Hospital Accreditation Standards: A Case Study from Egypt

The purpose of this study was to identify the challenges of Iranian hospital accreditation standards and provide solutions. A qualitative research design was used in this study. Open and semi-structured interviews were conducted in 2018. Thematic analysis was used to analyse qualitative data. Public, private, semi-public, charity and military hospitals in Tehran, Iran. A pluralistic evaluation approach was employed and 151 participants including policy makers, hospital management and staff, accreditation surveyors and university professors participated in this study. Challenges of hospital accreditation standards were grouped into two groups: standards development process and standards content. Lack of an independent standards development committee, insufficient expertise of committee members, inconsistencies among the standards' constructs, inappropriate standard classification, ambiguity of standards, unmeasurable standards, vague and inflexible scoring system, and inability to use some standards were the main challenges of Iran hospital accreditation standards. Establishing a scientific committee consisting of representative from hospitals, health insurance companies, professional and scientific associations and universities for standard development, training the committee members, and utilizing hospital's feedback will help address these problems. Iran's hospital accreditation standards face challenges that prevent them from achieving their goals, that is, improving the quality, safety, effectiveness and efficiency of hospital services. Necessary measures should be taken to solve these problems.

The implementation of hospital accreditation standards in healthcare systems in Yemen that ensure safe and high-quality healthcare services is hampered by specific challenges. Therefore, this study was purposed to explore the challenges and strategies for applying hospital accreditation standards among healthcare professionals in Yemen. A qualitative, phenomenological design was adopted to conduct this study. Semi-structured interviews were used to collect data during the period from January 1, 2022, to February 28, 2022. Based on the content analysis, the study outcomes and lack of (i) funding, (ii) competent human resources, (iii) optimal infrastructure, and (iv) equipment and supplies deter the implementation of hospital accreditation standards. Also, this study highlighted the cultural and social barriers limiting the effectiveness of hospital accreditation standards, the need for increased investment in healthcare infrastructure and human resources, and cultural sensitivity training for healthcare professionals to enhance the implementation of and compliance with hospital accreditation standards. Policymakers should engage global corporations and development partners for technical assistance and capacity building that support the local application of hospital accreditation standards.

Background Resident supervision plays an important role in accomplishing service excellence in teaching hospitals, while still supporting residents’ competency achievement. This preliminary study aims to obtain an overview of resident supervision and the achievement of quality services to conduct hospital accreditation standard. Material and methods A retrospective study with a cross-sectional design was conducted in May 2020 involving Obstetrics and Gynecology residents who carried out a Caesarean section. Data was collected from medical records manually, with additional information from Obstetrics and Gynaecology Department. Univariate analysis was completed to generate a profile of supervision and the achievement of quality services in accordance with hospital accreditation standard. Result Of the 86 Caesarean sections conducted in May 2020, only 75 involved residents, with 42 (56%) procedures carried out by chief residents and 33 (44%) by apprentice stage residents. Supervision during procedures was carried out in 74 cases (98.6%), with 33.3% given moderate-high supervision during hospitalization, 52% moderate low, and 14.7% low supervision. The completeness of the medical records revealed 85,3% appropriate marked site, 96% surgery reports, 78,7% education sheet. It is found that 64 % of pre-operative visits and 65,3% of post-operative visits were carried out by residents. In addition, case discussion, death case reports, as well as resident evaluation were carried out to conduct patient safety and quality service improvement. Conclusion Supervisory evaluation could be provided directly or by conducting case discussions, as well as medical record review; otherwise, to enhance quality achievement, the development of an integrated supervision system is required.

This study develops a multi-criteria decision-making (MCDM) framework to prioritize supply chain management practices (SCMPs) aimed at overcoming barriers to achieving net-zero emissions (NZE) in Thailand’s healthcare sector. Grounded in an extensive literature review and guided by three strategic management theories: resource-based view (RBV), resource dependency theory (RDT), and institutional theory (INT), this research identifies twelve key barriers across intra-organizational, inter-organizational, and institutional dimensions, along with nine essential SCMPs. To evaluate the relationships and importance of these barriers, the study employs integrates the fuzzy Einstein-based logarithmic methodology of additive weights (fuzzy Einstein-LMAW) for weight computation. Cumulative prospect theory (CPT) is utilized within a q-rung orthopair fuzzy sets (q-ROFS-CPT) framework to rank the SCMPs. Findings reveal that the most significant barrier is the ‘fragmented supply chain’, followed by ‘limited visibility and data transparency’ and the ‘absence of a nationwide NZE healthcare industry standard’. The highest priority SCMP is ‘integrating NZE with hospital accreditation standards’, succeeded by ‘supplier collaboration’ and ‘sustainable supply chain knowledge management’. These insights aid healthcare managers in refining policies and developing roadmaps for NZE adoption, while also providing a foundation for academia to explore context-specific barriers and formulate tailored SCMP strategies across different healthcare settings.

