Assessment of Patient Safety for Quality Improvement Based on Joint Commission International Accreditation Standards in Farabi Eye Hospital of Tehran University of Medical Sciences

Document Type: Original Article

Authors

1 Health Information Management Research Center, Tehran University of Medical Sciences, Tehran, Iran.

2 Department of Epidemiology & Biostatistics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran.

3 Department of Ophthalmology, Farabi Eye Hospital, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran.

4 Department of Health Care Management, Farabi Eye Hospital, Tehran University of Medical Sciences, Tehran, Iran.

5 Department of Health Care Management, School of Allied Medicine, Farabi Eye Hospital, Tehran University of Medical Sciences, Tehran, Iran.

6 Department of Health Care Management, School of Allied Medicine, Health Information Management Research Center, Tehran University of Medical Sciences, Tehran, Iran.

Abstract

Introduction: Quality improvement and patient safety are the most important aspects of health care delivery systems. Improving quality and safety in health care organizations is assured through accreditation.
To evaluate patient safety in Farabi Eye Hospital by Joint Commission International (JCI) accreditation standards for quality improvement.

Materials and Methods:
This descriptive-analytical study was carried out in 2014. The data collection instrument was the translated version of JCI checklist, the validity of which was confirmed by a panel of Iranian experts. The data were obtained through interviews with all heads of departments (n=80) and observation of documentation in each department by appraisers in Farabi Hospital. To analyze the data, Spearman's rank correlation coefficient and Mann-Whitney U tests were run using SPSS Version 16.
Results: The highest rate of compliance with JCI standards was 91.1%, pertaining to infection control and adopting an approach to reduce contamination. The lowest rate was associated with management monitoring of patients’ demographic information. In general, Farabi Eye Hospital observed the standards to a high level.

Conclusion:
Our findings exhibited that Farabi Eye Hospital is relatively efficient as to patient safety as a quality improvement factor. However, there were some shortcomings regarding some standards, which indicate deficient compliance with the JCI standards in this hospital. Absence of comprehensive training programs and defective policies and documentation are the key factors for patient safety quality improvement.

Keywords