Accreditation and ISO certification: do they explain differences in quality management in European hospitals?

Quality Objectives in Standardized Quality Management Systems

BACKGROUND AND OBJECTIVES

The effectiveness of a quality management system consistent with the ISO 9001 standard depends on how quality objectives are established and pursued. The aims of this article are to identify quality objectives in selected certified organizations providing medical services, assess their compliance with the requirements of the ISO 9001 standard, and determine factors influencing such objectives.

METHODS

The first theoretical part of the article is based on a systematic literature review. The empirical part contains an analysis of documentation related to quality management systems and conducted audits. The data were collected during 42 quality management system audits conducted in 16 health care organizations in the years 2015-2020. Uncategorized interviews were conducted with quality management system representatives. The data were verified by interviews with 6 management system auditors having at least 15 years' experience in auditing health care organizations. The assessment of the methodological correctness is based on the ISO 9001:2015 standard criteria.

RESULTS

The most frequently formulated quality objectives include improving customer satisfaction, task-based objectives related to planned works, improvements, and development of new medical services. The quality objectives fulfill the requirements of the ISO 9001 standard. However, they are not ambitious. The most significant factors influencing the processes of goal setting are economic (financial incentives, available resources for modernization), social (community needs), and managerial (the scope of performed analyses, the quality of the audit process, and the calculation of necessary effort).

CONCLUSIONS

Health care organizations need to pursue more ambitious objectives, intensify the use of performed medical analyses, and integrate quality objectives into management remuneration systems.

Assessing the Presence of the Joint Commission International Accreditation Requirements in Western Saudi Arabia Hospital Pharmacies: A Cross-sectional Study

Objective

The Central Board of Accreditation for Healthcare Institutions (CBAHI) the national Saudi accreditation body accredited most hospitals in Saudi Arabia whereas, the Joint Commission International (JCI) a well-known international accreditation body accredited some hospitals. We assessed Western Saudi Arabia hospital pharmacists' knowledge, opinions, and observations about pharmacy-related JCI accreditation criteria needed for hospitals.

Methods

This was a cross-sectional survey-based study conducted among pharmacy personnel working in the Ministry of Health (MOH), Military, and private hospitals in the Makkah region in western Saudi Arabia. The present report represents the findings of descriptive and comparative analyses. Comparative analyses were tested by Student's t-test, analysis of variance, and Chi-square when applicable and a P ≤ 0.05 was considered statistically significant.

Findings

One hundred and one pharmacists completed the survey; most of them were from Taif (53.5%) and Jeddah (37.6%) and fewer from Makkah (8.9%). The highest proportions were from MOH (55.4%), private (29.7%), and some from military (14.9%) hospitals. They worked mostly in hospitals accredited with CBAHI (93.1%) than JCI (58.4%) and only (41.6%) worked with quality units. Correct answers on knowledge items ranged from 14.9% to 65.3%. On five-point Likert Scale, they showed supportive ratings on how they perceived the importance of JCI statement provided (overall average score: 3.78) and on how statement criteria are implemented in their hospitals (overall average score: 3.76). Higher proportions of those working in quality units compared to their counterparts were aware that accreditation cycles for JCI and CBAHI are identical (66.7% vs. 55.9%, P = 0.009) and that JCI criteria are more concise than CBAHI (59.5% vs. 52.5%, P = 0.007). Higher proportions of those working in JCI-accredited hospitals compared to their counterparts were aware that JCI criteria are clearer than CBAHI (55.9% vs. 33.3%, P = 0.021) and that JCI criteria are more concise than CBAHI (61% vs. 47.6%, P = 0.012).

Conclusion

To a high extent, pharmacists were supportive of JCI criteria and considered the criteria to be implemented in their hospitals. There is a room for improvement to enhance awareness and support of JCI quality criteria among pharmacists.

Implementation of an Integrated Total Quality Management System in a Pulmonary Function Laboratory

BACKGROUND AND OBJECTIVES

A worldwide objective in the area of health is to offer high-quality services supported by certification strategies that contribute to improving standards for processes commonly used in medicine. However, few pulmonary function test laboratories (PFTLs) follow official standards in their daily operations or are organized around an integrated total quality management system (ITQMS) focused on their established processes. The aim was to determine the feasibility of implementing an ITQMS to accredit the International Organization for Standardization (ISO) 9001:2015 standard in a high-demand PFTL where 13 respiratory function tests are routinely performed together with teaching and research activities.

METHODS

This project was conducted at the PFTL of the Instituto Nacional de Enfermedades Respiratorias in Mexico City from November 2014 to August 2017 and involved the implementation of an ITQMS guided by ISO 9001:2015 in 5 phases: (1) the establishment of a work team; (2) the elaboration of situational diagnoses; (3) the development of guidelines for the ITQMS; (4) the implementation of the ITQMS model; and (5) the evaluation of the ITQMS.

RESULTS

Upon completing the 5 phases, an evaluation of the system by an internal audit identified 3 minor cases of nonconformity (NC), while additional observations and an external audit found 5 minor cases of NC. These issues were addressed through a root-cause analysis to establish an action plan for each one. At the end of the process, the institution was granted the ISO 9001:2015 certification for its 3 processes: medical attention in support of diagnoses, teaching, and research.

CONCLUSIONS

It is possible to implement an ISO quality management system as a routine operating methodology in a high-demand PFTL.

The impact of hospital accreditation on the quality of healthcare: a systematic literature review

BACKGROUND

Accreditation is viewed as a reputable tool to evaluate and enhance the quality of health care. However, its effect on performance and outcomes remains unclear. This review aimed to identify and analyze the evidence on the impact of hospital accreditation.

METHODS

We systematically searched electronic databases (PubMed, CINAHL, PsycINFO, EMBASE, MEDLINE (OvidSP), CDSR, CENTRAL, ScienceDirect, SSCI, RSCI, SciELO, and KCI) and other sources using relevant subject headings. We included peer-reviewed quantitative studies published over the last two decades, irrespective of its design or language. Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, two reviewers independently screened initially identified articles, reviewed the full-text of potentially relevant studies, extracted necessary data, and assessed the methodological quality of the included studies using a validated tool. The accreditation effects were synthesized and categorized thematically into six impact themes.

