Mod 2 - Stds and Acc

Module 2: Standards and
Accreditation
Rwanda
October 2021
Session 2 - Objectives
1. Share with others the importance of
accreditation standards in improving quality
of health care.
2. Describe and understand the systems that
make up a hospital.
3. Explain the components of a system: inputs,
processes, and outcomes.
4. Describe the elements of a good standard.
5. Describe how the Rwandan accreditation
standards manual is organized.
Standards
What is a standard?
• It is a statement of the quality expected
Why are standards important?

• Inform healthcare providers of expectations
• Guide monitoring and evaluation of care
• Patients receive same level of care regardless of the
setting
Implicit vs Explicit Standards
• Implicit = individuals understand standards

from their own viewpoint
• Explicit = written standards describe exactly
what is expected
Evidence-based standards
• Standards written according to current

research
• Expert consensus
Systems
Standards are developed for all hospital

systems.
What is a system?
• What are some of the

systems within our
bodies?
• What does the heart
do?
• What is the end result
of this process?
What are some of the systems
in a hospital?
Components of a System
• Inputs (structure) – resources needed to

carry out an activity
• Processes – activities
• Outcomes – results of the activities
What are some of the inputs,
processes and outcomes?
Inputs
Processes
Building
Trained staff Admission
Equipment Assessment
Supplies Test Procedures Outcomes
Written standards Patient Education
Treatment Improved health
Referral Efficient services
Patient satisfaction
What are some of the inputs,
processes and outcomes needed for
handwashing?
Inputs Processes Outcomes

Accreditation Standards are
Systems-based
• Accreditation standards are written for inputs

and processes.
• Organizations are expected to define and

measure outcomes.
Problems with standards
• Not documented
• Not communicated effectively
• Not available to staff
• Not updated regularly
• Do not meet criteria of a good standard
Characteristics of a good standard (1)
• Valid
• Based on scientific evidence or other
acceptable experience, expert consensus at a
minimum
• Reliable
• Leads to the same result each time it is applied
by anyone who uses it
Characteristics of a good standard (2)
• Clear
• Understood in the same way be everyone;
not subject to misinterpretation
• Realistic
• Can be achieved with existing resources,
suited to the setting
• Measurable
• can be quantified
Rwandan Hospital Standards
Review how the Accreditation Manual is organized

• Scope and purpose
• Standards development
• Standards framework
Five Risk Areas

• Leadership process and accountability
• Competent and capable workforce
• Safe environment for staff and patients
• Clinical care of patients
• Improvement of quality and safety
Classification of standards
Levels of effort
Introduction to
Accreditation
Definition of Accreditation
A process in which an entity, separate and distinct from

the hospital, assesses the hospital to determine if it
meets a set of standards designed to improve quality
and safety of care
Accreditation Program Requirements
• Relevant and achievable standards

• An objective and transparent survey and
decision process
• Knowledgeable and credible surveyors
• Education and support to facilities in
meeting standards
Does accreditation make a difference?
Accredited hospitals report significant

improvements in:
• Leadership
• Medical records management
• Infection control
• Staff training and professional credentialing
• Quality monitoring
Steps towards Accreditation (1)
1. Leaders embrace the concept
2. Concept and value of accreditation is
communicated to all staff
3. Quality structure established
4. Staff educated about the accreditation
standards
5. Baseline assessment conducted
Steps towards Accreditation (2)
6. Gaps identified and work plans developed

7. Standards implement through quality
improvement activities
8. Impartial external evaluation
• Progress surveys by external surveyors
• Final accreditation survey
9. Accreditation decision
Questions and Comments

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Module 2: Standards and

Why are standards important?

• Implicit = individuals understand standards

• Standards written according to current

Standards are developed for all hospital

• What are some of the

• Inputs (structure) – resources needed to

Inputs Processes Outcomes

• Accreditation standards are written for inputs

• Organizations are expected to define and

Review how the Accreditation Manual is organized

Five Risk Areas

A process in which an entity, separate and distinct from

• Relevant and achievable standards

Accredited hospitals report significant

6. Gaps identified and work plans developed

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