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Welcome to the
Internet portal of the Syndicate of Hospitals in Lebanon’s Web site
dedicated to the Accreditation Coaching Program.
The portal is a meeting
place for all Lebanese parties involved in the new hospital
accreditation. It is a free and open access source.
A specialized team is
committed to follow the portal daily, update it, make it interactive in
a way to respond to the needs and requirements of hospital professionals
and institutions.
Summary
Background
Presentation of the Accreditation Coaching Program
(click here)
TRAINING PROGRAM – April 2010 to September 2010
(click here)
REMOTE COACHING – April 2010 to April 2011 (click here)
CUSTOMIZED COACHING – April 2010 to December 2010 (click
here)
MOCK AUDITS – July 2010 to February 2011
(click
here)
Background
Within the scope of the
establishment of the new accreditation scheme with two new chapters of
the manual, the assessment of professional practices, the patient
safety, and the establishment of an accreditation process including
hospitals self-assessment and audit visit,
Considering the agreements between Ecole Supérieure des Affaires
(Beirut) and the High Authority of Health (France),
Considering the proposal of ESA (Beirut) to the Syndicate of Hospitals
in Lebanon in June 2009 and the graduate courses in assessment of
professional practices in July 2009,
Considering the deadlines granted by the Ministry of Health to launch
the new iteration of accreditation and audit training,
The Syndicate of Hospitals in Lebanon and Ecole Supérieure des Affaires
set forth the coaching program during the preparatory period.
Both parties aim to:
- Provide
Lebanese hospitals with optimum success in their accreditation
process
- Ensure
quality, seamless, integrated and continuing coaching during the
mentioned period (Training, Customized Coaching and Remote
Monitoring)
- Obtain homogeneous and reliable data
- Ensure
mock audits preparing official audit visit for accreditation
The coaching content and
experts' selection will be coordinated between ESA and the Syndicate of
Hospitals in Lebanon. The Technical Committee of Hospital Accreditation
(CTAH) and the Ministry of Public Health will be following the program.
The program is designed
to meet the needs of hospitals with continuous monitoring during the
dedicated preparatory period - 2010.
1. TRAINING
PROGRAM – April 2010 to September 2010
The training program includes group activities and workshops. They will
be provided between March and June 2010.
The main objective of
these workshops is to enable hospitals to not only master the tools,
methods and procedures necessary to achieve their quality control
process, but also to master the practical application within the
institutions by particularly taking into account its transversal vision.
Therefore, the
training-workshops are very practical and promote real cases and
exchanges between the different participating parties.
Other training-workshops
will be held upon the hospitals' request either in public
(inter-hospital) or in a customized way (for one hospital or a group of
hospitals).
In order to make out of
the accreditation program a success, nine subjects have been studied and
selected:
- Depending
on interest, implicit and explicit requests and needs expressed by
hospitals,
- Opportunities
for improvement observed in the previous iteration of accreditation,
- And
the added value of themes and subjects, of pedagogy and quality
engineering.
The training will be
provided by international expert trainers, in French and in English:
- Experts
in care and patient safety,
- Experts
in Clinical Pratice Assessment (CPA),
- Experts
in engineering of hospital quality and in self-assessment,
- Expert
visitors – auditors at the HAS,
- Members of CTAH,
-
Doctors, caregivers and hospital managers with
experience and / or expertise within the HAS and belonging to the
best institutions and establishments enforcing the matter of
hospital accreditation.
Each training is
provided to groups of 35 persons. The seminars will be organized in the
premises of the Union of Hospitals.
Each subject and each
workshop will be subject to an interactive report (summary of the
exchanges between the participants and the expert, training materials,
advice, opinions of participants, opportunities for improvement, etc.)
available on the Internet portal of the Syndicate of Hospitals in
Lebanon dedicated to the training program.
Training program
(click
here)
Training calendar
(click here)
Training syllabus
(click here)
Training Sessions with Presentations and Speakers Reports (click
here)
List of participants and their resume
(click
here)
Registration form
(click
here)
For more information (click here)
2. REMOTE
COACHING – April 2010 to April 2011
(click on FAQ Accreditation)
During the mentioned period, the program offers guidance and solutions
remotely. Electronic media will be available, including:
- An
FAQ section (click here), an interactive forum (click here) and an
Accreditation portal (click here) all dedicated to sharing CPA, care and
patient safety, self-assessment and audit procedure with all hospitals,
audit agencies, health personnel directly or indirectly
involved in
the process of accreditation.
o The
Internet portal and the FAQ respond quickly to the needs of
institutions, homogenize information, provide educational and
documentary media, keep traceability of exchange.
o Fact
sheets, CPA, returning on success stories, will be available on the
Internet portal to help standardize the monitoring and facilitate
exchanges between professionals and dedicated experts.
