Accreditation Survey Research Articles

Transformation of Puskesmas Pelambuan: Analysis of LAFKI Accreditation Survey (Case Study)

Community Health Centers (Puskesmas) play an important role in this context, as part of primary health care facilities. Community health centers must be able to provide quality basic health services and maintain the quality of these services. One strategy that can be used by Community Health Centers to achieve this goal is through the accreditation process. The aim of Puskesmas accreditation is to foster and improve the quality of service and safety for patients and the community on an ongoing basis. Accreditation is not just about getting a certificate, but more about a commitment to continuously improve the quality of health services provided to the community. The accreditation survey at the Pelambuan Community Health Center is an important effort to improve the quality of health services. This process involves surveyors conducting document checks and field searches to ensure that management, programs and clinical services comply with accreditation standards.

754. Utilization of Internal Special Program Review to Institute Change in an Academic ID Fellowship

Abstract Background Fellowship accreditation is crucial to ensure adequate clinical education for physicians in training, yet there is limited data on use of accreditation survey results for program quality improvement. The Accreditation Council for Graduate Medical Education (ACGME) administers annual surveys to trainees and core faculty to monitor education and identify potential non-compliance with ACGME accreditation standards. Our purpose is to describe the creation of an internal program review process for program improvement based on results of nationally implemented accreditation surveys. Methods We collected data from standardized ACGME survey responses administered to core faculty and fellows at our academic Infectious Diseases fellowship program. The identification of areas scoring lower than 20% in comparison with national average prompted creation of a Special Program Review (SPR) committee comprised of a program director, a program coordinator, and a trainee from programs outside of the program under review. This committee met separately with core faculty, trainees, and program leadership to compile an assessment of each survey component and opportunities for improvement. This review process of survey results was completed annually from 2020-2022. Results Between 2020-2022, surveys were completed by 100% of fellows (7/7 or 8/8) and up to 92% of core faculty (11/12). Key findings raised concerns involving clinical education, faculty supervision, patient safety, and teamwork. Actions taken in response to the SPR included the creation of: an updated backup and weekend coverage system, new didactic curricula, a morbidity and mortality conference, documentation limits, informal fellow/faculty dinners, opt out counseling, and a division culture committee. Conclusion A non-punitive internal review process mimicking accreditation standards is valuable for program assessment and improvement as means to identify areas of risk for accreditation issues at a national level. This review process is generalizable, as all accredited programs complete the survey annually. The quality improvement interventions taken will differ depending on survey findings and areas to be addressed. Disclosures All Authors: No reported disclosures

Revealing the Secrets of Mubarak Clinic's Success: A Success Story in Undergoing Accreditation Surveys (Case Study)

Accreditation, which is defined as the process of quality evaluation by an independent institution based on a set of established standards, is granted to Mubarak Clinic by the Indonesia Healthcare Facility Accreditation Agency or Lembaga Akreditasi Fasilitas Kesehatan Indonesia (LAFKI). The research method used is a case study, as a form of qualitative research, not focusing on the quantity of acquired data but based on the quality of the obtained data. Mubarak Clinic has demonstrated excellence in several areas, but there is room for improvement, especially in human resource management, facility management, and patient safety procedures. By focusing efforts on areas that need improvement, Mubarak Clinic can continue to enhance the quality and safety of patient care.

The Relationship Between Patient Experience Special Care Measures and Joint Commission Accreditation Standards Compliance

Accreditation evaluates healthcare organization quality of care and patient safety processes, but the influence of this activity on the patient experience is not well understood. This study was designed to explore the relationship between accreditation survey scoring and patient experience of care using a subset of The Joint Commission (TJC) accreditation standards that are conceptually aligned with the Home Health Consumer Assessment of Healthcare Providers and Systems (HHCAHPS) Special Care Issues composite. This was an observational study that used 2018 to 2019 CMS HHCAHPS data and TJC survey findings for 1464 accredited HHAs. The presence or absence of Requirements for Improvement (RFIs) indicating observed noncompliance and the Survey Analysis for Evaluating Risk (SAFER) score were used as independent variables in the analysis. Dependent variables included 3 HHCAHPS composite measures and 2 global rating measures. Data were analyzed using 2 sets of random effects logistic regression models. We found that an increase in RFIs scored on an HHA survey was associated with lower HHCAHPS score on all measures. When the frequency of RFIs and SAFER scores increased, there was a corresponding decline in HHCAHPS ratings, suggesting that patient experience ratings can potentially identify quality of care issues, when experience questions and quality concepts are sufficiently aligned. Adherence to Joint Commission accreditation standards may positively influence some aspects of the patient experience of care. While causality remains uncertain, accreditation appears to play a role in contributing to these outcomes.