RESULTS

We screened a total of 17,830 studies, of which 76 empirical studies that examined the impact of accreditation met our inclusion criteria. These studies were methodologically heterogeneous. Apart from the effect of accreditation on healthcare workers and particularly on job stress, our results indicate a consistent positive effect of hospital accreditation on safety culture, process-related performance measures, efficiency, and the patient length of stay, whereas employee satisfaction, patient satisfaction and experience, and 30-day hospital readmission rate were found to be unrelated to accreditation. Paradoxical results regarding the impact of accreditation on mortality rate and healthcare-associated infections hampered drawing firm conclusions on these outcome measures.

CONCLUSION

There is reasonable evidence to support the notion that compliance with accreditation standards has multiple plausible benefits in improving the performance in the hospital setting. Despite inconclusive evidence on causality, introducing hospital accreditation schemes stimulates performance improvement and patient safety. Efforts to incentivize and modernize accreditation are recommended to move towards institutionalization and sustaining the performance gains. PROSPERO registration number CRD42020167863.

A framework for the implementation of certification procedures in nurse level: a mixed approach study

Background

The implementation of certification procedures across healthcare systems is an essential component of the management process. Several promising approaches were developed toward a successful implementation of such policies; however, a precise adaptation and implementation to each local context was essential. Local activities must be considered in order to generate more pragmatic recommendations for managers. In this study, we built a framework for the implementation of certification procedures at nurse activity level. This was developed using two objectives: the identification of key implementation process components, and the integration of these components into a framework which considered the local socio-material context of nurses’ work.

Methods

We used a two-step mixed approach. The first was inductive and consisted of a qualitative case study conducted between April and December 2019. Here, we analyzed the implementation of certification procedures in a French teaching hospital. Data were collected using semi-structured interviews and observations. In the second approach, emerging data were deductively analyzed using the Quality Implementation Tool (QIT) and Translational Mobilization Theory (TMT). Analyses were combined to construct an implementation framework.

Results

Sixteen interviews were conducted with participants from different organizational levels, managers, mid-managers, and nurses. Additionally, 83 observational hours were carried out in two different wards. Our results showed that, (1) All retrieved elements during the process were successfully captured by the QIT components, only one component was not applicable. (2) We identified elements related to the local activity context, with the different interrelationships between actors, actions, and contexts using the TMT. (3) Our analyses were integrated and translated into a framework that presents the implementation of certification procedures in healthcare facilities, with a specific interest to the nurse/mid-manager level. By initially using QIT, the framework components took on a transversal aspect which were then adapted by TMT to the local work context.

Conclusions

We successfully generated a framework that supports the implementation of certification procedures at the activity level. Our approach identified a broader vision of the interactions between proximity managers, teams, and contexts during change mobilization, which were not encompassed by transversal framework only, such as QIT. In the future, more empirical studies are needed to test this framework.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06940-0.

Hospital accreditation impact on healthcare quality dimensions: a systematic review

PURPOSE

To systematically review the impact of hospital accreditation on healthcare quality indicators, as classified into seven healthcare quality dimensions.

DATA SOURCE

We searched eight databases in June 2020: EBSCO, PubMed, Web of Science, Emerald, ProQuest, Science Direct, Scopus and Virtual Health Library. Search terms were conceptualized into three groups: hospitals, accreditation and terms relating to healthcare quality. The eligibility criteria included academic articles that applied quantitative methods to examine the impact of hospital accreditation on healthcare quality indicators.

STUDY SELECTION

We applied the PICO framework to select the articles according to the following criteria: Population-all types of hospitals; Intervention-hospital accreditation; Comparison-quantitative method applied to compare accredited vs. nonaccredited hospitals, or hospitals before vs. after accreditation; Outcomes-regarding the seven healthcare quality dimensions. After a critical appraisal of the 943 citations initially retrieved, 36 studies were included in this review.

RESULTS OF DATA SYNTHESIS

Overall results suggest that accreditation may have a positive impact on efficiency, safety, effectiveness, timeliness and patient-centeredness. In turn, only one study analyzes the impact on access, and no study has investigated the impact on equity dimension yet.

CONCLUSION

Mainly due to the methodological shortcomings, the positive impact of accreditation on healthcare dimensions should be interpreted with caution. This study provides an up-to-date overview of the main themes examined in the literature, highlighting critical knowledge-gaps and methodological flaws. The findings may provide value to healthcare stakeholders in terms of improving their ability to assess the relevance of accreditation processes.

Clinicians' perspectives on quality: do they match accreditation standards?

BACKGROUND

Quality of training is determined through programs' compliance with accreditation standards, often set for a number of years. However, perspectives on quality of training within these standards may differ from the clinicians' perspectives on quality of training. Knowledge on how standards relate to clinicians' perspectives on quality of training is currently lacking yet is expected to lead to improved accreditation design.

METHODS

This qualitative study design was based on a case-study research approach. We analyzed accreditation standards and conducted 29 interviews with accreditors, clinical supervisors and trainees across Australia and the Netherlands about the quality and accreditation of specialist medical training programs. The perspectives were coded and either if applicable compared to national accreditation standards of both jurisdictions, or thematized to the way stakeholders encounter accreditation standards in practice.

RESULTS

There were two evident matches and four mismatches between the perspectives of clinicians and the accreditation standards. The matches are: (1) accreditation is necessary (2) trainees are the best source for quality measures. The mismatches are: (3) fundamental training aspects that accreditation standards do not capture: the balance between training and service provision, and trainee empowerment (4) using standards lack dynamism and (5) quality improvement; driven by standards or intrinsic motivation of healthcare professionals.

CONCLUSION

In our Australian and Dutch health education cases accreditation is an accepted phenomenon which may be improved by trainee empowerment, a dynamic updating process of standards and by flexibility in its use.

A focused ethnography in the context of a European cancer research hospital accreditation program

Background

A quality accreditation program (AP) is designed to guarantee predefined quality standards of healthcare organizations. Evidence of the impact of quality standards remains scarce and somewhat challenging to document. This study aimed to investigate the accreditation of a cancer research hospital (Italy), promoted by the Organization of European Cancer Institutes (OECI), by focusing on the individual, group, and organizational experiences resulting from the OECI AP.

Methods

A focused ethnography study was carried out to analyze the relevance of participation in the accreditation process. Twenty-nine key informants were involved in four focus group meetings, and twelve semistructured interviews were conducted with professionals and managers. Inductive qualitative content analysis was applied to examine all transcripts.

Results

Four main categories emerged: a) OECI AP as an opportunity to foster diversity within professional roles; b) OECI AP as a possibility for change; c) perceived barriers; and d) OECI AP-solicited expectations.

