Hospital Accreditation Research Articles

Challenges in the Australasian neurosurgery training program: who should be trained and where should they train?

Neurosurgical training poses particular challenges in Australia and New Zealand, given the large landmass, small population, and widely separated, often small, neurosurgical units. Such factors have necessitated a move away from autonomous, single-institution-based training to the selection of trainees by a centralized binational process. The success of this system is based on rigorous standardized evaluation of candidates' academic achievements, anatomical knowledge, references, and interview performance. Similarly, the accreditation of hospitals to train successful candidates has been standardized. The authors review the evolution of trainee selection and the accreditation of training posts in Australia and New Zealand. The records of the Neurosurgical Society of Australasia Surgical Education and Training Board were reviewed for documents pertaining to the selection of neurosurgical trainees and the accreditation of training posts. Application records and referee scores from 2014 to the present were reviewed to encompass process changes, in particular the change from written referee reports to standardized interviews of referees. Surgical logbook case numbers for 23 trainees completing training in 2016, 2017, and 2018 were collated and presented in an aggregated, de-identified form as a measure of adherence to accreditation standards. Written evaluations of the training experience were also sought from two trainees reflecting on the selection process, the quality of training posts, and training limitations. While a time-consuming process, the method of obtaining referee reports by interview has resulted in a wider spread of scores, more able to separate high- and low-scoring applicants than other components of the selection process. Review of the training post accreditation records for the last 2 years showed that adherence to standards has resulted in loss of accreditation for one unit and shortened periods of review for units with more minor deficiencies. Two applications for accreditation have been denied. Examination of caseload data showed that trainees more than fulfill minimum requirements in accredited training posts, confirming the robust nature of this aspect of unit accreditation. A key factor determining the success of neurosurgical training in Australia and New Zealand has been a willingness to evolve selection and other processes to overcome challenges as they become apparent. According to available analyses, the revised referee process and strict accreditation standards appear effective. The benefits and challenges of the current training system are discussed in the context of a paucity of international literature.

Challenges of implementation of hospital accreditation in Iran: an exploratory factor analysis

BackgroundToday, accreditation is considered as the most commonly used health assessment approach. Considering the importance and application of the process of this approach in the hospital, this study aimed to investigate the challenges of implementation of hospital accreditation in Iran using exploratory factor analysis.MethodsA cross-sectional study design was carried out from July to December 2017, consisting of 200 managers in the seven hospitals accredited by the MOH in Tehran, Iran. Samples were selected through the purposive sampling method, and data were collected using a structured questionnaire in which validity and reliability were confirmed. Likert’s five-choice range was used for the rating of items. Exploratory factor analysis was used to categorize the identified challenges and extract the mathematical model on them.ResultsExploratory factor analysis identified six dimensions (implementation, evaluation, content, structural, psychological, and managerial) with 40 items using a 5-point Likert scale. Each dimension accounted for greater than 63.20% of the total variance. The scale had strong content validity (indices = 0.84). Each dimension of Cronbach’s alpha ranged from 0.74 to 0.94. Implementation, evaluation, content, structural, psychological, and managerial components also formed the final identified areas.ConclusionThe present study showed that there were major challenges in the path to successful deployment of Iranian hospital accreditation, requiring serious action by managers and policymakers in this field.

Pengaruh Akreditasi Rumah Sakit dalam Perubahan Tingkat Kepatuhan Pengisian Surgical Safety Checklist di RS Nur Hidayah

Death and complication due to surgeries or surgical actions is a global health problem. The WHO estimates that at least half a million deaths that are caused by surgeries can be prevented. On 2008, the WHO released a campaign about safe surgery and the surgical safety checklist to improve the quality of our surgery cases and decrease the number of complication and deaths caused by surgeries. Hospital accreditation is used to improve the quality of hospital management, including in reducing numbers of death and complication due to surgeries. This is a quantitative descriptive approach study. The study population used were all surgical safety checklist. Sample number of 75 surgical safety checklist, 15 surgical safety checklist each from June 2017, August 2017, January 2018, June 2018, and January 2019. Data analysis shown by statistic table and percentage. There was a change of number in completing compliance of the surgical safety checklist before and after hospital accreditation. It showed that nearing hospital accreditation, the compliance rate was almost 100% on all the items. This continued a month after, but some of the items had a lower rate of compliance further after the hospital accreditation. The number of completing compliance of the surgical safety checklist nearing hospital accreditation is higher than after hospital accreditation. The sign in item have the highest rate of completing compliance whereas the sign out item had the lowest number of compliance.

