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

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.

A. Introduction

Accreditation in the healthcare has proven to be a driving force in improving quality care delivery to the patient. The shift in focus on improving standards in the ambulatory care settings has had a constructive long term impact on quality, cost-effectiveness, improvement and reliability. The standards in the ambulatory care would provide aid in identification, guidance and improvement on areas in a systematic and strategic manner.

B. Aim

The standards identify those aspects of program structure and operation that the HCAC regards as essential to program quality and achievement of ambulatory health care goals. They specify the optimal requirements for programs to ensure quality services related to patient management including patient care and the outcomes of the care, patient satisfaction, and patient safety. It also serves as an education guide for facilities that wish to establish new programs or improve existing programs.

C. Framework and guiding principles of HCAC Hospital Standards

The ambulatory care standards were developed in line with the non-inpatient care framework which emphasizes that ambulatory care that takes place as a day attendance at a health care facility has to be provided according to the best practice care to assure safe and sustainable, patient focused care. The non-inpatient care term covers a broad range of care delivery from preventative and primary care, through to specialist services and tertiary level care, and is collectively referred to as non-inpatient care. This Framework[2] does not imply that all these services will be delivered outside of hospitals; some services will and should continue to be delivered in hospitals for reasons of patient safety, quality and efficiency. However many services currently delivered in the hospital settings can be provided safely and effectively in the community setting.

The framework is aligned with the following guiding principles:

  • Improved access to services
  • Provide safe, high quality evidence based health care
  • Promote a patient centered continuum of care
  • Optimize public and private services
  • Improve the balance of preventative, primary and acute care
  • Support a highly skilled and dedicated workforce

What does patient -centered mean?

Patient-centered care is based on several key principles:

Dignity and respect:
Incorporating the values, beliefs and cultural backgrounds of clients into the planning and delivery of care; resolving complaints and conflicts as soon as possible.

Information sharing:
Encouraging clients to share their perspectives & questions and healthcare professionals providing information regarding illness & treatment options in terms that the client can understand.

Participation:
Preparing and supporting clients 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.

D. Eligible Institutions

All organizations provide ambulatory care services are eligible to apply.

E. Organization of the standards Manual

The standards will provide facilities with a framework for addressing service delivery and coordination, planning, policy, management and the relationship with other service providers and the wider community. The standards introduce the most important elements of patient safety to a facility and create the capacity for the ambulatory care to continually improve its quality of services to benefit patients

The standards are organized into key functions referred as “clusters”, they are divided into general clusters that are applicable to all ambulatory care organizations and adjunct clusters that might be applicable to ambulatory care organizations according to the scope of service provided. The clusters are arranged as follows:

General clusters:

Cluster 1: Patient Rights

Cluster 2: Leadership and Management

Cluster 3:Human Resources Management

Cluster 4: Ambulatory Care Access and Continuity of Care

Cluster 5: Ambulatory Care Facilities and Premises

  • Facilities and premises
  • Ambulatory care organization safety
  • Infection prevention and control
  • Emergency management

Cluster 6: Quality Improvement

Cluster 7: Ambulatory Care Information Management

  • Documents and records management

Cluster 8: Ambulatory Care Clinical Records Management

Adjunct clusters:

Cluster 9: Patient assessment and Care

  • Patient assessment
  • Patient care

Cluster 10: Anesthesia care

Cluster 11: Surgical care

Cluster 12: Emergency care

Cluster 13: Laboratory services

Cluster 14: Pharmaceutical services

Cluster 15: Imaging services

For each cluster, there is an intent statement that assists the ambulatory care staff members to understand the standards and a list of the key documents that are required for review by the surveyors. In each cluster, every standard is listed followed by the measurable elements

F. Classification of standards

A number of standards have been identified as essential according to the following criteria:

  • central organizational processes;
  • processes requiring workforce competencies;
  • processes with immediate impact on patient safety and clinical effectiveness;
  • address laws and regulations

A. Introduction

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.

B. Aim

Ensure and promote high quality of breast imaging services.

C. Framework and guiding principles of HCAC Hospital Standards

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.