Conclusions

The accreditation process is an opportunity for improving the quality and variety of care services for cancer patients through promoting an interdisciplinary approach to care provision. Perceiving accreditation as an opportunity is a prerequisite for overcoming the barriers that professionals involved in the process may report. Critical to a positive change is sharing the values and the framework, which are at the basis of accreditation programs. Improving the information-sharing process among managers and professionals may limit the risk of unmet expectations and prevent demotivation by future accreditation programs. Finally, we found that positive changes are more likely to happen when an accreditation process is considered an activity whose results depend on managers’ and professionals’ joint work.

A baseline assessment of patient safety culture and its associated factors from the perspective of critical care nurses: Results from 10 hospitals

INTRODUCTION

Critical care nurses are considered the key to patient safety improvement and play a vital role in enhancing quality of care in intensive care units (ICUs) where adverse events are frequent and have severe consequences. Moreover, there is recognition of the importance of the assessment and the development of patient safety culture (PSC) as a strategic focus for the improvement of patient safety and healthcare quality, notably in critical care settings.

OBJECTIVES

This study aimed to assess critical care nurses' perception of PSC and to determine its associated factors.

METHODS

This cross-sectional study was conducted among nurses working in the ICUs of the Tunisian centre (six Tunisian governorates). The study instrument was the French validated version of the Hospital Survey on Patient Safety Culture questionnaire, comprising 10 dimensions and a total of 50 items.

RESULTS

A total of 249 nurses from 18 ICUs participated in the study, with a participation rate of 87.36%. The dimensions scores ranged between 17.2% for the dimension "frequency of events reported" and 50.1% for the dimension "teamwork within units". Multivariable logistic regression indicated that respondents who worked in private hospitals were five times more likely to have a developed PSC (adjusted odds ratio [AOR]: 5.34; 95% confidence interval [CI], [2.28, 12.51]; p < 10^-3). Similarly, participants who worked in a certified hospital were two times more likely to have a more developed PSC than respondents who work in noncertified hospitals (AOR: 2.51; 95% CI, [.92-6.82]; p = 0.041). In addition, an increased nurse-per-patient ratio (i.e., reduced workload) increased PSC (AOR: 1.10; 95% CI, [1.02-1.12]; p = 0.018).

CONCLUSION

This study has shown that the state of critical care nurses' PSC is critically low and these baseline results can help to form a plan of actions for improvements.

Effects of external inspections on sepsis detection and treatment: a stepped-wedge study with cluster-level randomisation

OBJECTIVE

To evaluate the effects of external inspections on (1) hospital emergency departments' clinical processes for detecting and treating sepsis and (2) length of hospital stay and 30-day mortality.

DESIGN

Incomplete cluster-randomised stepped-wedge design using data from patient records and patient registries. We compared care processes and patient outcomes before and after the intervention using regression analysis.

SETTING

Nationwide inspections of sepsis care in emergency departments in Norwegian hospitals.

PARTICIPANTS

7407 patients presenting to hospital emergency departments with sepsis.

INTERVENTION

External inspections of sepsis detection and treatment led by a public supervisory institution.

MAIN OUTCOME MEASURES

Process measures for sepsis diagnostics and treatment, length of hospital stay and 30-day all-cause mortality.

RESULTS

After the inspections, there were significant improvements in the proportions of patients examined by a physician within the time frame set in triage (OR 1.28, 95% CI 1.07 to 1.53), undergoing a complete set of vital measurements within 1 hour (OR 1.78, 95% CI 1.10 to 2.87), having lactate measured within 1 hour (OR 2.75, 95% CI 1.83 to 4.15), having an adequate observation regimen (OR 2.20, 95% CI 1.51 to 3.20) and receiving antibiotics within 1 hour (OR 2.16, 95% CI 1.83 to 2.55). There was also significant reduction in mortality and length of stay, but these findings were no longer significant when controlling for time.

CONCLUSIONS

External inspections were associated with improvement of sepsis detection and treatment. These findings suggest that policy-makers and regulatory agencies should prioritise assessing the effects of their inspections and pay attention to the mechanisms by which the inspections might contribute to improve care for patients.

TRIAL REGISTRATION

NCT02747121.

Promoting patients' rights through hospital accreditation

BACKGROUND

Over the past decade, hospitals in many countries, including Israel, have undergone an accreditation process aimed at improving the quality of services provided. This process also refers to the protection and promotion of patients' rights. However, reviewing the criteria and content included in this category in the Israeli context reveals definitions and implications that differ from those presented by the law - specifically the Patient's Rights Act 1995. Moreover, the rights included in it are not necessarily equally represented in other legislation.

METHODS

This study seeks to examine the question of whether and to what extent the scope, contents, and definitions of patients' rights in the JCI Standards are similar to or different from patients' rights as they are addressed and protected in national legislation. The article provides a comparison and examination of the different regulatory frameworks of patients' rights, especially those in the accreditation of healthcare institution and legislation, analyzes the gaps between such frameworks, and suggests possible implications on our understanding of the concept of patients' rights.

RESULTS

The patients' right chapter in the accreditation process introduces and promotes the concepts of patient and family rights, increases the awareness and compliance of such concepts, and may create greater consistency in their introduction and application.

CONCLUSIONS

Discussion of the Israeli case not only demonstrates how regulatory frameworks are instrumental - for broader policy purposes, especially in the area of patients' rights and the rights of patients' families - but also calls for a more general examination of the concept of patients' rights in health policies and its contribution to the quality of health services. Reference to patients' rights in accreditation of healthcare institutions may promote and enhance this concept and contribute to the delivery of care, thereby complementing a lacuna in the law.

Knowledge mapping of hospital accreditation research: a coword analysis

PURPOSE

Hospital accreditation has been adopted internationally as a way and solution for healthcare quality improvement in hospitals. The purpose of this study was to review and knowledge mapping of bibliographic data about "Hospital Accreditation" and assess the current quantitative trends.

DESIGN/METHODOLOGY/APPROACH

Scientometric methods and knowledge visualization using the coword analysis techniques conducted in three steps based on the data related to the field of hospital accreditation from 1975 to 2018 obtained from the MEDLINE database. Bibliographic data for titles, abstracts and keywords articles were saved in CSV format and MEDLINE templates by applying filters. Data extracted were exported into an Excel spreadsheet and were preprocessed. The authors applied the text mining and visualization using VOSviewer software.

