How to Improve Hospital Accreditation - Linta Meyla Putri

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Hospital as a health care institution must provide quality services to the community. Quality of service is a standard that will be made to increase the hospital accreditation. In addition to the …

Hospital as a health care institution must provide quality services to the community. Quality of service is a standard that will be made to increase the hospital accreditation. In addition to the accredited national standards, some hospitals in Indonesia, especially government hospitals, will also be accredited to use international standards. Actually in Indonesia has a lot of hospitals which are internationally accredited, but most private hospitals. This condition is to give the impression that government hospitals are less credible and less able to provide the best service both communities. To achieve this, the government in collaboration with international accreditation agency that is Joint Commission International (JCI), USA.

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  • 1. Linta Meyla Putri HOSPITAL ADMINISTRATION “IMPROVING HOSPITAL ACCREDITATION BASED ON PATIENT-CENTERED PROGRAMS AND QUALITY MANAGEMENT OF HEALTH CARE” Linta Meyla Putri 101211131047 IKMB 2012 INRODUCTION Nowadays people are increasingly aware to choose a good health service. Some examples are the people currently no longer hesitate to ask question about alternative treatments they will receive according to their current financial condition. They also no longer hesitate to discuss with doctor about the use and side effects of prescription drugs to them. People are also starting to ask question whether the critical medical devices that are used to check them is sterile or not. Even some people who want to see the sterilization process. When there is a less satisfactory service, today they dont hestitate to reprimand medical staff who concerned on that case or they’ll give their complain to suggestion box. The people want the best service for them according their current condition . Hospital as a health care institution must provide quality services to the community. Quality of service is a standard that will be made to increase the hospital accreditation. In addition to the accredited national standards, some hospitals in Indonesia, especially government hospitals, will also be accredited to use international standards. Actually in Indonesia has a lot of hospitals which are internationally accredited, but most private hospitals. This condition is to give the impression that government hospitals are less credible and less able to provide the best service both communities. To achieve this, the government in collaboration with international accreditation agency that is Joint Commission International (JCI), USA. JCI chosen because most are affiliated with major hospitals in the world and is one of the accrediting agencies that are considered inexperienced. International accreditation is intended to equalize the quality of hospital services by government hospitals internationally. With the international accreditation is expected to grow also trust and recognition from the community that the government hospitals to provide the best health services . With this recognition is expected to stem the flow of people vying to seek treatment abroad. With the international accreditation, the government guarantees the quality improvement of health service
  • 2. Linta Meyla Putri, Improve Hospital Accreditation 2 in government hospitals without being accompanied by rising prices . LITTERATURE REVIEW Minister In Health No.12/2012 tentang Akreditasi Rumah Sakit adalah pengakuan terhadap Rumah Sakit yang diberikan oleh lembaga independen penyelenggara Akreditasi yang ditetapkan oleh Menteri, setelah dinilai bahwa Rumah Sakit itu memenuhi Standar Pelayanan Rumah Sakit yang berlaku untuk meningkatkan mutu pelayanan Rumah Sakit secara berkesinambungan, its mean that Accreditation is a process by which an institution or disciplinary unit within an institution periodically evaluates its work and seeks an independent judgment by peers that it achieves substantially its own educational objectives and meets the established standards of the body from which it seeks accreditation. (Permenkes, No.12 tahun 2012) Health Care Accreditation is a process in which an entity, sepate and distinct from the health care organization, usually nongovernmental, assesses the health care organization to determine if it meets a set of requirements designed to improve quality of care. (JCI Acccreditation Standards for Hospital, 2002) The ideal modern hospital is a place both where ailing people seek and receive care and where clinical education is provided to medical students, nurses, and virtually the whole spectrum of health professionals. It provides continuing education for practicing physicians and increasingly serves the function of an institution of higher learning for entire neighborhoods, communities, and regions. In addition to its educational role, the modern hospital conducts investigation studies and research in medical sciences both from clinical records and from its patients, as well as basic research in science, physics, and chemistry. (Wolper, 2011) The Joint Commision is a private, not-for-profit organization dedicated to continuosly improving the safety and quality of care provided to the public. The Joint Commission is the nation’s principal standards setter and evaluator for a variety of health care organization, including hospitals, critical access hospitals, ambulantory care organization, behavioral health care organizations, home care organizations, labolatories, long term care organizations, and office- based surgery practices. (Accreditation Process Guide for Hospitals, 2012) Joint Commission International (JCI) is a division of the JACHO (Joint Commision on Accreditation of Healthcare Organization). Joint Commission International (JCI)’s mission is to improve the quality of health care in the international community by providing worldwide accreditation services. (JCI Acccreditation Standards for Hospital, 2002)
