WHAT IS CHRONIC DIALYSIS TREATMENT ACCREDITATION PROGRAMME?
Voluntary and independent accreditation programme for Chronic Dialysis Centre.
ISQua defines Accreditation as “a self-assessment and external peer review process used by healthcare organisations to accurately assess their level of performance in relation to established standards and to implement ways to continuously improve the healthcare system.”
Assessment tool for chronic dialysis centres to assess their level of performance against applicable national standards, MSQH Chronic Dialysis Treatment Standards.
Provides a benchmark against which chronic dialysis centres can regularly assess their organisational performance with continuous improvement.
Accreditation
a self-assessment and external peer review process used by healthcare organisations to accurately assess their level of performance in relation to established standards and to implement ways to continuously improve the healthcare system.
3rd EDITION
CHRONIC DIALYSIS TREATMENT ACCREDITATION STANDARDS
The Chronic Dialysis Treatment Standards is applicable to all haemodialysis facilities and services in public and private sectors as well as facilities and services run by not-for-profit organisations.
These facilities and services are either hospital-basedor ‘free standing’ and provide only chronic haemodialysis treatment.
The standards were developed in collaboration with Malaysian Society of Nephrology, National Kidney Foundation and Ministry of Health (MOH).
The purpose of these standards is to ensure safe medical practice, patient safety and quality service at the Haemodialysis facilities and services.
The standards are organised under five (5) main areas of concern:
Organisation & Management
Human Resource Development and Management
Policies and Procedures
Facilities and Equipment
Safety and Performance Improvement Activities
Chronic Dialysis Treatment Accreditation
The MSQH may accredit any healthcare facility or service as defined by the Private Healthcare Facilities and Services Act 1998, which defines healthcare facility as any premises in which one or more member of the public receive healthcare services. Similar healthcare services in the public sector are also eligible to be surveyed and accredited.
Be a member of MSQH
Be a healthcare organisation in operation for a minimum of 12 months, either in the public or private sector.
Have a current and valid "license" as required by the Ministry of Health and any other relevant regulating body.
Ensure the availability of all services necessary to fulfil the organisation's mission and objectives. (These services may be provided on site, or may be provided off-site by partnerships with acceptable community or regional resources)
Complete and return a "Survey Application Form" to MSQH. The application must be signed by the Person-In-Charge (PIC) of the Hospital or an equivalent person with overall authority and responsibility for the healthcare facility
Survey Application
Chronic Dialysis Centre applying for a first accreditation survey must undergo an accreditation training conducted by MSQH trainers
Fill in online your "Survey Application Form". It must reach MSQH at least six (6) months before the expected date of survey. Applications for survey remain valid for 12 months from the date of application unless significant changes affect the facility.
Successful applicant will then be guided through the steps for training & education, organisational development, self assessment and will be informed regarding associated costs.
Any Chronic Dialysis Centre that is interested in the MSQH Chronic Dialysis Accreditation Programme may contact MSQH for further information.
msqh@msqh.com.my
+60 3 2681 2232
Benefit of Chronic Dialysis Treatment Accreditation Programme
- assurance that your service meets or exceeds the quality healthcare standards available in Malaysia
- Focus on quality and safety in patient care
- Strengthening community trust
- Greater client satisfaction
- Comprehensive and structured analysis of performance with better outcome of care
- Establishes organisational credibility, builds up staff and stakeholders, confidence towards the centre
- Enhanced public image and competitive edge
- Reduce risk and medical defence costs
- Confidence that your centre is client focused
- Assurance that your centre operates according to industry standards and meets international safety standards
- Confidence that risk is minimized and managed to create better shareholder value
- A valuable learning experience through self-assessment, reflection, and challenge to tradition
- Empowerment to improve the processes and change current practices in delivery of care
- Enhanced teamwork, staff satisfaction and staff morale
Accreditation Status Chronic Dialysis Treatment Accreditation Survey
Four Year Accreditation
- A Four-Year Accreditation is awarded to those facilities, which in the opinion of MSQH, substantially comply with the MSQH healthcare standards. It should be noted that the healthcare facilities must achieve substantial compliance in all Core Standards and other Safety Standards, to achieve Four-Year Accreditation.
Delayed Accreditation
- A Delayed Accreditation is awarded to those facilities which have met the requirements of most of the standards.
- A facility awarded a delayed accreditation is offered the opportunity to undergo a Re-Assessment within the six (6) months period.
- During the re-assessment, only those areas of deficiency noted in the initial survey are visited. However, this does not exclude visits to other areas deemed relevant by the surveyors.
- The facility should have taken action on the recommendations which were recorded by the surveyors at the initial survey, and should achieve substantial compliance to MSQH standards in order to qualify for the four year award.
Non-Accreditation
- Accreditation cannot be awarded to a facility in which the surveyors have observed and reported that a significant number of standards are not complied with.
- Facilities who are not accredited are encouraged to implement the recommendations made in the Survey Report and to re-apply for survey.
- It is recommended that a minimum of twelve (12) months should elapse, to allow time for remedial actions and rectification works, before the next survey is undertaken.