quality - ct 7

Quality of care in university hospitals in Saudi Arabia: a systematic review

Mohammed Aljuaid, 1,2

Fahmida Mannan, 3 Zain Chaudhry,

3 Salman Rawaf,

4

Azeem Majeed 4

To cite: Aljuaid M, Mannan F, Chaudhry Z, et al. Quality of care in university hospitals in Saudi Arabia: a systematic review. BMJ Open 2016;6: e008988. doi:10.1136/ bmjopen-2015-008988

▸ Prepublication history for this paper is available online. To view these files please visit the journal online (http://dx.doi.org/10.1136/ bmjopen-2015-008988).

Received 5 June 2015 Revised 1 November 2015 Accepted 3 December 2015

1Department of Primary Care and Public Health, Imperial College London, London, UK 2Department of Health Administration, King Saud University, Riyadh, Saudi Arabia 3Faculty of Medicine, Imperial College London, London, UK 4Department of Primary Care and Public Health, Imperial College London, London, UK

Correspondence to Mohammed Aljuaid; [email protected]

ABSTRACT Objectives: To identify the key issues, problems, barriers and challenges particularly in relation to the quality of care in university hospitals in the Kingdom of Saudi Arabia (KSA), and to provide recommendations for improvement. Methods: A systematic search was carried out using five electronic databases, for articles published between January 2004 and January 2015. We included studies conducted in university hospitals in KSA that focused on the quality of healthcare. Three independent reviewers verified that the studies met the inclusion criteria, assessed the quality of the studies and extracted their relevant characteristics. All studies were assessed using the Institute of Medicine indicators of quality of care. Results: Of the 1430 references identified in the initial search, eight studies were identified that met the inclusion criteria. The included studies clearly highlight a need to improve the quality of healthcare delivery, specifically in areas of patient safety, clinical effectiveness and patient-centredness, at university hospitals in KSA. Problems with quality of care could be due to failures of leadership, a requirement for better management and a need to establish a culture of safety alongside leadership reform in university hospitals. Lack of instructions given to patients and language communication were key factors impeding optimum delivery of patient-centred care. Decision- makers in KSA university hospitals should consider programmes and assessment tools to reveal problems and issues related to language as a barrier to quality of care. Conclusions: This review exemplifies the need for further improvement in the quality of healthcare in university hospitals in KSA. Many of the problems identified in this review could be addressed by establishing an independent body in KSA, which could monitor healthcare services and push for improvements in efficiency and quality of care.

INTRODUCTION Access to healthcare in the Kingdom of Saudi Arabia (KSA) has improved dramatic- ally over the past three decades. This improvement in access has brought chal- lenges for healthcare organisations, their

staff and other stakeholders, highlighting a need to improve the quality of healthcare. These challenges include: increasing demand for healthcare services coupled with a rise in costs, changing patterns of disease, shortage of healthcare professionals, a signifi- cant annual pilgrim population, a rise in medical errors and long waiting times.1–4 A key policy being implemented as a part of the ninth development plan in KSA (2009– 2014), with regard to health services, is the need to adopt methods to improve quality of care, and to apply these methods across all health sectors to ensure that appropriate levels of efficiency and quality are achieved.5 6

Indeed, measurement of patient satisfaction is central to identifying areas for improve- ment and thus achieving optimal delivery of healthcare services. In addition to patient sat- isfaction, it is important to consider access to healthcare as a fundamental quality of care indicator. Ovretveint addressed the definition of

quality in health services as ‘fully meeting the needs of those who need the services most, at the lowest cost to the organisation, within limits and directive set by higher authorities and purchases’.7 In addition, better health outcomes and greater effi- ciency in developing countries such as KSA can be achieved by adopting quality

Strengths and limitations of this study

▪ This is the first systematic review conducted on the quality of healthcare in university hospitals in Kingdom of Saudi Arabia (KSA).

▪ This review has highlighted heterogeneity in the delivery of care within university hospitals in KSA.

▪ The limited number of studies in this review may not represent the actual quality of healthcare in university hospitals in KSA.