  • 3. Linta Meyla Putri, Improve Hospital Accreditation 3 KARS (Komisi Akreditasi Rumah Sakit) is a Commite Of Hospital Accreditation in Indonesia, this is an independent statue and the main job is measuring the hospital services to give accreditation. DISSCUSSION In general, many healthcare centers have such primary objectives as providing primary, secondary, or tertiary care2 to the sick and injured; providing healthcare at a reasonable cost doing research working toward advancement of medical knowledge; helping in the maintenance of health and in the prevention of sickness, recruiting outstanding graduates from medical schools, providing education, and training employees in all the professional and nonprofessional activities customarily associated with a healthcare institution. (Dunn, 2002) To face the dynamics of society in such a way, the government through the Ministry of Health didn’t stay quite. The Ministry of Health Republic of Indonesia requires the implementation of hospital accreditation in order to improve hospital services in Indonesia. The foundations for the hospital accreditation is UU No. 36 of 2009 on Health, UU no. 44 of 2009 on the hospital and the Permenkes No.12/2012 on the organization and functioning of the health ministry. Accreditation means a recognition given to the government hospital for compliance with established standards. Hospitals that have been accredited, received recognition from the government that all things in it are in accordance with the standards. Facilities and infrastructure owned hospital, has standards. Procedures performed to patients are also in accordance with the standard . Based Health Ministry Of Indonesia version accreditation standards , there are three stages in the implementation of the accreditation is a basic level of accreditation, accreditation advanced and complete level of accreditation. a) Basic level accreditation services assess the five activities in hospitals, namely: Administration and Management, Medical Services, Nursing Services, Emergency Services and Medical Records . b) Advanced accreditation services assess the 12 activities in hospitals, namely: basic level service plus accredited Pharmacy, Radiology, Operating Room, Infection Control, High Risk Services, Laboratory and Safety , Fire and Disaster Awareness (K-3). c) Accreditation level 16 fully assess service activities in hospitals, namely: service accredited advanced plus Intensive Care, Blood Transfusion Services, Medical Rehabilitation Services and Nutrition Services. Hospitals may choose to implement a basic level accreditation (5 services), advanced (12 services) or full rate (16
  • 4. Linta Meyla Putri, Improve Hospital Accreditation 4 services) depends on the ability, readiness and needs of both the hospital at the time of the first assessment or reassessment after accredited. Certification is awarded to hospitals in the form: not accredited, conditional accreditation, full accreditation and special accreditation. Not accredited means that the assessment is 65% or one service activity only reached 60%. Conditional accreditation means appraisal reach 65%-75% and valid for one year. Full accreditation means that the assessment is 75% and is valid for 3 years. Special accreditation given if in three consecutive years reaches hospital is fully accredited and it is valid for 5 years. The hospital shall implement the accreditation of at least 6 months after the license renewal decree exit and 1 year after decree operating permit. Purpose of an accreditation survey is for assesses an organization’s compliance with JCI standards and their intent statements. For decades, hospitals participated in a voluntary self-regulatory process. In the early 1950s, a program of hospital self- inspection, sponsored by the American College of Surgeons, began expanding into the present Joint Commission on Accreditation of Healthcare Organizations (JCAHO). Originally, the “Joint Commission” surveyed and accredited only hospitals. Today JCAHO accreditation includes critical access hospitals, pathology and clinical laboratory services, home health agencies, behavioral health care services, long-term care facilities, ambulatory care centers, health care networks and managed care. The Joint Commission conducts a voluntary survey program of hospitals. A hospital must request and pay for a survey. The survey evaluates the organization’s compliance based on a) Interviews with staff and patients and other verbal information b) On-site observations of patients care processed by the surveyors c) The results of self-assessements when part of the accreditation process. The on-site survey process, as well as continued self-assessment, help organizations identify and correct problems and improve the quality of care and services. Actually, as a hospital manager there are two point that should have to improve for Hospital Accreditation, such as Improve Patient-Centered Standards and Improve Health Care Management Standards. A. Strategi to Improve Patient-Centered Standards, there are many standards that must improved, such as : 1. International Patient Safety Goals (IPSG) The purpose of the IPSG is to promote specific improvements in patient safety. The goals highlights problematic areas in health care and describe evidence and expert-based concensus solutions to these problems.
