Accreditation survey of Al-Kindy Teaching Hospital basic minimum standards for Iraqi Medical Teaching Hospitals

Introduction Accreditation survey of Al-Kindy Teaching Hospital during the months of February–May 2011 was performed as part of its technical assistance services to the management of the hospital. The hospital had formed an accreditation committee in October 2010 and began the process of self-assessment and implementation of the 2010 Iraqi National Accreditation Standards for Hospitals. As the hospital neared the completion of its efforts in early 2011, we did accomplish a survey of the hospital and provided feedback on ways to improve the accreditation process in preparation for an Iraqi Ministry of Health survey. Although we did indicate that it would take at least 18 months for a top-performing hospital to make significant progress toward accreditation, it agreed to perform the survey in an effort to provide assistance to the hospital. Methods The brief survey included interviews with hospital and department directors and a review of documents provided by the hospital as requested by Iraqi National Accreditation Committee (INAC). The interview process was conducted over a two-month period to minimize the security risk to all parties. The required documents were copied by the hospital and presented to the surveyor for review. Also, much time was spent educating nurse and the secretary to the accreditation committee, on the accreditation standards and the survey process. The aim was to provide training to assist the directors in understanding the standards and meeting them, including the writing of policies and procedures. The staff also trained on the accreditation survey process, including survey/sampling techniques and documentation requirements. The brief survey was a cursory look at the accreditation of the hospital. A comprehensive accreditation survey was not done. Some standards were not surveyed, document reviews and reviews of patient medical records were minimal and there were basically no site visits because of security issues. However, the brief survey should provide a good indication of the hospital’s accreditation-readiness and offer recommendations on further action that needs to be taken. Results The medical and health staff of Al-Kindy has done a lot of work to meet the accreditation standards, which were completely new to them and the health professionals in Iraq. Many of the changes have improved patient safety and the quality of patient care. There is still much work that needs to be done in order to meet the standards, even at a basic level. Although there were some bright spots, I will focus on the overall findings and recommendations for improvement. There were no written policies to explicitly meet each standard. The study indicated that there was not a policy to support each standard and this was not provided, even for the ones that explicitly require a written policy. The few “policies” that could be used to meet a standard did not include a date, revision date or an approval signature. Discussion There were very few written procedures and none that were written specifically for Al-Kindy. Most of them were part of an overall department operating manual and not easily surveyed. Often, they met some of the elements of the standard but did not meet each element of the standard in question. Again, there was no date, revision date or an approval signature on any of them. Procedures were not done consistently or in a standardized manner. This was especially evident during a review of patient medical records. Indications to be included on the H&P form was often left blank, operative notes were not complete and notes seemed to be sporadic. The directors did not fully understand the standards and how they were to be put into practice. They seemed to understand the standards and how they impact the delivery of care, but the review of applicable policies and procedures indicated that there was not such a good understanding of them. Oftentimes, policies were presented that were somewhat related to the standards under review but really didn’t meet the intent or letter of the standards. In addition to the above, overall documentation was poor. Orders were not timed and dated and many things, like discharge instructions, staff training and competency exams were not documented at all. Recommendations The hospital should appoint an accreditation committee to oversee the accreditation process of the hospital. It should meet at least monthly and include the Hospital Director, accreditation coordinator and members of upper management, at a minimum. It should develop a timeline for accreditation, monitor progress, establish priorities, encourage departments to complete assignments and make recommendations to improve the accreditation process. Specific tasks include: • Develop guidelines for preparing written policies that include the format to be used, content, revision requirements and approvals necessary. • Make sure directors are adequately trained on the policy guidelines and that they know how to write them. • Develop guidelines for writing procedures to meet the standards and include format to be used, content, revision requirements, approvals, training and documentation/record-keeping requirements. • Provide extensive training to the directors on how to write procedures per the guidelines. The hospital should appoint a person to be responsible for accreditation of the hospital. This person should receive extensive training in the accreditation process, interpretation of standards and the survey process, including documentation requirements, survey methods and sampling/objectivity techniques. This person should be part of the accreditation committee and report his/her activities and findings periodically. This person should also provide education and assistance to the directors in their accreditation process. Specific responsibilities include: • Participate in and report to the accreditation committee. • Assist directors in accreditation process. • Survey departments per standards and submit findings and recommendations to the committee, at a minimum. • Review a small sample of patient medical records each quarter Hospital and department directors should be trained on interpreting and implementing the standards, writing policies and procedures and documentation requirements. Their performance in this project should be included in an annual review of their work performance. Any poor performers should be reported to the DG or MoH. Their specific responsibilities should include the following: • Write policies for standards applicable to their areas and have them approved by the proper authority. Each policy must meet the standard, at a minimum, and be in conformance with hospital policy. • Write procedures for the standards that require a procedure, whether explicitly or implicitly. They should meet the standard, at a minimum, and be a written record of the actual procedure being used. Documentation or record-keeping requirements should be part of the procedure. • Educate staff on policies and train them on procedures, including documentation. Training should be documented and retained. • Oversee compliance to make sure procedures are being followed. • Report any significant problems to the accreditation committee or supervisor. Conclusion Implement a routine patient medical record review process to be done monthly. Guidelines should be established for review items and sampling techniques. Summary and specific physician results are to be reported to the hospital director. The review should include the following: • Sampling techniques that are representative of the whole but also include every physician and service. • Include all items required under the accreditation standards in the minimum. • Summary reports should include historical, comparative data to measure improvement.