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

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

3  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

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

5 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

6  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

7 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

8 TABLE (1-2) GROUP "A" Governmental hospitals (MOH, National Guard, KFSH and Security Forces) No.INDICATORS ACCREDITATION BEFOREAFTER 1.PATIENT SATISFACTION RATE 60%70% 2.STAFF SATISFACTION RATE 68%71% 3.WAITING TIME (ER) 4.5 HRS2.19 HRS 4.MEDICAL RECORDS DOCUMENTATION COMPLETENESS PERCENTAGE 40%63% 5.NO. OF EDUCATIONAL SESSIONS PER YEAR COMPLIANCE WITH POLICY & PROCEDURE RATE 35%55% 7.FINANCIAL REVENUE --

9 GROUP “B" Private Hospitals No.INDICATORS ACCREDITATION BEFOREAFTER 1.PATIENT SATISFACTION RATE 70%80% 2.STAFF SATISFACTION RATE 71%65% 3.WAITING TIME (ER) 1.34 HRS40 minute 4.MEDICAL RECORDS DOCUMENTATION COMPLETENESS PERCENTAGE 55%70% 5.NO. OF EDUCATIONAL SESSIONS PER YEAR COMPLIANCE WITH POLICIES & PROCEDURES RATE 25%47% 7.FINANCIAL REVENUE 2% 5%

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

13 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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15 Conclusion  Accreditation is more effective in private than government hospital  All accreditation organizations have clear strategic directions  Accreditation system has created patient and safety language ( new language )  Documentation system is improved.  Accredited hospitals are more profitable.  Monitoring process in place