This study deals with the implementation effectiveness of the k3rs program with achievement of compliance on hospital accreditation standards in Dr. R. M. Djoelham Hospital in Binjai of 2019. This research was conducted at Dr. R. M. Djoelham Regional Hospital in Binjai City because the efforts in achieving accreditation have not been met in accordance with K3RS standards. Based on the results of the study it can be concluded that K3RS (Occupational Health and Safety) implementation in Dr. R. M. Djoelham Regional Hospitas of Binjai City based on category communication is good. This is indicated by despite the lack of budget in conducting socialization and simulation, but they continue to carry out socialization to related units, especially those with high risk with K3RS.

The Joint Commission (TJC) has historically supplemented its hospital accreditation standards with a set of “super standards” focused on patient safety—formerly known as the National Patient Safety Goals and now titled the National Performance Goals™ (NPGs). The recently added a goal addressing nurse staffing as a patient safety function has drawn significant national attention. Given potential uncertainty regarding how this new goal may influence stroke center certification, this article clarifies the distinction between accreditation and certification standards and offers guidance for stroke program leaders in interpreting and responding to this development. Because TJC evaluates compliance with NPGs during certification surveys, TJC certified programs should expect greater focus on staffing adequacy in future reviews. Additionally, Det Norske VeritasHealthcare (DNV) and Accreditation Commission for Health Care (ACHC, formerly HFAP) incorporates similar standards within its hospital accreditation framework and/or Conditions of Participation (CoPs). Understanding these standards position stroke programs across accrediting bodies to proactively align staffing strategies with national safety priorities.

Quality midwifery education is critical to creating a decent workforce and improving mothers' and infants' health. Although international educational standards have been defined worldwide for the quality of midwifery education, there is a wide variety of types and natures of midwifery educational programs in different cultures. The purpose of this research is to compare the accreditation standards of midwifery education in Iran and other countries. This descriptive study was conducted using a comparative approach and the Beredy model, which was conducted in 2021. The inclusion criteria were program accreditation standards for midwifery undergraduate degrees and valid documents. Hospital accreditation standards, postgraduate accreditation standards, electronic and printed information that have not been approved by reputable publications, as well as reports, ideas, editorials, and views were among the exclusion criteria of this study. In this study, the standards used for midwifery accreditation in Iran and other countries and Organizations (the United States, the United Kingdom, Australia, the United Arab Emirates, the West African Health Organization, and ICM) were compared. According to the findings, the framework of midwifery accreditation standards, the mission and objectives, curriculum, students, faculty, resources and facilities, government financial management and administrative capacity, complaints and grievance, educational governance and quality, and environmental and participatory conditions. In line with the results of this study, it is suggested that due to the conditions and facilities of the community, the necessary changes be applied in the midwifery educational program accreditation in Iran.

Hospitals as a health service facility are required to make medical records Retention is the transfer of inactive DRM to inactive filing to reduce the amount of DRM that is on an active filing rack. The number of visits in the Husada Utama Hospital in Surabaya each year has increased that is not proportional to the large capacity of storage space, causing an incompatibility of the implementation of medical record document retention SOP. The purpose of this study was to identify problems using five elements of management namely man, money, method, material, machine. This research is a type of qualitative research. The results of this study are the identification of problems that occur and the causes of the problem are knowledge, education, training, operational costs, inactive storage space, medical record shelves, scanning equipment, computers and SOP. As a result of these problems will result in a buildup of medical record files which causes narrowing in the storage room that affects the hospital's accreditation standards. The alternative solutions to problems are the existence of SOP socialization, attending training, the existence of a budget for procurement of equipment, the expansion of storage space and the addition of medical record file shelves, the provision of scanning tools and computers as well as SOP evaluation.