  • 5. Linta Meyla Putri, Improve Hospital Accreditation 5 a) Identify Patients Correctly b) Improve Effective communication c) Improve the safety of high-alert medications d) Ensure correct-site, correct- procedure, correct patient surgery e) Reduce the risk of health care assosiated infection f) Reduce the risk of Patient Harm resulting from falls 2. Access to Care and Continuity of Care A health care organization should consider the care it provides as part of an integrated system of services, health care practitioners and professionals, and levels of care, which make up a continuum of care. The goal is to correctly match the patient’s health care needs with the services available, to coordinate the services provided to the patient in the organization, and then to plan for discharge and follow-up. The result is improved patient care outcomes and more efficient use of available resources. 3. Patient and Family Rights (PFR) Each patient is unique, with his or her own needs, strengths, values, and beliefs. Health care organizations work to establish trust and open communication with patients and to understand and protect each patient’s cultural, psychosocial, and spiritual values. Patient care outcomes are improved when patients and, as appropriate, their families or those who make decisions on their behalf are involved in care decisions and processes in a way that matches cultural expectations. These processes are related to how an organization provides health care in an equitable manner, given the structure of the health care delivery system and the health care financing mechanisms of the country. 4. Assessment of Patient (AOP) An effective patient-assessment process results in decisions about the patient’s immediate and continuing treatment needs for emergency, elective, or planned care, even when the patient’s condition changes. Patient assessment is an ongoing, dynamic process that takes place in many inpatient and outpatient settings and departments and clinics. Patient assessment consists of three primary processes: a) Collecting information and data on the patient’s physical, psychological, social status, and health history b) Analyzing the data and information, including the results of laboratory and imaging diagnostic tests, to identify the patient’s health care needs c) Developing a plan of care to meet the patient’s identified needs Patient assessment is appropriate when it considers the patient’s condition, age, health needs, and his or her requests or preferences. These processes are most effectively carried out when the various health professionals responsible for the patient work together. 5. Care of Patients (COP)
  • 6. Linta Meyla Putri, Improve Hospital Accreditation 6 A health care organization’s main purpose is patient care. Providing the most appropriate care in a setting that supports and responds to each patient’s unique needs requires a high level of planning and coordination. Certain activities are basic to patient care. For all disciplines that care for patients, these activities include a) planning and delivering care to each patient b) monitoring the patient to understand the results of the care c) modifying care when necessary; d) completing the care; and e) planning the follow-up. 6. Anasthesia and Surgical Care (ASC) The use of anesthesia, sedation, and surgical interventions are common and complex processes in a health care organization. They require complete and comprehensive patient assessment, integrated care planning, continued patient monitoring, and criteria-determined transfer for continuing care, rehabilitation, and eventual transfer and discharge. Anesthesia and sedation are commonly viewed as a continuum from minimal sedation to full anesthesia. As patient response may move along that continuum, anesthesia and sedation use are organized in an integrated manner. 7. Medication Management and Use Medication management is an important component in symptomatic, preventive, curative, and palliative treatment and management of diseases and conditions. Medication management encompasses the system and processes an organization uses to provide pharmacotherapies to its patients. This is usually a multidisciplinary, coordinated effort of staff of a health care organization, applying the principles of effective process design, implementation, and improvement to the selecting, procuring, storing, ordering/prescribing, transcribing, distributing, preparing, dispensing, administering, documenting, and monitoring of medication therapies. 