Physician Assistant Program Accreditation Analysis and Survey of Program Directors.

To inform physician assistant program directors through citation analysis after implementation of the Accreditation Review Commission on Education for the Physician Assistant (ARC-PA) Accreditation Standards, 5th edition. This research used descriptive statistics, Pearson correlation, and the coefficient of determination to analyze the citations reported by ARC-PA during January 2021 to February 2023. Concurrent first-time taker Physician Assistant National Certifying Exam (PANCE) results were used to determine whether a correlation exists between pass rates and citations. In addition, a survey was sent to each institution's current program director to investigate leadership concerns and differences between programs placed on a provisional, continued, or probation status by ARC-PA. Of the 98 program submissions for accreditation, 13 submissions resulted in a probation status outcome. For these 13 programs placed on probation, 46.2% and 30.8% were cited for being noncompliant with leadership Standards A2.09 and A1.02, respectively. Pearson correlation analysis indicates a significant negative correlation between ARC-PA citations and first-time taker PANCE pass rates ( P = .023, 95% confidence interval [CI] = [-0.49 to -0.04]). This is particularly true for programs with continued accreditation ( P = .007, 95% CI = [-0.67 to -0.13]) and programs that performed below the 85% benchmark ( P = .013, 95% CI = [-0.94 to -0.22]) for first-time taker PANCE pass rates. Although a negative correlation is observed between the number of levied citations and PANCE pass rates, the coefficient of determination does not indicate that the number of citations can predict PANCE pass rates ( R2 = 0.0368). Regarding survey data, 42.86% of programs placed on probation cited institutional support as their biggest program weakness or threat. Conversely, 22.22% of programs with provisional status and 12.5% of programs with continued status reported institutional support as their biggest weakness or threat. This research identifies leadership as a deficit of concern associated with programs placed on probation. In addition, a significant negative correlation exists between the number of citations and first-time taker PANCE pass rates-especially for programs with first-time taker PANCE pass rates below 85% or for programs with continued accreditation status.

Examining the Influence of Joint Commission International (JCI) Accreditation Surveys on Medication Safety Practices: A Cross-Sectional Study from Mediclinic Welcare Hospital in Dubai, UAE

Examining the Influence of Joint Commission International (JCI) Accreditation Surveys on Medication Safety Practices: A Cross-Sectional Study from Mediclinic Welcare Hospital in Dubai, UAE

Lessons learned from the metabolic and bariatric surgery accreditation and quality improvement program site surveys: common deficiencies and corrective actions

BackgroundThe Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) is a joint program between the American Society for Metabolic and Bariatric Surgery (ASMBS) and the American College of Surgeons (ACS). On-site surveys of the applicant programs to determine adherence to the MBSAQIP standards are a hallmark of the accreditation process. ObjectivesA retrospective review of 619 site surveys completed over 2 years was performed to include analysis of reviewer decisions, tabulation and cross-reference of identified deficiencies to the MBSAQIP standards and determine final disposition of corrective actions and overall accreditation rates. SettingAccredited Hospitals (Community and Academic) within MBSAQIP. MethodsThis is a retrospective review of site surveys by expert panel. Results≥1 MBSAQIP Standards deficiencies were present at 149 of the 619 program site surveys (24.07%). The 3 leading Standards in Deficiency were in order: Commitment to Quality Care, Continuous Quality Improvement Process, and Data Collection. Within a year following initial site survey of the149 programs with Standards deficiencies, 59 programs demonstrated compliance, 83 programs were placed on probation (with a specific time-frame to demonstrate compliance) and 7 programs were denied accreditation. Ultimately, 98.9% of programs were able to gain or maintain MBSAQIP accreditation. ConclusionsThe MBSAQIP accreditation through on-site surveys can identify and improve program adherence to MBSAQIP standards.

