ACCREDITED CPD PROVIDER INTERIM REPORT RESPONSE LETTER aucy 12%, 2018, Tz [ Samper | DR.LOUT AL-FAKHRI aie HEAD OF STAFF TRAINING AND DEVELOPMENT DEPARTMENT, ..< io. AE 644-12 sins) AL“AHLT HOSPITAL, DOHA, QATAR i . P.0. BOX 6403 jones Mb epaty Bete cv ear Dr. Loui, We thank AL AHLI HOSPITAL (AAH) for submitting its frst inter report outlning ow Ty Ras ‘addressed all NON-COMPLIANT and PARTIALLY-COMPLIANT STANDAROS ideatiied in its JUNE 5, 2016 accreditation report ‘The aim of these periodic reports 1s to support provider organizations in moving toward compliance for al aczreatation standards over the course oftheir accreditation perio. [After reviewing the Information forwarded by your organization, we would Ike to provide the following analysis and feedback General comments 1, AH had two non-compliant and shx partially compliant standards Identified in the accreditation report, 2. The interim report was not satisfactory (Le. demonstrates no progression on addressing non-compliant and partially compliant standards) to enable QCHP-AD t> change the level of compliance of any accreditation standard. This 1s considered an infraction, which requires remedial action; therfore, AA will receive a letter of concem from the QCHP- [AD requesting to submit another interim report within 90 days ‘Standard 1.2: ASSESSING EFFECTIVENESS Documentation submitte 1. FIRST INTERIM REPORT ATTACHMENT 1- E-MAIL ON RESULTS OBTAINED AFTER INTERNAL AUDIT OF FILES [ATTACHMENT 2 ~ NEEDS ASSESSMENT SURVEY TEMPLATE [ATTACHMENT 3 - SAMPLE FEEDBACK REVIEW ATTACHMENT 4A - SAMPLE MINUTES OF SPC MEETING [ATTACHMENT 5 - INVITATION TO TAKE PART IN THE HMC REF, AUDIT [ATTACHMENT 6A - DRBEEN WELCOME PAGE [ATTACHMENT 68 - WEBINAR INVITATION |0.ATTACHHENT 7 - PROMOTIONAL MATERIAL INVITING LHPS TO TAKE °ART IN THE HMC EF, AUDIT 1LATTACHHENT 8 - SAMPLE ATTENDANCE SHEET 1 Tol: +974 4407 0966 / 0987/5187: Fox +974 4407 0831 P.O Box: 7744, Doha - Oatar-wanw.achp.org.ga— 2 QCHP GS ‘Analysis and recommendations ‘comments: 4. The documentation provided by AAH under this standard detall ts strategies to assess the degree to which the organizational CPD mission statement hes been achieved. However, most of the proposed strategies are subjective and do not indude a consolidated approach that allows for identification of specific areas of Improvement. Some of the supporting documentation were irrelevant to the stated action and/or to the Standard (Assessing Eectiveness). 2. Abani Hosptial mentioned that I assesses the achlevement of the” CPO mission via diferent tools e.g. ongoing audits on quarterly basis, electronic evaluation of CPD ‘activities, participants feedback, assessment tools, sta performance, |3, The interim report mentioned that the CPD Steering Commitee conducts Internal audits to.check compliance against QCHP standards Attachment 1 Is an E-mall on results obtained after Internal audit of fle. It did not Include the audit schedule and process, the used audit tool or the specific audit ‘analysis results, The e-mail just stated that there Is weakness In the needs [assessment process and a recommendation for the CPD steerng commitise to ‘address this sue, [tachment 4a ~ Sample Minutes of SPC Meeting isa checklist for CPO presentation ‘Quidelines. It verifies that CPD activities’ presentations are reviewed and checked for compliance. However, it did not include any evidence for reviews or auelts of other ‘aspects and documents of CPD activities. = ‘Attachment 4 ~ Action Reglster Screenshot is a screen shot of SPC minutes of meetings. The content of the attachment is not relevant to Standard 1. 