How to Improve Hospital Accreditation - Linta Meyla Putri

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

Linta Meyla Putri, Improve Hospital Accreditation

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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)


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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


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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.


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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)


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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


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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


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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


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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.


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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


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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


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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

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9. Permenkes RI No.12 Tahun 2012

tentang Akreditasi Rumah Sakit

10. Sante, H. A. (2010). Impact and results

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10.Shaw, C. D. (2003). Evaluating

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11.Ulmer, C., McFadden, B., & Nerenz, D.

R. (2009). Standarization For Health

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Kesehatan

13.UU RI No.44 Tahun 2009 tentang

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14.Walcque, C., Seuntjens, B., &

Vermeyen, K. (2008). Comparative

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