Performance and satisfaction during the E-learning transition in the COVID-19 pandemic among psychiatry course medical students

BackgroundIn the field of medical education, students faced significant challenges during the COVID-19 pandemic. Abrupt alterations were made in the form of preventative precautions. Virtual classes replaced onsite classes, clinical placements were canceled, and social distance interventions prevented face-to-face practical sessions. The present study aimed to assess students' performance and satisfaction before and after the transition of a psychiatry course from onsite to entirely online during the COVID-19 pandemic. MethodsA retrospective, non-clinical, and non-interventional comparative educational research study included all students registered in the psychiatric course for the academic year 2020 (pre-pandemic/onsite) and 2021 (during the pandemic/online).To assess students' satisfaction, we utilized the National Commission for Academic Accreditation and Assessment (NCAAA) students' satisfaction survey used by the academic quality unit at KSU, College of Medicine.Satisfaction was assessed in six domains: course organization, learning resources, faculty experiences, clinical teaching, practical sessions, and overall satisfaction. The reliability of the questionnaire was measured using Cronbach's alpha test.To assess their performance, students’ grades from both periods were obtained from the exam center. ResultsA total of 193 medical students enrolled in the study; 80 received onsite learning and assessment, while another 113 received full online learning and assessment. The students' mean indicators of course satisfaction for the online courses exceeded their corresponding indicators significantly compared to the onsite courses. These indicators included students' satisfaction in terms of course organization, p < 0.001; medical learning resources, p < 0.050; faculty experience, p < 0.050; and overall course, p < 0.050. There were no significant differences regarding satisfaction in both practical sessions, p > 0.050, and clinical teaching, p > 0.050. The students' performance mean was significantly higher in the online (M = 91.76) compared to the onsite courses (M = 88.58) (p < 0.001), and the Cohen's D statistic showed there was a medium level of enhancement in students' overall grades (Cohen’s d = 0.41). ConclusionStudents perceived the switch to online delivery methods very favorably. Students’ satisfaction significantly improved regarding the themes of course organization, faculty experience, learning resources, and overall course satisfaction, while a similar level of adequate student satisfaction was maintained in terms of clinical teaching and practical sessions during the transition of the course to e-learning. In addition, the online course was associated with a trend toward higher students’ grades. However, the assessment of the achievement of course learning outcomes and the maintenance of this positive impact warrants further investigation.

Factors Influencing The Implementation Of Health Service Quality Governance In Puskesmas: Systematic Review

Puskesmas is a health service facility that organizes public health efforts and individual health efforts at the first level, by prioritizing promotive and preventive efforts in their working areas. Puskesmas as health service providers for the community must provide excellent service that meets community expectations. Puskesmas need effective quality governance, service performance, service procedures, and resources used to provide primary services as efficiently as possible. Service quality is an important factor that refers to the level of service perfection. Efforts to guarantee the quality of puskesmas are carried out through an accreditation survey which is carried out every 3 years. This study aims to look at the factors that influence the quality of health services at puskesmas from various literatures. To collect and synthesize previous information, this study used a Systematic Literature Review search approach with the PRISMA method, using databases related to medical and academic topics, media publications, Google Scholar. Factors that influence the implementation of health service quality governance at the puskesmas consist of structural factors such as physical facilities, human resources, the leadership role of the head of the puskesmas, access to services, facilities and infrastructure, budget, medical devices, and other facilities, process factors consist of the PDCA method (Planning, Doing, Checking, Actuating), as well as the outcome factors in the form of success on the level of service and degree of public health. The availability of resources, the implementation process carried out by the puskesmas has an impact on the quality of health services provided, as well as having an impact on the output achievements, and the accreditation results of the puskesmas