▪ The review is restricted to English-language pub- lications due to the lack of relevant research lit- erature in Arabic.

Aljuaid M, et al. BMJ Open 2016;6:e008988. doi:10.1136/bmjopen-2015-008988 1

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improvement methods. Al-Ahmadi and Roland reported that ‘Quality improvement can be driven both internally through organised effort within the healthcare system, and externally through public pressure’.8 Furthermore, Groene addressed seven ways to improve quality and safety in any hospital as the following: (1) ‘Align organ- isational processes with external pressure. (2) Put quality high on the agenda. (3) Implement supportive organisation-wide systems for quality improvement. (4) Assure responsibilities and team expertise at departmen- tal level. (5) Organise care pathways based on evidence of quality and safety interventions. (6) Implement pathway-oriented information systems. (7) Conduct regular assessment and provide feedback’.9

The health system in Saudi Arabia (SA) has three sectors: the Ministry of Health sector (MOH), the private sector and other government sectors. The MOH is the major government provider of health services in SA, with a total of 268 hospitals (38 970 beds), covering 60.2% of the total health services in SA. The private sector provides 22.1% of the total health services, espe- cially in cities and large towns, with a total of 136 hospi- tals (14 310 beds). The other government agencies sector, which provide services to a defined population, usually employees and their dependents, operates 39 hospitals (11 497 beds). This covers 17.7% of the total health services, include referral hospitals (eg, King Faisal Specialist Hospital and Research Centre), security forces medical services, army forces medical services, National Guard health affairs, ARAMCO hospitals, Royal Commission for Jubail and Yanbu health services, Red Crescent Society and Ministry of Education hospitals (university hospitals).10

The university hospitals include King Fahd University Hospital (KFUH) (428 beds) in the eastern region of SA, King Abdulaziz University Hospital (KAUH (507 beds) in the western region, and King Abdul-Aziz University Hospital (KAAUH) (85 beds) and King Khalid University Hospital (KKUH) (752 beds) in the central region.10 In some countries, such as the USA, university hospitals are often perceived to provide better quality of care than other hospitals.11 No study has examined whether this is the case in KSA. We carried out a systematic literature review to examine the following questions: 1. What is the quality of care in university hospitals in

KSA? 2. What are the common issues, problems, barriers and

challenges particularly in relation to the health ser- vices and the quality of care in university hospitals in KSA?

3. How does the quality of care in university hospitals compare with that of other health sectors in KSA?

The objectives of the review were to: ▸ Identify the key issues, problems, barriers and chal-

lenges particularly in relation to the health services and the quality of care in university hospitals in KSA;

▸ Highlight the weaknesses and strengths of quality of care;

▸ Provide recommendations describing how better quality of care can improve patient outcomes in uni- versity hospitals in KSA in the future.

METHODS Search strategy and selection The search strategy identified relevant studies through an online literature search using the following electronic databases: Medline, ISI Web of Knowledge, PubMed, Embase and Cochrane. The search terms used (table 1) were quality, OR quality of care, OR healthcare quality, OR safe, OR effective, OR patient-centred, OR timely, OR efficient, OR equitable AND university hospital, OR teaching hospital, OR medical school, AND KSA, OR SA. Details of the study identification and selection process are shown in figure 1.12

Study criteria Inclusion criteria Studies were included if they met the following criteria, they were: focusing on the quality of care in university hospitals in SA; focusing on issues, problems, barriers and challenges particularly in relation to the quality of care in university hospitals in KSA; published between January 2004 and January 2015; published in peer reviewed journals and only in English as there is no rele- vant Arabic research database.

Exclusion criteria Studies were excluded if they investigated the quality of care outside the university hospitals in KSA such as studies carried out in MOH, King Faisal Specialist Hospital and Research Centre security forces medical services, army forces medical services, National Guard health affairs and ARAMCO hospitals. Studies were excluded if they were published before 2004.