8. Patient and Family Education Patient and family education helps patients better participate in their care and make informed care decisions. Many different staff in the organization educate patients and families. Education takes place when the patient interacts with his or her physicians or the nurses. Others provide education as they provide specific services, such as rehabilitation or nutrition therapy, or prepare the patient for discharge and continuing care. Because many staff help educate patients and families, it is important that staff members coordinate their activities and focus on what patients need to learn. B. Strategi to improve Health Care Organization Management Standards 1. Quality Improvement and Patient Safety Approach to quality improvement and patient safety. Integral to overall improvement in quality is the ongoing reduction in risks to patients and staff. Such risks may be found in clinical
  • 7. Linta Meyla Putri, Improve Hospital Accreditation 7 processes as well as in the physical environment. This approach includes a. leading and planning the quality improvement and patient safety program b. designing new clinical and managerial processes well c. measuring how well processes work through data collection d. analyzing the data e. implementing and sustaining changes that result in improvement. Quality and safety are rooted in the daily work of individual health care professionals and other staff. As physicians and nurses assess patient needs and provide care, this chapter can help them understand how to make real improvements that help patients and reduce risks. Similarly, managers, support staff, and others can apply the standards to their daily work to understand how processes can be more efficient, resources can be used more wisely, and physical risks can be reduced. This approach takes into account that most clinical care processes involve more than one department or unit and may involve many individual jobs. This approach also takes into account that most clinical and managerial quality issues are interrelated. Thus, efforts to improve those processes must be guided by an overall framework for quality management and improvement activities in the organization, overseen by a quality improvement and patient safety oversight group or committee. (Griffth & R, 2006) 2. Prevention and Control of Infectious Goal of an organization’s infection prevention and control program is to identify and to reduce the risks of acquiring and transmitting infections among patients, staff, health care professionals, contract workers, volunteers, students, and visitors. The infection risks and program activities may differ from organization to organization, depending on the organization’s clinical activities and services, patient populations served, geographic location, patient volume, and number of employees. 3. Governance, Leadership and Direction Providing excellent patient care requires effective leadership. That leadership comes from many sources in a health care organization, including governing leaders (governance), leaders, and others who hold positions of leadership, responsibility, and trust. Each organization must identify these individuals and involve them in ensuring that the organization is an effective, efficient resource for the community and its patients. Effective leadership begins with understanding the various responsibilities and authority of individuals in the organization and how these individuals work together. Those who govern, manage, and lead an organization have both authority and responsibility. Collectively and individually, they are
  • 8. Linta Meyla Putri, Improve Hospital Accreditation 8 responsible for complying with laws and regulations and for meeting the organization’s responsibility to the patient population served. 4. Facility Management and Safety Health care organizations work to provide safe, functional, and supportive facilities for patients, families, staff, and visitors. The construction of the modern hospital is regulated or influenced by federal laws, state health department regulations, city ordinances, the standards of the Joint Commission on Accreditation of Healthcare Organizations, and national and local codes (building, fire protection, sanitation, etc.). (Wolper, 2011) To reach this goal, the physical facility, medical and other equipment, and people must be effectively managed. In particular, management must strive to a. reduce and control hazards and risks b. prevent accidents and injuries