Management System for Accreditation of Radiology Departments in Healthcare Organizations

Hospital accreditation becomes a trend to be trustable for healthcare providing. In particular, laboratories/radiology departments should be in concern because they are the base line of diseases diagnosis. However, accreditation of such departments is rarely considered in the literature. This study was conducted to regard radiology departments. The aim was to develop a self- assessment tool that guides radiology departments in hospitals seeking for accreditation. A management system was designed to identify systematic differences in medical planning and clinical solutions between accredited departments and non- accredited ones. The Joint Commission International (JCI) has been adopted as a benchmark standard. In implementation, an evaluation matrix has been established using the main processes of radiology departments versus a set of JCI standards. In addition, a questionnaire comprised of 86 questions has been developed to measure these standards. Further, by using Likert scale to answer the questions, a score index was generated for each process individually as well as for the overall performance. Based on the calculated scores, the department is classified into one of four groups. The system has proved its consistency; correctly separated JCI- accredited departments form non-accredited departments. Furthermore, a minimum level of JCI accreditation has been assigned. The system highlights the points of strength and the points of weakness that sustain accreditation. Also, it is a self-guide tool that can eliminate the need of external consultant. Moreover, other departments within hospitals can take the same approach towards accreditation fulfillment.