A stakeholder approach towards hospital accreditation in India

Impacts of accreditation on the performance of primary health care centres: A systematic review

Introduction

Evidence on the impacts of accreditation on primary health care (PHC) services is inconsistent. Thus, this study aimed to assess the impacts of accreditation on the performance of PHC centres.

Method

This study systematically reviewed articles published from 2000 to 2019 in the Web of Science, Scopus, ScienceDirect, Springer, PubMed and ProQuest. The following keywords were used: ((primary care OR primary health care) AND (accreditation) AND (impact OR effect OR output OR outcome OR influence OR result OR consequences)). The database search yielded a total of41256 articles, among which 30 articles were finally included in the review.

Results

Accreditation showed the most positive impacts on the quality, effectiveness, human resource management and strategic management of PHC services. Accreditation also positively affected safety, responsiveness, accessibility, customer satisfaction, documentation, leadership, efficiency and continuity of care. Few negative impacts were noted, including the possibility of accreditation being used as a bureaucratic tool, high cost of acquiring accreditation, difficulties in understanding the accreditation process, high staff turnover rate in accredited PHC centres and weak sustainability of some accreditation programmes.

Conclusion

Given its numerous positive impacts, accreditation could be used to effectively improve the performance of PHC centres.

Implementing a quality improvement initiative for private healthcare facilities to achieve accreditation: experience from India

BACKGROUND

The Manyata program is a quality improvement initiative for private healthcare facilities in India which provided maternity care services. Under this initiative, technical assistance was provided to selected facilities in the states of Uttar Pradesh, Jharkhand and Maharashtra which were interested in obtaining 'entry level certification' under the National Accreditation Board for Hospitals and Healthcare Providers (NABH) for provision of quality services. This paper describes the change in quality at those Manyata-supported facilities when assessed by the NABH standards of care.

METHODS

Twenty-eight private-sector facilities underwent NABH assessments in the three states from August 2017 to February 2019. Baseline assessment (by program staff) and NABH assessment (by NABH assessors) findings were compared to assess the change in quality of care as per NABH standards of care. The reported performance gaps from NABH assessments were then also classified by thematic areas and suggested corrective actions based on program implementation experience.

RESULTS

The overall adherence to NABH standards of care improved from 9% in the baseline assessment to 80% in the NABH assessment. A total of 831 performance gaps were identified by the NABH assessments, of which documentation issues accounted for a majority (70%), followed by training (19%). Most performance gaps could be corrected either by revising existing documentation or creating new documentation (62%), or by orienting facility staff on various protocols (35%).

CONCLUSION

While the adherence of facilities to the NABH standards of care improved considerably, certain performance gaps remained, which were primarily related to documentation of facility policies and protocols and training of staff, and required corrective actions for the facilities to achieve NABH entry level certification.

Developing a hospital accreditation model: a Delphi study

BACKGROUND

Hospital accreditation (HA) is an external evaluation of a hospital's structures, processes and results by an independent professional accreditation body using pre-established optimum standards. The Iranian hospital accreditation system faces several challenges. The overall aim of this study was to develop a model for Iran national hospital accreditation program.

METHODS

This research uses the modified Delphi technique to develop and verify a model of hospital accreditation. The first draft of the HA model was introduced through a critical review of 20 pioneer accreditation models and semi-structured interviews with 151 key informants from Public, private, semi-public, charity and military hospitals in Iran. Three rounds of Delphi were conducted with 28 experts of hospital accreditation to verify the proposed model. Panel members were selected from authors of research articles and key speakers in the area of hospital accreditation, senior managers of the country's health system, university professors in the fields of health policy and management across the country.

RESULTS

A comprehensive model for hospital accreditation was introduced and verified in this study. The HA model has ten constructs of which seven are enablers ("Management and leadership", "Planning", "Education and Research", "employee management", "patient management", "resource management", and "process management") and three are the results ("employee results", "patient and society results" and "hospital results"). These constructs were further broken into 43 sub-constructs. The enablers and results scored 65 and 35% of the model's total scores respectively. Then, about 150 accreditation standards were written and verified.

CONCLUSIONS

A comprehensive hospital accreditation model was developed and verified. Proper attention to structures, processes and outcomes and systemic thinking during the development of the model is one of the advantages of the hospital accreditation model developed in this study. Hospital accreditation bodies can use this model to develop or revise their hospital accreditation models.

Perception of Hospital Accreditation Impact among Quality Management Professionals in India: A Survey-Based Multicenter Study

Introduction

Accreditation ensures the standard of healthcare, yet accreditation effects on service quality are much debated. Some perceive it as improving quality and organizational performance, whereas others see it as overly bureaucratic and time-consuming, so adding it has limited advantage. The aim of the present study was to understand the perception of hospital staff working in quality management (i.e., doctors, nurses, and administrators) on accreditation, and determine whether years of accreditation have had any impact on their perception.

