Impact of Accreditation on Improvement of Hospital’s Infection Control Programs Quality and Safety in Saudi Arabian Hospitals

Asaad A Abduljawad^*

^*Correspondence: Asaad A Abduljawad, Department of Public Health, College of Health Sciences, Umm Al-Qura University, Prince Sultan Road, Makkah, Kingdom of Saudi Arabia, Email:

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Introduction

Accreditation of healthcare organizations is a voluntary and thorough evaluation process performed by an external accrediting body that assesses the quality of systems and processes in healthcare organizations. It is a growing activity that includes an assessment of services delivered, such as preventive services and patient’s satisfaction, and there is inadequate evidence of the effectiveness of its programs and interventions [1]. Accreditation started in the United States in the 1950’s when the college of surgeons started standardizing healthcare services and introduced what evolved to be the Joint Commission (TJC) today [2]. The year 1994 brought with it the Joint Commission International (JCI) aiming to heighten patient safety with its set of standards and thus improve the quality of care. A task force with a multinational representation worked together to develop new unified standards [3]. There are numbers of accrediting organizations or bodies worldwide where some of these organizations were developed and funded by the governments of those countries while others are quasi-governmental and notfor- profit organizations that are supported by national governments and key healthcare players and agencies [4]. In 2006, the ministry of health in the Kingdom of Saudi Arabia established the national healthcare accrediting body and coined the name of the Central Board of Accrediting Healthcare Institutions (CBAHI) [5]. This Saudi accrediting body would become the primary organization to be responsible for accrediting all healthcare organizations in the Kingdom that are licensed to render health services and developed their first set of hospital standards. CBAHI and JCI based their standards and principles to be set by the International Society for Quality in Healthcare (ISQua) [6], in addition to using the Joint Commission’s standards in the U.S. as their core [7]. Fundamental concepts of these standards were structured and based on quality management and continuous quality improvement theories, which are philosophical developments by gurus and scholars in healthcare, engineering, statistics, and finally medicine. These philosophers include Deming, Juran, Crosby, Shewhart, and Donabedian [8]. The IOM defined six attributes of healthcare quality in their study, “Crossing the Quality Chasm,” in 1998, and gave it the acronym STEEEP, of which the S pertains to patient safety and was the priority among improvement endeavors of the healthcare [9]. The primary concern of this committee was to inscribe and focus on patient safety as a significant healthcare and quality issue. They aimed at supporting performance expectations, structures, and functions to reduce errors in healthcare and improve quality by the enhancement of patient safety. The committee published the “To Err is Human” report, which had a significant influence on the medical practice [10].

For decades, medical and healthcare providers have been exclusively responsible for the quality of services they offer. Hospitals, healthcare organizations, and healthcare providers have been notorious for hindering quality improvement programs due to excessive time spent and focus on keeping up these programs rather than using the zealousness of these improvement practices. With the rise in consumer awareness, quality of healthcare became very important worldwide. In the Kingdom of Saudi Arabia, healthcare is in transition and transformation of quality of services in the vision 2030 initiatives [11], which has resulted in variation in both provider and patient experiences. Accreditation and its standards would cause consistent expectations and almost a unified delivery where healthcare providers are challenged, classified, and judged according to their ability to maintain quality. Physicians are held responsible for improving quality and patient safety [12].

In 2003, The Joint Commission enacted a set of hospital safety standards that were developed a year earlier called the National Patient Safety Goals (NPSG). Screening against these standards in hospitals in the United States seeking TJC accreditation is a requirement fulfilling these standards to get accredited [13]. Three years later, in 2006 and based on these national goals, JCI introduced the International Patient Safety goals [14]. In 2016, the Saudi national accrediting body CBAHI implemented a thorough public safety program, including 20 standards that are enforced by all public and private sectors no matter what the accreditation status is, referred to as the Essential Safety Requirements (ESR) [15].