c. maintain safe conditions. Written plans are developed and include the following six areas, when appropriate to the facility and activities of the organization: a) Safety and Security i. Safety The degree to which the organization’s buildings, grounds, and equipment do not pose a hazard or risk to patients, staff, or visitors. ii. Security Protection from loss, destruction, tampering, or unauthorized access or use. b) Hazardous materials Handling, storage, and use of radioactive and other materials are controlled, and hazardous waste is safely disposed. c) Emergency management Response to epidemics, disasters, and emergencies is planned and effective. d) Fire safety Property and occupants are protected from fire and smoke. e) Medical equipment Equipment is selected, maintained, and used in a manner to reduce risks. f) Utility systems Electrical, water, and other utility systems are maintained to minimize the risk of operating failures. 5. Staff Qualifications and Educations A health care organization needs an appropriate variety of skilled, qualified people to fulfill its mission and to meet patient needs. The organization’s leaders work together to identify the number and types of staff needed based on the recommendations from department and service directors. Recruiting, evaluating, and appointing staff are best accomplished through a coordinated, efficient, and uniform process. It is also essential to document applicant skills, knowledge, education, and previous work experience. It is particularly important to carefully review the credentials of medical and nursing staff, because they are involved in clinical care processes and work directly with patients. Health care organizations should provide staff with opportunities to learn and to advance personally and professionally. Thus, in service education and other
  • 9. Linta Meyla Putri, Improve Hospital Accreditation 9 learning opportunities should be offered to staff. 6. Management of Communication and Information Providing patient care is a complex endeavor that is highly dependent on the communication of information. This communication is to and with the community, patients and their families, and other health professionals. Failures in communication are one of the most common root causes of patient safety incidents. To provide, coordinate, and integrate services, health care organizations rely on information about the science of care, individual patients, care provided, results of care, and their own performance Many things have to be improved to increase the hospital accreditation, which is centered on patient care and improving the quality of health care management in order to achieve optimal patient recovery. To give satisfaction to the patient, then the standard of hospital services should be able to satisfy the patient. Therefore, it is necessary to establish some sort of independent commission hospital standards in hospital organizational structures. Whose task is to monitor the development of hospital services in order to meet standards. So this committee served as a supervisor for the hospital as well as an increase in the accreditation committee, and it must be continunous improvement. Continuous improvement may also be expressed when managers support continuous quality improvement projects that address specific problems or performance gaps. An improvement project involves assembling a team to solve a problem or improve performance in a designated area. The team is responsible for designing and implementing improvements to the underlying work process. Managers may demonstrate their support of project teams by effectively initiating the project, promoting buy-in, and taking specific management actions that will help the team succeed. (Kelly, 2003). Strategies should aim at fostering national accreditation initiatives and providing guidance for national accreditation efforts to ensure that accreditation systems are developed in a way that upholds the principles of health for all. The following strategies may be implemented by Member States in collaboration with WHO. The strategy that I’ll recommend are : a) Raising awareness at national level and encouraging debate by interested stakeholders to develop consensus on launching hospital accreditation. b) Strengthening hospital inspection units and improving administrative procedures in ministries of health in preparation for launching accreditation. c) Establishing national hospital registers with detailed profiles of individual hospitals.
