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

Introductionaccreditation survey of al-kindy teachinghospital during the months of february–may2011 was performed as part of its technical assistanceservices to the management of the hospital. thehospital had formed an accreditation committee inoctober 2010 and began the process of self-assessmentand implementation of the 2010 iraqi nationalaccreditation standards for hospitals. as the hospitalneared the completion of its efforts in early 2011, wedid accomplish a survey of the hospital and providedfeedback on ways to improve the accreditation processin preparation for an iraqi ministry of health survey.although we did indicate that it would take at least18 months for a top-performing hospital to makesignificant progress toward accreditation, it agreed toperform the survey in an effort to provide assistanceto the hospital.methodsthe brief survey included interviews with hospitaland department directors and a review of documentsprovided by the hospital as requested by iraqi nationalaccreditation committee (inac). the interviewprocess was conducted over a two-month period tominimize the security risk to all parties. the requireddocuments were copied by the hospital and presentedto the surveyor for review. also, much time was spenteducating nurse and the secretary to the accreditationcommittee, on the accreditation standards and thesurvey process. the aim was to provide training toassist the directors in understanding the standards andmeeting them, including the writing of policies andprocedures. the staff also trained on the accreditationsurvey process, including survey/sampling techniquesand documentation requirements. the brief surveywas a cursory look at the accreditation of the hospital.a comprehensive accreditation survey was notdone. some standards were not surveyed, documentreviews and reviews of patient medical recordswere minimal and there were basically no site visitsbecause of security issues. however, the brief surveyshould provide a good indication of the hospital’saccreditation-readiness and offer recommendationson further action that needs to be taken.resultsthe medical and health staff of al-kindy has donea lot of work to meet the accreditation standards,which were completely new to them and the healthprofessionals in iraq. many of the changes haveimproved patient safety and the quality of patientcare. there is still much work that needs to be donein order to meet the standards, even at a basic level.although there were some bright spots, i will focuson the overall findings and recommendations for improvement.there were no written policies to explicitly meeteach standard. the study indicated that there was nota policy to support each standard and this was notprovided, even for the ones that explicitly require awritten policy. the few “policies” that could be usedto meet a standard did not include a date, revisiondate or an approval signature.discussionthere were very few written procedures and nonethat were written specifically for al-kindy. most ofthem were part of an overall department operatingmanual and not easily surveyed. often, they met someof the elements of the standard but did not meet eachelement of the standard in question. again, there wasno date, revision date or an approval signature on anyof them.procedures were not done consistently or in astandardized manner. this was especially evidentduring a review of patient medical records. indicationsto be included on the h&p form was often left blank,operative notes were not complete and notes seemedto be sporadic.the directors did not fully understand the standardsand how they were to be put into practice. they seemedto understand the standards and how they impact thedelivery of care, but the review of applicable policiesand procedures indicated that there was not such agood understanding of them. oftentimes, policieswere presented that were somewhat related to thestandards under review but really didn’t meet theintent or letter of the standards.in addition to the above, overall documentation waspoor. orders were not timed and dated and manythings, like discharge instructions, staff training andcompetency exams were not documented at all.recommendationsthe hospital should appoint an accreditationcommittee to oversee the accreditation process of thehospital. it should meet at least monthly and includethe hospital director, accreditation coordinator andmembers of upper management, at a minimum. itshould develop a timeline for accreditation, monitorprogress, establish priorities, encourage departmentsto complete assignments and make recommendationsto improve the accreditation process. specific tasksinclude:• develop guidelines for preparing written policiesthat include the format to be used, content,revision requirements and approvals necessary.• make sure directors are adequately trained on thepolicy guidelines and that they know how to writethem.• develop guidelines for writing procedures tomeet the standards and include format to beused, content, revision requirements, approvals,training and documentation/record-keepingrequirements.• provide extensive training to the directors on howto write procedures per the guidelines.the hospital should appoint a person to be responsiblefor accreditation of the hospital. this person shouldreceive extensive training in the accreditation process,interpretation of standards and the survey process,including documentation requirements, surveymethods and sampling/objectivity techniques. thisperson should be part of the accreditation committeeand report his/her activities and findings periodically.this person should also provide education andassistance to the directors in their accreditationprocess. specific responsibilities include:• participate in and report to the accreditationcommittee.• assist directors in accreditation process.• survey departments per standards and submitfindings and recommendations to the committee,at a minimum.• review a small sample of patient medical recordseach quarterhospital and department directors should betrained on interpreting and implementing thestandards, writing policies and procedures anddocumentation requirements. their performance inthis project should be included in an annual reviewof their work performance. any poor performersshould be reported to the dg or moh. their specificresponsibilities should include the following:• write policies for standards applicable to theirareas and have them approved by the properauthority. each policy must meet the standard, ata minimum, and be in conformance with hospitalpolicy.• write procedures for the standards that require aprocedure, whether explicitly or implicitly. theyshould meet the standard, at a minimum, and be awritten record of the actual procedure being used.documentation or record-keeping requirementsshould be part of the procedure.• educate staff on policies and train them onprocedures, including documentation. trainingshould be documented and retained.• oversee compliance to make sure procedures arebeing followed.• report any significant problems to the accreditationcommittee or supervisor.conclusionimplement a routine patient medical record reviewprocess to be done monthly. guidelines should beestablished for review items and sampling techniques.summary and specific physician results are to bereported to the hospital director. the review shouldinclude the following:• sampling techniques that are representative ofthe whole but also include every physician andservice.• include all items required under the accreditationstandards in the minimum.• summary reports should include historical,comparative data to measure improvement.