Organogram of the Accreditation Office

Report Submitted to

Project Director

European Union Support to Health and Nutrition to the

poor in Urban Bangladesh
Room No – 1413, 15th Floor, Nagar Bhaban, 5 Phonix
Road, Dhaka – 1000

iota Consulting BD

House # 67, Road # 17, Block – C, Banani, Dhaka –

1213

iota Consulting BD
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 Contents
1 Organogram of the Accreditation Office.................................................................................. 2

1.1 Role of Government ......................................................................................................... 5

1.2 Structure: .......................................................................................................................... 5

1.2.1 Governing Board/Body .............................................................................................. 5

1.2.2 Possible Members of the Govorning Body ................................................................ 6

1.2.3 Constitution of the governing board ......................................................................... 8

1.3 Board Secretariat or Executive Body ................................................................................ 9

1.3.1 Administrative and Finance Division ....................................................................... 10

1.3.2 Advisory or Technical committees and Task force: ................................................. 11

2 Premises ................................................................................................................................. 12

3 Financing Options .................................................................................................................. 13

4 Monitoring and Evaluation..................................................................................................... 15

5 Management Information Systems........................................................................................ 17

5.1 Performance Indicators .................................................................................................. 17

5.2 Influencing Public Policies............................................................................................... 17

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1 Organogram of the Accreditation Office
Accreditation system for Bangladesh would be at the national level only, as we are not a

very big country. Recognizing the need for and working towards the realization of the

mission and vision of the organization and its accompanying policies and plans require the

building of appropriate infrastructure at the national level. The roles and responsibilities

should be identified initially to facilitate the structuring of the organization. The purpose

of this section is to expand in detail on the organization, structure and management of the

organization necessary for effective organization. As mentioned accreditation body would

be entrusted with overall policymaking at the national level, support state level

accreditation bodies. Develop and evolve in establishing training institutions and modules

for the accreditation process and liaison with other accrediting bodies. It could develop

national level standards, guidelines & protocols. It could conduct research, documentation,

information dissemination and evaluating the state level accreditation bodies. It could

function in a supportive role and as a federation of the accreditation body. The

accountability and audit of the accreditation bodies in terms of its functioning, relevance

needs to be incorporated within the existing system. It is envisaged that there would be a

Governing Board (GB) that would have representation from various associations and

organizations as well as the government and other stakeholders. In its composition, care

should be taken to allow each of the stakeholders to be equally represented. This would

prevent the GB from being monopolized and overtaken by dominant stakeholders. The

composition of the GB could be changed periodically. The main function of the

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accreditation body would be to assess whether hospitals comply with set standards, to

assist them to upgrade their standards and to play an educative and informative role. To

carry out these functions such as assessment, educational, administration and so on staff

would be employed. The staff could work either full time or part time depending on the

resources available. The staff at various levels would responsible and report to the

governing board.

ISO 17011 - Conformity Assessment – Requirements for Accreditation Bodies Accrediting

Conformity Assessment Body would be a good reference for the governance of the

accreditation bodies except finance.

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 Government

Board Members along with

chairman, vice chairman Supervision
and CEO/DG

Board Secretariat Support

CEO or Director General

Training and Assessor Committees

Administration Finance and Accounts Accreditation
Certification
Department Department Department
Department Technical Committee for
Standard and Guideline
Officer - 1 Officer - 1 Development and Revision
Assessment Section Appeal Section Lead Tutors

Research and
Officer - 2 Officer - 2 Associate Tutors Development Committee
Lead Assessors

Officer - n Officer - n Tutors Other Committees

Associate Assessors

Figure -Proposed Organogram of Hospital Accreditation Board or Council

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1.1 Role of Government

▪ Providing legal basis of the accreditation infrastructure

▪ Funding the creation of the organization (in a number of instances, this support has been
provided primarily through donor funds)
▪ Forming the accreditation board
▪ Supporting operation of the accreditation body
▪ Support for training of assessors
▪ Structuring assessments and rankings
▪ Promoting accreditation as means of excellence.

1.2 Structure:

The accreditation organization would have a governing board and an executive body

supported by appropriate divisions, cells and committees. There would be an

administrative and training division, a strategic planning cell and advisory committees and

task forces based on the need.

1.2.1 Governing Board/Body

The governing board would be the supreme authority, which would be the statutory body,

entrusted with the responsibility of managing the organization. The basic premise of this

framework is that it would be a result of discussions, debates on areas of concern,

collaboration and transparency between related parties, and open communication among

all the stakeholders.

▪ It would be the final authority in decision-making and an arbiter of major issues.

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 ▪ It would provide a platform for the various stakeholders to meet. Democratic

participation of all members that allow expression of differing points of view is

essential, with each member given equal voting rights. The participation of all

stakeholders is to be ensured and mechanisms could be worked out for meaningful

participation of consumer representatives also. Any member may raise issues of

importance; issues may be graded in importance and be taken upin their order of

importance. Evolving a consensus would be the guiding principle of all decisions.

