Hospital Accreditation Research Articles

Sosialisasi dan Pelatihan Penggunaan Aplikasi SIDOKAR Bagi Kelompok Kerja Dalam Mempersiapkan Akreditasi Rumah Sakit Umum Puri Raharja Denpasar

Hospital accreditation is critical to improving healthcare quality, reducing patient harm, protecting patients, communities, and human resources, and promoting government health initiatives. One of the problems encountered during accreditation was when the surveyor conducted a document audit. The team needed help showing the documents because they needed to be structured appropriately. The large number of documents in the form of hardcopy allows the document to be damaged or lost. The holding of training and socialization of SIDOKAR application-based technology can solve this problem which is expected to help organize and search documents quickly. The methods used in this activity are lectures and mentoring. The conclusion from this activity was that the activity was successfully realized by monitoring how well each working group was prepared to welcome the accreditation survey. In addition, the implementation of socialization and training also shows that the application can assist the working group in increasing the efficiency, effectiveness, and quality of the accreditation preparation process.

Progressive Analysis and Predictions of Leukemia (Cancer) Patients on a Machine Learning Model- The APPOLLO Hospitals Accredited

This abstract describes a machine learning model for predicting the prognosis of cancer patients with leukemia. The model is based on analyzing patient data such as age, gender, diagnosis, lab results, treatment history, and prior hospitalizations. The model employs supervised learning techniques such as random forests and gradient boosting to generate predictions of survival probabilities. Additionally, the model uses feature engineering to identify important features and reduce noise in the data. The model is evaluated using the area under the receiver operating characteristic curve (AUC) and other metrics. The results indicate that the model has good predictive accuracy and can be used to identify high-risk patients and guide clinical decisions. The goal of this project is to develop a machine learning model for the diagnosis and prognosis of leukemia in Indian patients. The model will use a progressive analysis of patient data to identify the characteristics associated with leukemia, including genetic markers, environmental exposures, lifestyle factors, and demographic information. Using this information, the model will be used to accurately predict the risk of developing leukemia in Indian patients. Additionally, the model will be used to identify the most effective treatments for those diagnosed with leukemia and to monitor the disease progression. Finally, the model will be evaluated for its accuracy and effectiveness in a clinical setting.

Hospital accreditation: an umbrella review.

Hospital accreditation is an established quality improvement intervention. Despite a growing body of research, the evidence of effect remains contested. This umbrella review synthesizes reviews that examine the impacts of hospital accreditation with regard to health-care quality, highlighting research trends and knowledge gaps. Terms specific to the population: 'hospital' and the intervention: 'accreditation' were used to search seven databases: CINAHL (via EBSCOhost), Embase, Medline (via EBSCOhost), PubMed, Scopus, the Cochrane Database of Systematic Reviews, and the Joanna Briggs Institute (JBI) EBP Database (via Ovid). 2545 references were exported to endnote. After completing a systematic screening process and chain-referencing, 33 reviews were included. Following quality assessment and data extraction, key findings were thematically grouped into the seven health-care quality dimensions. Hospital accreditation has a range of associations with health system and organizational outcomes. Effectiveness, efficiency, patient-centredness, and safety were the most researched quality dimensions. Access, equity, and timeliness were examined in only three reviews. Barriers to robust original studies were reported to have impeded conclusive evidence. The body of research was largely atheoretical, incapable of precisely explaining how or why hospital accreditation may actually influence quality improvement. The impact of hospital accreditation remains poorly understood. Future research should control for all possible variables. Research and accreditation program development should integrate concepts of implementation and behavioural science to investigate the mechanisms through which hospital accreditation may enable quality improvement.

Management Accounting System Dimensions as Mediating The Effect of Decentralization and Environmental Uncertainty on Managerial Performance

This research aims to determine and examine the effect of Decentralization and Environmental Uncertainty on Managerial Performance with the Management Accounting System as Intervening Variables in STARKES Accredited Hospitals in Bandung. The research method used is a combination method: sequential explanatory design. This study uses primary data consisting of questionnaires and interviews. The total population of this study is 11 hospitals. This research is hypothesis testing research. The research model was analyzed using PLS (Partial Least Square) analysis. The analysis results show that the management accounting system can mediate the effect of decentralization on managerial performance, where the company is more decentralized and supported by a high management accounting system, which will produce an adequate managerial performance. In addition, the management accounting system can mediate the effect of environmental Uncertainty on managerial performance. The higher the environmental Uncertainty and supported by the high use of MAS (Management Accounting System), the more adequate managerial performance.