D. Eligible Institutions

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

E. Organization of 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

  • Organization and Leadership (OL)
  • Patient Right's (PR)
  • Professional Qualifications and Training Program (PQPT)
  • Professional Performance Evaluation (PE)

 

 Cluster 2: Clinical Performance Standards

  • Patient Assessment (PA)
  • Results and Reporting Management (RM)

 

 Cluster 3: Quality Management Standards

  • Technical Quality (TQ)
  • Quality Improvement and Patient Safety (QS)
  • Health and Safety (HS)

 

 Cluster 4: Medical Records and Information Management

  • Medical records
  • Information Management

A. Introduction

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.

B. Aim

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

C. Framework and guiding principles of HCAC Hospital Standards

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.

D. Eligible Institutions

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

E. Organization of 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

  • Program Structure and Management
  • Community Mobilization
  • Patient rights 

 

Cluster 2: Clinical Management

  • Patient assessment
  • Patient care 

 

Cluster 3: Self-Management

  • Ancillary Services
  • Pharmaceutical services
  • Laboratory services
  • Cardiac diagnostic tests
  • Radiology services

 

Cluster 5: Staff Performance

Cluster 6: Quality and Safety

  • Quality improvement and patient safety
  • Information management

 

A. Introduction

As a front line, the pharmacist in the community setting would have the authority and autonomy in managing the patient’s medication and held accountable for their therapeutic outcome. The need to achieve optimum pharmaceutical care has been recognized and pharmacists within the community took initiative to promote good pharmacy practice that would lead to the intended outcomes of safety, quality, cost-effectiveness, improvement and reliability.

B. Aim

The HCAC has developed community pharmacy standards by focusing on a system-based approach to ensure the services provided to the community are of appropriate quality and they can be used as a reference that will be aiding the profession and highlighting its key role in the healthcare system.

C. Scope & Framework

The community pharmacy standards are developed in line with the GPP (Good Pharmacy Practice FIP/WHO guideline) which emphasizes the role of the pharmacist and its contribution to health improvement and helping patients with health problems to make the best use of their medicines.

The International Pharmaceutical Federation (FIP) is an organization with a worldwide focus and it has had a key role in implementing the philosophy of pharmaceutical care into community pharmacy practice. FIP first adopted the guidelines for Good Pharmacy Practice (GPP) in 1993. These guidelines were developed as a reference to be used by national pharmaceutical organizations, governments, and international pharmaceutical organizations to set up national standards of Good Pharmacy Practice. During the last years, FIP has been in the process of updating the GPP Guidelines. For that purpose, it produced a Reference guide on Good Pharmacy Practice in 2012. FIP has been closely cooperating with World Health Organization (WHO) in GPP standard development.

The framework is aligned with the following guiding principles:

  • Availability of pharmaceutical services, including: Supply, information, and workforce skill.
  • High quality and evidence-based health care.
  • Patient safety.
  • Health promotion.
  • Patient Welfare.
  • Code of ethics and professional conduct.

 

D. Eligible Institutions:

Any Community Pharmacy may apply for Community Pharmacy Accreditation program if it meets all the following criteria:

  • Is in compliance with applicable local laws and regulations and has a valid licensure by the approved entity.
  • Has been providing community pharmacy services for at least six months or more prior to the time of survey.

 

E. Organization of the Standards Manual

The standards are organized into key functions referred as “clusters”.

Cluster 1: Leadership and Management

Cluster 2: Patient Right

Cluster 3: Human Resource Management

Cluster 4:Pharmaceutical Process Management

  • Procurement
  • Inventory
  • Storage
  • Dispensing
  • Compounding
  • Patient & Family Counseling
  • Community Service


Cluster 5:
Environmental Health and Safety

Cluster 6: Quality Improvement

Cluster 7: Information Management.

For each cluster, there is an intent statement that assists the pharmacy staff to understand the standards and a list of the key documents that are required for review by the surveyors. In each cluster, every standard is listed followed by the measurable elements, and survey process. The survey process is identical to what the surveyors will look for to determine how to score the standard.