Data extraction and quality appraisal We developed a standardised sheet for data extraction from the studies that met the inclusion criteria. The data extraction sheet was based on the following character- istics of the included studies (authors, location and year, aim and objectives, study design, results, outcomes, lim- itations). All data were extracted from each study by three researchers. A full list of the data extraction criteria

Table 1 Search terms used in electronic database search

Search terms

Quality Quality of care, healthcare quality, safe,

effective, patient-centred, timely, efficient

and equitable

Hospitals University hospital, teaching hospital,

medical school

Saudi Arabia Kingdom of Saudi Arabia, KSA, Saudi

Arabia, SA

2 Aljuaid M, et al. BMJ Open 2016;6:e008988. doi:10.1136/bmjopen-2015-008988

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is presented in table 2. After we developed a standardised sheet for data extraction from the included studies, all articles were reviewed and analysed by the researchers. The quality and the risk of bias of all studies were evalu- ated using the Newcastle Ottawa scale for cross-sectional studies that was adapted by Herzog et al.13 In addition, all studies were assessed using the Institute of Medicine (IOM) indicators of high quality of care: safe, effective, patient-centred, timely, efficient and equitable.14

Ethics statement Ethical approval was not required as this study was a sys- tematic literature review.

RESULTS Of the 1430 references identified in the initial search, 590 titles and 55 abstracts were reviewed. After applying the inclusion criteria for titles and abstracts, 33 full-text articles were evaluated for more detailed evaluation. Twenty-six studies were excluded as they did not meet the inclusion criteria and one study was excluded because the study used the same sample as that used for another study. Eventually, eight studies were identified and met the inclusion criteria for this systematic review. The included studies are summarised in table 2. The Newcastle-Ottawa scale, a widely used tool for observa- tional studies, was utilised to determine the risk of bias

and the quality of the studies included. Some of the studies included show low scores on the quality scale, which questions their reliability. Most of the studies included scored well in the following domains of the Newcastle Ottawa scale: representativeness of the sample, satisfactory sample size and use of a validated measurement tool. However, many studies failed to report comparability between the respondents and non- respondent characteristics, which may not adequately control for confounding variables and may introduce an element of self-selection bias (table 3). Moreover, the reliance of many included studies on self-reporting may introduce information bias. All studies were assessed based on four indicators (Safe, Effective, Patient-centred and Timely) out of the six IOM indicators (table 4). The Efficient and Equitable indicators were not specific- ally reported on in any of the included studies.

Safety Five studies examined issues and concerns related to the safety domain. Al Awa et al reported nursing staff com- menting on the creation of barriers due to a multicul- tural and multilanguage environment at KAUH. However, there is a statistically significant improvement in the post-accreditation period compared with pre- accreditation (p<0.001) in all domains measured, namely: nursing clinical information, patient medication

Figure 1 Flow chart of study

selection process. 12

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Table 2 Summary of study characteristics included in the systematic review

Study location

and year Study design Aim and objectives

Sample

size Results Limitations

Al Awa et al,15

KAUH, 2011

Cross-sectional

survey

To achieve an unbiased

assessment of the impact of

accreditation on quality of patient

care and patient safety as

perceived by nursing staff.

721 675 met the survey criteria. Accreditation has

an overall statistically highly significant

perceived improvement on quality of patient

care and patient safety.

Subjective–nurse based

perceptions via questionnaire,

conducted retrospectively.

Atallah et al,22

KKUH, 2013

Cross-sectional

survey

To examine the patients’

satisfaction level on quality of

nursing care provided and to

identify differences in patients’

satisfaction of quality of nursing

care provided related to selected

Demographic characteristics.

100 100 agreed to participate with an agreement

rate of 40%. ‘Patients have a high level of

satisfaction with nursing care provided,

although certain aspects of nursing care such

as language, information giving and

attentiveness, were identified with lower rates’.

Selection bias: only those who

expressed interest in

participation were asked to fill out

the questionnaires’ polarised

results. Not multicentre sample.

Al Doghaither, 16

KKUH, 2004

Cross-sectional

survey

To assess inpatient satisfaction

with physician services at KKUH.

