“Our organization is always ready to implement and follow any accreditation agency guidelines and standards to establish best practices”
Dr. Rola Hammoud, DA, MHA, FACHE, is Chief Medical Executive at Clemenceau Medical Center, Dubai. Her extensive experience in anesthesiology spans over 25 years as she provides the safest care guided by the best practices and international standards to ensure patients are properly and promptly treated throughout their entire surgical path. Moreover, she has experience in the education and training of residents and participated in many regional and international anesthesia congresses and workshops as a speaker and trainer. “Hospitals” Magazine had the privilege to meet with Dr. Hammoud to address several topics. Below is the full interview:
What are the accreditation programs that your hospital has undergone, if any, and are you planning to pursue other accreditation programs?
At CMC Dubai, our laboratory and Pathology departments are accredited by the College of American Pathologist with the CAP Laboratory accreditation. Additionally, the hospital has received the Joint Commission International (JCI) accreditation for hospitals. Furthermore, we are currently in the process of preparing for Hospital Baby Friendly Initiative Certification.
What are the benefits of achieving accreditation and how does it help in reducing the cost of operation?
Achieving accreditation by an international accrediting organization is a recognition of our high levels of safety and quality in the care we provide to our patients. It is also a demonstration of the excellence in our delivery of services. The benefits are numerous for both the organization and the patients that are being served, including:
- Standardization of care and Reduction of variability – This will ensure all patients will receive the same consistent level of care and have a similar experience regardless of which department they visit or which staff they interact with. This will help in reducing errors and reducing risks.
- Building staff competencies and knowledge.
- Adoption of best practices by sharing the knowledge and the practices with other organizations (and also the surveyors).
- Stand out and differentiate the organization from others by showcasing the commitment to quality and ultimately attracting more patients (by winning their confidence).
- Stand out and differentiate the organization from others by showcasing the commitment to quality and ultimately attracting a highly qualified workforce that shows commitment to the levels of excellence of the organization
The outcome of accreditation is to improve patient safety and provide better quality care, how can you describe the impact of accreditation on your hospital and how is it an ongoing process?
Being a newly established hospital, the management of the organization had the vision to include the standards of JCI in the designs and planning phase and ensure that the highest levels of guidelines are followed. Once the implementation and commissioning phase kicked off, the same approach was trickled down and this became a solid part of the culture embedded in the mission.
Once the accreditation was achieved officially, this culminated into an official recognition of this work that was done by the team and provided the motivation to continue to do so.
Accreditation is not a one-time project or activity that is performed every 2/3 years. Accreditation is a voluntary conscious commitment to a specific level of standards where the organization will be in a state of continuous readiness. Using this ideology, the process and commitment is maintained through regular audits, environmental rounds and mock surveys.
Your organization’s familiarity with quality improvement is key to a successful implementation of accreditation. Can you tell us how you make sure this is done properly?
CMC adopts the total quality management approach (TQM). TQM principles are integrated in all systems. The Quality Improvement Plan and Program provides guidelines for systematically evaluating our functions, processes, systems, risks and outcomes to insure excellence in quality health care at our institution. This plan is set in alignment with the strategic goals of the governing board who in turn approves the plan and ensures all resources are allocated for its implementation.
Information and data are aggregated and used in a consistent manner to improve systems and processes. Systems and processes are designed and redesigned using a multidisciplinary approach in coordination with all hospital departmental quality and safety programs and plans. In continual improvement, CMC analyses its processes to reduce unnecessary variation and improve the quality of its services. A systematic approach to improvement is used to continually improve the organization’s processes.
In order to continually improve, CMC Dubai understands that it is a system of interdependent parts, all with the same mission, meeting the needs and exceeding the expectations of our customers. CMC Dubai seeks to optimize the performance of the entire system, rather than the performance of individual parts. Additionally, as a system of interdependent parts, CMC Dubai aligns its processes, technology, people, values, and policies to support its efforts targeted towards continuous improvement.
