Family Planning and Reproductive Health Centers of Excellence Certification Standards



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

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