350 350 patients (87.5% response rate). ‘These

findings offer hospital management information

about shortcomings requiring remedial

intervention. More specifically, less satisfied

groups being: Higher educational level and

male.

Should have conducted

multicentre study at other Saudi

teaching hospitals to produce

more representative data.

Alamri, 17

KAUH,

2012

Cross-sectional

survey

To determine the knowledge of

the residents working in KAAUH

about palliative care.

80 Of 80 residents, 65 responded (response rate

of 81%). Resident physicians enrolled in

postgraduate programmes possess suboptimal

knowledge of basic palliative care. There is a

need to improve palliative care education at

undergraduate and postgraduate level.

Study does not account for older

doctors, who may have greater

knowledge/authority over

palliative care, which could

influence the results. Does not

describe characteristics of

non-responders.

Mokhtar et al,20

KFUH, 2012

Retrospective

cohort/case–

control

To determine the 28-day

readmission rate for DM patients

at KFUH and to assess

compliance of healthcare

providers with the American

Diabetic Association guidelines

and to identify factors predicting

readmission.

124

(62 cases,

62 controls)

84% of the 62 cases were readmitted once

within 28 days, 11% were readmitted 2 times,

3% 3 times and 2% 4 times. Quality of

inpatient care exerts a substantial influence on

the risk of readmission. Study hospital should

improve the quality of care delivered to

diabetic patients.

Retrospective data analysis.

N=62, quite small sample size—

should have pooled results in a

multicentre study to improve their

sample size.

Hussein, 18

KAUH, 2014

Cross-sectional

survey

To investigate the relationship

between ICU nurses’ and

physicians’ perceptions of the

organisational health of a hospital

and quality of patient care, and to

assess and compare their

perceptions.

128 75/77 nurses and 49/51 physicians. Teamwork

was the highest scoring domain among the

hospital health determinants characterising

participants’ work environment. Participants

gave lower ratings to domains of effectiveness,

patient-centred care and safe care.

Self-reported questionnaire

Not multi-centred.

Continued

4 Aljuaid

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Table 2 Continued

Study location

and year Study design Aim and objectives

Sample

size Results Limitations

El-Jardali et al,19

KKUH&KAAUH,

2014

Cross-sectional

survey

To conduct a baseline

assessment of the patient safety

culture in a large hospital in

Riyadh. To compare results with

regional and international studies

that utilise the same tool. The

study was conducted to ‘Explore

the association between patient

safety culture predictors and

outcomes, taking into

consideration respondent

characteristics and facility size’.

2572 2572/3000 (85.7% response rate). The

dimensions with the highest positive score

were Organizational Learning and Continuous

Improvement (79.6%), and Teamwork within

Units (78.5%). The lowest scores were in the

dimensions of Hospital non-punitive response

to error (26.8%), Staffing (35.1%) and

Communication Openness (42.9%).

Comparing with other regions (USA and

Lebanon): KSA fared better in dimensions of

Teamwork across Hospital Units, Hospital

Handoffs and Transitions, and Organizational

Learning & Continuous Improvement.

Compared to Lebanon, KSA scored lower in:

Communication, Openness and Overall

Perception.

Lack of rigorous statistical

analyses (Cronbach-α values ranged between 0.214–0.892;

internationally accepted values

generally >0.6).

Has only accounted for HCP

perception in patient safety, but

has not asked patients

themselves.

Questionnaire-based.

Wahabi et al,21

KKUH, 2011

Cross-sectional

survey

To explore the opinion and

practice of the healthcare

professionals in KKUH in the use

of clinical practice guideline

CPGs.

2225 1257/2225 (56.5% response rate). Cronbach’s

α=0.67. Most respondents had a positive attitude to the use of CPGs in decision

making. >90% thought that they were effective

in unifying and improving the quality of

patients’ care. 97% respondents agreed that

CPGs were a good educational tool. <50%

respondents agree that clinical practice should

be based on scientific evidence all the time.

Overall, there is a good positive attitude

towards the use CPGs in clinical practice.