Progress of Development in Generations of the National Hospital Accreditation Program in Iran

Background: Studies have often examined the challenges presented to the implementation of accreditation. Nonetheless, after developing and implementing four generations of accreditation over 25 years, multiple questions have been left unanswered regarding the number of resolved challenges, the emergence of new challenges and problems, as well as the mitigation of these problems by policymakers and managers for the next generations. Objectives: Therefore, the present study aims to explain the development progress of the last two generations of the National Hospital Accreditation Program (NHAP) with the previous versions in Iran. Methods: As a qualitative research, Semi‐structured interviews were conducted in 2020. Through purposive sampling, 20 hospital managers at different levels with experience in all four generations participated. Thematic analysis was used to analyze. Results: The themes included designing the measurement criteria, the supervisor's performance (university and ministry), the hospital's performance, the measurement process, as well as announcing the results and outcomes. Moreover, the status of the development of the national accreditation with previous versions was explained in categories, including improvable points, improved problems, and cases of deterioration.‎ Conclusion: The revision process of the NHAP in Iran is indicative of an upward trend, and almost proper modifications have been made. Significant changes have been made since the third generation. Changes in performance-oriented and highlighted patient safety have been very helpful. Changing the assessment of universities affiliated to Ministerial, which is trying to become partly external evaluation. In addition, some positive changes have been achieved in the fourth generation, including a significant reduction in criteria, more professional evaluators, elimination of document uploads, and the definition of outpatient criteria. The improvable points were as follows: defining some measurement criteria, limitations of physicians' criteria, evaluating input instead of output, lack of medical guidelines, failure to pay attention to hospital-type criteria, lack of continuous monitoring of universities, and lack of motivation mechanisms for new criteria.

PENDAMPINGAN PEMBUATAN CLINICAL PATHWAY DALAM PENINGKATAN MUTU PELAYANAN KESEHATAN DI RSUD DR. SOEKARDJO KOTA TASIKMALAYA

<div class="page" title="Page 1"><div class="layoutArea"><div class="column"><div class="page" title="Page 1"><div class="layoutArea"><div class="column"><p><span>Clinical pathways are used for quality and cost control in health services in hospitals. A clinical pathway is the main requirement for quality control and cost control, especially in cases that have the potential to spend large resources. Research shows that the application of clinical pathways can reduce the length of stay and hospital costs. The existence of clinical pathways in hospitals is sought to refer to the National Guidelines for Medical Services (PNPK). The existence of clinical pathways at dr. Soekardjo does not all meet these criteria. Community service activities are carried out referring to the lecturer roadmap that has been made. The purpose of the activity is to the availability of clinical pathway forms that can be used in hospitals as needed and the preparation of clinical pathways according to PNPK criteria. The method of activity is in the form of FGD and Assistance in making clinical pathways. The activity was carried out well and agreed on a form that refers to the standards of the Hospital Accreditation Committee. Mentoring activities involve all health workers as users, both doctors, nurses, pharmacists, nutritionists, and PMIK so that the results are expected to be by the needs of the hospital. The results of the activity are in the form of an agreement on the form used and the arrangement of 10 clinical pathways according to the needs of the hospital. </span></p></div></div></div></div></div></div>

Comprehensive Disaster Risk Management Standards for Hospitals

Background: Hospitals play an important role in protecting the health and survival of people during disasters. Despite the development of risk management programs worldwide in recent years, hospital preparedness in disasters is low and one reason for that is the lack of hospital standards for disaster preparedness. This study aims to develop hospital accreditation standards for hospital disaster risk management based on national and international experiences. Materials and Methods: We used a mixed-method explanatory sequential approach. At first, a comparative study was conducted and the disaster risk management (DRM) hospital standards were extracted from 10 selected countries, namely the United States, Canada, Australia, Malaysia, India, Thailand, Egypt, Turkey, Saudi Arabia, and Denmark. Standards were analyzed according to the DRM life cycle and the most comprehensive framework was chosen. For national experiences, purposeful semi-structured interviews were conducted with 22 experts in disastrous events in the country and continued until the saturation stage. In addition, Graneheim and Landman’s contractual content analysis method was used for data analysis. After combining international standards and national experiences, the proposed standards were introduced and the content validity index and content validity ratio were done by 25 experts. Results: Differences were observed in the quality and quantity of the selected countries’ DRM standards. The national accreditation standards of the United States, Australia, and Canada had comprehensive standards and covered all aspects of the disaster risk management cycle. A total of 27 standards from the International Standards Review and 31 standards from interviews were added (a total of 58 standards). The content validity results of the standards were within acceptable limits. After editing and determining the measurement criteria, the final standards were introduced. Conclusion: This study introduces comprehensive DRM standards based on international and national documents and experiences that can be useful for policymakers and accreditation organizations in both developed and developing countries for hospital evaluation. This is also useful for hospitals as a roadmap for promoting preparedness in disasters.

