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

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by: Dr.Saeed Al by: Dr.Saeed Al QahtaniQahtaniHead, Planning Department Head, Planning Department

and Quality Management and Quality Management Consultant, KFSH,,Saudi Consultant, KFSH,,Saudi ArabiaArabia

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Agenda

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

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Aramco Medical Services 1990 27 hospitals are accredited. 33% (Governmental) JCIA (22). CCHSA (4). JCIA+ CCHSA+ACHS (1) CBAHI 2006 ( processing )

Accreditation History in Saudi Arabia

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

Purpose

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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

Objectives

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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

Methodology

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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%.

Results

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TABLE (1-2)GROUP "A" Governmental hospitals (MOH, National Guard, KFSH and Security Forces)

No. INDICATORSACCREDITATION

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 -- --

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GROUP “B" Private Hospitals

No. INDICATORSACCREDITATION

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%

What did you get after accreditation

84 80 76 7264

0102030405060708090

Clear process Strategic directions Safety culture Communication Performancemeasures

Items

Per

cen

tag

e

Percentage

Linear (Percentage)

Do you recommend another hospitals to go through accreditation system

80%

20%

Yes

No

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a. Effective communication. b. Continuous education. c. Satsifaction. d. Safety culture. e. documentation system.

The Top 5 positive impact of accreditation

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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.

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