Self-reported questionnaire. Low

response rate overall (56.5%),

especially physicians (25%) → introduced a selection bias, as

physicians are the ones using

CPGs most often.

CPGs, clinical practice guidelines; HCP, health care professionals; ICU, intensive care unit; KAUH, King Abdulaziz University Hospital; KAAUH, King Abdul-Aziz University Hospital, Riyadh; KFUH, King Fahd University Hospital; KKUH, Khalid University Hospital; KSA, Kingdom of Saudi Arabia.

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information, risk management information and nursing action to prevent risk. The greatest improvement was seen in the category of ‘risk management information’, namely, a 44% perceived improvement in ‘communica- tion to patient about safety’ (46–90%).15 In addition, Al-Doghaither showed that the mean satisfaction score of inpatients with regular physician check up on their condition/follow-up on daily rounds was 4.20. While the mean was only 2.10 for the category of ‘physicians are unable to know the individual condition of each patient with so many patients to see’.16 In a study about pallia- tive care, the knowledge of physicians regarding opioid use as an important medication in palliative care was generally very low.17 Another study indicated that nurses gave a significantly lower score to patient safety than did physicians, which could be due to failures of leadership, a requirement for better management or the need to establish a culture of safety alongside leadership reform in university hospitals.18 The first study to compare KSA patient-safety composite values with those of other regions around the world (USA and Lebanon) found that feedback and communication about errors are most strongly associated with frequency of events reported.19

Effective Five of the reviewed studies that met the inclusion cri- teria considered matters related to the IOM ‘effective’ domain. Al-Doghaither reported that having many physi- cians in charge of care resulted in a conflict in opinions regarding patient conditions and therapy plan.16 In add- ition, Alamri showed that knowledge in palliative care is suboptimal, thus impeding future practice.17 A study of the relationship between quality of inpatient care and early readmission for diabetic patients found that quality of inpatient care had a substantial effect on the risk of readmission. Adherence to the validated American Diabetes Association guidelines was also associated with reduced risk of readmission. However, adherence of healthcare providers to these guidelines was found to be suboptimal, which compromises the effective delivery of care.20 Furthermore, Hussein18 reported that a greater emphasis was needed on enhancing teamwork and devel- oping the competencies of healthcare professionals, to increase the hospital’s capacity to function effectively and address patients’ needs. The fifth reviewed study explored attitudes and practices of the healthcare provi- ders in KKUH towards clinical practice guidelines (CPGs). According to the healthcare professionals’ opinion, less than 50% of respondents agree that prac- tice should be based on scientific evidence, which shows resistance to evidence-based medicine in KSA. However, 97% of respondents agreed that CPGs were a good edu- cational tool and >90% thought that they were effective in unifying and improving the quality of patients’ care.21

Patient-centred Four studies considered the patient-centred domain. To assess the efficacy of hospital care provision, patient

T a b le

3 R e s u lt s o f th e c ri ti c a l a p p ra is a l o f th e in c lu d e d s tu d ie s

S e le c ti o n

O u tc o m e

R e p re s e n ta ti v e n e s s

o f th e s a m p le

S a m p le

s iz e

S tu d y

(f ir s t a u th o r)

N o n -r e s p o n d e n ts

A s c e rt a in m e n t

o f e x p o s u re

C o m p a ra b il it y

A s s e s s m e n t

S ta ti s ti c a l

te s t

T o ta l

o u t o f 1 0

A l A w a e t a l1 5

+ +

+ +

+ 5

A ta ll a h e t a l2 2

+ + +

+ +

+ +

7

A l- D o g h a it h e r1 6

+ +

+ +

+ +

+ +

8

A la m ri 1 7

+ +

+ +

+ +

6

M o k h ta r e t a l2 0

+ +

+ +

+ +

+ 7

H u s s e in

1 8

+ +

+ + +

+ +

7

E l- J a rd a li e t a l1 9

+ +

+ +

+ +

6

W a h a b i e t a l2 1

+ +

+ +

+ 5

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satisfaction is a key outcome measure by which one can assess the quality of hospital care. In a study about patients’ satisfaction relating to the quality of nursing

care, 86% of patients were satisfied with the quality of nursing care. However, two key factors impeding optimum patient-centred care were: ‘communication in

