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18QUALITY IMPLEMENTATION & ACCREDITATION HOSPITALS EXPERIENCESЦ
Ossama Al Adely
Lead Auditor &Healthcare Consultant OPI International Conformity Kingdom of Bahrain, Saudi Arabia
Abstract
Accreditation results in high quality of care and patient safety. Saudi Arabia has developed a national plan to implement quality systems in hospitals by setting the requirement for obtaining services with national accreditation for hospitals or international accreditation (JCI). As a result, Saudi Arabia has become the first country in the Middle East to obtain international accreditation. And most of the hospitals seek for national accreditation so that these hospitals can continue to provide medical services. Key words: quality of care, international accreditation (JCI), national accreditation, Saudi Arabia.
Сапа менеджментi жYйесiн енг1зу жане емдеу мекемелер/'н аккредитациялау тэжрибеЫ
Тушндеме
Аккредитация медициналык кызметтщ сапасын жогарылатып, наукастыц %ayind3diaiH к,амтамасыз етуге MYMKiHdiK 6epedi. Сауд Арабиясы барлык ауруханаларда медициналык кызмет кврсету yuHh MiHdemmi mYpde улттык немесе халыкаралык аккре-дитациядан (JCI) втyдi талап ететiн сапа жуйеанщ улттык жоспарын курды.
Нэтижеанде Сауд Арабиясы Таяу Шыгыста бiрiншi болып халыкаралык аккредитациям ие болды. Елдiц квптеген ауруханала-
ры сапалы медициналык кызмет кврсету MYмкiндiгi Yшiн улттык аккредитациядан втуге умтылады.
Kmrnrni свздер: медициналык къзметтщ сапасы, халыкаралык аккредитация (JCI), улттык аккредитация, Сауд Арабиясы.
Опыт внедрения системы менедмента качества и аккредитация лечебных учреждений
Резюме
Аккредитация обеспечивает высокое качество медицинской помощи и безопасность пациентов. Саудовская Аравия разработала национальный план по внедрению систем качества в больницах, установив обязательное требование получения национальной или международной аккредитации (JCI) для оказания услуг.
В результате Саудовская Аравия стала первой страной на Ближнем Востоке, получившей международную аккредитацию. Большинство стационаров страны стремятся к национальной аккредитации, чтобы они могли продолжать оказывать медицинские услуги.
Ключевые слова: качество медицинских услуг, международная аккредитация (JCI), национальная аккредитация, Саудовская Аравия.
Recieved: 27-12-2017 Mob: +966 50 744 7362
Accepted: 27-12-2017 Tel: +973 1 7 15 15 1 7
Fax +973 1 7 15 15 16
Corresponding author: Dr. Ossama Al Adely, Lead Auditor &Healthcare E-mail: o.Aladely@int-conformity.com Consultant OPI International Conformity Kingdom of Bahrain Address: 5th Floor, GBCORP Tower Bahrain Financial Harbour P.O Box 10945 Manama Bahrain
(Quality Implementation & Accreditation Hospitals Experiences)
(Ossama Al Adely)
Now most of the Countries looking for Healthcare Quality Assurance: That set of activities which defines norms, measures and improves performance of healthcare services, such that healthcare is as effective and as safe as possible. An organization is assessed by an external body to determine its performance compliance with agreed standards and the impact of its services on the patients. Central Board of Accreditation for healthcare institution (CBAHI). Usually Voluntary (Non-governmental, non-punitive) Grants Recognition Meet Pre-determined Standards Based upon Cycle of Standards Development, Auditing, & Improvement Training/Education (Joint Commission International).
The Accreditation Standards were developed by a consensus process of health care expert's representatives. Accreditation results in high quality of care and patient safety.
Saudi Arabia has a leading experience in applying quality systems in hospitals and obtaining international accreditation of (JCI) and national accreditation (CBAHI) of hospitals.
Saudi Arabia has developed a national plan to implement quality systems in hospitals by setting the requirement for obtaining services with national accreditation for hospitals or international accreditation.
As a result, Saudi Arabia has become the first country in the
Middle East to obtain international accreditation. And most
of the hospitals seek for national accreditation so that these
hospitals can continue to provide medical services.