CBAHI introduced in the 3rd edition of standards in 2016. Infection Prevention and Control (IPC) chapter of standards covers a plethora of issues, such as Infection control program, staff education, personal protective equipment, hand sanitation, sharps disinfection and sterilization, hospital acquired infections (HAI), employees’ health, communicable diseases, waste management, laundry management, and facility construction precautions. In this 3rd edition of standards, there are 44 IPC standards (that are listed with 1 digit in the manual), and 203 sub-standards (with 2 digits), and 52 measurable elements (with 3 digits), all of which are part of the IPC chapter.

The IPC standards in specific are 2 out of the total of 20 ESR standards in the 2016 manual. IPC 4 that comprises 4 sub-standards and 6 measurable elements, besides IPC 15 with 8 sub-standards and 6 measurable elements that CBAHI has mandated to be part of the ESR monitoring and surveys, summarized as shown in the following Tables 1 and 2.

Table 1: IPC4 standard. There is a designated multidisciplinary committee that provides oversight of the infection prevention and control program.

Table 2: IPC 15 standard. Facility design and available supplies support isolation practices.

Infection prevention control programs and activities are an essential part of TJC [16], JCI [17], and CBAHI [18], and their hospital standards are part of clinical and administrative activities fulfilling accreditation and patient safety requirements. Although there are various suggestions and a wide variety of testimonials of performance improvement in the healthcare sector after getting accredited, there are no sufficient and efficient quantitative empirical studies conducted to date to explain the overall advantages, gains, and effects of standardization achieved by accreditation on the quality of healthcare services specifically CBAHI standardizations on infection control activities and programs with none in the literature supported by primary source data.

The purpose of this study was to evaluate the level of improvement of the CBAHI ESR infection and prevention control (IPC) standards improvement in all Saudi hospitals after the first three years of implementing CBAHI’s ESR. The study aims to find out with primary source data if accreditation improved infection control in hospitals and the correlation between the ownership, bed size/capacity, and improvements in IPC using primary source data extrapolated from the accrediting body.

Methods

The population initially targeted in this study was all the 489 private, public, and governmental hospitals licensed to operate in the Kingdom of Saudi Arabia that had the Infection control standards from the ESR survey analyzed and reported during the 3 consecutive years visit of CBAHI surveyors between 2016-2018. The sample that is included in this study are 440 hospitals that fit the inclusion criteria, as this investigation excluded those hospitals that did not get at all 3 annual visits between 2016-2018. Data was collected after the researcher signed a confidentiality agreement with CBAHI at their headquarter offices in Riyadh, Saudi Arabia, and the results of this study will be published as group findings. The researcher indicated that hospital information and identities will be kept confidential and anonymous. The final two scores of both standards IPC 4 and IPC15, out of 100 for each hospital were provided by the accrediting body after summing and accumulating results for all 440 hospitals in a Microsoft excel spreadsheet. Also, ownership which are either governmental versus private, or the number of beds for each hospital was included. Data was fed into SAS 9.4 statistics software for statistical analysis to answer the study’s questions.

Results

To differentiate between results of means of hospital scores of 3 or more years and to quantitatively measure advancement or worsening of quality over these years, when these same participating or sampled hospitals are subject to the same IPC 4 and 15 repeated measurements over the years, statisticians use the mixed design analysis also named the split-plot analysis of variance (ANOVA) test [19]. The final sample analyzed had 304 governmental and 136 private hospitals at 69% and 31% respectively. The number of beds ranged from 13 beds to 1205, with an average of 146.72, and a mode of 50, and a median of 100 beds.

From Table 3 analyzing hospital IPC 4 scores from 2016 through 2018, overall scores improved from 78% to 94%. Effect of both hospital ownership type (P<0.06) and year of service (P<0.0001) were significant. Private hospitals did slightly better than government hospitals and were at 88.7% versus 86.0%, respectively.

Table 3: IPC 4 mixed design analysis.

