STANDARDS DEVELOPMENT AND REVISION PROCESS:
We strictly adhere to the set policy, procedure, guideline and plan for developing the standards. Please contact us on our email to obtain a copy of the process. The summary of the process is as below:
1. Standards Development and Consultation Process: It includes scanning the environment, community need assessment, establishing the need for developing the new standards, review of literature (national and international professional organizations), consulting national and international accreditation surveyors.
2. Standards Measurement Process: It includes expert review, testing on the field, data analysis, pilot survey and update on standards.
3. Standards Approval Process: It includes a proofreading, review, plagiarism, wording, language and grammar, approval and implementation. assessed for the capacity and efficiency of health and social care organisations.
4. Maintain and Evolve the Standards: It includes the continuous monitoring for improvement, feedback, data analysis and update.
5. Safety and Risk: Includes processes to manage risk and to protect the safety of patient’s/service users, staff and visitors.
6. Person-Centered Approach: Includes person-centred care, continuum of care and partnerships between patient’s/ service users and professionals.
The methodology for measuring the overall achievement of a set of standards and measurable elements is as follows:
Fully Met (FM): A standard or Measurable Element(s) will be scored as FM if:
- The compliance is more than or equal to Ninety percent (90%).
- Ninety percent (90%) compliance in the last twelve (12) months for the initial survey and thirty-six (36) months for the re-accreditation survey.
Partially Met (PM): A standard or Measurable Element(s) will be scored as PM if:
- The compliance is more than or equal to Fifty percent (50%) to eighty-nine percent (89%).
- Fifty percent (50%) to eighty-nine percent (89%) compliance in the last twelve (12) months for the initial survey and thirty-six (36) months for the re-accreditation survey.
Not Met (NM): A standard or Measurable Element(s) will be scored as NM if:
- The compliance is less than or equal to forty-nine percent (49%).
- Zero percent (0%) to forty-nine percent (49%) compliance in the last twelve (12) months for the initial survey and thirty-six (36) months for the re-accreditation survey.
If a Measurable Element (ME) of a standard was scored “Not Met (NM)" and some or all of the other MEs are dependent on the one scored “Not Met (NM)," then the remaining MEs that are tied to the prior ME are scored as “Not Met (NM)." For calculation purpose FM=100, PM=50, NM=0 and NA will not be counted in scoring.
Not Applicable (NA): A standard or Measurable Element(s) will be scored as NA when the standard or the measurable element is not applicable based on the hospital's scope of service and the application.
The impact or criticality of non-compliance may prejudice the score of each standard and measurable element.
ACCREDITATION DECISION RULES:
A hospital can achieve accreditation by demonstrating compliance with specific accreditation decision rules. These rules mandate achieving sure scores on a standard, chapter, and overall level, as the accreditation comprises four decisions.
Accredited (validity is three years): When an organization meets all the following conditions:
- All Core Standards should achieve a minimum 50% score with no Standard or Measurable Element with a Not Met Score.
- All Other Standards (excluding the Core Standards) should achieve a minimum 50% score.
- Each chapter should achieve a 90% score.
- The mean of all chapters should be 90%.
Denial of Accreditation:
When an organization meets all the following conditions:
- One or more Core Standards scored “Not Met."
- One or more measurable elements of Core Standards scored “Not Met."
- One or more other standards (excluding Core Standards) scored less than a “50%."
- A score of one or more standard chapters is less than a "90%."
- No acceptable compliance with applicable standards in the focused survey for any Not Met in Core Standards.
- The hospital willingly removes from the accreditation process.
- The presented data was forged or manipulated.
- The hospital does not meet national laws and regulations.
- The hospital failed to submit the Corrective Action Plan (CAP) within 15 days from the last day of the survey.
A Focused Survey will be conducted after ninety (90) days if any Measurable Element in any Core Standard is scored as Not Met.
Submit a corrective action plan for all Partially Met and Not Met within 15 days from the last day of the survey to maintain continuity.
A Mandatory Self-Assessment Survey on an annual basis should be conducted and submitted from the day of accreditation.
The accrediting organization will conduct an Un-Announced Survey at any given time without any prior notice or information in the accredited hospital.
Kindly send us an email at
Corporate.Quality@drsulaimanalhabib.com (or on our telephone: +966-11-5259999, Extension-3776) to obtain a copy of the standards, Policy and Plan on Standard Development, any questions regarding the standards review and revision process of Dr. Sulaiman Al Habib Medical Services Group Company, with "Standard Review" in the subject line. Please also include information about your background and the organization you represent.