Kepatuhan dan Ketepatan Tenaga Medis dalam Pengisian Assessment Pre Dialisis di Klinik Hemodialisis Nitipuran Health Center

Background: The National Hospital Accreditation Standards (SNARS) state that one of the key indicators in patient-focused service standards is patient assessment. The purpose of this study was to analyze the level of compliance and accuracy of medical personnel in pre dialysis assessments at NHC. Subjects and Method: This study uses a mixed method with the Cohort Study approach. Research subjects were medical records for quantitative data and doctors, nurses and head nurses for qualitative data. Quantitative data analysis with descriptive analysis, and qualitative analysis with in-depth interviews. Result: The level of compliance and accuracy of medical personnel in filling the pre dialysis assessment at the Nitipuran Hemodialysis Clinic is not quite good. The implementation of pre dialysis assessment at the NHC includes physical status, medical history, history of drug allergy, assessment of pain, risk of falls, and educational needs. Constraints include time constraints, assessments are filled in immediately without checking in detailly, there are gaps in the hourly monitoring records. Conclusion: compliance and accuracy of medical personnel in filling out assessments must be improved.

The Implementation Effectiveness of the K3RS Program with Achievement of Compliance on Hospital Accreditation Standards at Dr. R. M. Djoelham Hospital in Binjai of 2019

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.

Akreditasi:Pengaruhnya Terhadap Program Hand Hygiene Di Rumah Sakit Muhammadiyah Cirebon

This study aims to measure the implementation of the hand hygiene program at the Muhammadiyah Hospital Cirebon after accreditation. The method used is a qualitative analysis method, with a case study design. The research case is the Infection Control Prevention Working Group in which there is a hand hygiene program at the time of accreditation, including those that do not meet the minimum passing score, so the hand hygiene program implementation will be measured from an effective strategy, organizational characteristics, influence of the behavior of officers and patients and their families, and budget support from post accreditation management. The research instrument used interview guides with 4 respondents. The results of this study indicate that the Muhammadiyah Hospital in Cirebon does not yet have an effective strategy in building a hand hygiene culture. The post-accreditation Infection Control Prevention Team Organization is not running, so a hand hygiene program has not been established at the Muhammadiyah Hospital in Cirebon. The behavior of officers and patients the level of compliance with handwashing is still lacking, due to the use of consumables after accreditation is still low. In terms of the budget, the hospital has a good financial condition, but because there is no work program, the proposed expenditure budget of each unit does not reflect the need for programs that include training, procurement of consumables, and education for both officers and patients. ineffective hand hygiene strategies, PPI Committee organizational structure is not going well, there has been no change in hand hygiene behavior of employees, patients and visitors, and the PPI Committee budget is still contained in the unit budget, has not become a special budget item. Keyword: Hospital accreditation; cost; hand hygiene

Point-of-care testing blood gas analyzer use in emergency and critical care settings – Hamad Medical Corporation Experience