FINDINGS

Hospital accreditation studies have been increased rapidly over the past 30 years. 6,661 documents in the field of hospital accreditation had been published from 1975 to 2018. Hospitals or organizations active in the field of hospital accreditation were in the United States, Italy and Canada. The 10 most productive authors identified in the area of hospital accreditation with a higher influence were identified. "The United States", "accreditation", "Joint commission on accreditation" and "quality assurance, healthcare" had, respectively, the highest frequency. The cluster analysis identified and categorized them into four major clusters. Hospital accreditation field had a close relationship with the quality improvement, patient safety, risk and standards.

ORIGINALITY/VALUE

Hospital accreditation had focused on the scopes of implementation of accreditation programs, adherence to JCI standards, and focus on safety and quality improvement. Future studies are recommended to be conducted on design interventions and paying attention to all dimensions of hospital accreditation.

Contextual factors favouring success in the accreditation process in Colombian hospitals: a nationwide observational study

Background

To identify context factors associated with and predicting success in the hospital accreditation process, and to contribute to the understanding of the relative relevance of context factors and their organizational level in the success of QI initiatives.

Methods

Analytical study of cases and controls in a sample of hospitals of medium and high complexity in Colombia. Cases (n = 16) are accredited hospitals by the time of preparation of the study (2016) and controls (n = 38) are similar facilities, which have not succeeded to obtain accreditation. Eligibility criteria for both groups included complexity (medium and high), having emergency services, an official quality assurance license, and being in operation for at least 15 years. Besides eligibility criteria, geographical location, and type of ownership (public/private) are used to select controls to match cases.

Context measures are assessed using a survey instrument based on the MUSIQ model (“Model for Understanding Success in Quality”) adapted and tested in Colombia. Statistical analysis includes descriptive measures for twenty-three context factors, testing for significant statistical differences between accredited and non-accredited hospitals, and assessing the influence and strength of association of context factors on the probability of success in the accreditation process. A multivariate model assesses the predictive probability of achieving accreditation.

Results

Eighteen (78.3%) of the twenty-three context factors are significantly different when comparing cases and controls hospitals, particularly at the Microsystem level; all factors are statistically significant in favor of accredited hospitals. Five context factors are strongly associated to the achievement of accreditation but in the logistic multivariable model, only two of them remain with significant OR, one in the Macrosystem, “Availability of economic resources for QI” (OR: 22.1, p: 0,005), and the other in the Microsystem, “Involvement of physicians” (OR: 4.9, p: 0,04).

Conclusion

This study has applied an instrument, based on the MUSIQ model, which allows assessing the relevance of different context factors and their organizational level in hospitals, to explain success in the accreditation process in Colombia. Internal macrosystem and microsystem seem to be more relevant than external environment factors.

Certification as support for resilience? Behind the curtains of a certification body - a qualitative study

BACKGROUND

Certification in healthcare often involves independent private sector bodies performing legally required or voluntary external assurance activities. These certification practices are embedded in international standards founded in traditional beliefs about rational and predictable processes for quality and safety improvement. Certification can affect organizational and cultural changes, support collaboration and encourage improvement that may be conducive to resilient performance. This study explores whether ISO 9001 quality management system certification can support resilience in healthcare, by looking at characteristics in the objectives, methods, and practice of certification from a certification body's perspective.

METHODS

One of Norway's four certification bodies in healthcare was studied, using an explorative embedded single-case design. The study relies on document analysis of the international standards and associated guidances for the performance of certification bodies and thematic analyses of data from 60 h of observations of auditors in three certification processes and nine qualitative interviews with managers and personnel from the certification body. Results from the analyses were compared to identify discrepancies between the written and perceived certification approach and practice.

RESULTS

Standards and guidances for certification embed an elasticity between formal and consistent assessments of nonconformities in organizations and emphasize holistic approaches that brings added value. Auditors were then left with the latitude to navigate their auditing strategy during interaction with the auditees. Members of the certification body perceived and practiced a holistic and flexible auditing approach using opportunities to share knowledge, empower and make guidance for improvement.

CONCLUSIONS

ISO certification expects structures and systems to ensure consistent and objective certification processes. At the same time, it embodies a latitude to adopt flexible and context-specific certification approaches, as demonstrated by a certification body in this study, to give added value to the certified organizations. Such an ISO 9001 certification approach may support resilient performance in healthcare by nurturing the potential to respond and learn. These results are important for further development of methods that certification bodies use in the auditing encounter.

What Impact Does Accreditation Have on Workplaces? A Qualitative Study to Explore the Perceptions of Healthcare Professionals About the Process of Accreditation

Aim

This study seeks to explore the emerging psychosocial risks of healthcare accreditation in workplaces and understand healthcare professionals’ (HCPs) perceptions of work demands and the unexpected consequences such accreditation has created for them.

Methods

Twenty-seven semi-structured interviews and four focus group discussions were conducted with a variety of HCPs, including doctors, nurses, pharmacists, and allied health professionals. The study was conducted in three public hospitals and a network of primary healthcare centers in the United Arab Emirates. Interviews and focus group discussions were transcribed and analyzed using a theoretical thematic analysis approach.

Results

The results showed that a number of psychosocial risks were prevalent during the course of accreditation. HCPs faced increased work demands during such a process, including increased working hours, increased working pace, perceived time pressure, and conflicting information. Such demands were perceived to influence not only their health but also their families as well as patients’ care. In contrast, teamwork and coworker support were vital to mitigate the effect of such demands.

Implications

This study identified emerging risks during the process of accreditation. The findings show that the process of accreditation increases work-related risks before the inspection visit. These findings have significant implications for understanding how accreditation processes increase psychosocial risks; they also consolidate the idea that appropriate systems and support for HCPs should be a priority when planning for accreditation.

A Parsonian Approach to Patient Safety: Transformational Leadership and Social Capital as Preconditions for Clinical Risk Management-the GI Factor

The purpose of this study is to investigate the role of the combination of transformational leadership and social capital in safety capacity building. Drawing on the A-G-I-L concept of Talcott Parsons, we test a model for patient safety. The hypothesis is, that good safety management needs a combination of goal attainment (G) and integration (I), here called the GI factor. We tested this hypothesis by using transformational leadership as a surrogate for goal attainment and social capital as a surrogate for integration in a study of the perceptions of chief medical officers in 551 German hospitals. We conducted a cross-sectional hospital survey combined with secondary data analysis in all German hospitals with at least one internal medicine unit and one surgery unit (N = 1224 hospitals) in the year 2008 with a response rate of 45% (N = 551). The regression model explained 17.9% of the variance in perceived clinical risk management. We found that if both requirements for goal-oriented collective action-transformational leadership and social capital-are met, good safety management is more likely. The tentative conclusion is that it takes transformative leaders and cohesive followers together as a social basis to improve safety in hospitals.