F. Classification of standards

A number of standards have been identified as essential according to the following criteria:

  • central organizational processes;
  • processes requiring workforce competencies;
  • processes with immediate impact on patient safety and clinical effectiveness;
  • address laws and regulations

A. Introduction

The effects of oral disease on overall health are alarming. Oral disease has an impact on physical, psychological, social, and economic health and well-being, often resulting in pain, diminished function, and reduced quality of life. Furthermore, poor oral health is associated with increased bacterial systemic exposure and increased inflammatory factors that can lead to adverse health outcomes such as uncontrolled diabetes, cardiovascular disease, and respiratory disease.

The shift in focus on improving the provision of care in the ambulatory care settings due to the numerous advantages such as; reduction in health care related costs, reduction in length of stay at hospitals as well as promoting health through health education and prevention, thus emphasizing the health care on the people themselves and their own capacity to maintain health. The ambulatory care standards would provide aid in identification, guidance and improvement of areas that would lead if implemented in the ambulatory care settings to increasing patient safety in a systematic and strategic manner. Under the umbrella of ambulatory care undergoes the dental care and its services. The dental standards would also contribute the promotion quality and safety of dental services provided in relevant settings.

B. Aim

The standards identify those aspects that the HCAC regards as essential to achieve the intended goals. They specify the optimal requirements to ensure quality services related to patient management including patient care and the outcomes of the care, patient satisfaction, and patient safety. It also serves as an education guide for dental facilities that wish to establish new systems or improve existing ones.

C. Framework and guiding principles of HCAC Hospital Standards

The ambulatory care standards were developed in line with the non-inpatient care framework which emphasizes that ambulatory care that takes place as a day attendance at a health care facility has to be provided according to the best practice care to assure safe and sustainable, patient focused care. The non-inpatient care term covers a broad range of care delivery from preventative and primary care, through to specialist services and tertiary level care, and is collectively referred to as non-inpatient care. This Framework does not imply that all these services will be delivered outside of hospitals; some services will and should continue to be delivered in hospitals for reasons of patient safety, quality and efficiency. However many services currently delivered in the hospital settings can be provided safely and effectively in the community setting.

The framework is aligned with the following guiding principles:

  • Improved access to services
  • Provide safe, high quality evidence based health care
  • Promote a patient centered continuum of care
  • Optimize public and private services
  • Improve the balance of preventative, primary and acute care
  • Support a highly skilled and dedicated workforce

What does patient - centered mean?

Patient-centered care is based on several key principles:

Dignity and respect:
Incorporating the values, beliefs and cultural backgrounds of clients into the planning and delivery of care; resolving complaints and conflicts as soon as possible.

Information sharing:
Encouraging clients to share their perspectives & questions and healthcare professionals providing information regarding illness & treatment options in terms that the client can understand.

Participation:
Preparing and supporting clients 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.

D. Eligible Institutions

Facilities that offer dental services are eligible to apply.

E. Organization of the standards Manual

The standards are organized into key functions referred as “clusters”, they are divided into ten clusters as follows:

Cluster 1: Governance and Leadership

Cluster 2: Patient’s Rights

Cluster 3: Access and Continuity of Care

Cluster 4: Patient Care

  • Patient assessment
  • General Care
  • Anesthesia and inhalation sedation care
  • Dental Radiography
  • Emergency dental care
  • Medication care

Cluster 5: Clinical records Management

Cluster 6: Human Resources Management

Cluster 7: Facility and Environment Safety

Cluster 8: Infection Prevention and Control

Cluster 9: Quality Improvement and Patient Safety

Cluster 10: Information Management

For each cluster, there is an intent statement that assists the dental care professionals to understand the standards and a list of the key documents that are required for review by the surveyors. In each cluster, every standard is listed followed by the measurable elements, and survey process. The survey process is identical to what the surveyors will look for to determine how to score the standard.

F. Classification of standards

A number of standards have been identified as essential according to the following criteria:

  • central organizational processes;
  • processes requiring workforce competencies;
  • processes with immediate impact on patient safety and clinical effectiveness;
  • address laws and regulations

A. Introduction

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.

B. Aim

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

C. Framework and guiding principles of HCAC Hospital Standards

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.

D. Eligible Institutions

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

E. Organization of the standards Manual

The standards manual is grouped according to the following clusters:

Cluster 1: Program Management

  • Program Structure and Management
  • Community Mobilization 

 

Cluster 2: Clinical Management

  • Patient Rights
  • Patient assessment
  • Patient care

 

Cluster 3: Self-Management

Cluster 4: Ancillary Services

  • Pharmaceutical services
  • Laboratory services

 

Cluster 5: Staff Performance

Cluster 6: Quality and Safety

  • Quality improvement and patient safety
  • Information management

 

A. Introduction

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.

