Dissertation presentation

Dissertation Presentation
Study of the Process
of Hospital
Accreditation
and Its Impact on
Healthcare Facilities
Presented By:
Yasser Alsharif, Muwafag Kamash
Nasrat Esmat, Amer Tayeb
Supervised By: Dr. Mohammad Kamal Hussain

Presentation Outline
• Background
• Introduction
• The aims of the work / Objectives
• Literature Review
• Research Methodology
– Research Design
– Population and Sampling
– Data Collection Procedure
– Research Instrument
• Data Analysis & Results
• Results
• Conclusion/ Recommendation/ Suggestions

Background
• Quality simply means satisfying the customer.
• Agency for health care research and quality defined
quality as “"the degree to which health care services
for individuals and populations increase the likelihood
of desired health outcomes and are consistent with
current professional knowledge."
• Hospital accreditation has been defined as “A self-
assessment and external peer assessment process
used by health care organizations to accurately assess
their level of performance in relation to established
standards and to implement ways to continuously
improve”.

Introduction
• Patient safety and patient-centered care are emerging as
important drivers in healthcare transformation. The
increased priority and attention needed by patients
regarding their health outcome as well as safety and quality
of care have led stakeholders, policy makers and healthcare
provider organizations to adopt standardized processes for
evaluating healthcare facilities. (1)
• Quality management is a method of achievement business
that continuously develops products and services to
succeed performance. According to the American Society
for Quality (2008), the goal of quality management in any
business is to achieve maximum customer satisfaction at
the lowest overall price to the organization while continuing
to achieve goals. (2)

Introduction Cont.…
• Accreditation is the most frequently external quality
assessment that will give the clear picture of
healthcare organizations’ and also give standards to
follow and manage the same in health care facilities.(3)
• This study aims to find the process of hospital
accreditation followed by the accredited hospital
(national/ international accreditation) based in
Makkah region and its impact on healthcare facilities
after accreditation.

The aims of the work / Objectives
• Dissertation Objectives:
– The objective of this study is to assess the
perceived impact of accreditation on quality
of care in hospitals, through the lens of
quality care professionals.
– This study also investigate the perceived
contributing factors that can explain changes
in quality of care.

The aim of the work / Objectives Cont.…
• Specific Objectives:
– To get an idea of the quality management understanding
among the employee of healthcare facilities.
– To assess the process followed by healthcare institution for
quality accreditation.
– To assess the importance and impact of accreditations in
healthcare.
– To assess the awareness of quality accreditation (national/
international) standards among the staffs.
– Knowing the benefits of accreditation to reach the optimal
level.
– To observe how the accreditation process, affect
healthcare facilities.

Literature Review
• Many literature have been reviewed during the
entire dissertation period to get the rationale and
understanding about the topic.
• Effort have been invested to select the relevant
literature for study purpose.
• Selected literature have been added to the
dissertation report.

Research Methodology
• Research Design:
– This cross-sectional descriptive study has
conducted at King Abdullah Medical City
Hospital (KAMC) in Nasim, Mecca, Kingdom of
Saudi Arabia to determine population
perception about the impact of accreditation
on healthcare facility.

Research Methodology Cont.…
• Population and Sampling:
– This study performed at participants of international/ national
accredited hospital based in Makkah.
– The study population considered all quality and management
both Saudi and non-Saudi staffs, who started working in the
hospital before accreditation and continued to work during and
after accreditation at the King Abdullah Hospital in Mecca
Region,
– The sampling frame includes all quality in various departments
and units of the hospital.
– After defining the population, and establishing the sampling
frame; simple random sampling has conducted out of 62 staff in
King Abdullah Hospital a sample size of 62 staffs had received
the self-administered questionnaire and randomly selected and
asked to participate in this research.

• Consent: The distributed questionnaire for data
collection have a column as consent and filled
questionnaire considered for the same.

• Data Collection Procedure:
– After taking official permission letters from authorized
organizations to conducting the study in King Abdullah
Hospital.
– We collaborated with a quality office in the King Abdullah
Hospital to distribute the questionnaire.
– 62 self-administered questionnaires disturbed on 25th of
March 2017 and received 40 questionnaires on 2nd April
2017 with a response rate of 64.5 percent.
– We excluded 22 questionnaires due to incompleteness in
response received from the hospital have the mean equal
to 35.5 percent.
– The Respondents' Rights and Research Ethics had been
respected and considered during all study phases.

Research Instrument
• The research instrument was a self-administered questionnaire
designed in a manner to determine population perception on the
impact of accreditation on healthcare facility related to the highly
positive impact of accreditation on healthcare environment,
processes, outcome, and patient ‘satisfaction.
• Questionnaire used in this study consisted of two parts;
– the first part covered demographic data of participated staff;
– the second part composed of three dimensions about impact of
hospital accreditation on healthcare facility include highly
positive impact of accreditation on healthcare environment,
processes, outcome, and patient ‘satisfaction, each dimension
consist of four items, that will draw from literature review; and
• Four points (4= strongly agree, 3= Agree, 2=Fair, 1=Disagree) rating
Likert scale will be used for measure quality's perception toward the
impact of hospital accreditation on healthcare facility.