Exploring hospital certification processes from the certification body's perspective - a qualitative study

BACKGROUND

Hospital certification is an external assessment mechanism to assure quality and safety systems. Auditors representing the certification body play a key role in certification processes, as they perform the assessment activities and interact with the involved healthcare organizations. There is limited knowledge about the approaches and methods that auditors use, such as role repertoire, conduct, and assessment practice. The purpose of this study was to explore auditors' practice in hospital certification processes, guided by the following research questions: What styles do auditors apply in hospital certification processes, and how do auditors perceive their role in hospital certification processes?

METHODS

The study was performed in two stages. In the first stage, non-participant observations (59 h) were conducted, to explore the professional practice of three lead auditors in certification processes of Norwegian hospitals. In the second stage, semi-structured interviews were conducted with these three observed lead auditors. The role repertoires and conducts identified were analyzed by using a deductive approach according to a surveyor (equivalent with auditor) styles typology framework.

RESULTS

Two distinct auditor styles ("explorer" and "discusser") were identified among the three studied auditors. Both styles were characterized by their preference for an opportunistic and less structured type of interview practice during certification audits. All three auditors embedded a guiding approach (reflections about findings, stimulate improvements, experience transfer from other industries) to their perception and practice of certification audits, interacting with the auditees. The use of group interviews instead of individual interviews during certification audits, was the rule of their professional practice.

CONCLUSION

The auditors' perceptions and styles demonstrated a multifaceted certification reality, in contrast to what is often presumed as consistent, stringent and independent practices. These findings may have implications for reliability judgements when developing hospital certification programs, and for the refinement of the current framework used here to study the different auditing practices.

S. Impact of accreditation on performance of healthcare organizations

Purpose

The purpose of this paper is to review the accreditation research in specific to its effect on the performance of healthcare organizations.

Design/methodology/approach

A comprehensive search and analysis of literature on the effect of healthcare accreditation were conducted between June 2017 and May 2018. The study identified 62 empirical research studies that examined the effect of healthcare accreditation programmes. Study particulars such as year of publication, objectives, focus of the study, research settings and key findings were recorded. A content analysis was performed to identify the frequency of the main themes in the literature. Knowledge gaps needing further examination were identified.

Findings

Majority of the accreditation impact studies were carried out in the developed nations (n = 49). The thematic categories, that is the impact on “patient safety and healthcare quality” (n = 26), “healthcare professionals’ views” (n = 28) and “clinical process and outcomes” (n = 17) were addressed more times. Whereas the other two thematic categories “organizational performance” and “consumers’ views or satisfaction,” each was examined less than 10 instances. This review reveals mixed views on effect of healthcare accreditation. The varied quality of studies and the availability of a few studies on consumers’ perception of accreditation effectiveness were the important limiting factors of this review.

Originality/value

The findings are valuable to healthcare managers and hospital administrators in accreditation decisions, whereas findings are of value to researchers and academicians in terms of gaps identified for future research studies pertaining to the impact of healthcare accreditation. Future studies need to consider holistic theoretical frameworks for assessing the effect of accreditation on performance of healthcare organizations to achieve precise results.

Transparency about internal audit results to reduce the supervisory burden: A qualitative study on the preconditions of sharing audit results

Many working hours of healthcare professionals are spent on administrative tasks. Administrative burden is caused by political choices, legislation, the requirements of health insurers and supervisors. Coordination between the parties involved, is lacking. Therefore, we studied to what extent sharing internal audit results of hospitals with external supervisors is possible and the necessary preconditions. We interviewed 42 individuals from six hospitals and the Dutch Health and Youth Care Inspectorate. The interviewees expressed that there is no coordination in timing and content between internal audits and external supervision. They were in favour of sharing internal audit results with external supervisors to reduce the supervisory burden. They stated that internal audits give insight into quality problems and improvements, how hospital directors govern quality and safety, and the culture of improvement within healthcare provider teams. With this information, the inspectorate can judge to what extent hospitals are learning organisations. The interviewees mentioned the following preconditions for sharing audit results: reliable and risk-based information about quality and safety, collected by expert, trained auditors, and careful use of this information by the inspectorate in order to maintain openness among audited healthcare professionals. In conclusion, internal audit results can be shared conditionally with external supervisors. When internal audit results show that hospitals are open, learning and self-reflecting organisations, the healthcare inspectorate can reduce their supervisory burden.

[Comparative analysis of context factors for the accreditation of public and private hospitals in Colombia]

OBJECTIVE

To determine and compare the contextual elements and factors that may favor the achievement of accreditation of public and private healthcare hospitals.

MATERIALS AND METHODS

Based on a source study of cases and controls conducted in medium and high complexity hospitals of Colombia, 16 accredited and 38 non-accredited, this auxiliary study investigated the 38 non-accredited hospitals according to their public or private nature. The MUSIQ instrument ("Model for Understanding Success in Quality") was used to collect data used as reference, while the dimensions "Environment-Macrosystem-Microsystems-Quality Equipment" of the elements and context factors underwent a comparative analysis by means of Chi square test and Student's t or Mann-Whitney's U test after distribution normality verification using the Shapiro-Wilk test. In all cases, a p-value equal to or less than 0.05 was considered significant.

RESULTS

The 23 elements and factors that make up the 4 context dimensions for the achievement of accreditation in health in public and private hospitals were evaluated. It was found that tree had significant differences associated with greater progress in private hospitals, namely, the information systems to support the Quality Improvement (QI) and job stability in the macrosystem, and the motivation factor in the microsystem. The remaining 20 elements and factors evaluated in this study did not have significant differences.

CONCLUSION

There are differences in elements and factors of the context between public and private hospitals that can favor privates in the achievement of accreditation in health.

