Alkhenizan Abdullah, Shaw Charles
Department of Family Medicine and Polyclinics, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia.
Ann Saudi Med. 2010 Sep-Oct;30(5):386-9. doi: 10.4103/0256-4947.67082.
Accreditation is usually a voluntary program, in which trained external peer reviewers evaluate health care organization's compliance with pre-established performance standards. Interest in accreditation is growing in developing countries, but there is little published information on the challenges faced by new programs. In Saudi Arabia, the Central Board for Accreditation of Healthcare Institutions (CBAHI) was established to formulate and implement quality standards in all health sectors across the country. The objective of this study was to assess a developing accreditation program (CBAHI standards) against the International Society for Quality in Health Care (ISQua) principles to identify opportunities for improvement of the CBAHI standards.
A qualitative appraisal and assessment of CBAHI standards was conducted using the published ISQua principles for accreditation standards.
The CBAHI standards did not describe the process of development, evaluation or revision of the standards. Several standards are repetitive and ambiguous. CBAHI standards lack measurable elements for each standard. CBAHI standards met only one criterion (11.1%) of the Quality Improvement principle, two criteria (22.2%) of Patient/Service User Focus principle, four criteria (40%) of the Organizational Planning and Performance principle, the majority (70%) of the criteria for the safety principle, only one criteria (7.1%) for the Standards Development principle, and two criteria (50%) of the Standards Measurement principle.
CBAHI standards need significant modifications to meet ISQua principles. New and developing accreditation programs should be encouraged to publish and share their experience in order to promote learning and improvement of local accreditation programs worldwide.
认证通常是一个自愿参与的项目,由经过培训的外部同行评审员评估医疗保健机构对预先制定的绩效标准的遵守情况。发展中国家对认证的兴趣日益浓厚,但关于新认证项目所面临挑战的公开信息却很少。在沙特阿拉伯,成立了医疗保健机构认证中央委员会(CBAHI),以制定和实施全国所有卫生部门的质量标准。本研究的目的是根据国际医疗保健质量协会(ISQua)的原则评估一个正在发展的认证项目(CBAHI标准),以确定改进CBAHI标准的机会。
使用ISQua发布的认证标准原则对CBAHI标准进行定性评估。
CBAHI标准未描述标准的制定、评估或修订过程。几个标准重复且含糊不清。CBAHI标准缺乏每个标准的可衡量要素。CBAHI标准仅符合质量改进原则的一项标准(11.1%)、患者/服务用户关注原则的两项标准(22.2%)、组织规划与绩效原则的四项标准(40%)、安全原则的大多数标准(70%)、标准制定原则的一项标准(7.1%)以及标准衡量原则的两项标准(50%)。
CBAHI标准需要进行重大修改以符合ISQua原则。应鼓励新的和正在发展的认证项目发布并分享其经验,以促进全球范围内地方认证项目的学习与改进。