Table 4 Summary of studies based on safe, effective, patient-centred and timely indicators

Indicators Findings Sources

Safe ▸ Despite the barriers due to a multicultural and multilingual environment in KAUH, there is a statistically significant improvement in postaccreditation compared with preaccreditation

period in all domains measured (p<0.001). The greatest improvement was seen in the ‘Risk

Management of Information’ domain, namely a 44% perceived improvement in

‘communicating to patients about safety’ (46–90%) by nursing staff.

▸ The mean satisfaction score of inpatients with ‘Physician regularly checking up on patient’s condition/follow-up on daily rounds’ was (4.2). While the mean for ‘Physicians are unable to

know the individual condition of each patient with so many patients to see’ was (2.1).

▸ The knowledge of physicians regarding opioid use as an important medication in palliative care was generally very low.

▸ Nurses’ and physicians’ perceptions give safety a total mean score of 59.1% (low) with nurses giving a significantly lower value than physicians (56.6% vs 62.9%) and that could

be due to failures of leadership, need for better management and need to establish culture

of safety alongside leadership reform in university hospitals.

▸ First study to compare KSA patient-safety composite values with other regions around the world, namely, USA and Lebanon. Baseline assessment has identified key areas of

strengths and weaknesses in overall perception of patient safety (from staff). Feedback and

communication about errors are most strongly associated with frequency of events

reported.

15 16 17

18 19

Effective ▸ Conflict in opinions regarding patient conditions and therapy plan arises with so many physicians in charge of care.

▸ Knowledge in palliative care is suboptimal, which impedes future practice in palliative care. ▸ Quality of inpatient care exerts a substantial influence on the risk of readmission for

diabetic patients at KFUH. Also, adherence to validate the American Diabetes Association

guidelines was associated with reduced risk of readmission. However, adherence of

healthcare providers to these guidelines was found to be suboptimal in the cases, therefore

it can be thought to compromise effective delivery of care.

▸ More emphasis is required to enhance teamwork and to develop the competencies of healthcare professionals in order to increase the hospital’s capacity to function effectively

within the context of the patient’s needs.

▸ <50% of respondents agree that practice should be based on scientific evidence, which shows resistance to evidence-based medicine in KSA. 97% respondents agreed that CPGs

were good educational tools. >90% thought that they were effective in unifying and

improving the quality of patients’ care.

16 17 20

18 21

Patient-centred ▸ To assess the efficacy of hospital care provision, patient satisfaction is widely accepted as a key outcome measure by which one can assess the quality of hospital care. ‘86% of

patients showed an overall satisfaction about the quality of nursing care provided’. 2 key

factors impeding optimum patient-centred care are: ‘communication in Arabic’ and ‘lack of

instructions given to patient during preadmission’.

▸ The mean of ‘necessary precautions for maintaining patient’s privacy during physical examination’ was (4.70), and the mean of ‘patient’s condition, opinion and preference

considered in planning his/her care activities’ was (4.78). However, the mean of ‘physicians

ask patient about his/her opinion of the quality of care provided and the problems

encountered’ was (1.45) and the mean of ‘most physicians focus on treating illness rather

than taking a real interest in the patients and their complaints’ was (3.2).

▸ It is recommended that improvements be made on health education given to patients regarding diabetes, to improve the quality of their care.

▸ Nurses and physicians share a similarly low perception of patient-centred care (58.7 v 58.8%) is postulated due to: ‘insufficient support given by the leadership to a

patient-centred approach.

22 16 20 18

Timely ▸ The mean satisfaction score of inpatients with ‘physician services for patients’ requests are promptly attended to by treating physician at any hour of the day’ was (3.82).

16

CPGs, clinical practice guidelines; KAUH, King Abdulaziz University Hospital; KAAUH, King Abdul-Aziz University Hospital, Riyadh; KFUH, King Fahd University Hospital; KSA, Kingdom of Saudi Arabia.