Why Isn't Nurse Staffing Evaluated as Part of Hospital Accreditation and Quality Designations?

Why Isn't Nurse Staffing Evaluated as Part of Hospital Accreditation and Quality Designations?

Challenges and Strengths of Fourth-Generation Accreditation Standards from the Perspective of Nurses at Afzalipour Hospital in Kerman: A Qualitative Study

Background: Accreditation is a team effort to improve service quality. Nurses, as key members of the care team, play an important role in implementing accreditation standards. This study aimed to explain the challenges and strengths of the implementation of fourth-generation accreditation from the perspective of nurses. Methods: The present study was a qualitative one conducted using content analysis. The research population included nurses of Afzalipour hospital in Kerman, Iran. Using purposive and snowball sampling, 5 nurses, 5 head nurses, and 3 supervisors were selected for accreditation. The data were collected through semi-structured interviews. The interviews were transcribed, coded, categorized, and analyzed separately. Then, using content analysis, the data obtained from the interviews were reduced and given a structure and system. Data analysis was performed using MAXQDA software (version 10). Results: The most important challenges in this study were increasing nurses’ workload and working pressure and weakening nurses’ relationship with the patient. Moreover, there was no adequate infrastructure to implement accreditation. The strengths of implementing accreditation standards included increasing nurses’ awareness, improving reporting and documentation, increasing patient safety, and improving organizational processes. Conclusion: The results of this study emphasized the need to implement accreditation standards to integrate working methods and improve the quality of services and patient safety. Solving the existing challenges is a way to ensure the quality and continuous improvement of nursing services. In general, the results of this study provide useful information to policy makers and senior managers of the health system to reform the structure of hospital accreditation.

The Benefits of Accreditation for Healthcare Quality

Background: Accreditation is widely regarded as a reliable method for assessing and improving the quality of medical care provided. However, the effect that it has on performance and outcomes is not yet fully understood. The purpose of this review was to locate and assess the available evidence regarding the effects of hospital accreditation. Methods: We conducted in-depth searches of a variety of electronic databases, including PubMed, CINAHL, PsycINFO, EMBASE, MEDLINE (OvidSP), CDSR, CENTRAL, ScienceDirect, SSCI, RSCI, and SciELO, as well as other sources, using subject headings that were pertinent to our inquiry. No matter how the studies were designed or written, we included all quantitative research that had been reviewed by experts and published in the past twenty years. In accordance with the guidelines provided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses, two reviewers independently screened the initially identified articles, read the full texts of potentially relevant studies, extracted the necessary data, and evaluated the methodological quality of the studies that were included in the analysis using a validated tool. The results of the accreditation effects were analyzed, and six distinct impact themes were identified and categorized as a result. Results: After reviewing a total of 17,830 studies, we decided to include only 76 of the empirical studies that investigated the effects of accreditation because they satisfied our criteria. Different research approaches were taken in each of these studies. Our findings indicate that hospital accreditation has a consistent and positive effect on safety culture, process-related performance measures, efficiency, and the length of stay for patients. On the other hand, employee satisfaction, patient satisfaction and experience, and the 30-day hospital readmission rate were found to be unrelated to accreditation. Because of the contradictory findings regarding the impact of accreditation on the mortality rate and infections associated with healthcare, it was difficult to reach definitive conclusions regarding these outcome measures. Conclusion: Compliance with accreditation standards is posited to have multiple plausible benefits, one of which is an improvement in a hospital's overall performance, and there is some evidence to support the notion that this proposition. The introduction of hospital accreditation schemes encourages performance improvement and patient safety, despite the lack of evidence supporting a definitive link between the two. It is recommended that efforts be made to modernize accreditation and provide incentives for getting it in order to move toward institutionalization and maintain performance gains.

MEDICAL RECORD MANAGEMENT STANDARDS ASSESSMENT AT MARANATHA DENTAL AND MOUTH HOSPITAL (DMH)

Medical record management is an effort to maintain and manage medical record documents, both conventionally (paper-based) and electronically at each hospital health service facility. The author conducted field observations of the Maranatha Dental and Oral Hospital (RSGM) which were carried out directly through semi-structured interviews with RSGM Maranatha regarding the current state of the medical record management unit. This study was structured to determine the state of the medical record management of RSGM Maranatha and provide solutions to problems related to compliance with the National Hospital Accreditation Standards (SNARS) and Joint Commission International (JCI). The author implements Phases 1 – 5 of COBIT 2019 as a reference framework in this research, the limits of the standards used are SNARS MIRM (Management of Information and Medical Records) 8 – 15 and JCI 4th and 5th Edition. This research is expected to provide relevant suggestions so that it can be a benchmark for hospitals in carrying out the medical record management process.