4. Regarding participants’ feedback, it was mentioned in AAH's acton plan that an Electronic Evaluation Feedback Is established and in-place and that a computer- generated summary on feedback (In collaboration with IT Department) Is in process. Moreover, the interim report mentioned that all post activities evaluaton Is dane online, the CPD Steering Committee monitors scores and discusses scores las than three and action is taken if needed. However, only a Sample Feedback Review (Attachment 3) for fone session in one of AAN's CPD activites was submitted. No dacumentation was Submitted to venfy using an Electronic Evaluation Feedback for activities, Implementation of the computer-generated summary or monitoring the evaluation scores by the CPO Steering Committee, Moreover, collective results of data analysis for participant’ feedback for AAH CPD activites during the past year was nat submitted, 5. attachment 2, Needs Assessment Survey Template, is just a template and did not Include any collective resuts forthe past year needs assessment ceried out for AAH (CoD activities. 6, In AAW’ action plan It was mentioned that AAH would develop an assessment aligned to CPD ativties intended learning outcomes ang wil provide opportunites for staffs ‘competency enhancement. However, the submitted attachment § (Invation to take part Inthe HMC Ref. Audit) is an invitation to take pert in an octivty that ossesses completeness, legibility of hospital referral which Is not relevant to the stated action ‘andor tothe standard (Assessing Effectiveness). 2 “Tel: 49744407 0966 /0937 /5157. Fax: +974 4407 0831 P.O Box: 7748, Doha - Cate wer. gehp.org gaeect QCHP Gg / In AAN's action plan it was mentioned thet AAH would develop and support e-learning ‘and other flexible and Innovative learning methodologies. However, the submitted attachments were a Webinar Invitation (Attachment 6a) and screen shots from Dr baen’s website (Attachment Gb). The Webinar Invitation is for a non-accredited activity broadcasted from Stanford University School of Medicine to AAH'S participants. Both attachments are not relevant to Standard 1.2. 8. In ABMs action plan it was mentioned that CPD Steering Commitee is establishing 2 tool fon how the recommendations have been implamented to evaluate all completed CPD ‘activities and assess the extent to which the learning outcomes have been met However, attachment 7 is just a promotional material inviting practitoners to take part in an audit activity, which isnot relevant to the stated action. 9, Regarding staff performance, ARM's action plan mentioned that wil Implement 2 systematic periodic review of data relating to staf compliance with practice guidelines, Staff turnover rates and disciplinary action rates, however, no supporting documentation was sent to verify that Its implemented. 130, The interim report mentioned that an online attendance using bar code scanner is under Implementation to convert all the logistical activities of pre and post CFD event with RFID scanners using Master badge tool. Attachment 8 (Sample Attendance sheet) Included time in, time out, total minutes and No, of hours attended. Recommendation: 1. AAH should develop a structured organizational strategy/process to assess the degree to \which the CPO mission has been achieved, including achievements in target audiences), ‘overall purpose or goals and anticipated or expected results. The strategy/process hauled identify opportunities and plans for Improvement. The organizational strategy/process must include valid, reliable tols (Hike quality Indicators, benchmarking from outcomes data), should be Implemerted by AAH and should consider contextual factors that can influence the effectiveness of mission statement. 3. ARH is encouraged to develop a CPD Activity Audit template to be used by the CPD steering committee for auditing all aspects of AAH's CPD activities ta ensure they are compliant with the standards. 4, AAH must submit al relevant supporting documentation demonstrating how the standard has been addressed: = Supporting documentation demonstrating the development and implementation of a structured organizational strategy/process to assess the achievement of the CPD program's purpose, target audience and goals or expected results reflected in the (CPO mission statement = Suppoting documentation demonstrating that stratagy/peoress. nesassing the achievement of the CPD mission statement has enabled AAH to identify specific ‘opportunities and plans for improvement. Te: +974 4407 0366 / 0957/5187: Fox +974 4407 0831 P.O Box: 7744, Doho - Cntr wwergchp.org.99