New Hospital Accreditation Model to Focus on Clinical Outcomes

The purpose of hospital accreditation is to improve the quality of health services, ensure patient safety, and provide protection to the public. The current accreditation process primarily assesses input and process stages, such as the availability of standards, documents, and assessment elements. However, this approach is considered insufficient to guarantee the quality of clinical outcomes.

Going forward, hospital accreditation should comprehensively focus on three main stages of hospital services: input (human resources and regulations), process (daily services), and output (service results). It is no longer enough to merely ensure that all standards and traceable documents are complete. Accreditation must also prove that patient care has been delivered and has resulted in good, justifiable clinical outcomes.

The Ministry of Health has overhauled the hospital accreditation system to be based on real-time clinical outcomes, using the Hospital Accreditation Standard (Starkes) as a reference under Minister of Health Decree Number HK.01.07/MENKES/1596/2024. This new policy involves eight approved accreditation bodies (LPA). The process will shift from a five-yearly administrative evaluation to one that also measures recovery rates, surgical failure rates, and patient survival rates.

While the existing Starkes instrument provides complete standards for the input and process stages, additional standards and assessment elements are needed for the clinical outcome stage. These new elements must consider various factors, including the severity of a patient’s illness upon admission, which objectively contributes to clinical outcomes. Input from medical specialists, sub-specialists, consultants, and other clinicians is crucial to ensure the outcome assessment accurately reflects the real services provided to patients. This new accreditation process is likely to resemble existing medical and clinical audits or patient death reviews already routinely conducted in hospitals, and should also assess mechanisms such as diagnosis confirmation within 48 hours of admission and the appropriateness of clinical pathways.