Background: Point-of-care testing (POCT) facilitates rapid decisions by performing tests near or at the patient side. POCT integration accelerates clinical decisions and enhances patients’ standard of care in emergency settings. POCT positively influences patient care especially during life-threatening situations or in the operating rooms and critical care areas as it enables the rapid provision of information related to blood gases and electrolytes. Such a process reduces Therapeutic Turnaround Time (TTAT) and pre-analytic and post-analytic testing errors 1. Methods: POCT has been implemented across Hamad Medical Corporation (HMC) Emergency Departments and Critical Care Units in line with applicable hospital regulations and accreditation requirements. The aim of this project was to standardize blood gas analyzer methods and processes over all HMC facilities. The POCT team worked according to the College of American Pathologists (CAP) standards and regulations and selected the most advanced technologies available on the market for integration of the equipment on the HMC network while enabling for remote-access. This has been achieved by ensuring full connectivity integration to the hospitals Laboratory Information System (LIS). Training programs have been conducted to ensure that only competent and certified staff are authorized to perform patient testing in the Emergency Departments and Critical Care Units 2. Results: A total of 80 blood gas analyzers have been installed including 47 analyzers in Emergency Departments and Critical Care Units. During the period from August 2018 up to August 2019, 179,659 tests were performed by 3123 different operators including nurses, respiratory therapists, and perfusionists. The POCT system detects, troubleshoots, and minimizes errors by continuous monitoring of Quality Key Indicators (QKI). Conclusion: Successful implementation of POCT for blood gas analysis enabled rapid, accurate, and cost-effective patient testing. Furthermore, POCT of blood gases in emergency areas has reduced process complexity and improved operational workflow and led to an enhanced lean process.1 Effective communication through electronic documentation, quality assessment, and ongoing monitoring by the POCT team in parallel with healthcare providers who are performing bedside POCT will achieve compliance with international standards for emergency and critical care areas.

Qualidade de Serviços Hospitalares sob a Perspectiva dos Processos de Acreditação

A temática da qualidade de serviços hospitalares é assunto de interesse público e objeto central de muitas discussões da sociedade, figurando, inclusive, entre as principais preocupações dos gestores e usuários do sistema de saúde. Apesar do tema qualidade ser discutido, academicamente, há décadas, este tornou-se mais evidente e robusto a partir do surgimento dos processos de acreditação hospitalar, principal ferramenta utilizada pelos gestores para estruturar, validar e legitimar os processos dedicados a gestão da qualidade no ambiente hospitalar. Em face da recência do tema, nível de complexidade e interesse social acerca do assunto, este artigo objetiva compreendê-lo a partir de um estudo bibliométrico seguido de uma revisão sistemática da literatura. Para isso, foram avaliados 45 artigos selecionados nas bases de dados: Ebsco, Periódicos Capes, Scopus, Spell e Web of Science. Os resultados apontaram que a acreditação hospitalar colabora para mudanças profundas no que se refere à qualidade e segurança na assistência, mas que há incipiências e lacunas em alguns temas como: perspectiva dos pacientes com relação à qualidade e satisfação; resultados financeiros advindos da acreditação; motivos que levam ao descredenciamento de instituições; estudos comparativos das diferenças entre as exigências das diferentes entidades acreditadoras; e, estudos voltados ao comportamento do consumidor hospitalar.

Analysis of main result quality indicators of tertiary maternal and child health hospitals

Objective To acquire the main result quality indicators status of tertiary maternal and child health(MCH) hospitals in China, supporting the decision making. Methods The National Maternal and Child Health Institutions Resources and Operations Survey Direct Reporting System was used to collect the management operation, inpatient death, re-return, hospital-acquired infection, surgical complications and patient safety of these hospitals in China in 2017. Statistical descriptions were made using average, rate and composition comparison data. Results The proportion of health technicians of tertiary MCH hospitals in China was 83.66%, the average hospitalization days were 5.96 days, with bed occupancy rate of 90.01%. The success rate of neonatal resuscitation was high. Meanwhile, the mortality rate of hospitalized maternal critical illness, the total hospitalization mortality rate of neonatal patients, the incidence of complications in surgical patients, the incidence of neonatal injury and the incidence of birth injury in vaginal delivery were higher in the institutions that had not participated in the MCH hospital accreditation. Conclusions The management of tertiary MCH hospitals in China was in good condition, and the relevant policies and projects have achieved remarkable results. Compared with general hospitals, hospital infection and re-return indicators were good. The quality and safety of tertiary MCH hospitals which have not participated in the MCH hospital assessment were poor. It is recommended to carry out MCH hospital accreditation to improve quality and safety. Key words: Healthcare surveys; Maternal and child health hospital; Total quality management; Result quality indicators

The history of quality and safety of the surgical patient: from the initial standards to the present day.