Practices on the outcomes-based education (OBE) implementation in select HEI graduate school programs in the Philippines as input to institutionalizing mandatory accreditation

This qualitative-quantitative research aimed to determine the extent of practices in the implementation of Outcomes-Based Education (OBE) among select Higher Education Institutions (HEIs) in Panay Island, Philippines in terms of an academic institution’s Vision-Mission-Goals, faculty, curriculum and instruction, support to students, research, extension and community involvement, library, physical facilities, laboratories, and administration. Further, this study aimed to find whether the practices of the respondents on OBE implementation are influenced by the level of accreditation. The respondents of the study were the 120 permanent faculty members coming from 17 HEIs offering graduate school programs. The data gathered would provide the basis for institutionalizing mandatory accreditation among HEIs. Using the Accreditation Survey Instrument (ASI) of the Accrediting Agency of Chartered Colleges and Universities in the Philippines (AACCUP), the results revealed that the extent of practices on the OBE implementation except in areas of research, and extension and community involvement were very satisfactory. The result is attributed to the fact that HEIs have met 50% greater than the standards, demonstrating good OBE practices in their graduate school programs. Furthermore, the results of the study also show that the challenges encountered by the faculty members in the practices of OBE implementation were evident in poor research outputs due to inadequate research and extension funds, resulting in weak extension, community involvement, and poor linkages. The level of accreditation of HEIs has a direct bearing and significant influence on the extent of their practices on OBE implementation. Therefore, accreditation is a practical scheme to evaluate and monitor quality program offerings among HEIs in the Philippines to maintain higher standards through OBE typology.

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.

Virtual medical education accreditation survey visits and viability for the future.

Coronavirus disease 2019 (COVID-19) drastically disrupted daily life and abruptly forced curricular modifications in undergraduate medical education. Despite level of preparedness, medical schools moved instruction online for students to access remotely. Similarly, accreditation visits by the Liaison Committee for Medical Education (LCME) were also moved from in-person to virtual formats during these chaotic times. Little guidance was available to transition to the new process. Medical schools that were scheduled for a virtual survey visit were required to pivot without tried experience on how to prepare for and conduct these high stakes online visits. New processes needed to be developed to successfully navigate a virtual accreditation visit. To date, there has been nothing in the literature from those who have participated on LCME teams nor from medical schools who have undergone a virtual survey visit. This article accounts for one medical school's experience from its 2021 LCME virtual visit and makes recommendations to consider when planning for such a significant event. The future of virtual visits is taken into account as this method has its benefits including elimination of travel and the associated time and cost. Yet, the perspectives from others who have participated in a virtual LCME accreditation visit should be studied. While the LCME will return to in-person visits in 2022-23, it is important for medical schools to share their experiences and lessons learned from their virtual accreditation visit should the need arise to reinstate virtual visits in the future.

Factors Affecting the Academic Performance of Teacher Education Students in DOrSU-San Isidro Campus

Factors Affecting the Academic Performance of Teacher Education Students in DOrSU-San Isidro Campus. Objective: This quantitative research study aimed to assess the factors affecting the academic performance of students from DOrSU-San Isidro Campus. Methods: This study employed survey research design to determine the distribution of factors affecting the academic performance of the BEEd students in DOrSU-San Isidro Extension Campus in terms of personal condition, study habits, home-related factor, school-related factor and lecturer factor. Moreover, t-test was used in testing the differences on the academic performance of students when analyzed according to their sex. Findings: The results revealed that there is no disparity between male and female students when compared based on their academic performance. Conclusions: Further, it is suggested in this study to keep the Teacher Education Curriculum responsive and relevant by periodically conducting curriculum reviews and voluntarily submit to accreditation survey visits. This will help them ensure that they are offering quality services to their students regardless of their background. Keywords: teacher education, academic performance, survey research design, Philippines DOI: http://dx.doi.org/10.23960/jpp.v13.i2.202316

BENEFICIOS DE LA ACREDITACIÓN AACSB COMO PREDICTOR DE LA ACTITUD DE LOS DOCENTES HACIA EL PROCESO DE ACREDITACIÓN: UN ESTUDIO EXPLORATORIO