Methods

This was a cross-sectional, descriptive, data-based study initiated by the Consortium of Accredited Healthcare Organizations. It consisted of primary data obtained in form of responses to a 30-item questionnaire and collected from 415 respondents. A probability (p) value of less than 0.05 was considered statistically significant.

Results

For all 30 items, a significantly greater number of participants had a favorable response (p < 0.001). A greater number of administrators, as compared with doctors and nurses, responded positively on the impact of accreditation (p < 0.05). Participants from hospitals with 1-4 years of accreditation, as compared with participants from hospitals with 4-12 years of accreditation, gave a favorable response (p < 0.05).

Conclusion

One of the most important hurdles to implementing accreditation programs is the dilemma of healthcare professionals, especially senior hospital staff, regarding the positive impact of accreditation. The need to educate healthcare professionals about the potential benefits of accreditation, which should resolve any cynical attitude of healthcare professionals towards accreditation, is of utmost importance.

The development of hospital accreditation in low- and middle-income countries: a literature review

Hospital accreditation has been transferred from high-income countries (HICs) to many low- and middle-income countries (LMICs), supported by a variety of advocates and donor agencies. This review uses a policy transfer theoretical framework to present a structured analysis of the development of hospital accreditation in LMICs. The framework is used to identify how governments in LMICs adopted accreditation from other settings and what mechanisms facilitated and hindered the transfer of accreditation. The review examines the interaction between national and international actors, and how international organizations influenced accreditation policy transfer. Relevant literature was found by searching databases and selected websites; 78 articles were included in the analysis process. The review concludes that accreditation is increasingly used as a tool to improve the quality of healthcare in LMICs. Many countries have established national hospital accreditation programmes and adapted them to fit their national contexts. However, the implementation and sustainability of these programmes are major challenges if resources are scarce. International actors have a substantial influence on the development of accreditation in LMICs, as sources of expertise and pump-priming funding. There is a need to provide a roadmap for the successful development and implementation of accreditation programmes in low-resource settings. Analysing accreditation policy processes could provide contextually sensitive lessons for LMICs seeking to develop and sustain their national accreditation programmes and for international organizations to exploit their role in supporting the development of accreditation in LMICs.

Challenges of implementing the accreditation model in military and university hospitals in Iran: a qualitative study

Background

The aim of this study was to present challenges of implementing the accreditation model in university and military hospitals in Iran.

Methods

In this qualitative study, purposive sampling was used to select hospital managers and implementers of the model working in 3 hospitals affiliated to Kerman University of Medical Sciences and in 3 military hospitals in Kerman, Iran. A total of 39 participants were interviewed, and semi-structured questionnaires and thematic analysis were used for data collection and analysis, respectively.

Results

In this study, 5 major codes and 17 subcodes were identified: (1) perspectives on accreditation model with 5 subcodes: a difficult and time-consuming model, less attention to the patient, accreditation as a way of money acquisition, not being cost-effective, and accreditation means incorrect documentation; (2) absence of appropriate executive policy, with 3 subcodes: lack of financial funds and personnel, disregarding local conditions in implementation and evaluation, and absence of the principle of unity of command; (3) training problems of the accreditation model, with 2 subcodes: absence of proper training and incoordination of training and evaluation; (4) human resources problems, with 3 subcodes: no profit for nonphysician personnel, heavy workload of the personnel, and physicians’ nonparticipation; (5) evaluation problems, with 4 subcodes: no precise and comprehensive evaluation, inconformity of authorities’ perspectives on evaluation, considerable change in evaluation criteria, and excessive reliance on certificates.

Conclusions

This study provided useful data on the challenges of implementing hospitals’ accreditation, which can be used by health policymakers to revise and modify accreditation procedures in Iran and other countries with similar conditions. The accreditation model is comprehensive and has been implemented to improve the quality of services and patients’ safety. The basic philosophy of hospital accreditation did not fully comply with the underlying conditions of the hospitals. The hospital staff considered accreditation as the ultimate goal rather than a means for achieving quality of service. The Ministry of Health and Medical Education performed accreditation hastily for all Iranian hospitals, while the hospitals were not prepared and equipped to implement the accreditation model.

Managers' perceptions of the effects of a national mandatory accreditation program in Danish hospitals. A cross-sectional survey

OBJECTIVE

This study aimed to examine and compare middle and senior hospital managers' perceptions of the effects of a mandatory accreditation program in Denmark, the Danish Healthcare Quality Program (Den Danske Kvalitetsmodel [DDKM]) after it was terminated in 2015.

DESIGN

A cross-sectional online questionnaire survey.