B. Aim

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.

C. Framework and guiding principles of HCAC Hospital Standards

Family Planning and Reproductive Health Programs cover, but are not limited to, the following:

  • Contraceptive services
  • Reproductive health services
  • Reproductive health screening and assessment services (including cervical cancer screening)
  • Sexually transmitted infections (STIs) screening and assessment, diagnosis and treatment, and disease intervention services
  • Pregnancy testing, risk assessment, and early pregnancy care services, timely appropriate care and follow-up
  • Client education and anticipatory guidance.
  • Institutions must have attained HCAC or another recognized institution accreditation prior to applying for centers of excellence certification.

D. 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.

E. Organization of the standards 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

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.

Section 2: Domains & Criteria

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

 

Section 3: Assessment & Scoring Guide

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 4: Glossary, Required documents

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

A. Introduction

The fourth edition of the HCAC Hospital Accreditation Standards has retained the patient centered-focus as in the previous editions but several changes were made to eliminate duplication, clarify the wording of standards, revise standards based on current evidence, and add new standards that reflect current practice. Also, several standards were reclassified as either core or critical. These decisions were based on data derived from accreditation scoring results and stakeholders feedback meetings. For instance, if the majority of hospitals were meeting a “stretch” standard, then it was reclassified to “core”. The definition of critical includes those standards required by law and regulation, as well as standards that have the potential to result in harm to patients, staff, or visitors if not carried out. This edition contains 15 clusters, 426 standards.

B. Aim

Accreditation helps the hospital enhance patient care through a continuous quality improvement process. In almost all cases this can be achieved without major investments in infrastructure. It also strengthens community confidence by highlighting the hospital’s commitment to provide safe and quality care to the community.The purpose of accreditation is to encourage and support health facilities to undergo comprehensive survey processes and achieve national benchmarks that demonstrate the highest standards of health care quality

C. Framework and guiding principles of HCAC Hospital 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:
Incorporating the values, beliefs and cultural backgrounds of patients into the planning and delivery of care; resolving complaints and conflicts as soon as possible.

Information sharing:
Encouraging patients to share their perspectives & questions and healthcare professionals providing information regarding illness & treatment options in terms that the patient can understand.

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.

D. Eligible Institutions

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

E. Organization of the standards Manual

This manual follows the structure of the hospital standards. They are divided into 15 clusters as follows:

Cluster 1: Ethics and Patients’ Rights

Cluster 2: Access and Continuity of Care

Cluster 3: Patient Care

  • Patient Assessment
  • General Care
  • Surgical Care
  • Anesthesia and Sedation Care
  • Emergency Services
  • Dental Care
  • Critical Care
  • Neonatal Care
  • Pediatric Care
  • Obstetric Care
  • Dialysis Services
  • Rehabilitation Services
  • Fertilization Services

Cluster 4: Diagnostic Services

  • Laboratory
  • Blood Bank
  • Radiology Services

Cluster 5: Medication Management

Cluster 6: Infection Prevention and Control

  • Sterilization

Cluster 7: Environmental Safety

Cluster 8: Support Services

  • Housekeeping
  • Food Service and Kitchen
  • Laundry

Cluster 9: Quality Improvement and Patient Safety

Cluster 10: Medical Records

Cluster 11: Information Management

Cluster 12: Human Resources Management

  • Employee Health

Cluster 13: Management and Leadership

Cluster 14: Education and Training

  • Patient and Family Education
  • Employee Training and Education

Cluster 15: Research

For each cluster, there is an intent statement that assists the staff to understand the standards and a list of the key documents that are required for review by the surveyors. In each cluster, every standard is listed followed by the measurable elements, and survey process. The survey process is identical to what the surveyors will look for to determine how to score the standard.

F. Classification of standards

Standards are classified as critical, core, and stretch. The guiding definitions are as follows:

Critical (69 Standards)
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 (317 Standards)
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 (40 Standards)
Stretch standards are standards that are important, but not easy to implement due to time or resource constraints, or a need for culture change.