Certification ISO 9001 in clinical ethics consultation for improving quality and safety in healthcare

This paper refers to the quality management process of the Laboratory of Clinical Bioethics (LCB) of the University of Padua (Italy), which has obtained the quality certification to ISO 9001:2008, as a Clinical Ethics Support Service. Its activities consist mainly in clinical ethics consultations and training services, addressed to those who are called to decisions with ethical implications in the clinical setting, proposing a structured approach to identify and analyze the ethical issues that may loom in the relationships between health professionals and patients, and participating in their solution. The expected benefits of the application of ISO 9001 were mainly the following: to formalize the procedure adopted for clinical ethics consultation and training, to obtain a controlled management of documents, information and data, to ensure and demonstrate the quality of the provided activities and to make methods and organization publicly available. The main results which have been achieved with the 'quality management project' are summarized as follows: the enunciation of LCB Mission and Quality Policy; the drafting of the procedure by which clinical ethics consultation is provided; the formalization of members' skills and the adoption of relevant process and outcome indicators. Our experience may be useful in promoting accountability for the quality of ethics consultation services. We consider the certification process as a tool for transparent and reliable management of one of the most critical tasks in the current context of healthcare, motivating similar facilities to undertake similar pathways, with the aim to provide quality control on their activities.

Investigation of the conditions affecting the joining of Hungarian hospitals to an accreditation programme: a cross-sectional study

OBJECTIVE

Quantitative studies have shown the various benefits for having accreditation in hospitals. However, neither of these explored the general conditions before applying for an accreditation. To close this gap, this study aimed to investigate the possible association between joining an accreditation programme with various hospital characteristics.

DESIGN

A cross-sectional study was implemented using the databases of the 2013 Hungarian hospital survey and of the Hungarian State Treasury.

SETTING

Public general hospitals in Hungary.

PARTICIPANTS

The analysis involved 44 public general hospitals, 14 of which joined the preparatory project for a newly developed accreditation programme.

MAIN OUTCOME MEASURES

The outcomes included the percentage of compliance in quality management, patient information and identification, internal professional regulation, safe surgery, pressure sore prevention, infection control, the opinions of the heads of quality management regarding the usefulness of quality management and clinical audits, and finally, the total debt of the hospital per bed and per discharged patient.

RESULTS

According to our findings, the general hospitals joining the preparatory project of the accreditation programme performed better in four of the six investigated activities, the head of quality management had a better opinion on the usefulness of quality management, and both the debt per bed number and the debt per discharged patient were lower than those who did not join. However, no statistically significant differences between the two groups were found in any of the examined outcomes.

CONCLUSIONS

The findings suggest that hospitals applying for an accreditation programme do not differ significantly in characteristics from those which did not apply. This means that if in the future the accredited hospitals become better than other hospitals, then the improvement could be solely contributed to the accreditation.

Evaluation of the organisation and effectiveness of internal audits to govern patient safety in hospitals: a mixed-methods study

OBJECTIVES

Hospital boards are legally responsible for safe healthcare. They need tools to assist them in their task of governing patient safety. Almost every Dutch hospital performs internal audits, but the effectiveness of these audits for hospital governance has never been evaluated. The aim of this study is to evaluate the organisation of internal audits and their effectiveness for hospitals boards to govern patient safety.

DESIGN AND SETTING

A mixed-methods study consisting of a questionnaire regarding the organisation of internal audits among all Dutch hospitals (n=89) and interviews with stakeholders regarding the audit process and experienced effectiveness of audits within six hospitals.

RESULTS

Response rate of the questionnaire was 76% and 43 interviews were held. In every responding hospital, the internal audits followed the plan-do-check-act cycle. Every hospital used interviews, document analysis and site visits as input for the internal audit. Boards stated that effective aspects of internal audits were their multidisciplinary scope, their structured and in-depth approach, the usability to monitor improvement activities and to change hospital policy and the fact that results were used in meetings with staff and boards of supervisors. The qualitative methods (interviews and site visits) used in internal audits enable the identification of soft signals such as unsafe culture or communication and collaboration problems. Reported disadvantages were the low frequency of internal audits and the absence of soft signals in the actual audit reports.

CONCLUSION

This study shows that internal audits are regarded as effective for patient safety governance, as they help boards to identify patient safety problems, proactively steer patient safety and inform boards of supervisors on the status of patient safety. The description of the Dutch internal audits makes these audits replicable to other healthcare organisations in different settings, enabling hospital boards to complement their systems to govern patient safety.

The impact of accreditation on healthcare quality improvement: a qualitative case study

Purpose Research on accreditation has mostly focused on assessing its impact using large scale quantitative studies, yet little is known on how quality is improved in practice through an accreditation process. Using a case study of an acute teaching hospital in Portugal, the purpose of this paper is to explore the dynamics through which accreditation can lead to an improvement in the quality of healthcare services provided. Design/methodology/approach Data for the case study was collected through 46 in-depth semi-structured interviews with 49 clinical and non-clinical members of staff. Data were analyzed using a framework thematic analysis. Findings Interviewees felt that hospital accreditation contributed to the improvement of healthcare quality in general, and more specifically to patient safety, as it fostered staff reflection, a higher standardization of practices, and a greater focus on quality improvement. However, findings also suggest that the positive impact of accreditation resulted from the approach the hospital adopted in its implementation as well as the fact that several of the procedures and practices required by accreditation were already in place at the hospital, albeit often in an informal way. Research limitations/implications The study was conducted in only one hospital. The design of an accreditation implementation plan tailored to the hospital's context can significantly contribute to positive outcomes in terms of quality and patient safety improvements. Originality/value This study provides a better understanding of how accreditation can contribute to healthcare quality improvement. It offers important lessons on the factors and processes that potentiate quality improvements through accreditation.

How changing quality management influenced PGME accreditation: a focus on decentralization and quality improvement

BACKGROUND

Evaluating the quality of postgraduate medical education (PGME) programs through accreditation is common practice worldwide. Accreditation is shaped by educational quality and quality management. An appropriate accreditation design is important, as it may drive improvements in training. Moreover, accreditors determine whether a PGME program passes the assessment, which may have major consequences, such as starting, continuing or discontinuing PGME. However, there is limited evidence for the benefits of different choices in accreditation design. Therefore, this study aims to explain how changing views on educational quality and quality management have impacted the design of the PGME accreditation system in the Netherlands.

METHODS

To determine the historical development of the Dutch PGME accreditation system, we conducted a document analysis of accreditation documents spanning the past 50 years and a vision document outlining the future system. A template analysis technique was used to identify the main elements of the system.

RESULTS

Four themes in the Dutch PGME accreditation system were identified: (1) objectives of accreditation, (2) PGME quality domains, (3) quality management approaches and (4) actors' responsibilities. Major shifts have taken place regarding decentralization, residency performance and physician practice outcomes, and quality improvement. Decentralization of the responsibilities of the accreditor was absent in 1966, but this has been slowly changing since 1999. In the future system, there will be nearly a maximum degree of decentralization. A focus on outcomes and quality improvement has been introduced in the current system. The number of formal documents striving for quality assurance has increased enormously over the past 50 years, which has led to increased bureaucracy. The future system needs to decrease the number of standards to focus on measurable outcomes and to strive for quality improvement.