There are currently various concepts related to quality, which have been implemented by many hospitals and other healthcare institutions. The search for continuous improvement, the implementation of a quality culture and hospital accreditation have also been common, in these institutions. However, the history of hospital audits and accreditation is complex and full of dynamic concepts. The American College of Surgeons was pioneer in publishing, more than a century ago, the first document pertaining quality standards. After that, various programs and concepts have been developed and remodeled by distinct entities. In this article, we briefly review the history of quality in the world and Brazil. We also discuss related concepts regarding its assessment in healthcare.

The Impact of Hospital Accreditation on Nurses' Perceptions of Quality of Care?

Introduction: Accreditation is the recognition of the quality of services that have met the National Hospital Accreditation Standards. In implementing hospital accreditation , it covers patient safety goals, patient-focused service standards, hospital management standards, national programs and integration of health education in hospital services. How is the impact of hospital accreditation on the quality of care, especially nursing services in accordance with the perceptions and attitudes of nurses in hospitals. Therefore, it is necessary to identify the impact of applying hospital accreditation in accordance with nurses' perceptions and attitudes towards nursing services. Methods: For this reason, articles data with a for publication from 2008-2018 are needed, of the 418 systematic literature articles taken from Scopus, Science direct, and Proquest. There are 15 articles chosen to search for literature with keywords; the impact of accreditation on nurses' perceptions and attitudes about the quality of care.Results: Five of the 15 articles that fit the design criteria that address the impact of hospital accreditation according to nurses' perceptions and attitudes in improving nursing services.Conclusion: The study results show that hospital accreditation make a nurses perception the quality of care. Quality of care is the one of impact from hospitals accreditation. Nurses in accredited hospitals feel a higher level of quality of health services.

A Brief History of Quality Improvement in Health Care and Spinal Surgery.

While medical and technological advances continue to shape and advance health care, there has been growing emphasis on translating these advances into improvement in overall health care quality outcomes in the United States. Innovators such as Abraham Flexner and Ernest Codman engaged in rigorous reviews of systems and patient outcomes igniting wider spread interest in quality improvement in health care. Codman’s efforts even contributed to the founding of the American College of Surgeons. This society catalyzed a quality improvement initiative across the United States and the formation of the Joint Commission on Accreditation of Hospitals. Since that time, those such as Avedis Donabedian and the Institute of Medicine have worked to structure the process of improving both the quality and delivery of health care. Significant advances include the defining of minimum standards for hospital accreditation, 7 pillars of quality in medicine, and the process by which quality in medicine is evaluated. All of these factors have affected current practice more each day. In a field such as spinal surgery, cost and quality measures are continually emphasized and led to large outcome databases to better evaluate outcomes in complex, heterogeneous populations. Going forward, these databases will be instrumental in developing practice patterns and improving spinal surgery outcomes.

Hospital Readiness Assessment for Disasters Using the Hospital Safety Index in Several Accredited Hospitals in Yogyakarta Province

Indonesia is a disaster-prone country, so research on hospital preparedness for disasters is necessary. One of the tools to measure the readiness of hospitals in facing disasters using the Hospital Safety Index (HSI) from WHO. This study aims to determine the readiness of hospitals to deal with disasters using HSI. Research location in PKU Yogyakarta, PKU Bantul, PKU Kotagede, PKU Nanggulan, and PKU Wonosari. These PKU that have been accredited by the Hospital Accreditation Committee in Yogyakarta Province. The approach used is descriptive qualitative. The independent variable is the HSI from WHO, and the dependent variable is the Hospital Accreditation Committee (Komite Akreditasi Rumah Sakit/KARS) accredited hospital. The respondents are the person in charge of the structural part of the disaster management system. The checklist refers to the HSI form from WHO. Each statement provides three types of answers, namely low, medium, and high. All statements are a total number of low scores, medium scores, and high scores using the HSI calculator. The results of the study are that hospitals with plenary accreditation have higher HSI scores so that they prepared to face disasters than hospitals that have not been plenarily accredited.

Embedding best transfusion practice and blood management in neonatal intensive care

BackgroundTransfusion is a common procedure for neonates receiving intensive care management. Recognising a paucity of patient blood management (PBM) programmes in neonates, we aimed to embed blood management and best...