Research Instrument
• The research instrument was a self-administered questionnaire designed in
a manner to determine population perception on the impact of
accreditation on healthcare facility related to the highly positive impact of
accreditation on healthcare environment, processes, outcome, and patient
‘satisfaction.
• Questionnaire used in this study consisted of three parts;
– the first part covered demographic data of participated quality staff;
– the second part composed of three dimensions about impact of
hospital accreditation on healthcare facility include highly positive
impact of accreditation on healthcare environment, processes,
outcome, and patient ‘satisfaction, each dimension consist of four
items, that will draw from literature review; and
– the third part included open question to give respondents the chance
to describe any other issues related to the study.
• Four points (4= strongly agree, 3= Agree, 2=Fair, 1=Disagree) rating Likert
scale will be used for measure quality's perception toward the impact of
hospital accreditation on healthcare facility.

Results
• This study explored the process of quality accreditation
and impact of the quality management after
accreditation.
• After reviewing all the questions responds, it is found
that there is consistent evidence that shows that
accreditation programs improve the process of care
provided by healthcare services.
• There is considerable evidence to show that
accreditation programs improve clinical outcomes of a
wide spectrum of clinical conditions.
• And above all, Accreditation programs should be
supported as a tool to improve the quality of healthcare
services.

Conclusion/ Recommendation/ Suggestions
• The outcomes of this study come with supports and
importance on literature review associated to
positive impact of accreditation programs on
healthcare environment processes, outcome and
patient satisfaction.
• According to respondents, this study shows highly
positive level of the impact of accreditation on
healthcare facility related to highly positive impact
of accreditation on healthcare environment,
processes, outcome, and patient ‘satisfaction.

Conclusion/ Recommendation/ Suggestions
Cont.…
• In lights of the study results, we emphasized the
implementation of local or national accreditation
programs for healthcare facilities with many types or
specialties groups.
• In order to improve quality and ensure the safety of
healthcare services, we encourage both public and
private health sectors to be accredited either
voluntary or mandatory based on government
regulations, establish specialized department to
monitor and facilitate accreditation‘s processes in
each regions of Saudi Arabia.

References
1. Brubakk K, Vist GE, Bukholm G, Barach P, Tjomsland O. A systematic review of hospital accreditation: the challenges of
measuring complex intervention effects. BMC Health Serv Res. 2015;15:280. Epub 2015/07/24.
2. Spath P. Introduction to healthcare quality management. Health Administration Press; 2009.
3. Viswanathan HN, Salmon JW. Accrediting organizations and quality improvement. Am J Manage Care. 2000;6(10):1117–
30.
4. Dean, J.W. and Bowen, D.E. 1994. Management theory and total quality: improving research and practice through theory
development. Academy of Management Review, Vol. 19, No. 3, pp. 392-418.
5. ASQ, (2013). The ASQ Global State of Quality.American Society for Quality, with the collaboration of the APQC –American
Productivity & Quality Center.
6. Mousa Al Shammari1, Sami Al Habib,Dakilala Al Shubrami et al. Impact of Hospital‘Accreditation on Patient Safety in Hail
City, Saudi Arabia: Nurses‘Perspective, IOSR Journal of Nursing and Health Science, Volume 4, Issue 1 Ver. I (Jan.-Feb.
2015), PP 51-55.
7. CBAHI. (2005). Introduction to The Saudi Central Board for Accreditation of Healthcare Institutions. Riyadh, Saudi Arabia:
CBAHI.
8. Almasabi, M. H. (2013). An Overview of Quality and Accreditation in the Health Sector within Saudi Arabia. International
Journal of Health Research and Innovation, 1 (3), 1-5.
9. Al-Awa, B., Al Mazrooa, A., Rayes, O., El Hati, T., Devreux, I., & Al-Noury, K. (2011). Comparison of Patient Safety and
Quality of Care Indicators Between Pre-and Post-Accreditation Periods in King Abdulaziz University Hospital. Ann Saudi
Med, 32 (2), 143-150.
10. ELJARDALI l, F. (2008). The impact of hospital accreditation on quality of care: perception. International Journal for Quality
in Health Care , 20 (5), 363-371
11. Lorch, S., Maheshwari, P., & Shoshan, E. (2012). The impact of certificate of need programs on neonatal intensive care
units. Journal of Perinatology, 32 (0743-8346/12), 39-44. 5.
12. El-Jardali, F. (2014). The impact of accreditation of primary healthcare centers: successes, challenges and policy
implications as perceived by healthcare providers anddirectors in Lebanon. BMC Health Services Research, 14 (86),
doi:10.1186/1472-6963-14- 86.
13. Alkhenizan, A. (2011). Impact of Accreditation on the Quality of Healthcare Services: a Systematic Review of the literature.
Ann Saudi Med, 31 (4), 407-416

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