When serious differences of opinion occur, however, the decision of the majority

would stand. The governing body would have to meet at least four times a year,

with invited observers from the Government HealthDepartments, including Public

1.2.2 Possible Members of the Govorning Body

▪ Chairman

▪ Vice-chairman

▪ Secretary, Ministry of Health & Family Welfare (as in BAB)

▪ Secretary, Ministry of Food, Relief and Disaster Management (as in BAB)

▪ Secretary, Ministry of Science and Information & Communication Technology (as in

BAB)

▪ Director General, Directorate General of Health services

▪ Nominated by government, one renowned medical professional of the rank

professor

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▪ Director, Hospital Services, Directorate General of Health services

▪ Director General, Directorate General of Drug Administration (as in NABH)

▪ President, Federation of Bangladesh Chamber of Commerce and Industry; (as in

NABH)

▪ One representative to be nominated by the office of the Attorney General at the

rank of Deputy Attorney General.

▪ President, Bangladesh Medical and Dental Council

▪ President, Bangladesh Medical Research Council

▪ One representative from Bangladesh Medical Association

▪ One representative from Bangladesh Dental Society

▪ One representative from Bangladesh Pharmacy Council

▪ One representative from Bangladesh nursing and midwifery council, a graduate

nurse

▪ One person having profound knowledge on accreditation, administration and

similar kind of training activity of medical background.

▪ President, Bangladesh Private Clinic Diagnostic Owners Association (Malaysia)

▪ One representative to be nominated by the Vice-Chancellor of Bangabandhu

Sheikh Mujib Medical University (BSMMU) at the rank of Professor; (Malaysia)

▪ One representative from Department of Consumer Rights Protection (Malaysia)

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1.2.3 Constitution of the governing board
The board would be composed of nominees of representative associations and

organizations as well as the govt. and other stakeholders. In it’s composition, it would allow

each of the stakeholders to be equally represented. This would prevent the board from

being monopolized- and overtaken by dominant stakeholders. The composition of the

board should be changed every year with a fresh set of nominations. The composition of

the governing board for Bangladesh would be the following:

▪ Chairman

▪ Vice-chairman

▪ Secretary, Ministry of Health & Family Welfare (as in BAB)

▪ Secretary, Ministry of Food, Relief and Disaster Management (as in BAB)

▪ Secretary, Ministry of Science and Information & Communication Technology (as in

BAB)

▪ Director General, Directorate General of Health services

▪ Nominated by government, one renowned medical professional of the rank

professor

▪ Director, Hospital Services, Directorate General of Health services

▪ Director General, Directorate General of Drug Administration (as in NABH)

▪ President, Federation of Bangladesh Chamber of Commerce and Industry; (as in

NABH)

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 ▪ One representative to be nominated by the office of the Attorney General at the

rank of Deputy Attorney General.

▪ President, Bangladesh Medical and Dental Council

▪ President, Bangladesh Medical Research Council

▪ One representative from Bangladesh Medical Association

▪ One representative from Bangladesh Dental Society

▪ One representative from Bangladesh Pharmacy Council

▪ One representative from Bangladesh nursing and midwifery council, a graduate

nurse

▪ One person having profound knowledge on accreditation, administration and

similar kind of training activity of medical background.

▪ President, Bangladesh Private Clinic Diagnostic Owners Association (as in Malaysia)

▪ One representative to be nominated by the Vice-Chancellor of Bangabandhu

Sheikh Mujib Medical University (BSMMU) at the rank of Professor; (as in Malaysia)

▪ One representative from Department of Consumer Rights Protection (as in

Malaysia)

1.3 Board Secretariat or Executive Body

The executive body would consists of the director of the accreditation body, assistant

directors of various divisions and cells. This would be the constitution of the Executive

Body. The Executive Body would be accountable and answerable to the Governing Board.

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 It would be entrusted with the responsibility of implementing the decisions of the

Governing Board. Reporting and financial-decision mechanisms will need to be established

leading to the ultimate authoritative body. Its terms of reference could well include

responsibilities for policy overviews and their planning and coordination and the allocation

of resources. The executive body would been trusted with the responsibility of

implementing the decisions of the governing board. It would be accountable and

answerable to the governing board. There could be separate chief executive appointed by

the Board to carry out the diverse functions.

1.3.1 Administrative and Finance Division

with responsibility for statutorily - required activities - e.g. organizing meetings, logistic

support and managing the financial affairs of the organization. It would be responsible for

the general administration, which would include finances, human resources, operations,

documentation and legal issues. The manner in which the body works, its terms of

reference and its administration and servicing etc. should receive careful attention. The

creation, arrangement, appraisal, maintenance and preservation and access to the records

forming that archive are tasks often overlooked in an organization and for which guidelines

would be a useful tool. There is a need to develop effective processes for strategic

planning, and integration of key management information. Separate sections need to be

developed to meet management information needs. Plans to be developed to ensure

greater availability and integration of consistent data for management information

purposes. Assess major risks and prepare risk management strategies.