- A
newsletter to capitalize on exchange between hospitals.
- A
CPA newspaper to disseminate the best CPA approaches of care
institutions, their successes and results along with CPA Awards
contest (click here)
- The
CTAH and the Ministry of Health will be invited to monitor the content
of the Internet portal. An expert will be dedicated to the proper
functioning of the remote coaching in coordination with the Syndicate of
Hospitals in Lebanon.
In addition, the program provides the institutions with an optional
coaching: Customized coaching and Mock audit.
3. CUSTOMIZED
COACHING – April 2010 to December 2010
Customized coaching days for each institution will be available
depending on the demand, the size and the convenience of the
institutions.
- The
coaching purpose is to:
o analyze
potential discrepancies between the set goals and the reality of the
institution including EPP and patient safety, in cooperation with
teams and individuals responsible for accreditation
o diagnose
potential obstacles, encountered difficulties and possible
solutions, in cooperation with teams and individuals responsible for
accreditation
o propose
an action plan endorsed by all stakeholders
o gather
all staff for awareness and informative conferences in order to
motivate them and bring teams closer (particularly medical teams),
answer their questions, alert them or encourage and thank them for
their efforts
o submit
a full report on the institution's situation and the French expert's
recommendations, which helps teams re-examine and re-adjust their
actions and ensures the optimum success of the institution's
accreditation
The customized coaching
will be held in two stages:
o A
day of personalized inventory
o A
monitoring day (during the three months following the inventory) for
institutions (- 90 beds)
or
o Two
monitoring days - spaced in time (during the three months following
the inventory) for institutions (+ 90 beds)
o A
personalized remote coaching offered by dedicated experts.
The coaching is provided
by French experts (the same expert for each institution)
in full control of guidance methods and audit of care institutions:
o
Visitor experts – auditors at the HAS
o Doctors,
caregivers and hospital managers with experience and / or expertise
within the HAS and belonging to the best institutions and
establishments enforcing the matter of care quality and hospital
accreditation.
French experts may be
accompanied by doctors, caregivers and hospital managers with sufficient
experience and / or expertise in the field in Lebanon.
To best meet the needs of the institution, dates of coaching will be set
and reviewed with the program's officials, the involved institution and
the expert.
Notes
- The
program is set to fully comply with the rules of confidentiality.
IMPORTANT
The institution wishing to take advantage of the entire coaching program
can benefit from a package deal, including a free supplementary day of
customized coaching:
o Two
monitoring days (during the three months following the inventory) for
institutions (- 90 beds)
or
o Three
monitoring days – spaced in time (during the three months following the
inventory) for institutions (+ 90 beds)
For more information
(click here)
4.
MOCK AUDITS – July 2010
to February 2011
A "mock audit" visit will be offered at each institution.
- The
purpose of the audit is to:
-
prepare
and simulate the teams to the audit visit
-
ensure the smooth process of self-evaluation
-
verify records and documents necessary for the accreditation visit:
accreditation application file, self-assessment report, documentary
management, etc.
-
assess the improvements made since the potential coaching visits
-
meet with health care teams, CPA teams, quality, safety committees,
etc.
- submit an audit report on the situation of the institution and
"express" recommendations allowing teams to make final adjustments
before submitting the accreditation application file and the date of
the audit visit.
The mock audit is
provided by a French visitor-expert and one or two Lebanese auditors
(depending on the institution's size) over two days (no matter the size
of the institution) who have a full control of the audit methods of care
institutions:
-
Visitor experts – auditors at
the HAS
-
Doctors,
caregivers and hospital managers with experience and / or expertise
within the HAS and belonging to the best institutions and establishments
enforcing the matter of care quality and hospital accreditation.
-
The Lebanese
auditors are doctors, caregivers and hospital managers enjoying
sufficient experience and / or expertise in quality audit. They will be
subject to the Union's approval in order to avoid any conflict of
interest.
- The
program is committed to respect ethical rules in terms of auditing. The
proposed Lebanese auditors are not part of the team of consultants
responsible for the customized coaching of the institution, the team of
auditors or the audit body responsible for the accreditation visit.
Notes
- The
program is set to fully comply with the rules of confidentiality.
For more information (click here)
To register in the
Coaching
Program
for Hospital Accreditation
(click
here)
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