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by: Dr. Saeed Al Qahtani Head, Planning Department and Quality Management 1 Consultant, KFSH, by: Dr. Saeed Al Qahtani Head, Planning Department and Quality Management 1 Consultant, KFSH, , Saudi Arabia

Agenda • History of accreditation. • Purpose of study. • Objectives. • Methodology. • Agenda • History of accreditation. • Purpose of study. • Objectives. • Methodology. • Results. • Recommendations. • Conclusion. 2

Accreditation History in Saudi Arabia § § § § Aramco Medical Services 1990 27 Accreditation History in Saudi Arabia § § § § Aramco Medical Services 1990 27 hospitals are accredited. 33% (Governmental) JCIA (22). CCHSA (4). JCIA+ CCHSA+ACHS (1) CBAHI 2006 ( processing ) 3

Purpose To study the Impact of Accreditation on Patient Care in Hospitals in Saudi Purpose To study the Impact of Accreditation on Patient Care in Hospitals in Saudi Arabia 4

Objectives 1. To measure the impact of accreditation on patient /staff 2. To determine Objectives 1. To measure the impact of accreditation on patient /staff 2. To determine the impact of accreditation on utilization resources 3. To study the relationship between obtaining the accreditation and increased financial revenue 4. To identify the top 5 elements that affect positively in the organization 5

Methodology § § § 25 hospitals ( sample size ) Data collection ( questionnaire Methodology § § § 25 hospitals ( sample size ) Data collection ( questionnaire ) 5 Dimensions: a. Patient Safety b. Leadership c. Workforce development d. Patient focus e. U. M & F. M 6

Results 1. Patient safety culture is increased by 10%. 2. Staff are more satisfied Results 1. Patient safety culture is increased by 10%. 2. Staff are more satisfied by 5%( governmental hospitals only). 3. Patients are more satisfied by 7%. 4. Leadership is more committed by 20%. 5. Utilization resources are more utilized by 18%. 6. Patients bill of rights are more implemented by 10%. 7

TABLE (1 -2) GROUP TABLE (1 -2) GROUP "A" Governmental hospitals (MOH, National Guard, KFSH and Security Forces) No. INDICATORS ACCREDITATION BEFORE AFTER 1. PATIENT SATISFACTION RATE 60% 70% 2. STAFF SATISFACTION RATE 68% 71% 3. WAITING TIME (ER) 4. 5 HRS 2. 19 HRS 4. MEDICAL RECORDS DOCUMENTATION COMPLETENESS PERCENTAGE 40% 63% 5. NO. OF EDUCATIONAL SESSIONS PER YEAR 94 231 6. COMPLIANCE WITH POLICY & PROCEDURE RATE 35% 55% 7. FINANCIAL REVENUE -- -- 8

GROUP “B GROUP “B" Private Hospitals No. INDICATORS ACCREDITATION BEFORE AFTER 1. PATIENT SATISFACTION RATE 70% 80% 2. STAFF SATISFACTION RATE 71% 65% 3. WAITING TIME (ER) 1. 34 HRS 40 minute 4. MEDICAL RECORDS DOCUMENTATION COMPLETENESS PERCENTAGE 55% 70% 5. NO. OF EDUCATIONAL SESSIONS PER YEAR 70 190 6. COMPLIANCE WITH POLICIES & PROCEDURES RATE 25% 47% 7. FINANCIAL REVENUE 2% 5% 9

The Top 5 positive impact of accreditation a. Effective communication. b. Continuous education. c. The Top 5 positive impact of accreditation a. Effective communication. b. Continuous education. c. Satsifaction. d. Safety culture. e. documentation system. 12

Recommendations • accreditation culture. • Accreditation not certificate only. • Decision makers in MOH Recommendations • accreditation culture. • Accreditation not certificate only. • Decision makers in MOH should support hospitals ( under accreditation/accredited) through increased annual budget. • Rewarding system for staff to be created. • Quality of services should be considered during preparation for accreditation. 13

THE IMPACT OF ACCREDITATION 14 THE IMPACT OF ACCREDITATION 14