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1.3.2 Advisory or Technical committees and Task force:
The Board is also served by advisory committee specially formed with specific terms of

reference as per the need. It could be to define and review standards, assess applications,

recommend surveyors and advise on major decisions. For matters relating to accreditation

design, there could be discipline-specific Specialist Advisory Committees (SACs),

constituted by the governing board as and when required. The Advisory Committees would

provide advice to the Board as and when necessary. For matters relating to research and

development, there will be a multi-disciplinary Advisory Committee fulfilling a similar role.

These committees rely on a major input from relevant specialist societies which have the

right to nominate members. The specialty committee Chairmen are appointed by the

Board. These committees report to the governing board and their recommendations

would have to be approved by the governing board, which could also make the necessary

clarifications and recommendations. The purpose of these is to serve as task forces to bring

together members with relevant knowledge and expertise to help to formulate policies

and to provide advice on the conduct of activities. Ideally, they will draw on the reservoirs

of expertise represented in the local specialist groups. These national level sub-

organizations should be linked with the main board through cross-representation of

memberships. The size of the committees, sub-committees, task Forces will depend on the

work they are established to perform.

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2 Premises
The organization’s headquarters would have permanent staff that includes the CEO and

assistant directors together with secretarial and administrative assistants. The office is

responsible for all organizational aspects, for the arrangement of inspection visits, and for

the dispatch of occasional bulletins detailing news of importance. If premises are beyond

the financial means of the organization, then keep a permanent post office box number or

make arrangements with a bank to credit subscriptions directly into the organization’s

account could be worthwhile for the time being.

For Bangladesh the premises of the Directorate General of Health Services (DGHS) could

be serve the accreditation council.

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3 Financing Options
Stable financial resources are critical to the existence of the body and for the proper

functioning of the body. Therefore it is important that the organization operates programs

with sustainability in mind. Initial funding for the organization could come from grants.

Ongoing financial support could include

▪ Survey fees for assessment paid by participating providers. The advantage of this

optionis that it would capitalize on the private sector initiative and interest.

Disadvantages of this option include potential problems with funding.

▪ Possible public funding: A combination of private and public sector involvement

could be essential for any system of accreditation of hospitals.

▪ Membership fees: Contributions from medical associations, member

pharmaceutical companies, leading corporate hospitals. Such contributions raise

important questions about the influence that such bodies may have on the

accreditation process.

▪ Third party payers: In the near future, third party payers would be interested in

paying for relevant information. Also, if the accreditation system proves itself to be

credible and reliable, insurance companies may use accreditation as tool to decide

which health care organizations to reimburse. Therefore it could be a priority that

such information that could inform these also should be available and its quality

should be ensured.

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▪ Grants from various bilateral / multilateral funding agencies, state governments,

philanthropic organizations, corporate sponsorships etc.

▪ Other options could include Public share holding, alliance with international quality

organizations, and income generating activities.

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4 Monitoring and Evaluation
Assessment and review of performance is essential, because knowledge of performance

stimulates improvement. Monitoring and evaluation of institution's efforts to integrate

quality systems will be monitored by regional monitoring teams. There could be a

minimum necessary of MIS which could guide the process. It would involve selection of key

indicators and also submission of the involved health care providers of minimum essential

information to the organisation on a periodic basis.

Objectives:

▪ Oversee implementation of quality systems

▪ Monitor the quality of accredited organizations through the prioritization and

investigation of complaints received from various sources, reports of sentinel

events, and out of compliance notifications

Monitoring team will oversee quality systems implementation in hospitals. Whilst the

institutions will assess their own performance, the regional team monitors

performance over time and therefore can compare institutions, rank them and give

feedback at the regional forum. Monitoring should be carried out using a

comprehensive checklist.

The monitoring team will provide supportive supervision by:

▪ Frequent monitoring of institutions

▪ Assisting in problem identification, analysis and solution

▪ Advising on implementation strategies,

▪ Responding to new problems

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▪ Encouraging high performance by comparing institutions and promoting best

practice.

Members of the monitoring team should be trained as QA facilitators. Members of the

team should be drawn from the regional levels so that there are resource people

available in the districts. Key performance indicators which will be submitted by the

accredited hospital on a periodic basis will be a mandatory requirement to renew

accreditation. This will:

▪ Confirm that institutions' internal quality assurance procedures are working

effectively.

▪ Focus on those issues necessary for the funding bodies to secure their

responsibilities for public accountability and public information.

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5 Management Information Systems
A comprehensive MIS for the storage and retrieval of descriptive and evaluative data and

information flowing from participating institutions is useful and is a priority. The MIS could

also pull together the fragmented and duplicated health related data collection activities

currently practiced. MIS for

▪ Documentation and information systems

▪ Newsletters, journal publications, conferences organize regular fora for quality

▪ Information skills training to staff

▪ Organizing seminars and conferences

5.1 Performance Indicators

A set of minimum indicators of the achievement of the goals of the organization should be

defined to ensure a standardization and uniform analysis of data collected by an MIS.

5.2 Influencing Public Policies

▪ Carrying out policy research and analysis on issues identified for influencing, which

have a major bearing, positive or negative, on quality, rationality and accountability

in healthcare.

▪ Networking, coalition building

▪ Capacity building

▪ Information dissemination

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