REPEATED FINDINGS MANAGEMENT FROM ACCREDITATION TO RE-ACCREDIATION

Objectives

Türkiye Health Care Quality and Accreditation Institute (TÜSKA) executes survey, annual surveys and reaccreditation surveys within the scope of Hospital Accreditation Program. This study aims to analyses the repeated frequency of Assessment Criteria (AC) whose fulfillment levels are Partially Met (PM) and Not Met (NM) in surveys so that accreditation bodies can develop a strategy about AC with repeated findings in hospitals.

Methods

All survey reports of a public and a private hospital that had undergone re-accreditation survey were used in the study. The first survey and remote surveys of hospitals are based on the SAS Hospital – v1.1/2015 standard set, which has 7 aspects, 34 chapters, 59 standards and 242 assessment criteria, and re-accreditation surveys are based on SAS Hospital – v2.0/2017 standard set, which has 7 aspects, 33 chapters, 58 standards and 240 assessment criteria. Each AC in the survey reports was examined, and ACs which were decided as PM and NM were included in the study. It was checked how many times the ACs decided as PM and NM were repeated.

Results

All ACs of accreditation surveys carried out in public and private hospitals were reviewed, and ACs whose fulfillment level decision was PM or NM in at least two surveys were evaluated. When Table 1 is examined, it is seen that a total of 5 ACs, including 1 for Document Management, 2 for Risk Management, 1 for Information Management and 1 for Emergency Management are PM in survey and re-accreditation survey. It is determined that a total of 2 ACs, 1 for Worker Health and Safety and 1 for Information Management are PM in the survey and in the 2nd annual survey. It was ascertained that 1 AC related to Hospitality Services in the survey and in the 1st annual survey, are found to be PM. It is seen that the highest number of repeated ACs belongs to Risk Management and Information Management.

When Table 2 is examined, it is visible that there is no AC that is PM in the survey and re-accreditation survey. It is seen that a total of 6 ACs, including 1 for Document Management, 1 for Risk Management, 1 for Drug Management, 1 for Emergency Healthcare Services, 1 for Waste Management, and 1 for Material and Device Management, are determined to be PM in the survey and in the 1st annual survey. It is observed that 1 AC of the Material and Device Management is PM in the survey, in the 1st and 2nd annual surveys. Moreover, it is found that 1 AC for Risk Management is also PM in the survey and the 2nd annual survey while 1 AC for Laboratory Services is PM in the 2nd annual survey and re-accreditation survey. It is seen that the number of repeated AC is related to Risk Management at the highest level in private hospitals.

Conclusion

According to the results of the public and private hospital accreditation surveys, It has been determined that the most repeated Assessment Criteria, which has a common finding in both hospitals, belongs to the Risk Management chapter. Apart from the Risk Management Assessment Criteria, another chapter with common findings is Document Management. It would be appropriate for accreditation bodies to develop strategies for the repeated findings management in order to ensure continuous improvement, which is one of the main objectives of accreditation.