International healthcare accreditation : an analysis of clinical quality and patient experience in the UAE

A mixed method research design was used to answer the question; ‘does accreditation have an impact on hospital quality, clinical measures and patient experience?’ The thesis contains three study components: 1) A case study determining the predictors of patient experience; 2) a cross-sectional study examining the relationship of hospital accreditation and patient experience and 3) A four year time series analysis of the impact of accreditation on hospital quality using 27 quality measures. A case study analysis of patient experience, using a piloted, validated and reliable survey tool, was conducted in Al Noor Hospital. The survey was administered via face-to-face interviews to 391 patients. Patient demographic variables, stay characteristics and patient experience constructs were tested against five patient experience outcome measures using regression analysis. The predictors of positive patient experience were the patient demographics (age, nationality, and health status), hospital stay characteristics (length of stay and hospital treatment outcome) and patient experience constructs (care from nurses, care from doctors, cleanliness, pain management and quality of food). Recommendations were made on how hospital managers can improve patient experience using these modifiable factors. The cross-sectional study found that accredited hospitals had significantly higher inpatient experience scores than non-accredited hospitals. The hospital level variables, other than patient volume, had no correlations with patient experience. The interrupted time series analysis demonstrated that although accreditation improved the quality performance of the hospital with a residual benefit of 20 percentage points above the baseline level, this improvement was not sustained over the 3-year accreditation cycle. The accreditation life cycle theory was developed as an explanatory framework for the pattern of performance during the accreditation cycle. This theory was consequently supported by empirical evidence. Recommendations were made for improvement of the accreditation process. The Life Cycle Model and time series analysis were proposed as strategic tools for healthcare managers to recognise and prevent the negative trends of the accreditation life cycle in order to sustain improvements gained from accreditation. The findings of the three research components were triangulated to form a theory on the impact of accreditation on clinical quality measures and patient experience. This thesis is important from a research perspective, as healthcare accreditation, although commonly used to improve quality, is still under researched and under theorised. This is the first investigation of accreditation to use interrupted time series analysis, the first analysis on patient experience and hospital accreditation and also the first study on patient experience in the Middle East. Thus it adds to the evidence base of accreditation and patient experience but also has policy and management implications

The impact of hospital accreditation on quality measures:An interrupted time series analysis

BACKGROUND: Developing countries frequently use hospital accreditation to guarantee quality and patient safety. However, implementation of accreditation standards is demanding on organisations. Furthermore, the empirical literature on the benefits of accreditation is sparse and this is the first empirical interrupted time series analysis designed to examine the impact of healthcare accreditation on hospital quality measures. METHODS: The study was conducted in a 150-bed multispecialty hospital in Abu Dhabi, United Arab Emirates. The quality performance outcomes were observed over a 48 month period. The quality performance differences were compared across monthly intervals between two time segments, 1 year pre- accreditation (2009) and 3 years post-accreditation (2010, 2011 and 2012) for the twenty-seven quality measures. The principal data source was a random sample of 12,000 patient records drawn from a population of 50,000 during the study period (January 2009 to December 2012). Each month (during the study period), a simple random sample of 24 percent of patient records was selected and audited, resulting in 324,000 observations. The measures (structure, process and outcome) are related to important dimensions of quality and patient safety. RESULTS: The study findings showed that preparation for the accreditation survey results in significant improvement as 74% of the measures had a significant positive pre-accreditation slope. Accreditation had a larger significant negative effect (48% of measures) than a positive effect (4%) on the post accreditation slope of performance. Similarly, accreditation had a larger significant negative change in level (26%) than a positive change in level (7%) after the accreditation survey. Moreover, accreditation had no significant impact on 11 out of the 27 measures. However, there is residual benefit from accreditation three years later with performance maintained at approximately 90%, which is 20 percentage points higher than the baseline level in 2009. CONCLUSIONS: Although there is a transient drop in performance immediately after the survey, this study shows that the improvement achieved from accreditation is maintained during the three year accreditation cycle

The impact of a fast track area on quality and effectiveness outcomes: A Middle Eastern emergency department perspective

<p>Abstract</p> <p>Background</p> <p>Emergency department (ED) overcrowding is a ubiquitous problem with serious public health implications. The fast track area is a novel method which aims to reduce waiting time, patient dissatisfaction and morbidity. |The study objective was to determine the impact of a fast track area (FTA) on both effectiveness measures (i.e. waiting times [WT] and length of stay [LOS]) and quality measures (i.e. LWBS rates and mortality rates) in non-urgent patients. The secondary objective was to assess if a FTA negatively impacted on urgent patients entering the ED.</p> <p>Methods</p> <p>The study took place in a 500 bed, urban, tertiary care hospital in Abu Dhabi, United Arab Emirates. This was a quasi-experimental, which examined the impact of a FTA on a pre-intervention control group (January 2005) (n = 4,779) versus a post-intervention study group (January 2006) (n = 5,706).</p> <p>Results</p> <p>Mean WTs of Canadian Triage Acuity Scale (CTAS) 4 patients decreased by 22 min (95% CI 21 min to 24 min, <it>P </it>< 0.001). Similarly, mean WTs of CTAS 5 patients decreased by 28 min (95% CI 19 min to 37 min, <it>P </it>< 0.001) post FTA. The mean WTs of urgent patients (CTAS 2/3) were also significantly reduced after the FTA was opened (<it>P </it>< 0.001). The LWBS rate was reduced from 4.7% to 0.7% (95% CI 3.37 to 4.64; <it>P </it>< 0.001). Opening a FTA had no significant impact on mortality rates (<it>P </it>= 0.88).</p> <p>Conclusion</p> <p>The FTA improved ED effectiveness (WTs and LOS) and quality measures (LWBS rates) whereas mortality rate remained unchanged.</p

The impact of hospital accreditation on clinical documentation compliance:a life cycle explanation using interrupted time series analysis

OBJECTIVE: To evaluate whether accredited hospitals maintain quality and patient safety standards over the accreditation cycle by testing a life cycle explanation of accreditation on quality measures. Four distinct phases of the accreditation life cycle were defined based on the Joint Commission International process. Predictions concerning the time series trend of compliance during each phase were specified and tested. DESIGN: Interrupted time series (ITS) regression analysis of 23 quality and accreditation compliance measures. SETTING: A 150-bed multispecialty hospital in Abu Dhabi, UAE. PARTICIPANTS: Each month (over 48 months) a simple random sample of 24% of patient records was audited, resulting in 276 000 observations collected from 12 000 patient records, drawn from a population of 50 000. INTERVENTION(S): The impact of hospital accreditation on the 23 quality measures was observed for 48 months, 1 year preaccreditation (2009) and 3-year postaccreditation (2010–2012). MAIN OUTCOME MEASURE(S): The Life Cycle Model was evaluated by aggregating the data for 23 quality measures to produce a composite score (Y(C)) and fitting an ITS regression equation to the unweighted monthly mean of the series. RESULTS: The four phases of the life cycle are as follows: the initiation phase, the presurvey phase, the postaccreditation slump phase and the stagnation phase. The Life Cycle Model explains 87% of the variation in quality compliance measures (R(2)=0.87). The ITS model not only contains three significant variables (β(1), β(2) and β(3)) (p≤0.001), but also the size of the coefficients indicates that the effects of these variables are substantial (β(1=)2.19, β(2)=−3.95 (95% CI −6.39 to −1.51) and β(3)=−2.16 (95% CI −2.52 to −1.80). CONCLUSIONS: Although there was a reduction in compliance immediately after the accreditation survey, the lack of subsequent fading in quality performance should be a reassurance to researchers, managers, clinicians and accreditors