A. Introduction

Accreditation in the healthcare has proven to be a driving force in improving quality care delivery to the patient. The shift in focus on improving standards in the medical laboratory community has had a constructive long-term impact on quality, cost-effectiveness, improvement and reliability. The standards in the medical laboratory would provide aid in identification, guidance and improvement on areas in a systematic and strategic manner.

The standards identify those aspects of program structure and operation that the HCAC regards as essential to program quality and achievement of laboratory health care goals.

They specify the optimal requirements for programs to ensure quality services related to patient management including patient care and the outcomes of the care, patient satisfaction, and patient safety. It also serves as an education guide for facilities that wish to establish new programs or improve existing programs.

B. Aim

The Medical Laboratory Accreditation Standards are intended to fulfill the following objectives:

  • To reduce the potential errors that might occur in the medical laboratory processes.
  • To improve the outcome in providing quality results that plays a major role in high quality patient care.
  • To improve outcomes of treatment and management of priority diseases and conditions,
  • To provide maximum patient satisfaction

C. Framework of HCAC Medical Laboratories Standards

The HCAC Medical laboratory Accreditation Standards provide the guiding framework within which laboratory performance is evaluated, the standards specify quality management essentials in the laboratory that in total form quality management system along with competency requirements for medical testing, the standards are built using the WHO Laboratory Quality Stepwise Implementation Tool (LQSI).

A laboratory, just like any other organization, consists of numerous processes in which inputs are turned into outputs through one or more process steps. The core process of the laboratory is the primary process consisting of three stages: thepre-analytical stage(the sample is collected, received at the laboratory, registered and processed), theanalytical stage(the actual laboratory test is performed and the result is recorded), and thepost-analytical stage(the result is authorized, reported and archived and the sample is discarded/ archived).[1]

A quality management system can be described as a set of building blocks needed to control, assure and manage the quality of the laboratory's processes. By ensuring that all the processes related to the QSEs perform correctly, quality can be assured.

Guiding Principles - Medical Laboratories incorporate the principles of:

  • Health is a basic human right.
  • Accuracy – delivering accurate results that have a significant impact in decreasing testing errors and enhancing patient treatment in a timeless manner.
  • Quality Improvement–Assure and manage the quality of laboratory processes
  • Evidence based practice - Services are provided according evidences from scientifically credible research
  • Safety-Patients, staff and community have the right to safe care and treatment

D. Eligible Institutions

All medical laboratories are eligible to apply.

E. Organization of the standards Manual

The standards will provide medical laboratories with a framework for addressing service delivery and coordination, planning, policy, management and the relationship with other service providers and the wider community. The standards introduce the most important elements of patient safety to a medical laboratory and create the capacity for the medical laboratories to continually improve its quality of services to benefit patients

The standards are organized into key functions referred as “clusters”, they are divided into seven clusters. The clusters are arranged as follows:

Cluster 1: Governance and Leadership

Cluster 2: Human Resources Management

Cluster 3: Medical Laboratory Operations

  • Laboratory workflow “Pre-analytic, analytic, post-analytic”
  • Laboratory Equipment
  • Procurement and Inventory Management

Cluster 4: Medical Laboratory Facilities and Premises

  • Emergency management
  • Laboratory Safety
  • Infection prevention and Control

Cluster 5: Patient Rights

Cluster 6: Quality Improvement

  • Quality control
  • Quality Improvement

Cluster 7: Laboratory information management

For each cluster, there is an intent statement that assists the laboratory staff members to understand the standards and a list of the key documents that are required for review by the surveyors. In each cluster, every standard is listed followed by the measurable elements, and survey process. The survey process is identical to what the surveyors will look for to determine how to score the standard.

F. Classification of standards

A number of standards have been identified as essential according to the following criteria:

  • central organizational processes;
  • processes requiring workforce competencies;
  • processes with immediate impact on patient safety and clinical effectiveness;
  • address laws and regulations

A. Introduction

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.

B. Aim

To embed high quality and reliable medical transportation services.

C. Framework and guiding principles of HCAC Hospital Standards

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.