SETTING

All 26 somatic and psychiatric public hospitals in Denmark.

PARTICIPANTS

All senior and middle managers.

METHODS

A questionnaire with open and closed response (five-point Likert scale) questions. Quantitative data were analyzed descriptively and through ordered logistic regression by management level. Qualitative data were subjected to a software-assisted content analysis.

RESULTS

The response rate was 49% (533/1059). In both the qualitative and quantitative data sets, participants perceived the DDKM as having: led to an increased focus on registration, documentation and additional and unnecessary procedures. While the DDKM was perceived as increasing a focus on quality, the time required for accreditation was at the expense of patient care. There were significant differences by management level, with middle managers having more negative perceptions of the DDKM related to time spent on documentation and registration.

CONCLUSION

While the DDKM had some perceived benefits for quality improvement, it was ultimately considered time-consuming and outdated or having served its purpose. Including managers, particularly middle managers, in refinements to the new quality improvement model could capitalize on the benefits while redressing the problems with the terminated accreditation program.

Hospitals accreditation status in Indonesia: associated with hospital characteristics, market competition intensity, and hospital performance?

Background

Hospital accreditation is widely adopted as a visible measure of an organisation’s quality and safety management standards compliance. There is still inconsistent evidence regarding the influence of hospital accreditation on hospital performance, with limited studies in developing countries. This study aims to explore the association of hospital characteristics and market competition with hospital accreditation status and to investigate whether accreditation status differentiate hospital performance.

Methods

East Java Province, with a total 346 hospitals was selected for this study. Hospital characteristics (size, specialty, ownership) and performance indicator (bed occupancy rate, turnover interval, average length of stay, gross mortality rate, and net mortality rate) were retrieved from national hospital database while hospital accreditation status were recorded based on hospital accreditation report. Market density, Herfindahl-Hirschman index (HHI), and hospitals relative size as competition indicators were calculated based on the provincial statistical report data. Logistic regression, Mann-Whitney U-test, and one sample t-test were used to analyse the data.

Results

A total of 217 (62.7%) hospitals were accredited. Hospital size and ownership were significantly associated with of accreditation status. When compared to government-owned, hospital managed by ministry of defense (B = 1.705, p = 0.012) has higher probability to be accredited. Though not statistically significant, accredited hospitals had higher utility and efficiency indicators, as well as higher mortality.

Conclusions

Hospital with higher size and managed by government have higher probability to be accredited independent to its specialty and the intensity of market competition. Higher utility and mortality in accredited hospitals needs further investigation.

Electronic supplementary material

The online version of this article (10.1186/s12913-019-4187-x) contains supplementary material, which is available to authorized users.

Role of a hospital accreditation program in developing a process management system

Purpose

The purpose of this paper is to clarify the effects of the Iranian Hospital Accreditation Program (IHAP) on hospital processes from the viewpoint of the staff charged with establishing the program.

Design/methodology/approach

This qualitative study is based on the data collected in semi-structured interviews conducted in 2016, which involved eight questions. Interviews were held with 70 staff members at 14 hospitals. Managerial staff were purposively interviewed based on their familiarity and involvement with the program. The hospitals were divided into five groups, comprising public, private, charity, military and social service hospitals. A thematic analysis was carried out using the collected data.

Findings

Three themes emerged from the data, which together comprise a process management cycle: the establishment, implementation, and control phases of the program. For each phase, various positive trends, as well as hurdles for establishing the program, declared which were framed two sub-themes as positive effects and challenges.

Originality/value

The findings contribute to the body of evidence used by policy-makers and hospital managers to improve the change management processes related to the Iranian IHAP. Although positive changes in the process management cycles at Iranian hospitals were noted, successful implementation of the program demands a thorough assessment of the hospitals’ technical and financial needs (taking into account disparities between hospitals), and there is an urgent requirement for a plan to meet these needs.

Implementing a nationwide quality improvement approach in health services

PURPOSE

The purpose of this paper is to present an innovative quality improvement intervention developed in Morocco and discuss its implementation. Until 2004, the Moroccan Ministry of Health (MoH) encouraged pilots of quality improvement approaches but none of them were revealed to be sustainable. Internal assessments pinpointed factors such as lack of recognition of the participating team's efforts and lack of pressure on managers to become more accountable. In 2005, Morocco opted for an intervention called "Quality Contest" (QC) targeting health centres, hospitals and health district offices and combining quality measurement with structures ranking, performance disclosure and reward system.

DESIGN/METHODOLOGY/APPROACH

The QC is organized every 18 months. After the self-assessment and external audit step, the participating structures are ranked according to their scores. Their performances are then disseminated and the highest performing structures are rewarded.

