Accreditation is an ongoing process of assessing health services organizations against standards of excellence to identify what is being done well and what needs to be improved as per pre-established standards of excellence. The main two cornerstones of accreditation are internal self-assessment against pr-established standards and external peer review by Surveyors assigned by the accrediting organization/authority. The main purpose of accreditation is to continuously improve the quality of performance, enhance patient safety culture and implement a risk management framework to keep safe practice top priority. Accreditation involves all members of your organization, from your board of directors to front-line staff as well as members of the community including patients and families and your community partners.
The World Health Organization (WHO), recognized accreditation as the single most important approach for improving the quality of health care structures. It allows healthcare facilities to understand how to make better use of available resources, increase efficiency, enhance quality and safety, and reduce risk.
According to the International Society for Quality in Health Care (ISQua), accreditation is a self-assessment and external peer review process used by healthcare organizations to accurately assess their level of performance in relation to established standards and to implement ways to continuously improve the healthcare system.
Accreditation has many advantages including among them continuous quality improvement, implementing and sustaining patient safety practices and become nationally and internationally recognized for excellence.
NHRA Accreditation in Bahrain The legal framework of national accreditation in Bahrain came about in response to the ratification of Law no. (21) of 2015 regarding private health care facilities which specified, in Article 19, NHRA’s responsibilities for reviewing and evaluating the health services in all facilities. This is to ensure equality of those services, ensure highest performance and ensure compliance with regulations and standards related to patient safety, clinical performance, infection control, medication management, continuity of care, risk management and other technical standards.
In Bahrain, The National Healthcare Regulatory Authority (NHRA) has developed two sets of accreditation standards one for hospital and one for medical center. In order to implement Article 19, the Supreme Health Council issued decision No. (7) of 2016 specifying the required NHRA standards, and subsequently issued Decision No. (26) of the same year regarding the accreditation of health care facilities in the Kingdom of Bahrain. Not only must an accredited facility meet the specific standards listed for each of the visited areas at the time of the survey, but it must also demonstrate to the survey team that it has effective policies and systems in place to ensure that the standards continue to be met throughout the three-year accreditation cycle.
The National Healthcare Regulatory Authority (NHRA) standards composed in different elements (chapters). The elements are classified into three categories: Core Element, Support Elements and Facility Specific Elements.
These separate elements have been built upon to create a comprehensive survey inspection/audit template, which is relevant to the individual hospital or Medical Center (Healthcare facilities) that are licensed in the Kingdom of Bahrain.
All healthcare facilities will be assessed against the standards (the applicable ones) of all core elements. The support elements are assessed as being applicable or not applicable and assessed accordingly, and the facility specific elements are only assessed in the healthcare facility that provide the relevant services.
In order to achieve NHRA Accreditation the healthcare facility has to achieve 80% compliance with applicable standards. NHRA Accreditation will be into three levels. Gold-Level Accreditation
Steps involved in the NHRA Accreditation process:
The facility completes and submits its application for accreditation with the supporting documents and self-assessment report to NHRA.
The NHRA Accreditation Committee reviews the application form and supporting documentation.
The Accreditation Committee will assign the surveyors and arrange the survey visit in consultation with the facility.
The survey visit is conducted by the selected NHRA survey team for each facility.
The surveyor team during the visit will prepare the survey report
The report is considered by the NHRA Accreditation Committee, which makes the recommendation on the award of accreditation, along with the specific recommendations that are made by the survey team. The Accreditation Committee then, raises this recommendation to the CEO, who will eventually finalize the decision.
NHRA officially notifies the facility of the final decision.
NHRA Accreditation Survey and Results
Based on the accreditation survey findings and decision of The Accreditation Committee, the facility will be granted one of the following categorization:
Diamond: For facilities that achieve 95% or more of the NHRA accreditation standards.
Platinum: For facilities that achieve between 90% and 94% of the NHRA accreditation standards.
Gold: For facilities that achieve between 80% and 89% of the NHRA accreditation standards.
Silver: For facilities that achieve between 70% and 79% of the NHRA accreditation standards
Any facility, which fails to achieve the accreditation award after an appeal or the appeal is dismissed by NHRA, will not be licensed to operate. The facility will be suspended and given a period of six months to implement improvement, raises its standard and resubmit to be evaluated by NHRA. Failure to achieve 70 per cent score after the second attempt, will result in permanent closure of the facility.
ISQua Guidelines and Principles for the Development of Health and Social Care Standards. 4th Edition, 1.2, September 2015.
NHRA Accreditation Overview [Accessed 2/10/2019] https://www.nhra.bh/Departments/Accreditation/
NHRA National Accreditation Policy for Healthcare Facilities, V2.0 Effective: October 2017
Accreditation Canada Qmentum Accreditation Program [Accessed 2/10/2019]