D. 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.

E. Organization of 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)

A. Introduction

Primary health care shifts the emphasis of health care to the people themselves and their needs, reinforcing and strengthening their own capacity to maintain health. The growth of these services has been driven by community members’ desire to receive a service that is accessible, at an appropriate cost, with a focus on health promotion and disease prevention and health education. Accordingly, primary health care needs to be delivered close to the people using health technologies that are accessible, acceptable, affordable and appropriate.[1] Primary health care centers serve the health care needs of their community, and thus, are integral to the well-being of these communities.

B. Aim

The standards identify those aspects of program structure and operation that the HCAC regards as essential to program quality and achievement of primary health care goals. They specify the optimal requirements for programs to ensure quality services related to health promotion and disease prevention, family planning and reproductive health, client care and outcomes of care, client satisfaction, and client safety. It also serves as an education guide for facilities that wish to establish new programs or improve existing programs.

C. Framework and guiding principles of HCAC Hospital Standards

One of the goals of primary health care is the enhancement of reproductive health services. Based on the philosophy of the World Health Organization (WHO), reproductive health implies that people are able to have a responsible, satisfying and safe sex life and that they have the capability to reproduce and the freedom to decide if, when and how often to do so. Implicit in this philosophy is the right of men and women to be informed of and to have access to safe, effective, affordable and acceptable methods of fertility regulation of their choice. While overall health conditions in Jordan - low infant mortality rates and high life expectancy - are among the best in the region, the population growth rate continues to be a major development constraint - especially when analyzed in light of the quantity and quality of services to be provided to accommodate this rapid increase in population. In light of the importance of this issue, HCAC has group of standards related to family planning (FP) and reproductive health (RH) services as part of the care offered in the primary health care facilities.

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

Client-centered care is based on several key principles:

Dignity and respect:
Incorporating the values, beliefs and cultural backgrounds of clients into the planning and delivery of care; resolving complaints and conflicts as soon as possible.

Information sharing:
Encouraging clients to share their perspectives & questions and healthcare professionals providing information regarding illness & treatment options in terms that the client can understand.

Participation:
Preparing and supporting clients 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.

D. Eligible Institutions

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

E. Organization of the standards Manual

The standards will provide facilities with a framework for addressing service delivery and coordination, planning, policy, management and the relationship with other service providers and the wider community. The standards introduce the most important elements of client safety to a facility and create the capacity for the primary care center to continually improve its quality of services to benefit clients.

This manual follows the structure of the primary care standards. They are divided into 12 clusters as follows:

Cluster 1: Governance and Leadership

Cluster 2: Clients’ rights

Cluster 3: Access and Continuity of Care

Cluster 4: Client Care

  • Client Assessment
  • General Care
  • Local Anesthesia Care
  • Dental and oral health care
  • Non-communicable diseases
  • Communicable diseases
  • Emergency Care
  • Reproductive Health
  • Child Health
  • Medication Management
  • Laboratory services
  • Radiology

Cluster 5: Medical Records

Cluster 6: Human Resource Management

Cluster 7: Facility and Environment

Cluster 8: Infection Prevention and Control

Cluster 9: Quality Improvement and Client Safety

Cluster 10: Information Management

Cluster 11: Health Education

Cluster 12: Community Engagement

For each cluster, there is an intent statement that assists the staff to understand the standards and a list of the key documents that are required for review by the surveyors. In each cluster, every standard is listed followed by the measurable elements, and survey process. The survey process is identical to what the surveyors will look for to determine how to score the standard.

F. Classification of standards

Standards are classified as critical, core, and stretch. The guiding definitions are as follows:

Critical (34 Standards)
Critical standards are those standards that address laws and regulations or, if not met, may cause death or serious harm to clients, visitors, or staff.

Core (94 Standards)
Core standards are the standards addressing systems, processes, policies and procedures that are important for client care. However, partially met compliance with these standards must not pose a threat of harm or death for clients, visitors or staff.

Stretch (14 Standards)
Stretch standards are standards that are important, but not easy to implement due to time or resource constraints, or a need for culture change.

Recruitment and Certification of Surveyors (Under Development)

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 Program.
  • Primary Health Care and Family Planning Centers Accreditation Program.
  • Breast Imaging Units Certification Program.
  • Medical Laboratories Accreditation Program.
  • Ambulatory Care Program.

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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