FINDINGS

The results showed an improvement in performance among participating structures, constructive exchange of successful experiences between structures, as well as communication of constraints, needs and expectations between MoH managers at central and local levels; the use of peer-auditors was appreciated as it enabled an exchange of best practices between auditors and audited teams but this was mitigated by the difficulty of ensuring their neutrality; and the recognition of efforts was appreciated but seemed insufficient to ensure a sense of justice and maintain motivation.

ORIGINALITY/VALUE

This intervention is an example of MoH leadership that has succeeded in introducing transparency and accountability mechanisms (ranking and performance disclosure) as leverage to change the management culture of the public health services; setting up a reward system to reinforce motivation and adapting continuously the intervention to enhance its sustainability and acceptability.

Developing hospital accreditation standards in Uganda

BACKGROUND

Whereas accreditation is widely used as a tool to improve quality of healthcare in the developed world, it is a concept not well adapted in most developing countries for a host of reasons, including insufficient incentives, insufficient training and a shortage of human and material resources. The purpose of this paper is to describe refining use and outcomes of a self-assessment hospital accreditation tool developed for a resource-limited context.

METHODS

We invited 60 stakeholders to review a set of standards (from which a self-assessment tool was developed), and subsequently refined them to include 485 standards in 7 domains. We then invited 60 hospitals to test them. A study team traveled to each of the 40 hospitals that agreed to participate providing training and debrief the self-assessment. The study was completed in 8 weeks.

RESULTS

Hospital self-assessments revealed hospitals were remarkably open to frank rating of their performance and willing to rank all 485 measures. Good performance was measured in outreach programs, availability of some types of equipment and running water, 24-h staff calls systems, clinical guidelines and waste segregation. Poor performance was measured in care for the vulnerable, staff living quarters, physician performance reviews, patient satisfaction surveys and sterilizing equipment.

CONCLUSION

We have demonstrated the feasibility of a self-assessment approach to hospital standards in low-income country setting. This low-cost approach may be used as a good precursor to establishing a national accreditation body, as indicated by the Ministry's efforts to take the next steps. Copyright © 2015 John Wiley & Sons, Ltd.

Steering healthcare service delivery: a regulatory perspective

PURPOSE

The purpose of this paper is to explore regulation in India's healthcare sector and makes recommendations needed for enhancing the healthcare service.

DESIGN/METHODOLOGY/APPROACH

The literature was reviewed to understand healthcare's regulatory context. To understand the current healthcare system, qualitative data were collected from state-level officials, public and private hospital staff. A patient survey was performed to assess service quality (QoS).

FINDINGS

Regulation plays a central role in driving healthcare QoS. India needs to strengthen market and institutional co-production based approaches for steering its healthcare in which delivery processes are complex and pose different challenges.

RESEARCH LIMITATIONS/IMPLICATIONS

This study assesses current healthcare regulation in an Indian state and presents a framework for studying and strengthening regulation. Agile regulation should be based on service delivery issues (pull approach) rather than monitoring and sanctions based regulatory environment (push approach).

PRACTICAL IMPLICATIONS

Healthcare pitfalls across the world seem to follow similar follies. India's complexity and experience is useful for emerging and developed economies.

ORIGINALITY/VALUE

The author reviewed around 70 publications and synthesised them in healthcare regulatory contexts. Patient's perception of private providers could be a key input towards steering regulation. Identifying gaps across QoS dimensions would be useful in taking corrective measures.

Beyond Accreditation: A Multi-Track Quality-Enhancing Strategy for Primary Health Care in Low-and Middle-Income Countries

Many define an equitable health care system as one that provides logistical and financial access to “quality” care to the population. Realizing that fact, many low- and middle-income countries started investing in enhancing the quality of care in their health care systems, recently in primary health care. Unfortunately, in many instance, these investments have been exclusively focused on accreditation due to available guidelines and existing accrediting structures. A multi-track quality-enhancing strategy (MTQES) is proposed that includes, in addition to promoting resource-sensitive accreditation, other quality initiatives such as clinical guidelines, performance indicators, benchmarking activities, annual quality-enhancing projects, and annual quality summit/meeting. These complementary approaches are presented to synergistically enhance a continuous quality improvement culture in the primary health care sector, taking into consideration limited resources available, especially in low- and middle-income countries. In addition, an implementation framework depicting MTQES in three-phase interlinked packages is presented; each matches existing resources and quality infrastructure. Health care policymakers and managers need to think about accreditation as a beginning rather than an end to their quest for quality. Improvements in the structure of a health delivery organization or in the processes of care have little value if they do not translate to reduced disparities in access to “quality” care, and not merely access to care.

Health systems performance assessment in low-income countries: learning from international experiences

BACKGROUND

The study aimed at developing a set of attributes for a 'good' health system performance assessment (HSPA) framework from literature and experiences in different contexts and using the attributes for a structured approach to lesson learning for low-income countries (LICs).