This study aims to investigate the effect of teaching hospital management practices on the quality performance of health services by involving elements such as hospital accreditation standards, quality management, and JCI Academic Hospital-specific standards that are indirectly connected. This study chose a survey-based quantitative approach to clinical professional students in vertical teaching hospitals under the direct management of the Ministry of Health of the Republic of Indonesia. Six proposed hypotheses were tested by Partial Least Square-Structural Equation Modeling (PLS-SEM) analysis. The test results showed a positive influence between hospital teaching governance and hospital accreditation compliance, quality assurance and JCI Academic Hospital standards. Third, compliance with teaching hospital standards was also found to have a significant positive effect on the performance of teaching hospital service quality. Understanding the role of governance in encouraging the performance of teaching hospital service quality can help develop effective managerial strategies in achieving complete service quality for patients and clinical profession participants. This research resulted in contributions to existing practices and literature as governance modeling in dual quality standards charged to teaching hospitals.

Accreditation of hospitals is very important to do as an effort to improve quality and patient safety. Many of the standards that must be implemented in hospitals, requiring an optimal role for all stakeholders (stakeholders), especially the participation of employees. This condition greatly be affected by employees’ perception of the benefits of hospital accreditation. The purpose of the study is to examine employee perceptions about the benefits of accreditation associated with participation, satisfaction, commitment and employee performance. The benefits of this research are expected to be input for the hospital management, to encourage all employees to learn about the hospital accreditation standards. Data from the study was obtained by means of a survey of hospital employees, using a Likert scale. Furthermore, the data do tests of validity and reliability and path analysis (path analysis), to see the correlation between variables. Research conducted on 259 randomly selected respondents, composed of physicians, nurses, medical support, as well as administrative personnel. The results of this studyindicate that there is significant influence between the perception of the benefits ofaccreditation to the participation of accreditation with a significance level of 0.000, the perception of the benefits of accreditation with the organizational commitment amounting to 0,016, the perception of the benefits of accreditation and job satisfaction amounting to 0,000, participation accreditation with organizational commitment amounting to 0,039, accreditation participation with satisfaction employment amounting to 0,000, accreditation participation with performance amounting to 0,000, job satisfaction with organizational commitment amounting to 0,039, organizational commitment with performance amounting to 0,018, job satisfaction with performance amounting to 0.000.

BackgroundSince 2007, the Mental Health Commission of Canada has worked collaboratively across all provinces to publish a framework and strategy for recovery and well-being. This federal document is now mandated as policy for implementation between 2012 and 2017. The proposed strategies have been written into provincial health plans, hospital accreditation standards, and annual objectives of psychiatric departments and community organizations. The core premise is: to empower persons with mental illness and their families to become participants in designing their own care, while meeting the needs of a diverse Canadian population. However, recovery principles do not come with an implementation guide to fit the variability of different local contexts. How can policy recommendations and accreditation standards be effectively tailored to support a diversity of stakeholder values? To our knowledge, there is little evidence indicating the most effective manner to accelerate the uptake of recovery-oriented services among providers in a given/particular mental health treatment setting.Methods/DesignThis three-year Canadian Institute of Health Research Partnership in Health System Improvement and The Rx&D Health Research Foundation (HRF) Fostering Canadian Innovation in Research study (2013 to 2017) proposed participatory approaches to implementing recovery principles in a Department of Psychiatry serving a highly diverse Canadian and immigrant population. This project will be conducted in overlapping and recursive phases: I) Conduct formative research to (a) measure the current knowledge and attitudes toward recovery and recovery-oriented practices among service providers, while concurrently (b) exploring the experiential knowledge of recovery service-users and family members; II) Collaborate with service-users and the network-identified opinion leaders among providers to tailor Recovery-in-Action Initiatives to fit the needs and resources of a Department of Psychiatry; and III) Conduct a systematic theory-based evaluation of changes in attitudes and practices within the service-user/service-provider partnership group relative to the overall provider network of the department and identify the barriers and supports within the local context.DiscussionOur anticipated outcome is a participatory toolkit to tailor recovery-oriented services, which will be disseminated to the Mental Health Commission of Canada and Accreditation Canada at the federal level, agencies at the provincial levels, and local knowledge end-users.