Those efforts are monitored continuously by Key performance indicators that are reported regularly to the governing board.
We also make sure quality concepts are understood by all staff and we perform regular trainings on those concepts. All those efforts make us continuously ready for the accreditation process.
The executive team of the hospital is key to ensuring the continuity of the process and making sure that all the staff understands their role in achieving accreditation standards, how important is leadership and direction?
Governing Board / leadership of the hospital bears ultimate responsibility for the quality of patient care rendered and for patient safety within the hospital. This important investment in quality needs adequate resources, and accordingly planning needs to be done, approved and monitored by the highest level of the organization to ensure its implementation.
Leadership of the organization will shape the quality culture of the hospital through its vision and support the coordination among all the departments and services in measurement and improvement efforts. While identifying the priorities of the organization, leadership will include continuous improvement, patient safety and accreditation as part of the strategic goals which will show leadership by example and dictate how this will reflect of the rest of the team and staff. The management will ensure all staff understand the strategy and work towards achieving its goals.
Clear policies and procedures are key to achieving accreditation success, how do you ensure that your staff applies them daily?
To ensure compliance, one-time training and lecturing upon recruitment is not enough. A competency-based orientation demonstrated better outcome and knowledge dissemination. This is complemented by continuous refreshments and on-site visual demonstration of these vital practices (quick summary pocket cards). Complex and vertical processes (involving multiple units / departments) are always illustrated in diagrams and drawing to simplify the steps and help staff to comprehend easier.
On-site daily monitoring and follow-up are required to ensure the continuous application of approved policies, procedures and workflows. The quality team conduct focused patient tracers, system tracer, quality rounds and establish a robust monitoring, auditing programs enhanced by KPIs and reviews.
Do you think that your organization is ready for more accreditation programs?
And how do you think organizations should perform after getting an accreditation? Is it an ongoing process?
Our organization is always ready to implement and follow any accreditation agency guidelines and standards to establish best practices and improve of services and the care of our patients.
After an accreditation, the organization shall work towards maintaining continuous readiness. Using this ideology, the process and commitment is maintained year long and ensured by working that preparedness is not only for the next survey, but for the next patient.
This is why our quality team continues to perform rounds, tracers, mock surveys and drills all year long.
Bringing a hospitality approach to Hospitals is becoming a key strategy for hospitals to have better outcomes and higher patient satisfaction, what is the importance of #HOSPOTEL in accreditation programs?
Multiple accreditation agencies incorporate patient rights, patient education and patient experience in their standards. The new approach now is heading towards establishing a patient-centered approach and person-centered approach in the delivery of the care systems and this is evident in the progression of the standards. The trend currently also shows that patients are now interviewed during on-site accreditation surveys and further standards require the capturing of patient perspectives by evaluating their experience and journey. All these are assessed in depth during the surveys also and a great deal of importance is given to them.
Additionally, with the increase in the health literacy of the general population and the ease of access to information, patient engagement in all aspects of care/treatment through education and participation of the decision-making process is now a must for all.
Furthermore, evidence shows that engaged and satisfied patients lead to more abidance by the health education and instruction of the care team and ultimately have better outcomes.
Systems and smiles are needed to improve the healthcare business, where do you think improvements are needed to insure a successful business?
The success of a business relies mostly on the quality of the product or service that is being delivered. Ensuring that this consistency of delivery is achieved at the first time and at all times is vital.
Understanding the customer and his expectation is also an important factor as the service will not be sold if it is not needed or delivered as per the needs of this customer. So, combining the previous 2 points leads to conclude that the service should be of the highest quality as per the customer expectations and make sure that standardization and consistency of delivery are maintained so the experience doesn’t vary over time.
Finally, focusing only on the customer is not enough and work should be done to also provide the optimal levels of satisfaction and experience for the staff too. An improvement is this regard can help a business sustain the levels of the desired quality.