METHODS

Literature review to identify relevant attributes for a HSPA framework; attribute validation for LICs in general, and for Uganda in particular, via a high-level Ugandan expert group; and, finally, review of a selection of existing HSPA frameworks using these attributes.

RESULTS

Literature review yielded six key attributes for a HSPA framework: an inclusive development process; its embedding in the health system's conceptual model; its relation to the prevailing policy and organizational set-up and societal context; the presence of a concrete purpose, constitutive dimensions and indicators; an adequate institutional set-up; and, its capacity to provide mechanisms for eliciting change in the health system. The expert group contextualized these attributes and added one on the adaptability of the framework.Lessons learnt from the review of a selection of HSPA frameworks using the attributes include: it is possible and beneficial to involve a range of stakeholders during the process of development of a framework; it is important to make HSPA frameworks explicit; policy context can be effectively reflected in the framework; there are marked differences between the structure and content of frameworks in high-income countries, and low- and middle-income countries; champions can contribute to put HSPA high on the agenda; and mechanisms for eliciting change in the health system should be developed alongside the framework.

CONCLUSION

It is possible for LICs to learn from literature and the experience of HSPA in other contexts, including HICs. In this study a structured approach to lesson learning included the development of a list of attributes for a 'good' HSPA framework. The attributes thus derived can be utilized by LICs like Uganda seeking to develop/adjust their HSPA frameworks as guidelines or a check list, while taking due consideration of the specific context. The review of frameworks from varied contexts, highlighted varied experiences which provide lessons for LICs.

Stakeholder analysis: theAndalusian Agency For Healthcare Quality case

The aim of this study was to identify the different groups that can affect or be affected by an agency charged with the promoting and guaranteeing of health care quality in Andalusian region (Spain) and to provide a framework with the stakeholders included in different categories. The study adopted a cross-sectional research design. A case study with structured interviews among Andalusian Agency for Healthcare Quality Steering Committee members was carried out in 2010 to define stakeholders' categories and map the interest groups using 5 attributes: influence, importance, legitimacy, power, and urgency. After identification and categorization, stakeholders were weighted qualitatively according to the attributes of importance and influence using 4 possible levels. A matrix was made with the collected data relating both attributes. Furthermore, 8 different types of stakeholders were identified according to attributes power, legitimacy, and urgency. The study concludes that identifying and classifying stakeholders are fundamental to ensuring the success of an organization that must respond to needs and expectations, especially those of its clients. Moreover, knowing stakeholder linkages can contribute to increase organizational worth. This is essential for organizations basically directed to the provision of services in the scope of health care.

Stakeholder perspectives on implementing accreditation programs: a qualitative study of enabling factors

BACKGROUND

Accreditation programs are complex, system-wide quality and safety interventions. Despite their international popularity, evidence of their effectiveness is weak and contradictory. This may be due to variable implementation in different contexts. However, there is limited research that informs implementation strategies. We aimed to advance knowledge in this area by identifying factors that enable effective implementation of accreditation programs across different healthcare settings.

METHODS

We conducted 39 focus groups and eight interviews between 2011 and 2012, involving 258 diverse healthcare stakeholders from every Australian State and Territory. Interviews were semi-structured and focused on the aims, implementation and consequences of three prominent accreditation programs in the aged, primary and acute care sectors. Data were thematically analysed to distil and categorise facilitators of effective implementation.

RESULTS

Four factors were identified as critical enablers of effective implementation: the accreditation program is collaborative, valid and uses relevant standards; accreditation is favourably received by health professionals; healthcare organisations are capable of embracing accreditation; and accreditation is appropriately aligned with other regulatory initiatives and supported by relevant incentives.

CONCLUSIONS

Strategic implementation of accreditation programs should target the four factors emerging from this study, which may increase the likelihood of accreditation being implemented successfully.

Accreditation of hospitals in Lebanon: is it a worthy investment?

OBJECTIVE

This study explores the views of Lebanese hospitals on the worthiness of accreditation vis-à-vis its associated expenses in addition to examining the type and source of financial investments incurred during the accreditation process.

DESIGN

Observational cross-sectional design.

PARTICIPANTS

All private short-stay hospitals registered with the Syndicate of Private Hospitals in Lebanon (110 hospitals).

MAIN OUTCOME MEASURE

Hospital's views on the worthiness of accreditation in lieu of its associated expenses. Other measures explored included areas of expenditure increase and sources of expenses coverage for accreditation.