The purpose of the study is to investigate the attitude of faculty members of the College of Business Administration at Kuwait University (CBA-KU) toward the AACSB accreditation system and the way they perceive the benefits of accreditation. The level of association and the causal effect of perceived benefits on shaping faculty attitude are also addressed. A questionnaire was administered to all faculty members at CBA-KU resulting in a final response of 43 observations. While the one-sample t-test and Pearson correlation were used to investigate faculty attitude and perceived benefits and their level of association, Regression analysis was utilized in testing the effect of perceived benefits on faculty attitudes. Findings revealed a relatively high positive attitude toward AACSB accreditation and a significant above-average level of agreement with all addressed benefit statements. Significant positive correlation between benefits and attitudes and a significant effect of academic benefits on faculty attitude were also confirmed. The study is the first AACSB accreditation survey in Kuwait which enriches the understanding of the value of earning the accreditation and highlights some factors that enhance faculty positive attitude toward AACSB accrediting.

Analisis Peran SDM dalam Keberhasilan Capaian Akreditasi Paripurna di Rumah Sakit X Pekalongan

Health services require quality service and good patient safety on an ongoing basis, and accreditation is considered a powerful method to improve the quality of health services. This study aims to describe and analyze the role of leadership and motivation in achieving accreditation at RS X Pekalongan. This research is a qualitative descriptive study. Information was obtained through in-depth interviews, observation, and document review. The sampling technique used purposive sampling, with the number of main informants as many as 19 respondents and triangulation informants as many as 4 respondents. Based on the research results, all parties in the hospital play a role in the accreditation process and all employees have their respective roles. The leadership of the director in accreditation is very good, as evidenced by the design of tasks that can be carried out properly, and in terms of increasing employee motivation, the director has provided rewards both material and non-material, as well as training according to standards. . In maintaining the results of its accreditation, the hospital instills a sense of responsibility for accreditation to all employees. Hospital owners provide moral support to hospitals by participating in a series of accreditation survey events, providing useful input during meetings and also approving funding proposals related to accreditation. Keywords: Accreditation, leadership, motivation, achievement of accreditation

The cost of a first and second hospital-wide accreditation in Flanders, Belgium.

Hospital accreditation is a popular and widely used quality control and improvement instrument. Despite potential benefits, ques-tions are raised whether it constitutes appropriate use of hospitals' limited financial resources. This study aims to calculate the cost of preparing for and undergoing a first and second accreditation by the Joint Commission International or Qualicor Europe in acute-care hospitals. All (n = 53) acute-care hospitals in Flanders (Belgium) were invited to participate and report on the costs in preparing for and undergoing a first and/or second accreditation cycle. To measure costs, a questionnaire with six domains and 90 questions was developed based on literature review, policy documents and a multidisciplinary expert group. All costs were recalculated to 2020 euro to correct for inflation and reported as medians with interquartile range. A total of 25 hospitals (47%) participated in the study. Additional investments and direct operational costs for a first accreditation cycle amounted to 879.45 euro (interquartile range: 794.81) per bed and 3.8 full-time equivalent (FTE) per hospital additional new staff members were recruited for coordination and implementation of the trajectory. A second accreditation survey costed remarkably less with a total cost of extra investments and direct operational cost of 222.88 euro (interquartile range: 244.04) per bed and less investment in additional staff (1.50 FTE). Most of the costs were situated in consulting costs and investments in infrastructure. The median total extra cost (direct operational cost and additional investments) amounted to 0.2% of the hospital's operating income for a first accreditation cycle and 0.05% for a second cycle. A first accreditation cycle requires a strong financial commitment of hospitals, as many costs result from the preparation in the years prior to an accreditation survey. A second survey is less expensive for hospitals, but still requires a considerable effort in terms of budget and staff. Policy makers should be aware of these significant costs as hospitals are operating with public resources and budget is scarce. The identification of these costs is a necessary building block to evaluate cost-effectiveness of accreditation versus other quality improvement systems and the continuation of these accreditation systems and their costs needs further study and a thorough debate.

