Assessment of Patient (AOP) standards in Teaching hospitals in Iran Dr.Fereshteh Farzianpour, Associate professor Department of Health Management and Economics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran farzianp@sina.tums.ac.ir Elnaz kalantari, MSPH student, Department of Health Management and Economics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran ilnazkalantari@yahoo.com Abbas Rahimi Foroushani, Associate professor, Department of Epidemiology and Biostatistics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran. (Corresponding author).rahimi@ tums.ac.ir Abstract Samira Alirezaei, Ph.D student, Faculty of Management, Tehran, Iran s.alirezaei.6856@gmail.com The aim of the present study is to evaluate the applicability of standards of Assessment Of Patient (AOP) in selected teaching hospitals of Tehran University of Medical Sciences from the manager point of view.this study was the cross sectional descriptive - analytic study examined in 1 hospitals covered by Tehran University of Medical Sciences. In this study, two questionnaires:" AOP standards and measurable elements of AOP standards to collect data from the book "International Accreditation Standards for Hospitals" was used.based on the results of the study, the highest and lowest mean scores of implementation possibility of standards of AOP.1 (assessment of care needs patient process) related to the Valiasr and Sina hospitals; AOP.2 ( at appropriate intervals) related to Valiasr and Zanan hospitals; AOP.3 ( by qualified individuals) and AOP.4 ( in collaboration with those responsible for patient care ) related to Farabi and Zanan hospitals; AOP.5 ( laboratory services delivery) related to Farabi and Valiasr hospitals and AOP.6 (to meet patient needs by radiology services delivery) related to Firozgar and Valiasr hospitals. Score of assessment of patient standards in public hospitals was more than specialized ones.the most important consequence of assessment of patient by international standards is recognizing of nursing and medical patient needs. So we can use a proper framework for performance excellence and improved patient satisfaction from health services by assessment of patient standards. Keywords: Assessment of Patient (AOP) standards, Teaching hospitals, Iran 1. INTRODUCTION An effective evaluation of the patient will result in making decisions about the immediate and ongoing medical needs in emergency cases, elective, or planned care and when the patient's condition changes.(1) According to the World Health Organization, quality is the key factor in improving the outcomes of health as well as providing efficient services.(2) Joint Commission International was developed in 1994 as a division of Joint Commission Resources. JCI assists organizations in developing an internal system of quality by offering International Accreditation and Standards and Consulting services. The JCI hospital standards will be used as a guide and are organized into two sections : Patient Centered Standards and Health care Organization Management Standards.(3) A patient-centered hospital needs attention to many factors such as appropriate access of patients to the health care system, proper assessment of patients, logical medication management, and anesthesia and surgicalcare. (4) Joint Commission International Accreditation Standards are globally unique tools designed to measure the quality of patient care and for the efficient and effective functioning of the organization, which in fact is the basis of quality assurance, systematic approach offers.(5) 119 office@penseejournal.com
Growing interest in patient centered care coincides with growing attention to quality improvement and cost containment in the U.S. health care system.(6,7,8) Global experience shows that using standards in providing the services can lead to promotion, efficiency and improved quality; while large organizations need to improve patient care quality and ensure safe care environment and continuous activity to reduce patient and staff risks in order to increase their share in care delivering markets and decrease their costs.(9,1) Developing standards in different countries shows the evolution of the hospital standards purely structural and normative standards to standards based on continuous quality improvement and comprehensive quality management have changed. (11) However, in Iran in order to evaluate the hospitals, the Ministry Of Health standards used in this context, studies suggest that these standards are not complete and comprehensive. (12)The aim of the present study is to evaluate the applicability of AOP standards in teaching hospitals of Tehran University of Medical Sciences and identify the causes of the difference between the achieved scores in this study with other studies. 