RESULTS

Three-fifths of responding hospitals (63% response rate) considered accreditation as a worthy investment. Favorable views on accreditation were mostly related to its effect on enhanced quality and safety culture. Unfavorable views regarding the worthiness of accreditation investment were justified by absence of link with enhanced tariffs from payers (25.7%). All hospitals incurred increased expenses due to accreditation. Areas of highest increase included training of staff (95.7%), consultants' costs (80.0%) and infrastructure maintenance (77.1%). Most of the hospitals covered expenses through internal absorption (52%) or bank loans (45.7%).

CONCLUSIONS

The financial burden of accreditation on hospitals has to be factored in the decision of its adoption at a national level, especially in developing countries.

Narrative synthesis of health service accreditation literature

AIMS

To systematically identify and synthesise health service accreditation literature.

METHODS

A systematic identification and narrative synthesis of health service accreditation literature published prior to 2012 were conducted. The search identified 122 empirical studies that examined either the processes or impacts of accreditation programmes. Study components were recorded, including: dates of publication; research settings; levels of study evidence and quality using established rating frameworks; and key results. A content analysis was conducted to determine the frequency of key themes and subthemes examined in the literature and identify knowledge-gaps requiring research attention.

RESULTS

The majority of studies (n=67) were published since 2006, occurred in the USA (n=60) and focused on acute care (n=79). Two thematic categories, that is, 'organisational impacts' and 'relationship to quality measures', were addressed 60 or more times in the literature. 'Financial impacts', 'consumer or patient satisfaction' and 'survey and surveyor issues' were each examined fewer than 15 times. The literature is limited in terms of the level of evidence and quality of studies, but highlights potential relationships among accreditation programmes, high quality organisational processes and safe clinical care.

CONCLUSIONS

Due to the limitations of the literature, it is not prudent to make strong claims about the effectiveness of health service accreditation. Nonetheless, several critical issues and knowledge-gaps were identified that may help stimulate and inform discussion among healthcare stakeholders. Ongoing effort is required to build upon the accreditation evidence-base by using high quality experimental study designs to examine the processes, effectiveness and financial value of accreditation programmes and their critical components in different healthcare domains.

The attitude of health care professionals towards accreditation: A systematic review of the literature

Accreditation is usually a voluntary program, in which authorized external peer reviewers evaluate the compliance of a health care organization with pre-established performance standards. The aim of this study was to systematically review the literature of the attitude of health care professionals towards professional accreditation. A systematic search of four databases including Medline, Embase, Healthstar, and Cinhal presented seventeen studies that had evaluated the attitudes of health care professionals towards accreditation. Health care professionals had a skeptical attitude towards accreditation. Owners of hospitals indicated that accreditation had the potential of being used as a marketing tool. Health care professionals viewed accreditation programs as bureaucratic and demanding. There was consistent concern, especially in developing countries, about the cost of accreditation programs and their impact on the quality of health care services.

Acreditação: ferramenta ou política para organização dos sistemas de saúde?

OBJETIVO: Buscar na literatura científica que trata do tema acreditação, elementos que possam indicar a articulação existente entre a metodologia e a formulação de políticas, para a organização de sistemas de saúde, com o intuito de problematizar a percepção corrente da acreditação, como uma ferramenta da qualidade destituída de intenções dos governos. MÉTODO: Optou-se pela revisão integrativa da literatura tendo como bases bibliográficas a LILACS, SCOPUS e ISI Web of Knowledge. RESULTADO: No mundo, a metodologia parece estar próxima a uma ferramenta da política, constituindo diretrizes para a organização e avaliação dos serviços e sistemas de saúde. CONCLUSÃO: Não existe uma visão única sobre os propósitos de um sistema de acreditação. Portanto, no caso brasileiro, designá-la apenas como ferramenta de qualidade ou produto de mercado seria prematuro.

Healthcare accreditation systems: further perspectives on performance measures

OBJECTIVE

The purpose of this paper is to identify and suggest a number of performance measures to facilitate the evaluation of accreditation programs in healthcare.

METHODS

The paper is based on an exploratory research which has used qualitative methods, including snowball sampling technique, email interview and thematic content analysis.

PARTICIPANTS

Respondents (experts and professionals) were selected from a diverse spectrum ranging from healthcare organizations, universities and accreditation-associated institutions.

RESULTS

The analysis of the data provided key measures to be considered in the evaluation of accreditation programs' impact at macro and micro levels as well as their nature and operations. The measures can be used to, for example, assess the degree of stakeholders' reliance on accreditation results, measure the cost of accreditation for participating organizations and serve as a formal mechanism for accredited organizations to appeal accreditation decisions.

CONCLUSIONS

This paper has brought together a number of generic, yet influential and workable, measures which could be utilized for assessing the overall performance of an accreditation program in healthcare. The application of these measures depends on the features of given accreditation program and the context in which the program operates. Therefore, the next step/steps in the assessment of an accreditation program might be choosing the measures suiting that program.