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Arabic’ and ‘lack of instructions given to patient during preadmission’.22 In addition, another study aiming to assess ‘inpatient satisfaction with physician services’, showed that the highest mean satisfaction scores were for patient condition, opinions and preferences (4.78) and for maintaining patients’ privacy during physical examination (4.70). The lowest mean score was for asking patients about their opinions on the quality of care and the problems faced.16 Mokhtar et al20 recom- mended that improvements should be made in the health education given to patients regarding diabetes, to improve the quality of their care. Furthermore, a study about the relationship between nurses’ and physicians’ perceptions of organisational health and quality of patient care reported that nurses and physicians share a similarly low perception of patient-centred care (58.7% v 58.8%). This may be due to ‘insufficient support given by the leadership to a patient-centred approach’.18

Timely Only one of the included studies concerned the ‘timely’ domain. The study by Al-Doghaither showed that the mean satisfaction score of inpatients with physician ser- vices was higher for patients whose requests were promptly attended to by the treating physician.16

DISCUSSION This review identifies and summarises the prior studies on the quality of healthcare in university hospitals in KSA. Four of the reviewed studies collected their data in KKUH and KAAUH. Three of the studies were con- ducted in KAUH. One study used the medical records of diabetic patients admitted to KFUH. The review highlights a need to improve the quality of

healthcare delivery, specifically in areas of patient safety, clinical effectiveness and patient-centredness, at univer- sity hospitals in KSA. A recent study exemplified a link between these three dimensions, suggesting they should be considered as a group.23 Five of the reviewed studies concern patient safety as one of the important indicators of quality of care. A study by Hussein18 indicated that there was a significant difference between the mean scores of nurses’ and physicians’ perceptions regarding the safety domain, giving nurses (56.6) a lower value than physicians (62.9; p=0.024). Therefore, this differ- ence could be due to failures of leadership, a need for better management and a need to establish a culture of safety alongside leadership reform in university hospitals. According to Hughes’24 argument, the demands of patient care are carried out mainly by nurses rather than physicians. Moreover, nurses spend more time than phy- sicians do, looking after patients, which could explain the nurses’ higher workload. In addition, El-Jardali et al19 found that feedback and communication about errors are most strongly associated with lower frequency of events reported. This finding could be due to fear of reporting and some respondents’ beliefs that reporting

errors could be held against them. Van Geest and Cummins25 reported that the reasons for not reporting errors could be related to fear, humiliation and the pres- ence of a punitive response to error. However, there is a statistically significant improvement in the postaccredita- tion compared with preaccreditation period. The great- est improvement was seen in communicating to patients about safety (46–90%) as reported by nurses.15 Similarly, a previous study indicated that the accreditation pro- gramme enhanced and improved the performance and quality of care provided by healthcare services.26

The review also highlighted various issues relating to the effectiveness domain. A study about inpatient satis- faction with physician services at KKUH reported that physicians are unable to know the individual condition of each patient, with so many patients to see, which causes increasing conflict in opinions regarding patient conditions and therapy plans.16 Furthermore, another study examining the knowledge of physicians about pal- liative care in KAUH indicated it was suboptimal, imped- ing best practice in palliative care.17 Similarly, a US study showed that a low level of knowledge in palliative care has been documented for physicians who care for patients having diminished mental capacity.27

Continuous medical education and practical training should be made available to improve the level of knowl- edge in palliative care. In addition, a study regarding nurses’ and physicians’ perceptions of organisational health and quality of patient care reported that more attention is required to enhance teamwork and to develop the skills of healthcare professionals in order to increase the hospital’s capacity to function effectively within the context of patient’s needs.18 A study of the perspectives of health professionals about CPGs showed that the number of respondents agreeing that practice should be based on scientific evidence is below average, which shows resistance to evidence-based medicine in KSA.21 However, using practice based on scientific evi- dence should lead to improved outcomes and reduced costs, and should also form the basis for monitoring vari- ability in practice and identify opportunities for improvement.28