  • 10. Linta Meyla Putri, Improve Hospital Accreditation 10 d) Studying efforts and experiences in hospital accreditation in the Region and exchanging experiences through a network of interested institutions and experts. e) Collaborating with regional and international bodies for advocacy of hospital accreditation. f) Participating in annual international forums, meetings of the International Society for Quality in Health Care to update knowledge on hospital accreditation and share experiences with others. g) Designating an expert advisory group on hospital accreditation in the Region to provide objective guidance to national authorities in addressing accreditation issues. h) Reviewing periodically and documenting progress in implementing hospital accreditation in the Region. Applying, after adaptation, the suggested steps for implementing hospital accreditation at national and local (hospital) levels. Improvement gradients are embedded into the health care accreditation process. First, the standards encourage organizations to achieve particular criteria. Second, accrediting bodies revise their standards over time so they are based on up-to-date research and accepted best practices. Both of these elements elicit continuous quality improvement efforts. The goal is to contribute to the provision of high-quality and safe health care services and to improve patients’ health outcomes (Braithwaite, 2010; Øvretveit, 2009). CONCLUSION Accreditation can be the single most important approach for improving the quality of health care structures. In an accreditation system, institutional resources are evaluated periodically to ensure quality of services on the basis of previously accepted standards. Standards may be minimal, defining the bottom level or base, or more detailed and demanding. Accreditation is not an end in itself, but rather a means to improve quality. The accreditation movement is gaining prominence due to globalization and especially the global expansion of trade in health services. It will eventually become a tool for international categorization and recognition of hospitals. When implemented appropriately, accreditation can strengthen the fundamental leadership and steering role of national health authorities. In general, many healthcare centers have such primary objectives as providing primary, secondary, or tertiary care to the sick and injured; providing healthcare at a reasonable cost; doing research; working toward advancement of medical knowledge; helping in the maintenance of health and in the prevention of sickness; recruiting outstanding graduates from medical schools; providing education; and training employees in all the professional and nonprofessional activities customarily
  • 11. Linta Meyla Putri, Improve Hospital Accreditation 11 associated with a healthcare institution. There are two things that need to be noticed to improve hospital accreditation, which is focused on patient care and hospital management service improvement. This must be followed with some strategy and there should be special committee to monitor the development of services in the hospital. We should improve Patient-Centered Standards International Patient Safety Goals (IPSG), Access to Care and Continuity of Care, Patient and Family Rights (PFR), Assessment of Patient (AOP), Care of Patients (COP), Anasthesia and Surgical Care (ASC), Medication Management and Use , Patient and Family Education . Health Care Organization Management Standards such as Quality Improvement and Patient Safety, Prevention and Control of Infectious , Governance, Leadership and Direction, Facility Management and Safety, Staff Qualifications and Educations, Management of Communication and Information
  • 12. Linta Meyla Putri, Improve Hospital Accreditation 12 REFERENCES 1. Blackmore, B. (2007). Hospital Accreditation . Alternatives To The Joint Commission. 2. Braithwaite, J., Greenfield, D., Westbrook, J., Pawsey, M., Westbrook, M., Gibberd, R., et al. (2010). Health service accreditation as a predictor of clinical and organizational performance: A blinded, random, stratified study. Quality and Safety in Health Care, 19, 14–21. 3. Dunn, R. (2002). Haimann's Healthcare Mangement. Chicago: Health Administration Press. 4. Griffth, J. R., & R, K. (2006). The Well- Managed Healthcare Organization. Chicago: Health Adminstration Press. 5. Hort, K., Djasri, H., & Utarini, A. (2013). Regulating the quality of health care: Lessons from hospital accreditation in Australia and Indonesia. Melbourne: Nossal Institute Of Global Health. 6. Joint Commission International. (2011). Accreditation Standards For Hospital. United States of America: Joint Commision International. 7. Kelly, D. L. (2003). Applying Quality Management in Healthcare. Chicago: Health Administration Press. 8. LAWRENCE, W. F. (2011). Health Care Administration : managing organized delivery systems. 5th ed. United States of America: Jones and Bartlett Publisher. 9. Permenkes RI No.12 Tahun 2012 tentang Akreditasi Rumah Sakit 10. Sante, H. A. (2010). Impact and results of health care quality improvement and patient safety programmes in hospitals. France 10.Shaw, C. D. (2003). Evaluating accreditation. International Journal for Quality in Health Care, 15, 455–456. 11.Ulmer, C., McFadden, B., & Nerenz, D. R. (2009). Standarization For Health Care Quality Improvement. Washington DC: The National Academic Press. 12. UU RI No.36 Tahun 2009 tentang Kesehatan 13.UU RI No.44 Tahun 2009 tentang Rumah Sakit 14.Walcque, C., Seuntjens, B., & Vermeyen, K. (2008). Comparative Study Of Hospital Accreditation Program in Europe. Belgium: Belgian Health Care Knowledge Centre. 15.WHO. (2003). Accreditation Of Hospital and Medical Education Institution. Regional Comitte For The Eastern Mediterranean.