Addressing access barriers to health services: an analytical framework for selecting appropriate interventions in low-income Asian countries

While World Health Organization member countries embraced the concept of universal coverage as early as 2005, few low-income countries have yet achieved the objective. This is mainly due to numerous barriers that hamper access to needed health services. In this paper we provide an overview of the various dimensions of barriers to access to health care in low-income countries (geographical access, availability, affordability and acceptability) and outline existing interventions designed to overcome these barriers. These barriers and consequent interventions are arranged in an analytical framework, which is then applied to two case studies from Cambodia. The aim is to illustrate the use of the framework in identifying the dimensions of access barriers that have been tackled by the interventions. The findings suggest that a combination of interventions is required to tackle specific access barriers but that their effectiveness can be influenced by contextual factors. It is also necessary to address demand-side and supply-side barriers concurrently. The framework can be used both to identify interventions that effectively address particular access barriers and to analyse why certain interventions fail to tackle specific barriers.

Regulating India's health services: to what end? What future?

India has a comprehensive legal and regulatory framework and large public health delivery system which are disconnected from the realities of health care delivery and financing for most Indians. In reviewing the current bureaucratic approach to regulation, we find an extensive set of rules and procedures, though we argue it has failed in three critical ways, namely to (1) protect the interests of vulnerable groups; (2) demonstrate how health financing meets the public interests; (3) generate the trust of providers and the public. The paper reviews the state of alternative approaches to regulation of health services in India, using consumer and market based approaches, as well as multi-actor and collaborative approaches. We argue that poor regulation is a symptom of poor governance and that simply creating and enforcing the rules will continue to have limited effects. Rather than advocate for better implementation and expansion of the current bureaucratic approach, where Ministries of Health focus on their roles as inspectorate and provider, we propose that India's future health system is more likely to achieve its goals through greater attention to consumer and other market oriented approaches, and through collaborative mechanisms that enhance accountability. Civil society organizations, the media, and provider organizations can play more active parts in disclosing and using information on the use of health resources and the performance of public and private providers. The overview of the health sector would be more effective, if Indian Ministries of Health were to actively facilitate participation of these key stakeholders and the use of information.

Reviewing the application of the balanced scorecard with implications for low-income health settings

High-income countries (HICs) are increasingly making use of the balanced scorecard (BSC) in healthcare. Evidence about BSC usage in low-income countries (LICs) is deficient. This study assessed feasibility of BSC use in LICs. Systematic review of electronic databases shows that the BSC improved patient, staff, clinical, and financial outcomes in HICs. To translate the experience of BSC use in HICs to their use in LICs, the applicability parameters of the National Committee for Quality Assurance were applied. Despite contextual challenges, pilot testing of BSC use can be undertaken in selected LICs. Committed leadership, cultural readiness, quality information systems, viable strategic plans, and optimum resources are required.

Regulating health care in low- and middle-income countries: Broadening the policy response in resource constrained environments

Regulation is traditionally seen as the use of bureaucratic and administrative controls by government to correct market failure. Yet traditional methods such as licensing and certification frequently fail to control behaviour because of the limited resources available to government in low- and middle-income countries, and because of the powerful countervailing incentives that encourage deviant behaviour to continue. It is increasingly being realised, therefore, that goals of policy can sometimes be achieved more efficiently by involving other actors in the regulatory mechanism. In addition, a more flexible view of regulatory tools and strategies may enable governments, particularly in resource constrained environments, to utilise a much wider range of administrative controls and market enhancing incentives. The review suggests a wide range of tools that may be utilised to encourage better behaviour. These require that governments become aware of the need to reinforce controls with enabling incentives, utilise external standards where local measures are deemed inadequate and promote greater access to information on standards and services to consumers and providers.

A prospective, multi-method, multi-disciplinary, multi-level, collaborative, social-organisational design for researching health sector accreditation [LP0560737]

BACKGROUND

Accreditation has become ubiquitous across the international health care landscape. Award of full accreditation status in health care is viewed, as it is in other sectors, as a valid indicator of high quality organisational performance. However, few studies have empirically demonstrated this assertion. The value of accreditation, therefore, remains uncertain, and this persists as a central legitimacy problem for accreditation providers, policymakers and researchers. The question arises as to how best to research the validity, impact and value of accreditation processes in health care. Most health care organisations participate in some sort of accreditation process and thus it is not possible to study its merits using a randomised controlled strategy. Further, tools and processes for accreditation and organisational performance are multifaceted.

METHODS/DESIGN

To understand the relationship between them a multi-method research approach is required which incorporates both quantitative and qualitative data. The generic nature of accreditation standard development and inspection within different sectors enhances the extent to which the findings of in-depth study of accreditation process in one industry can be generalised to other industries. This paper presents a research design which comprises a prospective, multi-method, multi-level, multi-disciplinary approach to assess the validity, impact and value of accreditation.

