Rwanda Health Facilities accreditation surveys
Survey Process
The survey team is composed of certified surveyors with a team leader. Any conflict of interest is declared
Prepare and communicate the accreditation survey schedule and agenda with the organization to be surveyed and adjusts if indicated.
The survey team meets with the hospital director and management team prior to the survey taking place to achieve the following objectives:
- To introduce the members of the survey team;
- To provide an overview of the survey process;
- To connect surveyors with specific staff members who will accompany them during the survey process;
- To determine if there are any issues with the agenda and allow for minor modification when possible and,
- To clarify information that was submitted on the healthcare facility profile
- Review of documents: the list is sent to the health facility 2 weeks in advance; the surveyor will ascertain if the documents are available, complete, and current.
- Review of medical records: This session is held to validate the hospital’s compliance with required clinical documentation.
- Facility tour: The survey is conducted within the healthcare facility and, when required, a selected health center within the catchment area. Comprehensive and thorough observations to determine if the organization has implemented safe practices for managing facilities operations. During the facility tour surveyors will get a general overview of the structure and layout of the healthcare facility as well as an overall impression of, for example, maintenance, cleanliness, general security, obvious risks, etc
- Patient unit visit: to ensure consistent and thorough evaluation of patient care within the healthcare facility. A Patient Care Unit Interview Guide is to provide surveyors with a list of suggested questions to assist in obtaining information to determine whether standards are met when surveying patient care areas
- Medication area inspection: Medication areas are inspected when visiting the pharmacies, surgery, inpatient, and outpatient areas where medication is stored, prepared, and administered.
- Group interviews: they include(i) leaders’ interviews to ensure consistent and thorough evaluation of leadership roles and functions within the healthcare facility; (ii) Infection Prevention and Control Interviews to ensure consistent and thorough evaluation of the infection control practices implemented within the healthcare facility; (iii) Human Resources Interview; (iv) Quality Improvement Committee Interview to ensure consistent and thorough evaluation of the quality improvement practices implemented within the healthcare facility.
- The scoring: is based on the healthcare facility’s capacity to develop the policies, procedures, and plans that set quality expectations. When these have been established, these policies, procedures, and plans are implemented and ultimately monitored to ensure the effectiveness and sustainability of processes. An assessment tool is used to ensure that the score is accurate, fair evidence-based.
- The Survey Report. The last day of the survey schedule is for the survey team to aggregate all the findings and come to a consensus regarding the scores. It contains the findings (justifying the scores) and recommendations