CONCLUSION

The challenge for accreditors is to find the right balance between trusting and controlling medical professionals. Their choices will be reflected in the accreditation design. The four themes could enhance international comparisons and encourage better choices in the design of accreditation systems.

Quality agencies at the global level: characteristics and functions-a narrative review

Purpose

To provide a comparative description of the structure, function and activities of quality agencies around the world and describe the published evidence of their impact on the health system.

Data sources

A narrative review was conducted using the information found on websites, articles, books and gray literature in English and Spanish.

Study selection

The search process included three complementary approaches: (i) websites of agencies, ministries of health and quality-related official institutions; (ii) evaluations, reports, audits or documents regarding quality agencies; and (iii) scientific articles and gray literature found (key word: quality agency) using Ebsco databases. Information was completed using the 'snowball' technique, tracking internet materials and citing literature of reviewed documents.

Data extraction

The analytical framework to summarize the information included the agencies' mission, structures, target institutions, activities (following a six-domain model), funding, information management and impact evaluations.

Results of data synthesis

Information was found regarding quality agencies in 62 countries. Those focusing mainly on accreditation were discarded for further analysis. Agencies with a broader focus, according to the six-domain model for quality improvement (QI) strategies, were found in nine countries. Information resulted very heterogeneous in form and substance. However, they share the function of strengthening and advising on 'public goods', through information, knowledge management and development of standards. No impact evaluations of any type were found.

Conclusion

The characteristics of existing quality agencies are very heterogeneous, being accreditation the main common focus. There is a lack of both a comprehensive approach to QI strategies and a formal assessment of their impact or contribution for improving quality.

Patients' assessment of quality of care in public tertiary hospitals with and without accreditation: comparative cross-sectional study

AIM

To compare patients' assessment of quality of care provided by public tertiary hospitals grouped according to accreditation status.

BACKGROUND

Healthcare institutions worldwide are increasingly adopting accreditation as continuing initiative aimed at improving structures, processes and outcomes associated with quality of care. Patients being recipients of health care need to participate in assessing the quality of care they experienced while confined for therapeutic management.

DESIGN

Comparative, cross-sectional.

METHOD

Data were collected from patients confined in public tertiary hospitals (n = 517 in four with accreditation and n = 542 in four without accreditation) in Riyadh, Saudi Arabia between February 2011-June 2011. Patients rated key performance indicators grouped under the dimensions of structure, process and outcome. Mann-Whitney U-test, Spearman Correlation Coefficient and coefficient of determination were used in analysing data.

RESULTS

Patients in accredited public tertiary hospitals perceived structure, outcome and overall quality of care statistically higher than patients in non-accredited hospitals. No statistical differences were found in process (access and communication) indicators. Accreditation status is marginally associated with structure; outcome; and overall quality of care. The proportion of variance in the ranks of accreditation status explained the proportion of variance in the ranks of structure; outcome; and overall quality of care.

CONCLUSION

The results apparently showed better structure, outcome and overall quality of care in accredited hospitals. Accreditation's association in the overall quality of care apparently remained unclear. Further studies are needed to appreciate the contribution of accreditation.

Evaluating the impact of accreditation and external peer review

Purpose

– Accreditation and external peer review play important roles in assessing and improving healthcare quality worldwide. Evidence on the impact on the quality of care remains indecisive because of programme features and methodological research challenges. The purpose of this paper is to create a general methodological research framework to design future studies in this field.

Design/methodology/approach

– A literature search on effects of external peer review and accreditation was conducted using PubMed/Medline, Embase and Web of Science. Three researchers independently screened the studies. Only original research papers that studied the impact on the quality of care were included. Studies were evaluated by their objectives and outcomes, study size and analysis entity (hospitals vs patients), theoretical framework, focus of the studied programme, heterogeneity of the study population and presence of a control group.

Findings

– After careful selection 50 articles were included out of an initial 2,025 retrieved references. Analysis showed a wide variation in methodological characteristics. Most studies are performed cross-sectionally and results are not linked to the programme by a theoretical framework.

Originality/value

– Based on the methodological characteristics of previous studies the authors propose a general research framework. This framework is intended to support the design of future research to evaluate the effects of accreditation and external peer review on the quality of care.

A systematic review of hospital accreditation: the challenges of measuring complex intervention effects

Background

The increased international focus on improving patient outcomes, safety and quality of care has led stakeholders, policy makers and healthcare provider organizations to adopt standardized processes for evaluating healthcare organizations. Accreditation and certification have been proposed as interventions to support patient safety and high quality healthcare. Guidelines recommend accreditation but are cautious about the evidence, judged as inconclusive. The push for accreditation continues despite sparse evidence to support its efficiency or effectiveness.

Methods

We searched MEDLINE, EMBASE and The Cochrane Library using Medical Subject Headings (MeSH) indexes and keyword searches in any language. Studies were assessed using the Cochrane Risk of Bias Tool and AMSTAR framework. 915 abstracts were screened and 20 papers were reviewed in full in January 2013. Inclusion criteria included studies addressing the effect of hospital accreditation and certification using systematic reviews, randomized controlled trials, observational studies with a control group, or interrupted time series. Outcomes included both clinical outcomes and process measures. An updated literature search in July 2014 identified no new studies.

Results

The literature review uncovered three systematic reviews and one randomized controlled trial. The lone study assessed the effects of accreditation on hospital outcomes and reported inconsistent results. Excluded studies were reviewed and their findings summarized.

Conclusion

Accreditation continues to grow internationally but due to scant evidence, no conclusions could be reached to support its effectiveness. Our review did not find evidence to support accreditation and certification of hospitals being linked to measurable changes in quality of care as measured by quality metrics and standards. Most studies did not report intervention context, implementation, or cost. This might reflect the challenges in assessing complex, heterogeneous interventions such as accreditation and certification. It is also may be magnified by the impact of how accreditation is managed and executed, and the varied financial and organizational healthcare constraints. The strategies hospitals should impelment to improve patient safety and organizational outcomes related to accreditation and certification components remains unclear.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-015-0933-x) contains supplementary material, which is available to authorized users.