Factors associated with bariatric surgery rates in federative units in Brazil.

To analyze the socioeconomic, demographic and health management factors associated with bariatric surgery rates performed by the Brazilian Unified Health System (SUS) in the federative units in Brazil. Description and analysis of bariatric surgeries rates (per 100,000 inhabitants) performed by SUS in adults from 18 to 65 years old, in the 27 federative units of Brazil, between 2008 and 2018; thus, the econometric methodology of count panel with negative binomial distribution (population-averaged, fixed effects and random effects) was used. Socioeconomic and demographic factors were also investigated, considering the real gross domestic product per capita, the average years of study of adults and life expectancy at birth, and those of health management, given the primary health care coverage, the rate of digestive system surgeons and the rate of hospitals accredited in high complexity care to patients with obesity in the SUS. In regional terms, the performance of public bariatric surgeries in Brazil over the period analyzed suffered a great disparity; the procedures happen mostly in the South and Southeast regions, and scarcely in the North region. Moreover, we found a positive relationship between the rate of bariatric surgeries and life expectancy, the rate of digestive system surgeons and the rate of hospitals accredited in high complexity care; however, the average number of years of adult study and coverage of primary health care is a negative association regarding real gross domestic product per capita. In the period analyzed, the investigated factors explained the rate of bariatric surgeries. Therefore, to train specialized health professionals, the accreditation of hospitals according to the legal framework, preventive actions of primary care, and socioeconomic and demographic factors, conditioning for the offer of surgical treatment by the SUS were crucial. Thus, these are all relevant factors for the formulation of public policies in this area.

Consequences of the new generation of hospital accreditation with the Three-Branch Model in Iran

Consequences of the new generation of hospital accreditation with the Three-Branch Model in Iran

ANALYSIS OF THE APPLICATION OF PATIENT SAFETY CULTURE IN PRABUMULIH CITY HOSPITAL, SOUTH SUMATERA, INDONESIA

Prabumulih City Hospital Accreditation graduation predicate in 2019 which decreased from fully accredited to mid-accredited, where one of the working groups that had not passed was the facility management and safety working group with a score of 67.62. This is also supported by data from the results of recording patient safety incidents for 3 consecutive years from 2018 to 2020. Departing from this problem, the authors are interested in conducting research on "Analysis of the Application of Patient Safety Culture in Prabumulih City Hospital in 2021. " The purpose of this study was to determine and analyze the application of patient safety culture and the factors that influence patient safety culture at Prabumulih City Hospital in 2021. This research is a quantitative study conducted in June and July 2021 on employees of the Prabumulih City Hospital. The sample in this study amounted to 252 people. Sampling was carried out using the stratified random sampling method with the research instrument being a questionnaire. The data were tested using univariate analysis, bivariate chi-square, and multivariate logistic regression. The results of the chi-square test showed that there is a significant relationship between Patient Safety Culture and the 8 independent variables studied, while the variables are age, gender, education level, employment status, work experience, type of work, income, and resources. Based on the multivariate analysis, it was found that the dominant variable that most influenced the application of patient safety culture was the resource variable, with an ap value of 0.000 <0.05 and the largest OR value of 84.564 meaning that the resource variable had 84.564 times the opportunity to influence the patient safety culture at the Prabumulih Hospital in 2021. In conclusion, there is a significant and dominant relationship between the resource variable and the application of patient safety culture at the Prabumulih City Hospital in 2021.

Social Performance: A Vital Turning Point for Better Hospital Care in Indonesia

COVID-19 refocused the importance of social responsibility awareness and social performance measurement of health care. Hospitals must carry out social accountability behaviors while still providing adequate facilities and services. However, any analysis of social performance still contains many ambiguities and can differ in its reference points depending on the nature of the different stakeholders. The study uses an explanatory study to measure the social performance of hospitals in Indonesia and examine the indicators and dimensions that influence social performance in hospitals the most. Data of 752 accredited hospitals were obtained from the Indonesian Commission on Accreditation of Hospital (ICAHO) in Indonesia. Data analysis was conducted using Structural Equation Model (SEM) methodology and SPSS AMOS software. The study found a significant and positive effect of environmental forces and information technology resources on social performance. Further, the study found that intrapreneurship (entrepreneurship efforts within established institutions) in hospitals mediated the effects of organizational architecture, environment forces, and information technology toward/in favor of social performance. This study contributes to improving the quality healthcare by demonstrating novelty for how social performance can be measured and better efforts adopted to produce more social value-based healthcare through the use of organizational architecture, environmental forces, and information technology.