Reconfiguration of palliative oncological nursing care: nursing contributions.

to analyze the strategies implemented by nurses to reconfigure palliative oncological care due to the hospital accreditation process in Hospital do Câncer IV (Hospital of Cancer IV). qualitative research of historical-social approach, whose direct sources in use were written documents and four spoken accounts. implemented strategies were: creation of the Nursing Division; nursing staff management; consolidation of Continuing Education sector; creation of Internal Nursing Bylaws through development of norms and routines; meetings; discussion of clinical cases; training and classes; creation of Núcleo de Assistência de Enfermagem (Nursing Assistance Core); creation of a tumoral and ostomy wound-dressing ambulatory; and organization of the 5th Vital Sign Forum. Final considerations: nurses, supported by an alliance with the institution directors, implemented effective strategies and reached significant advancement. As they took part in this endeavor, they became legitimate spokespeople of an authorized discourse in the field of oncological nursing care in Brazil.

Evaluation results of national hospital accreditation program in Iran: The view of hospital managers

BackgroundAccreditation programs have a crucial role in improving the safety and effectiveness of hospital services. Many factors contribute to achieve accreditation goals. This study evaluated the national Iranian hospital accreditation program from the view of hospital managers in Iran. MethodsThe study was conducted in 2015 using a validated questionnaire designed to collect feedback concerning accreditation processes and impacts. In total, 547 managers were surveyed using a stratified random sampling method. A 5-degree scale Likert from totally disagree=1 to totally agree=5 has been used for the evaluation. Descriptive and inferential statistics were used to analyze the data. ResultsApproximately half of hospital managers were satisfied with the accreditation standards and surveying methods. The reason for their dissatisfaction was the high number of measures (2.38). The main challenges to the accreditation method were reported inadequate surveyor training (2.94) their satisfaction with the infrastructure was low because of a lack of hospital resources. Nonetheless, the accreditation program was perceived as being successful in improving patient safety (3.80), patient compliance (3.72), and error reduction (3.53). ConclusionAn effective accreditation program requires reducing the number of standards and making them clearer as well as the infrastructure for the implementation of accreditation such as sufficient and sustainable funds, enough human resources and equipment should be provided. Appropriate surveyors should be selected and trained professionally to ensure inter-rater reliability among them.

Analysis of Subgroups with Lower Level of Patient Safety Perceptions Using Decision-Tree Analysis

This study was aimed to investigate experiences, perceptions, and educational needs related to patient safety and the factors affecting these perceptions. Study design was a descriptive survey conducted in November 2019. A sample of 1,187 Koreans aged 20-80 years participated in the online survey. Based on previous research, the questionnaire used patient safety-related and educational requirement items, and the Patient Safety Perception Scale. Descriptive statistics and a decision tree analysis were performed using SPSS 25.0. The average patient safety perception was 71.71 (± 9.21). Approximately 95.9% of the participants reported a need for patient safety education, and 88.0% answered that they would participate in such education. The most influential factors in the group with low patient safety perceptions were the recognition of patient safety activities, age, preference of certified hospitals, experience of patient safety problems, and willingness to participate in patient safety education. It was confirmed that the vulnerable group for patient safety perception is not aware of patient safety activities and did not prefer an accredited hospital. To prevent patient safety accidents and establish a culture of patient safety, appropriate educational strategies must be provided to the general public.

Developing hospital accreditation standards: Applying fuzzy DEMATEL

ABSTRACT Accreditation means the systemic evaluation of healthcare centers. In this process, the opinions of a group of experts are noted to evaluate healthcare organizations and make decisions about granting them qualifications. In this study, the fuzzy DEMATEL technique was utilized to rank and weight the categories, subcategories, and standards of hospital accreditation. The present research is empirical in terms of purpose and descriptive-survey in terms of data collection. The statistical population included Iran’s national accreditation standards. Eight experts, appraisers, senior appraisers, and policymakers of Iran’s national accreditation have been selected. The fuzzy DEMATEL technique was employed to determine the internal correlation between the existing criteria (standards) and their weights in a bid to identify the influenced structure of effective criteria or standards. Regarding the categories, management and leadership affected other factors of hospital standards and improved them. According to the proposed ranking and weighting model obtained from the expert opinions, most standards of management, executive management leadership, and the main decision-making body were effective in hospitals. These standards can improve hospital weaknesses and strengths. Hence, hospitals can bring about positive changes by taking effective measures and paying special attention to the main body of management.