The 2011 version of the accreditation standards for a level 3 general hospital relates to descriptions about the use of medical record information; 636 entries in 378 items and 48 core indexes in seven chapters relate to medical record information. Of these items, 103, accounting for 27.25%, relate to all chapters, and 22 relate to core entries, accounting for 45.83%. Chapter seven almost fully concerns daily statistical evaluation. There are at least about 150 links that should be carried out in combination with medical records in the process of accreditation, and therefore, the importance and effect of medical records in accreditation becomes obvious. The hospital accreditation standards further suggest that the science, discipline construction, and continuous improvement of medical information management should be given the same priority as record writing quality in hospital development, and thereby medical information can be used effectively.

Clinical pathway (CP) is one of the requirements required in hospital accreditation standards. It has an important role in controlling quality, and costs and supporting patient safety, especially in cases that have the potential to consume large amounts of resources, one of which is a sectio cesarean (SC). Apart from being able to reduce maternal mortality due to normal childbirth, SC procedures can also cause post-operative injuries. This research explores the barriers and challenges to implementing the sectio caesarean clinical pathway among health workers in hospitals. This qualitative case study research recruited 10 informants consisting of 3 obstetricians, 2 executive nurses, the head of the inpatient room, the head of the operating room, the deputy director of medical services, and 2 patients who had undergone SC at the hospital purposively. In-depth interviews were conducted in March 2024 at a private hospital in Bandar Lampung, Indonesia. Thematic analysis was used for data analysis. Several themes emerged as obstacles to the implementation of CP SC in this research, namely: 1) individuals, 2) patients, 3) infrastructure, and 4) hospital management support. Apart from that, the challenges faced include the need to carry out socialization, monitoring, and evaluation activities, as well as collaborative activities between health workers and hospitals to share experiences to increase compliance in implementing CP SC. Hospital management is expected to provide regular outreach, training, and personal approaches to health workers regarding the implementation of CP SC. Collaboration between professionals and hospitals is also needed to share experiences regarding the implementation of sectio caesarean clinical pathways in hospitals.

Background: The safety of patient was important component in quality of service in health. The hospital of Wonosari was belongs to the government districts of Gunung Kidul type C whom has contribution in services of health for people. In 2016 facilities like barcode not yet in all rooms, human resources have not consistenly reported KTD, the bathroom floor was slippery so that it can cause an incidence of patient safety risk. Now overall the implementation of patient safety has been running optimally, such as the availability of supporting facilities and later of SOP, socoalization and training on evaluation and supervision have been held. The aims of this study to analyze the implementation of patient safety goals based on the hospital accreditation standards (KARS) at RSUD Wonosari Yogyakarta. Methods: this studied used qualitative methods through in-depth interviews, observation and document review. Data collection was done by interviewing 5 informants Results: Identification of patients using two identities, effective communication with SBAR and TBaK, stores medications that need to be watched out in a separate place, tagging used checklist patient at surgery, applied 6 steps and 5 handwashing moments from WHO, conduct initial assessment and reassessment of patients at risk of falled. Conclusion: The implementation of patient safety goals based on the KARS standard in RSUD Wonosari Yogyakarta has been running optimally.

The completeness of inpatient medical records plays a vital role in ensuring the quality of healthcare services and compliance with hospital accreditation standards. This study aims to design an inpatient medical record audit application that addresses existing inefficiencies in manual audit processes at RSUD Prof. Dr. Margono Soekarjo Purwokerto. The research was conducted using the System Development Life Cycle (SDLC) with a waterfall model approach, consisting of needs analysis, system design, coding, and testing. Data collection involved observation and interviews with inpatient coding staff, which revealed several issues in the current Google Spreadsheet-based audit system, including inflexible checklists, high risk of data loss, poor synchronization, and duplicate entries. The proposed web-based application offers functional features such as multi-user login, patient data upload, dynamic checklists, open and close audit forms, and graphical audit reports. Non-functional requirements emphasize security, accessibility, simplicity, and responsiveness. User requirements focus on ease of navigation, printable reports, and support for daily work routines. The system was implemented using JavaScript and tested through black-box testing, which confirmed all functionalities performed as expected. User satisfaction was evaluated through a questionnaire distributed in the medical records department with 13 respondents, 1 department head and 12 coders, the results showed an overall satisfaction level of 92.59%. This application improves audit efficiency, reduces input errors, and supports hospital efforts to meet accreditation indicators. The findings suggest that a well-designed information system can significantly enhance the management and monitoring of medical record completeness.