Analyzing an Implementation of Patient Safety Targets Standards at Ja'far Medika Hospital Based on Hospital Accreditation National Standards (SNARS) Issue 1.1

Background : The complexity of hospital operations has the errors’ potential. Patient safety will have an impact on the patient's medical condition as well as increasing health costs. Ja'far Medika Hospital scored 82.4 in the KARS accreditation survey using SNARS edition 1.1 in 2019. This study analyzes the implementation of patient safety target standards at Ja'far Medika Hospital Karanganyar based on SNARS edition 1.1. Methods : This study is a quantitative descriptive study by document review, observation of infrastructure facilities, and observation of the implementation of patient safety at Ja'far Medika Hospital. Results and discussion : The accomplishment of the implementation of patient safety goals that meet the passing grade are the accuracy of identifying patient by 85%, reducing the risk of infection related to health services/healthcare-acquired infections (HAIs) by 82.3%, and reducing the risk of injury due to falls by 87.5%. Whereas the targets below the passing grade are improve effective communication by 78.5%, Increased safety of high alert medication (HAM) by 75%, and the confirmation of the exact location, procedure, and patient of the operation by 50%. Conclusion : The implementation of patient safety targets at Ja'far Medika Hospital has not been carried out optimally with the target of Effective Communication improvement, the safety enhancement of high alert drugs/drugs that need to watched out and the confirmation of the exact location, procedure, and patient of the operation

Virtual medical education accreditation survey visits and viability for the future

Coronavirus disease 2019 (COVID-19) drastically disrupted daily life and abruptly forced curricular modifications in undergraduate medical education. Despite level of preparedness, medical schools moved instruction online for students to access remotely. Similarly, accreditation visits by the Liaison Committee for Medical Education (LCME) were also moved from in-person to virtual formats during these chaotic times. Little guidance was available to transition to the new process. Medical schools that were scheduled for a virtual survey visit were required to pivot without tried experience on how to prepare for and conduct these high stakes online visits. New processes needed to be developed to successfully navigate a virtual accreditation visit. To date, there has been nothing in the literature from those who have participated on LCME teams nor from medical schools who have undergone a virtual survey visit. This article accounts for one medical school’s experience from its 2021 LCME virtual visit and makes recommendations to consider when planning for such a significant event. The future of virtual visits is taken into account as this method has its benefits including elimination of travel and the associated time and cost. Yet, the perspectives from others who have participated in a virtual LCME accreditation visit should be studied. While the LCME will return to in-person visits in 2022-23, it is important for medical schools to share their experiences and lessons learned from their virtual accreditation visit should the need arise to reinstate virtual visits in the future.

Virtual Trauma Center Surveys, Are They Virtually the Same?

The coronavirus pandemic forced regulatory agencies to develop innovative methods for achieving regulatory compliance. The accrediting body for trauma centers in Pennsylvania, the Pennsylvania Trauma Systems Foundation (PTSF), was one of the many agencies forced to find creative and safe ways to maintain prepandemic processes of evaluating trauma centers for compliance with trauma standards. With the uncertainty of government and hospital regulations prohibiting on-site participation and precautionary efforts to protect the health and well-being of survey participants, a virtual site visit survey process was developed to facilitate trauma center accreditation within the Commonwealth of Pennsylvania. The purpose of this article is to describe an accrediting body's experience with implementing a virtual accreditation site visit survey process for Level I and II trauma centers. In 2021, the PTSF piloted the virtual survey process and completed two virtual accreditation surveys. Feedback from participants included both positive and negative responses. The virtual format was effective in maintaining a high-quality accreditation process. However, multiple downsides were identified, including loss of interactive participation, loss of collaboration, limited educational opportunities, and increased presurvey workload for all participants. The in-person and virtual formats can accomplish the goal of the accreditation survey. The negative implications identified suggest that a traditional on-site accreditation process is preferred, with the virtual format reserved for extenuating circumstances.

Accreditation Surveys in the Pandemic Era

Accreditation Surveys in the Pandemic Era