Patient satisfaction is a key outcome measure by which one can assess the quality and efficacy of hospital care provision. A study of patients’ satisfaction with the quality of nursing care provided reported an overall high level of satisfaction. However, lack of instructions given to patients during preadmission and language communication were key factors impeding optimum patient-centred care.22 Decision-makers in KSA univer- sity hospitals should consider programmes and assess- ment tools to reveal problems and issues related to language as a barrier to quality of nursing care. Another study reported that most physicians focus on treating illness rather than taking a real interest in the patients and their complaints, and they do not ask patients about their opinions of the quality of care provided.16 Also, Hussein18 indicated that nurses and physicians share a

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similarly low perception of patient-centred care. Thus, the establishment of continuing training programmes in communication and interaction skills is needed for physi- cians and nurses, to make them aware of the problems impeding optimum quality of care. Our study highlighted results similar to those of a previous study regarding the quality of care in KSA.29 The results of this systematic review show a need to enhance and improve the quality of care in the university hospitals in KSA.

Implications Further studies are needed to identify the major con- tributory factors to the current and future quality of healthcare in university hospitals in KSA. In addition, with the new government planning to increase the number of university hospitals from 4 to 23 in less than 10 years, ensuring high quality of care across all these hospital units will be a major issue. Thus, it may be necessary to establish an independent governing body for university hospitals in KSA. This organisation would offer numerous benefits, addressing the unique needs of all university hospitals. The organisation will help to develop quality health services that are coordinated and responsive to patient needs, while establishing a stronger position to improve services at university hospitals, ensuring they are tailored to the needs of the local population. This review outlines a need to provide train- ing programmes in communication skills for healthcare professionals within university hospitals.

Limitations of this review The limited number of studies in this review may not represent the actual quality of healthcare in university hospitals in KSA. The majority of the reviewed studies used a cross-sectional study design. The Newcastle Ottawa scale, used to assess the risk of bias and quality of the studies included, yielded low scores for most studies reviewed. Also, most of the study methodology used is questionnaire based and self-reported, which can lead to information bias. Moreover, the small sample size of the studies affects the generalisability in all uni- versity hospitals in KSA. Another limitation of this review is that most studies lack an adequate description of non- respondent characteristics. Although each study is con- ducted in just one university hospital, conducting multi- centre studies at other Saudi university hospitals is essential to produce more representative data.

CONCLUSION This review exemplifies the need for further improve- ment in the quality of healthcare. Many of the problems identified in this review could be addressed by establish- ing an independent governing body in KSA, which could survey healthcare services and push for improve- ments in efficiency of care provision. Moreover, a com- prehensive and continuous quality assessment and improvement system in university hospitals is essential to

achieve these objectives. Future research should aim to provide more objective assessments and identify effective interventions to improve the quality of care in university hospitals in KSA.

Collaborators Dr Sondus Hassounah and Dr Holger Kunz.

Contributors MA, SR and AM prepared the study protocol. This included designing the search strategy, helping in selecting studies for inclusion and developing a data extraction form. FM and ZC also helped in selecting studies for inclusion. MA, FM and ZC carried out the search, identified potential studies for inclusion, extracted the data, assessed the quality of the included studies, and carried out the data analysis under the supervision of SR and AM. MA, FM and ZC wrote the manuscript, which was then revised by SR and AM. All the authors have approved the final version. The guarantor is MA.

Funding This research was supported by sponsorship provided to Mohammed Aljuaid, by King Saud University, Riyadh, Saudi Arabia.. The Department of Primary Care and Public Health at Imperial College London is grateful for support from the National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research & Care (CLAHRC) scheme, the NIHR Biomedical Research Centre scheme, and the Imperial Centre for Patient Safety and Service Quality.

Competing interests None declared.

Provenance and peer review Not commissioned; externally peer reviewed.

Data sharing statement No additional data are available.

Open Access This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non- commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http:// creativecommons.org/licenses/by-nc/4.0/

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