Antibiotic stewardship teams and Clostridioides difficile practices in United States hospitals: A national survey in The Joint Commission antibiotic stewardship standard era.

Clostridioides difficile infection (CDI) can be prevented through infection prevention practices and antibiotic stewardship. Diagnostic stewardship (ie, strategies to improve use of microbiological testing) can also improve antibiotic use. However, little is known about the use of such practices in US hospitals, especially after multidisciplinary stewardship programs became a requirement for US hospital accreditation in 2017. Thus, we surveyed US hospitals to assess antibiotic stewardship program composition, practices related to CDI, and diagnostic stewardship. Surveys were mailed to infection preventionists at 900 randomly sampled US hospitals between May and October 2017. Hospitals were surveyed on antibiotic stewardship programs; CDI prevention, treatment, and testing practices; and diagnostic stewardship strategies. Responses were compared by hospital bed size using weighted logistic regression. Overall, 528 surveys were completed (59% response rate). Almost all (95%) responding hospitals had an antibiotic stewardship program. Smaller hospitals were less likely to have stewardship team members with infectious diseases (ID) training, and only 41% of hospitals met The Joint Commission accreditation standards for multidisciplinary teams. Guideline-recommended CDI prevention practices were common. Smaller hospitals were less likely to use high-tech disinfection devices, fecal microbiota transplantation, or diagnostic stewardship strategies. Following changes in accreditation standards, nearly all US hospitals now have an antibiotic stewardship program. However, many hospitals, especially smaller hospitals, appear to struggle with access to ID expertise and with deploying diagnostic stewardship strategies. CDI prevention could be enhanced through diagnostic stewardship and by emphasizing the role of non-ID-trained pharmacists and clinicians in antibiotic stewardship.

Time-frame comparison of hystero-preservation in the surgical treatment of uterine prolapse: a population-based nation-wide follow-up descriptive study, 2006-2013 versus 1997-2005.

The purpose of our study was to describe the surgical trend and time-frame comparison between 1997-2005 (1stperiod) and 2006-2013 (2nd period) of hystero-preservation for uterine prolapse, based upon a nationwide population-based National Health Insurance (NHI) claim data in Taiwan. Women, who underwent primary surgeries for uterine prolapse, either uterine suspension with hystero-preservation or hysterectomy during 1997-2013, were identified from National Health Insurance Research Database (NHIRD).We analyzed the related variables including surgical types (hystero-preservation or hysterectomy), patient age and concomitant anti-incontinence surgery, surgeon age, gender, and service volume; and hospital accreditation level, and service volume. We identified a total of 46,968 inpatients, 6629 (14.11%) hystero-preservation group, and 40,339 (85.89%) hysterectomy group. Hystero-preservation significantly increased during the 17year follow-up study period (1997 to 2013) (P value =0.0147). The overall surgeries for uterine prolapse increased among patients ≥70years, with concomitant anti-incontinence surgery, surgeons ≥45years, high volume surgeons, and hospitals. Multiple logistic regression revealed hysterectomy was less used in 2nd period (OR 0.45, 95%, confidence interval (CI) 0.43-0.48). Hysterectomy was more often used in patient aged ≥50years, surgeon aged ≥45years, and low volume hospitals. In case of concomitant anti-incontinence surgery (OR 0.48, CI 0.45-0.52), high volume surgeons (more than 30 surgeries) and hospitals (more than 73 surgeries) hystero-preservation was more often used. Time-frames, younger patients, concomitant anti-incontinence surgery, younger surgeons, and high volume surgeons and hospitals increase hystero-preservation for uterine prolapse. Surgeons and hospitals should be ready to respond to the wishes of female patients who want to preserve the uterus.