2. MATERIALS AND METHODS This cross-sectional study was conducted in hospitals affiliated to Tehran University of Medical Sciences during 213. Data collection was performed using author-designed questionnaire of Assessment Of Patient based on JCI standards (212); which included demographic data and 42 questions in three sections (Clinical / Laboratory / Radiology). Our population study consisted of 26 personnel (metron,head nurse and superviser) in clinical section and 36 personnel (technical officers and ward managers) in laboratory and radiology sections employed in 1 teaching Hospitals. The questionnaire covered 6 domains including: AOP.1 (assessment of care needs patient process) with 14 questions, AOP.2 ( at appropriate intervals) with 1 question, AOP.3 ( by qualified individuals) with 1 question, AOP.4 ( in collaboration with those responsible for patient care) with 2 questions, AOP.5 ( laboratory services delivery) with 13 questions and AOP.6 ( radiology services delivery) with 11 questions. Each question had three choices with ranks of )2 = implementation, 1 = relatively implementation, = non implementation) and the total score of AOP and of each dimension of AOP was calculated by adding the ranks. The questionnaire was reviewed by experts and the total Cronbach s alpha was calculated /929. Also to evaluate the reliability of each question of AOP, a Cronbach s alpha was calculated after removing the interested question from the set of all questions. Results showed that these values were ranged from /92to /93. Each question was designed with three answers of ) 2 = yes, 1 = partly, = No). People asked to complete the questionnaire in each hospital in the priority order included hospital manager, Metron, Supervisors and head nurses. Since the main aim of the study was first to estimate the average of AOP scores in all hospitals, study sample size was determined based on 95% confidence interval for the population mean of AOP. In total 265 questionnaires were sent to 1 hospitals and a total of 26 (1%) questionnaires were successfully completed without any missing values and used for data analysis. Statistical significance was set at 5% and SPSS software version 11.5 was used for data analysis and statistical tests of one way ANOVA and T-test was used. 3. RESULTS The 1 hospitals studied consisted of 3 (3%) general hospitals and 7 (7%) were specialized hospitals. The 4 hospitals had less than 3 beds and 6 hospitals had more than 3 beds. In clinical section 5 men (19/2 %) and 21 (8/7 %) women; in laboratory section 11 men (61/1 %) and 7 (38/9 %) women and in radiology section 12 men (66/7 %) and 7 (33/3 %) women completed the questionnaires. The findings of the study are as follows: All standards of AOP, with mean 9/54% were applicable and fairly applicable. The mean scores of general hospitals were higher compared with specialized hospitals in all domains of AOP standards (table 1). Table 1: Mean and standard deviation and results of t-test related to scores of each domain and AOP for type of hospital in selected hospitals of Tehran University of Medical Sciences in 213 Domain Type of Hospital Mean Standard Deviation P value assessment of care needs patient process General 11/96 15/6 Specialized 97/52 18/1 at General 11/7 2/3 /3 /3 12 office@penseejournal.com
appropriate intervals by qualified individuals in collaboration with those responsible for patient care laboratory services delivery radiology services delivery Specialized 1/97 3/1 General 1/33 2/16 Specialized 9/67 2/84 General 11/49 2/48 Specialized 1/66 3/32 General 135/33 1/6 Specialized 134/8 2/3 General 18/43 4/35 Specialized 17/88 8/9 /4 /2 /2 /8 Table 2: Mean and standard deviation and results of t-test related to scores of each domain and AOP for gender in selected hospitals of Tehran University of Medical Sciences in 213 Domain Gender Number Mean Standard Deviation P value assessment of care needs patient process Men 64 / 64 66 / 64 Women 666 66 / 64 6 / 4 at appropriate intervals by qualified individuals in collaboration with those responsible for patient care laboratory services delivery Men 66 / 88 2 / 63 Women 26 66 / 2 2 / 36 Men 6 / 48 6 / 38 Women 26 6 / 86 2 / 46 Men 62 / 4 2 / 6 Women 26 6 / 6 2 / 64 Men 66 666 / 66 6 / Women 3 66 / 66 2 / 83 /66 /6 /4 /64 radiology services delivery Men 62 66 / 46 4 / 3 Women 4 66 6 / 6 Table 3: Mean and standard deviation and results of t-test related to scores of each domain and AOP for organizational position of respondents in selected hospitals of Tehran University of Medical Sciences in 213 Domain Post Number Mean Standard Deviation P value assessment of care needs patient process Manager & Metron 2 113/85 7/4 Supervisor & Head nurse 24 98/82 16/5 /66 121 office@penseejournal.com
