Hospital Accreditation

As far as the Audit Organizations who are certified to give ISO certificate for hospitals, is it allowed for these AO to sign contracts with the hospitals that they had a business with or it will be a conflict of interest?

It's forbidden for an AO to sign contracts with hospitals they worked with about ISO Certification as consultant or trainer.

A small consultancy project had been worked upon in one hospital in 2006 by an Audit Organization. Is it allowed for the AO to audit this hospital knowing
that the project had finished in 2006 and no other contact was taking place from that time up to date between the hospital and the AO?

NO. The AO is not allowed to audit hospitals they had worked with before.

Is it allowed for a hospital to provide surgical services without having an intensive care unit to admit possible complications post surgery?

In the "general hospital" category, if surgical services are provided, the hospital should have equipped recovery room for monitoring with resuscitation team, in addition to a contract with a tertiary care hospital for emergency referrals.

When certain chapters are not applicable (ex. Cardiac lab or chemotherapy), does this result in losing the hospital grades or does it expose the hospital to lower classification by the MOPH?

The fact that some chapters are not applicable has no incidence on the level of accreditation. Only, the applicable chapters have to be considered unless the hospital considers itself a tertiary or university hospital.

Is the presence of a physiotherapy unit critical to the classification of the hospital and if the service is outsourced, should the AO audit the outsourced center or simply the contract between the hospital and the center will be enough?

If the physiotherapy service is outsourced, it has to be clearly organized between the hospital and the provider. If it is inside the hospital, it can be evaluated. If it is outside, the auditors should analyze the contract but also the way physiotherapy is provided to patients according to the standards and consider the fact that the provider is accredited (accreditation as part of a hospital) or ISO certified.

Is it allowed for an Audit Body to give public training (targeting all hospitals) on management and accreditation topics without any customized training for specific hospitals?

This goes against the rule based on which the AO has been selected. Due to delays in the implementation of the accreditation procedure, open training sessions had been tolerated. The CNAH decided during the last meeting that any kind of training sessions should be stopped starting July 1, 2010.

Les consultants peuvent-ils auditer des hôpitaux où ils ont eu des consultations?

La politique générale est que les organismes d'audit ne peuvent faire un audit que dans les hôpitaux où ils ne sont pas intervenus pour du conseil ou de la formation. Ils doivent respecter l'absence de conflit d'intérêt tel qu'il a été mentionné dans le document " Modalités d'agrément et de fonctionnement des organismes d'audit pour l'accréditation des établissements de santé du Liban"

Quelles sont les langues à adopter pour la rédaction des rapports d'autoévaluation?

Le rapport d'auto-évaluation peut être rédigé en français ou en anglais. A priori, l'arabe est proscrit car le CTAH aura la possibilité de demander à avoir accès à ces documents et il est nécessaire que les experts puissent les comprendre.

Le rapport d'auto-évaluation doit il être envoyé au CTAH?

Le CTAH ne reçoit pas le rapport d'auto-évaluation directement. Celui- ci est transmis à l'organisme agréé 3 mois avant la date prévue de l'audit et constitue le socle de l'audit à réaliser.

Sous quelle forme le rapport d'auto-évaluation doit-il être envoyé?

Concernant le support d'envoi du rapport d'auto-évaluation, il convient qu'il soit défini par un commun accord entre l'organisme agréé et l'établissement de santé et que ce soit formalisé dans le contrat.

I would like to ask you if it is allowed to organize a meeting with hospital managers to introduce our organization to them, in particular that we have received a large number of calls for this reason, and if it is allowed, could the agenda of this meeting be to brief the participants about Gates and to remind them of the expected timetable, the content of the audit report and the audit visit process?

The AO can introduce itself and its staff but any kind of marketing activities should stop starting July 1, 2010.