79 hospitals were accredited by JCI, 71 hospital were
accredited by CBAHI.
The purpose of the accreditation process:
1. Improve healthcare services.
2. Ensure the safety of patients, staff and visitors.
The Impact of Accreditation in health care services Impact of Accreditation on the Quality of Healthcare Services: «The majority of the studies showed general accreditation for acute myocardial infarction (AMI), trauma, ambulatory surgical care, infection control and pain management; and subspecialty accreditation programs to significantly improve the process of care provided by healthcare services by improving the structure and organization of healthcare facilities. Several studies showed that general accreditation programs significantly improve clinical outcomes and the quality of care of these clinical conditions and showed a significant positive impact of subspecialty accreditation programs in improving clinical outcomes in different subspecialties, including sleep medicine, chest pain management and trauma management».
The studies have shown that accredited hospitals report significant improvements in:
- Leadership;
- Medical records management;
- Infection control;
- Reduction in medication errors;
- Staff training and professional credentialing;
- Clinical outcomes.
Accreditation considered as the most known and applicable methods used for assessing the performance of healthcare organizations and ensuring the quality and safety of care delivered to patients.
KPIs in relation to the outcomes of an accreditation program.
• Improved patient outcomes and patient/family satisfaction.
• Improved staff satisfaction and lower turnover.
• Improved financial performance.
• Improved communication and organizational culture.
• Infection prevention indicators.
• Medical Records Completeness.
• Mortality / Morbidity Indicators.
• Greater safety for patients and staff and fewer adverse events
A study were conducted in King Khalid Hospital (KKH), Hail City, Saudi Arabia (jci accredited hospital), to investigate the nurses' perception toward the impact of Hospital's Accreditation on patient safety related to nursing documentation, patient medication information, and healthcare associated infection, self-administrated questionnaire, five points rating scale (Likert scale) was used in the measurement and distributed to 200 nursing staff . The respondents reported high positive impact of hospital's Accreditation on patient safety with overall score 4.17 out of 5 points [1].
Another study was conducted to find out the impact of JCI accreditation on patient safety and quality of care indicators at KFHU, University of Dammam, Saudi Arabia, and well-structured department-specific accreditation management program were developed and implemented throughout the intervention period, and two types of outcome parameters were develoed to be studied, 1) Performance indicators (KPIs) challenging patient safety consisting of Health care associated infections, blood transfusion reactions, and patient falls, 2) Quality of care indicators includes Patients and employees' satisfaction indices. These outcomes were studied at three intervals (Pre accreditation Phase, accreditation period and post accreditation period). The results shows significantly improved post -accreditation, HealthCare associated infection per 1000 patients days (4.25- 3.5- 2.13; p<0.001), blood transfusion reaction % (1.4 - 0.09 - 0.01; P<0.001), patient falls per 1000 patients days (7.18 -3.65 - 0.97: p<0.001), and Patients satisfaction % (54 - 71 - 89; p<0.001), Employees' satisfaction % (69.5
- 78 - 93; p =0.034) [2].
Benefits of Accreditation:
1. Helps organize and strengthen patient safety efforts.
2. Strengthens community confidence in the quality and safety of care, treatment and services.
3. Provides a competitive edge in the marketplace.
4. Improves risk management and risk reduction.
5. May reduce liability insurance costs.
6. Provides education to improve business operations.
7. Provides professional advice and counsel, enhancing staff education.
8. Provides a customized, intensive review.
9. Enhances staff recruitment and development.
10. Provides deeming authority for Medicare.
11. Recognized by insurers and other thirdparties.
References
1. Mousa Al Shammari, Sami Al Habib, Ph.D., Dakilala Al Shubrami ,Mussad Al Rashidi: Impact of Hospital Accreditation on Patient Safety in Hail City,Saudi Arabia: Nurses'Perspective, 2015.
12. Provides a framework for organizational structure and management.
13. May fulfill regulatory requirements in select states.
14. Provides practical tools to strengthen or maintain performance excellence.
15. Aligns health care organizations with one of the most respected names in health care.
2. Ahmed Al Kuwaiti: The impact of accreditation on enhancing patient safety and improving the quality of care indicators at King Fahad Hospital of the University (KFHU), 2016.