at appropriate intervals by qualified individuals in collaboration with those responsible for patient care laboratory services delivery radiology services delivery Manager & Metron 2 13/15 1/6 Supervisor & Head nurse 24 11/2 2/7 Manager & Metron 2 11/5 1/3 Supervisor & Head nurse 24 9/9 2/5 Manager & Metron 2 24 1/9 Supervisor & Head nurse 24 1/9 2/9 Ward Manager 9 134/4 1/8 Technical Officer 9 134/4 2/5 Ward Manager 5 17/2 3/1 Technical Officer 13 18/6 8/3 /2 /6 /9 Evaluation of Factors Affecting Scores of Domains: According to the t-test: - The type of hospital affects the domains of assessment of care needs patient process (p=.3), at appropriate intervals (p=.3), by qualified individuals (p=.4) and assessment of patient process in collaboration with those responsible for patient care (p=.2). (Table1) - The gender of respondents affects the domains of assessment of care needs patient process (p= ), assessment of patient process by qualified individuals (p=.4) and in collaboration with those responsible for patient care (p=.6). (Table2) - Organizational post affects the domains of assessment of care needs patient process (p= ), at appropriate intervals (p=.2), by qualified individuals (p= ) and assessment of patient process in collaboration with those responsible for patient care (p= ). (Table3) - The number of beds affects the domains of assessment of care needs patient process (p=.2), at appropriate intervals (p=.3) and in collaboration with those responsible for patient care (p=.1). - The age and job experience of respondents only affects the domain of by qualified individuals (p= ) 4. DISCUSSION Applicability of the Standards Gary et al. (212) reported the applicability of JCI standards in access to care and continuity of care (ACC) in a range between 87/7 to 1 percent applicable and relatively applicable.(13) Farzianpour et al.(211) reported the applicability of JCI standards in quality improvement and patient safety (QPS) in a range between 62/5 to 1 percent applicable and relatively applicable with no significant difference between general and specialty hospitals (P value =.7) ; however the number of beds in the hospital was an effective factor on the applicability score of the standards (P value =.3) (14) In a study by Turani et al. (29) on hospitals of Iran University of Medical Sciences, the mean rates of observance of standards of quality improvement and patient safety were 72%, 57.6% and 57.4%. Among these, the hospital with an implemented EFQM excellence model had the highest score.(15) Amirifar et al. (21) conducted a study in the emergency department of a general hospital of Tehran University of Medical Sciences to report that only 31.6% of standards of quality improvement and patient safety were observed completely, while 44.9% were observed relatively and 23.5% were not observed at all.(16) Victor et al. evaluated the quality managers of 97 hospitals of intensive care in Ontario, Canada via email and concluded that expansion of capacity of quality improvement requires investments and education.(17) The mean score of JCI standards was 64.3% (patient centered standards: 66%, organization centered standards: 62.6%). The maximum rate of consideration was related to medication management and use standards (75.5%) and the minimum rate of consideration was related to patient and family rights standards (54.9%).(18) 122 office@penseejournal.com
Results of a clinical audit of Assessment Of Patient at the research of Rahimi et al indicated : AOP.1 (assessment of care needs patient process : 7%); AOP.2 ( at appropriate intervals : 65%); AOP.3 ( by qualified individuals: 8%); AOP.4 ( in collaboration with those responsible for patient care: 7%); AOP.5 ( laboratory services delivery:9%). (19) Beheshti hospital showed the lowest mean preparation level (68%) and the worst preparation in AOP.1, AOP.5, and AOP.2 with 56, 67 and 75 percent, respectively; whereas Zahra hospital demonstrated the highest mean level of standards and the best scores in AOP.4, AOP.5, and AOP.2 with 75, 96 and 1 percent, respectively. There was no difference among the four hospitals on the mean level of AOP index (P=.6).(3) in the present study the applicability of JCI standards was ) in a range between 95 to 1 percent applicable and relatively applicable, and but we found difference between general and specialty hospitals. Although the authors faced limitations for comparing the results with those of international studies, comparison with Iranian studies indicates that our hospitals are in an intermediate level regarding quality improvement and patient safety. Furthermore, hospitals that use excellence models and systems of quality management demonstrate a better status. 5. CONCLUSION AND RECOMMENDATION According to this study, the AOP standards are applicable in hospitals of Tehran University of Medical Sciences; however, their application requires greater efforts by the hospitals. Implementation and actualization of standards in hospitals require certain infrastructures such as better knowledge on the part of managers regarding the principles and tools of quality improvement, training personnel about the standards, implementation of models of quality management and organizational excellence, reinforcing the public affairs in hospitals and using hospital information system (HIS) all of which influence the process of realization for standards of quality improvement and patient safety. So by using AOP standards in hospitals following results are obtained: By applying this model is possible to determine the critical points and critical