From Table 4, results of IPC 15 standard show that over the three years period, from 2016 to 2018, overall scores improved from 66% to 70%. For private hospitals, scores improved from 76% to 82%, while for government hospitals, scores improved then consequently decreased. The effect of both hospital types (P <0.0001) and year of service (<0.02) were significant. Additionally, there was a trend for interaction between hospital types and year of performance (P=0.11). Private hospitals did better than government hospitals (80% versus 58%).

Table 4: IPC 15 mixed design analysis.

Correlating IPC 4 and IPC 15 to the number of beds in hospitals using Pearson’s correlation, the data shows that there is a very weak association between size of healthcare institution in addition to no effect of the number of beds on the improvement of the infection control program in these hospitals over the years when applying accreditation and CBAHI ESR standards on them from 2016-2018 (Table 5).

Table 5: Pearson’s Correlation between Number of beds and IPC 4 and 15.

Discussion

The assessment of the improvement of infection control program measurement standards, and the quality and safety at hospitals that go through a rigorous accreditation process are measured quantitatively. In this evidence-based study with primary source data, results of this investigation are coherent with previous studies that patient safety and the quality measures improve by time and over the years and are a result of the application of hospital accreditation [20]. In a systemic review of over 17000 publications Hussein et al. concluded in their study that accreditation is associated with better safety, processes, efficiency, and both staff and patient increased satisfaction [21].

It is a debatable topic determining if private hospitals outperform public hospitals and provide better, safer, and high standard of quality care. In most European countries the overall quality provided by governmental hospitals are equally compared to those private counterparts. That could be due to many reasons, such as the recent introduction of private hospitals to some European healthcare systems in recent years [22]. However hospitals in Nordic countries are totally publicly run and operated, where it is difficult to benchmark with private hospitals, and in a systemic review done on western European countries, Kruse et al. concludes that there is no major differences in quality of care between private and public hospitals [23]. The results of this study indicate that private hospitals had better performance pertaining to infection control quality structures, processes, and outcomes. This could be due to several reasons such as private hospitals especially those for-profit must get accredited to renew their operating licenses in the Kingdom of Saudi Arabia, compared to governmental hospitals that are owned by the Saudi government and could be the only operating healthcare entity in some cities and towns. Another factor to be taken into consideration is that the government owns more hospitals than those that are private, and another study could be designed to compare the top fifty hospitals of both private and public according to several quality measures.

Quality of healthcare delivered in hospitals could be correlated to the hospital size determined by the number of beds. Large hospitals show that the quality of healthcare is lowest when compared to smaller hospitals [24], however the results show that hospital size nor number of beds have any significant correlation with the safety of infection control standards and programs at Saudi hospitals. That could be because universal infection control precautions should be followed whatever the healthcare size or setting is.

Another point to consider regarding healthcare quality, besides accreditation, is the wide gap that prevails between evidence-based best practices and treatment practices day-to-day clinical medicine. Indeed, the "Closing the Quality Gap" series is an excellent resource, as it reflects on care coordination, a planned system of patient care operations involving several participants, as well as the patient [25].

The IOM has identified care coordination as one of the twenty national priorities for action to improve healthcare quality along its six dimensions. Care coordination interventions are particularly attractive in that they have the potential to improve both efficiency and quality. However, as the number of aging people with chronic illnesses expands, together with the everincreasing complexity of care, challenges are created to care coordination endeavors at all levels: The patient, the clinical practice, and other components of the health system. The concern here is identifying which techniques would promote the adoption of clinical evidencebased best practices that support intervention. Some of the suggested mediations are using tools to prompt a clinician to recall information, prompt of specific care processes like medication adjustments, facilitation of relay of clinical data to providers, patients’ education and reminders, promotion of self-management such as education on the usage of devices for blood pressure or glucose self-monitoring. Indeed, developing measures and approaches to investigate the efficiency and quality of care coordination interventions.

Conclusion

In conclusion with this study results, the Saudi healthcare system and hospitals around the kingdom improved in their implementation of infection control measures over the years with the introduction of healthcare accreditation and specifically the ESR standards and is an example to be followed for those systems that strive for better quality of healthcare.

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