records and Information Management
  • Medical records
  • Information Management

Any questions or inquiries about our standards and quality programs? We’re here to answer

Our standards manuals are also available here, order them now!

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