self-assessment at any time and benefit from a proper framework for performance excellence. Improve the safety of all patients in the same Improve patient satisfaction with health services and their families 6. Limitations Our research was a new subject, with limited resources Assessment Of Patient (AOP) considering the lack of research in this area. Other limitations were accreditation standards of patient that hospitals administrators and medical staff were less familiar with the accreditation standards of care of patients. Ethical Considerations Ethical issues (Including plagiarism, Informed Consent, misconduct, data fabrication and/or falsification, double publication and/or submission, redundancy, etc.) have been completely observed by the authors. ACKNOWLEDGEMENTS The researchers would like to extend their sincere thanks of the managers of hospitals of Tehran University of Medical Sciences. The managers who kindly filled out the questionnaire of the present study. Conflict of interest: None declared. REFERENCES 1.Rahimi,Fatemeh.Ramezani,Zhila.Saeedi,Fereshteh.Mohseni,Soraya.Ghajari,Masomeh. Evaluation Assessment Of Patient (AOP) standards according to Accreditation standard in Cardiac and CCU1 ward in Shahid Rajai Hospital in Karaj in the second half of 211. 2. Farzianpour, F., Arab, M., Amoozagar, S., Fouroshani, A.R. and Rashidian, A., et al. (211) Evaluation of international standards of quality improvement and patient safety (QPS) in Hospitals of Tehran University of Medical Sciences (TUMS) from the managers point of view. World Applied Sciences Journal, 15, 647-653. 3. Tavakoli,N. Abbasi,Sh. External Evaluation of Four Hospitals According to Patient-centred Care Standards. ACTA INFORM MED. 213 Sep; 21(3): 176-179. 123 office@penseejournal.com
4. Latha Rajendra Kumar.Robin Yurk.Advances in Accreditation for Global Health Care.IntHealthCert International.21(Oct);Vol 1(3): 12-14. 5. Mohammadpour A, Mehdipour Y, Karimi A, Rahdari A. A comparative study of the Iran Ministry of Health patient and family education standards with joint commission on Accreditation of Healthcare Organizations. Health Information Management 29; 6(2):122. 6. Institute of Medicine Committee on Health Care in America: Crossing the quality chasm: a new health system for the 21st Century. Washington (DC): National Academy Press; 21. 7. Gawande A: The cost conundrum, The New Yorker. New York, NY: Conde Nast; 29. 8. Weeks WB, Gottlieb DJ, Nyweide DJ, Sutherland JM, Bynum J, Calino LP, Gillies RR, Shortell SM, Fisher ES: Higher Health Care Quality And Bigger Savings Found At Large Multispecialty Medical Groups. Health Aff 21, 29:991 997. 9. ARIAH, Improving America s Hospitals (211) The joint commission s annual report on quality and safety.http://www.jointcommission.org/annualreport.aspx 1. Topic Library Item (213) Facts about the joint commission. http://www.jointcommission.org/facts_about_the_joint_c ommission 11. Sadaghiyani E. Joint commission on accreditation health care organizations, standards of hospital evaluation and accreditation. Tehran: Social Security Research Center; 24. 12. Ahmadi M, Khoshgam M, Mohammadpoor E.Comparative study of the ministry of health standards for hospital with international joint commission hospitals accreditation standards. Hakim J. 27;1(4):45-52. 13.gary S.Evaluation ofinternational standards Access to care and continuity of care (ACC) in hospital of tehran university of medical sciences.tehran:tehran university of medical sciences and health services;213.p:121. 14. Farzianpour, F., Arab, M., Amoozagar, S., Fouroshani, A.R. and Rashidian, A., et al. (211) Evaluation of international standards of quality improvement and patient safety (QPS) in Hospitals of Tehran University of Medical Sience. 15. Turani, S., R. KHodayari Zarnagh and F. Farhadi, 21. Readiness of educational hospitals of Iran. University of medical sciences for establishment, Joint Commission International Accreditation Standards for hospitals: approach of patient centered, (may/1/21), Olympic Hotel. Iran, Institute of Human Resource Empowerment,. 16. Amirifar, S., 21. Evaluation of Emergency medical sciences department in Emam KHomeyni Hospital based on standards Ministry of Health and Medical Education and standards Joint Commission International [Thesis]. Faculty of Paramedical, Tehran University of Medical Science. 17. M.Daleneedham,J.David,D.Victor,M. Sean, and J.Peter.Improving data quality control in quality improvement projects.international Journal for Quality in Health Care 29; Volume 21, Number 2: pp. 145 15. 18. Khodayari Zarnaq,R. Tourani,S. Qaderi,A. Salehi,M. Jafari,H. Readiness of teaching hospitals in attracting medical tourists based on joint commission international standards. JQUMS, Vol.17, No.1, 213, pp.48-54. 19. Rahimi,Fatemeh.Ramezani,Zhila.Saeedi,Fereshteh.Mohseni,Soraya.Ghajari,Masomeh. Evaluation Assessment Of Patient (AOP) standards according to Accreditation standard in Cardiac and CCU1 ward in Shahid Rajai Hospital in Karaj in the second half of 211. 124 office@penseejournal.com