Hospital Services

We can assume that the first initiative to improve quality in hospital services

in Egypt was done in eighties by Health Insurance Organization. Different

manuals and clinical guidelines were developed to improve clinical

performance and hospital information system for educational and cost control

purposes. Early in the nineties, baby friendly hospital standards have been

adopted by MOHP in collaboration with UNICEF to promote breast-feeding

in Egypt. The program started in ten hospitals then extended to many hospitals

including university hospitals.

In 1993, the Cost Recovery Project started to improve the hospital services

through preparing 26 manuals including policies and procedures for different

administrative and technical hospital’s functions. The project initiated QA

pilot program in five hospitals in five health directorates. A plan of action was

done for each hospital to achieve the following goals:

- Culture transformation and commitment to culture of quality inside the

hospital

- Completing the necessary infrastructure of the hospital

- Increasing utilization of the hospital through improving the services

- Satisfying external and internal customers

For every goal some objectives were set up and methods to achieving such

objectives. Accordingly, a quality assurance committee was formed with

specific functions in some of these hospitals and a quality coordinator was

assigned with identified duties.

In 2001, The General Directorate of Quality, supported by the Health

Sector Reform Program, developed an accreditation tool for hospitals

based on 9 groups of standards for all functions and hospital activities. The

standards cover the following issues:

- Patient rights

- Patient care(General clinical area, Surgical and anesthesia services,

Baby friendly hospitals, Continuum of care)

- Safety

o Environmental safety

o Clinical safety(Sterilization, Infection control, Employee Health

Program)

- Supportive services

o Clinical supportive services(Pharmacy, Laboratory, Radiology,

Emergency Care)

o Non-clinical supportive services(Housekeeping, Laundry and

linen services, Kitchen and dietary management)

- Medical staff

- Nursing

- Medical records

- Quality improvement program

- Hospital management

After three consensus-building meetings, with the participation of different

stakeholders, the fifth draft of the tool has been issued. The tool was

subjected to a pilot trial in 6 hospitals to ensure its applicability and

objectivity. In addition, a curriculum of training for quality coordinators

and hospital facilitators was prepared in collaboration with healthcare

quality unit, Ain Shams Faculty of Medicine and sponsored by the Health

Sector Reform Project. The aim is to build up capacity to launch the

program of hospital accreditation at a national level. One of the key issues

of implementing the accreditation program is the way of selecting and

training evaluators (surveyors). Criteria for selection and training

requirements are identified as well as the composition of the surveyor team

and the survey process.

Concerning the General Organization of Educational Hospitals, quality

issues were considered in late nineties when two hospitals following the

organization succeeded to obtain the ISO certification one in 1999 and the

other in 2003. Efforts are exerted now to get use of this experience in the

rest of the organization’s hospitals. In 2003, ISO 9000/2000 has certified

the Administrative departments of the organization itself.

Revised Accreditation program were done 2007 .Standards are classified

to A, B and C. Great efforts for Accreditation standards implementation

were done. Certificate Awarding is classified to Foundation Level, Basic

Level and Egypt Accreditation. Some hospitals completed Egypt

accreditation level and others got foundation level

Pyramid of Healthcare Accreditation

Basic Quality Level

Foundation Quality

Pre-survey Assessment (Mock)

Self-Assessment

Egypt Accreditation