• Logo
  • SBMUJournals

An Audit of Emergency Department Accreditation Based on Joint Commission International Standards (JCI)

Behrooz Hashemi, Maryam Motamedi, Mania Etemad, Farhad Rahmati, Mohammad Mehdi Forouzanfar, Fatemeh Kaghazchi
596

Views


Abstract

Introduction: Despite thousands of years from creation of medical knowledge, it not much passes from founding the health care systems. Accreditation is an effective mechanism for performance evaluation, quality enhancement, and the safety of health care systems. This study was conducted to assess the results of emergency department (ED) accreditation in Shohadaye Tajrish Hospital, Tehran, Iran, 2013 in terms of domesticated standards of joint commission international (JCI) standards. Methods: This is a cohort study with a four months follow up which was conducted in the ED of Shohadaye Tajrish hospital in December 2013. The standard evaluation check list of Iran hospitals (based on JCI standards) included 24 heading and 337 subheading was used for this purpose. The effective possible causes of weak spots were found and their solutions considered. After correction, assessment of accreditation were repeated again. Finally, the achieved results of two periods were analyzed using SPSS version 20. Results: Quality improvement, admission in department and patient assessment, competency and capability test for staffs, collection and analysis of data, training of patients, and facilities had the score of below 50%. The mean of total score for accreditation in ED in the first period was 60.4±30.15 percent and in the second period 68.9±22.9 (p=0.005). Strategic plans, head of department, head nurse, resident physician, responsible nurse for the shift, and personnel file achieved the score of 100%. Of total headings below 50% in the first period just in two cases, collection and analysis of data with growth of 40% as well as competency and capability test for staffs with growth of 17%, were reached to more than 50%. Conclusion: Based on findings of the present study, the ED of Shohadaye Tajrish hospital reached the score of below 50% in six heading of quality improvement, admission in department and patient assessment, competency and capability test for staffs, collection and analysis of data, training of patients, and facilities. While, the given score in strategic plans, head of department, head nurse, resident physician, responsible nurse for the shifts, and personnel file was 100%.


Keywords

Emergency service, hospital; accreditation; quality Improvement; quality assurance, health care

References

Benor DE. Faculty development, teacher training and teacher accreditation in medical education: twenty years from now. Medical Teacher. 2000;22(5):503-12.

Commission J. Hospital accreditation standards: Joint Commission Resources; 2010. p. 17.

Tabibi S, Maleki M, Movahednia S, Gohari M. Relationship between Hospitals Ownership and Performance Assessment Score of Emergency Departments in the Hospitals Affiliated to Iran University of Medical Sciences 2007. Journal of Health Administration. 2009;12(36):25-32.

Jaafaripooyan E, Agrizzi D, Akbari-Haghighi F. Healthcare accreditation systems: further perspectives on performance measures. Int J Qual Health Care. 2011;23(6):645-56.

Shaw C, Groene O, Mora N, Sunol R. Accreditation and ISO certification: do they explain differences in quality management in European hospitals? Int J Qual Health Care. 2010;22(6):445-51.

Crawford L. Senior management perceptions of project management competence. International journal of project management. 2005;23(1):7-16.

Karmi M, Amin A, vand MV, Tahmasebi A, Mosavi S, Amini M, editors. Audit and improve compliance with accreditation standards in Ibn Sina National Hospital , Tehran clinical units. first Congress in clinical audit and quality improvement; 2012: Tabriz university of medical sciences.

mohammad karim Bahadori hr, shahram tofighi,ramin ravangard. Accreditation of hospitals covered by performance indicators in Lorestan University of Medical Sciences Hospital. 2008;7(1):11-5.

El-Jardali F, Jamal D, Dimassi H, Ammar W, Tchaghchaghian V. The impact of hospital accreditation on quality of care: perception of Lebanese nurses. Int J Qual Health Care. 2008;20(5):363-71.




DOI: https://doi.org/10.22037/emergency.v2i3.6521

Refbacks

  • There are currently no refbacks.