DISCUSSION

The accreditation program which assesses over 1,000 health services in Australia is used as an exemplar for testing this design. The paper proposes this design as a framework suitable for application to future international research into accreditation. Our aim is to stimulate debate on the role of accreditation and how to research it.

Comparison of health care professionals' and surveyors' opinions on problems and obstacles in implementing quality management system in Thailand: A national survey

OBJECTIVE

To explore problems and obstacles of hospitals in Thailand implementing quality management systems according to the hospital accreditation (HA) standards.

DESIGN

Questionnaire survey.

SETTING

Thirty-nine hospitals in all 13 regions of Thailand.

PARTICIPANTS

A total of 728 health care professionals and 41 surveyors of the national accreditation program.

MAIN OUTCOME MEASURES

Health care professionals' and surveyors' opinions on problems and obstacles in 24 items representing Thailand HA standards.

RESULTS

The response rates were 94.9 and 73.2% in health care professionals and surveyors, respectively. More than 90% of both groups thought that there had been problems in the items such as 'quality improvement (QI) activities' and 'integration and utilization of information'. The items considered by health care professionals as major obstacles included 'adequacy of staff' (34.6%) and 'integration and utilization of information' (26.6%), for example. For surveyors, 'integration and utilization of information' was ranked highest as presenting a major obstacle (43.9%), followed by 'discharge and referral process' (31.7%) and 'medical recording process' (29.3%). The rank orders for the 24 items as problems and major obstacles were similar in both groups (Spearman's rank correlation 0.436, P = 0.033 and 0.583, P = 0.003, respectively). Surveyors had a higher degree of concern and paid more attention to care-related items than health care professionals.

CONCLUSIONS

Health care professionals have been facing many problems with multidisciplinary process-related issues of the accreditation standard, whereas surveyors might have had some difficulties in conveying the core QI concepts to them. The findings might be explained by the effects of health care reform on the underlying accreditation principles. One of the strategies to respond to the situation was presented.

Treatment-seeking behaviour in urban Sri Lanka: trusting the state, trusting private providers

Trust is central to good relationships between patients and health-care providers because, firstly, patient uncertainty about health conditions requires them to have confidence in a doctor's motives and decisions, and secondly, trust facilitates communication and patient focus which encourages people to utilise health services. This paper focuses on patient trust because of its effect on treatment-seeking behaviour and the treatment costs incurred by poor households. Drawing from other studies the paper distinguishes between trust based on the perceived technical competence of the provider, and on inter-personal dimensions of quality of care. Trust is also analysed at two inter-related levels: personal trust that is built through face-to-face encounters with providers; and more abstract institution-level trust. The paper applies these notions of trust to examine treatment-seeking behaviour in two poor urban communities in Colombo, Sri Lanka. Household survey data and qualitative data show that people from a range of income groups preferred to use public providers for more serious illnesses because public services were free and they trusted the technical competence of public providers at both a personal and institutional level. The data also show, however, that inter-personal quality of care was lacking in the public sector and that residents from the two communities, including a considerable minority of the poorest, preferred to use private providers for moderate acute illnesses. People were willing to pay for private services because it saved time, doctors listened and they could build better relationships with private doctors. Despite the strengths of Sri Lanka's public health sector, poor relationships act as an access barrier and push a range of income groups to the private sector. The threat to access and affordability posed by these poor relationships should be the focus of current reform debates.

Hot topics in international emergency medicine

The Global Burden of Disease report published in 1996 predicted that by 2020 the majority of illness burden globally will be from in-juries, mental illness, and chronic diseases. Patients with many of the disorders leading the list frequently require emergent care. This article provides a brief literature-based introduction to these and other important topics relevant to international development of emergency medicine.

The role of oversight in the health sector: the example of sexual and reproductive health services in India

This paper examines the role of oversight in influencing the health sector, using examples from sexual and reproductive health services in India. Rather than simply trying to provide services through traditional bureaucratic mechanisms, governments can make use of oversight tools to influence how health care is delivered through the public and private sectors. Three main oversight functions are described: understanding health system performance, deciding when to intervene in the health system and strategizing and implementing change. Governments also need to understand the ethical basis for decisions. The potential for administering oversight through policy-making, disclosing and informing, regulating, collaborating, and strategically subsidising and contracting services in sexual and reproductive health is described. This approach implies an engagement with a broader set of stakeholders in the health sector than is often the case. It requires a set of skills for public officials beyond managing public programmes, and relies on a larger role for other stakeholders and the general public. When applied to reproductive and sexual health, implementation of the full range of oversight functions offers new opportunities to provide more effective, equitable, accountable and affordable services.