Student Dissertation

Agency : IPSG, JCI, Risk of Health Care Associated Infection, Indentifying Patient Correctly, Compliance Percentage.

Objective : • To examine current standards of procedures and processes of the LLH Hospital,Musaffah • To analyze the gaps and issues in all processes and procedures that corresponds to JCI standards for IPSG chapter (International Patient Safety Goals) • To interpret the results and assess compliance level of the hospital procedures and processes to JCI

Background : There is a global trend towards the pursuit of healthcare quality, driven forward as countries attempt to engage in the more effective management of resources and services amidst concerns of increasing costs, competing priorities and patient safety. One approach to managing quality on an organization wide basis and in a hospital context is through the implementation of accreditation, which involves the assessment of work and organizational practices against predefined standards, conducted by multidisciplinary clinical and support service teams. The level of compliance against standards is then evaluated by the external teams of surveyor and on that basis accreditation rating is arrived at for the organization Joint Commission International (JCI) is an international body issuing healthcare standards following the principles of Total Quality Management to improve quality and patient safety. The public/private sector hospitals are the leading hospitals in the United Arab Emirates (UAE) in achieving accreditation and meeting JCI standards. Indeed many hospitals in the Middle East in general and in the UAE in particular are in the process of achieving accreditation.

Methodology : For the purpose of the study and data collection, inpatient ward, intensive care unit, emergency department, radiology department were visited and observed over the span of two and half months. The observations were noted in checklists and compared with the existing policies for the same

Findings : The overall compliance rate for IPSG is 85% & out of all the six goals of IPSG best result is seen for the compliance of 5th goals of IPSG i.e. reducing the risk of health care associated infections which is 100%. The lowest performance is seen for the 1st goal i.e. identifying patient correctly which is about 70%. Apart from that rest of the goals of IPSG have a stable compliance rate of 87.5%.

Recommendations : It could be inferred from the study that there is overall compliance of IPSG standards of JCI with few variations in some of the elements that could be achieved by training and motivation of the staffs for a more systematic pursue of the policies and procedures laid down for IPSG


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