Implementing an hospital accreditation programme in a context of NPM reforms: Pressures and conflicting logics

IMPACT This article shows how the politics associated with the New Public Management movement impacts organizations and how these pressures can be internalized by organizations and employees and professionals’ resistance to management initiatives overcome. Accreditation programmes can bridge two very different logics (professional and business) that often conflict with each other. The key is not to interfere with the professional identity and autonomy of the main actors.

A time-frame comparison study of surgical volume shifts on female primary stress urinary incontinence surgery.

The objective was to investigate the surgical volume shifts for primary female stress urinary incontinence (SUI) over a 20-year period (1999-2018) in Taiwan. This was a retrospective cohort study based on Taiwan's National Health Insurance Research Database. We divided the time-frame into four periods: first period (1999-2003), second period (2004-2008), third period (2009-2013), and fourth period (2014-2018). The variables included major surgical types for SUI (retropubic urethropexy, pubovaginal sling, midurethral sling, etc.), surgeon gender, specialty, surgical volume (high ≥30, median 5-29, low <5), and hospital accreditation level. Reoperation rates within 1 year were analyzed as an outcome measurement. A total of 51,018 patients were identified. Major surgical types increased significantly during the first three periods and slightly decreased during the fourth period. The proportion of surgical volume shifted from high- to medium-, and low-volume, but it reversed during the fourth period. The proportion of SUI surgeries decreased in medical centers, whereas it increased in regional and local hospitals. The proportion of SUI surgeries by female surgeons increased. Similar phenomena occurred in MUS. As for surgeon specialty, major surgical types were performed by gynecologists and urologists equally, whereas MUS were performed more by gynecologists than by urologists. Unexpectedly, 1-year reoperation rates were higher in high-volume surgeons. The surgical trend of SUI surgeries shifted from high- to medium-, and low-volume surgeons, medical centers to regional and local hospitals during the study periods. This implied surgical skills and performance spreading, which may have a great influence on patient and healthcare provider choice of treatment.

On the Relationships among Nurse Staffing, Inpatient Care Quality, and Hospital Competition under the Global Budget Payment Scheme of Taiwan’s National Health Insurance System: Mixed Frequency VAR Analyses

Background: Time series analyses on the relationship between nurse staffing and inpatient care quality are rare due to inconsistent frequencies of data between common observations of nurse-staffing (e.g., monthly) and inpatient care quality indicators (e.g., quarterly). Methods: In order to deal with the issue of mixed frequency data, this research adopted the MF-VAR model to explore causal relationships among nurse staffing, inpatient care quality, and hospital competition under the global budget payment scheme of Taiwan’s healthcare system. Results: Our results identified bi-directional causation between nurse staffing and patient outcomes and one-way Granger causality running between nurse staffing and reimbursement payments for inpatient care services. Impulse-response analyses found positive (negative) effects of the patient-to-nurse ratio on adverse patient outcomes (reimbursement payments) in all types of hospitals and detrimental effects of adverse patient outcomes on the patient-to-nurse ratio in medical centers and regional hospitals across a 12-month period. Conclusions: These findings suggest that nurse staffing is an essential determinant of both patient outcomes and reimbursement payments. Strategic policies such as direct subsidy and hospital accreditation for appropriate nurse staffing levels should be implemented for medical centers and regional hospitals to mitigate the harmful effects of adverse patient outcomes on nurse staffing.

Improving Health Service Quality Management in Hospitals (Literature Study)

Hospitals as the main goal of overcoming public health complaints should try to provide best quality services to patients from all walks of life. For this reason, it is necessary to have service quality management as a process of optimizing the implementation of health activities according to established health service standards. The research method used is a literature study method related to a series of activities related to the collection of library data regarding improving the quality management of health services in hospitals that are sourced from research journals that will be read, writtten, and then the datas will be processed. Quality management of health services in hospitals can be improved by paying attention to aspects of fulfilling hospital accreditation according to established standards, fulfilling hospital minimum service standards, implementing management functions in health programs such as BPJS Kesehatan, as well as analysing integrated quality management (TQM) and based on ISO 9001:2015

Is it Worth to Invest in Hospital Accreditation?

Hospital accreditation programs can be defined as the systematic assessment of hospitals against accepted standards