Satisfaction measurement instruments for healthcare service users: a systematic review

Patient satisfaction surveys can be an interesting way to improve quality and discuss the concept of patient-centered care. This study aimed to conduct a systematic review of the validated patient satisfaction measurement instruments applied in healthcare. The systematic review searched the MEDLINE/PubMed, LILACS, SciELO, Scopus and Web of Knowledge. The search strategy used the terms: "Patient Satisfaction" AND "Patient centered care" AND "Healthcare survey OR Satisfaction questionnaire" AND "Psychometric properties". 37 studies were included and almost all studies showed that satisfaction is a multidimensional construct. In these studies, 34 different instruments were used and most surveys contained the dimension patient-healthcare professional interactions, physical environment and management process. The COSMIN score for methodological quality showed that most of them scored a good or fair average. We can conclude that there is not a gold standard instrument for patient satisfaction assessment but some dimensions are essential for this construct.

Effect of accreditation on the quality of chronic disease management: a comparative observational study

Background

Practice accreditation is widely used to assess and improve quality of healthcare providers. Little is known about its effectiveness, particularly in primary care. In this study we examined the effect of accreditation on quality of care regarding diabetes, chronic obstructive pulmonary disease (COPD) and cardiovascular disease (CVD).

Methods

A comparative observational study with two cohorts was performed. We included 138 Dutch family practices that participated in the national accreditation program for primary care. A first cohort of 69 practices was measured at start and completion of a 3-year accreditation program. A second cohort of 69 practices was included and measured simultaneously with the final measurement of the first cohort. In separate multilevel regression analyses, we compared both within-group changes in the first cohort and between-groups differences at follow-up (first cohort) and start (second cohort). Outcome measures consisted of 24 systematically developed indicators of quality of care in targeted chronic diseases.

Results

In the within-group comparison, we found improvements on 6 indicators related to diabetes (feet examination, cholesterol measurement, lipid lowering medication prescription) and COPD (spirometry performance, stop smoking advice). In the between-groups comparison we found that first cohort practices performed better on 4 indicators related to diabetes (cholesterol outcome) and CVD (blood pressure outcome, smoke status registration, glucose measurement).

Conclusions

Improvements of the quality of primary care for patients with chronic diseases were found, but few could be attributed to the accreditation program. Further development of accreditation is needed to enhance its effectiveness on chronic disease management.

ISO 9001 certification for hospitals in Bulgaria: does it help service?

The aim of our study is to review the published literature on establishment and implementation of ISO 9001 QMS in European hospitals, to study the availability of International Organization for Standardization (ISO) quality management systems (QMS) in Bulgarian hospitals and to outline the main advantages of ISO implementation in the hospitals in Bulgaria. The information on availability of ISO QMS in the hospitals in Bulgaria was gathered via Bulgarian certification register, the registries of various quality associations, websites of hospitals and certification companies presented in Bulgaria. A total number of 312 hospitals in Bulgaria were screened for the availability of QMS certified against the ISO 9001 requirements. The experience of European hospitals that implemented QMS is positive and the used approaches to improve the processes and the demonstrated effects from ISO implementation are analysed by the researchers. Unlike other European Union member states, the establishment of quality management systems in Bulgaria is not compulsory. However, our study revealed that 14.42% of the hospitals in Bulgaria have implemented and have certified quality systems against the requirements of ISO 9001. Our study confirmed that a quality management system using the ISO 9001 standard is useful for the hospitals as it can help to increase the operational efficiencies, to reduce errors, improve patient safety and produce a more preventive approach instead of a reactive environment.

DUQuE quality management measures: associations between quality management at hospital and pathway levels

Objective

The assessment of integral quality management (QM) in a hospital requires measurement and monitoring from different perspectives and at various levels of care delivery. Within the DUQuE project (Deepening our Understanding of Quality improvement in Europe), seven measures for QM were developed. This study investigates the relationships between the various quality measures.

Design

It is a multi-level, cross-sectional, mixed-method study.

Setting and Participants

As part of the DUQuE project, we invited a random sample of 74 hospitals in 7 countries. The quality managers of these hospitals were the main respondents. Furthermore, data of site visits of external surveyors assessing the participating hospitals were used.

Main Outcome Measures

Three measures of QM at hospitals level focusing on integral systems (QMSI), compliance with the Plan-Do-Study-Act quality improvement cycle (QMCI) and implementation of clinical quality (CQII). Four measures of QM activities at care pathway level focusing on Specialized expertise and responsibility (SER), Evidence-based organization of pathways (EBOP), Patient safety strategies (PSS) and Clinical review (CR).

Results

Positive significant associations were found between the three hospitals level QM measures. Results of the relationships between levels were mixed and showed most associations between QMCI and department-level QM measures for all four types of departments. QMSI was associated with PSS in all types of departments.

Conclusion

By using the seven measures of QM, it is possible to get a more comprehensive picture of the maturity of QM in hospitals, with regard to the different levels and across various types of hospital departments.

The effect of certification and accreditation on quality management in 4 clinical services in 73 European hospitals

OBJECTIVE

To investigate the relationship between ISO 9001 certification, healthcare accreditation and quality management in European hospitals.

DESIGN

A mixed method multi-level cross-sectional design in seven countries. External teams assessed clinical services on the use of quality management systems, illustrated by four clinical pathways.

SETTING AND PARTICIPANTS

Seventy-three acute care hospitals with a total of 291 services managing acute myocardial infarction (AMI), hip fracture, stroke and obstetric deliveries, in Czech Republic, France, Germany, Poland, Portugal, Spain and Turkey.

MAIN OUTCOME MEASURE

Four composite measures of quality and safety [specialized expertise and responsibility (SER), evidence-based organization of pathways (EBOP), patient safety strategies (PSS) and clinical review (CR)] applied to four pathways.

RESULTS

Accreditation in isolation showed benefits in AMI and stroke more than in deliveries and hip fracture; the greatest significant association was with CR in stroke. Certification in isolation showed little benefit in AMI but had more positive association with the other conditions; greatest significant association was in PSS with stroke. The combination of accreditation and certification showed least benefit in EBOP, but significant benefits in SER (AMI), in PSS (AMI, hip fracture and stroke) and in CR (AMI and stroke).

CONCLUSIONS

Accreditation and certification are positively associated with clinical leadership, systems for patient safety and clinical review, but not with clinical practice. Both systems promote structures and processes, which support patient safety and clinical organization but have limited effect on the delivery of evidence-based patient care. Further analysis of DUQuE data will explore the association of certification and accreditation with clinical outcomes.

Is having quality as an item on the executive board agenda associated with the implementation of quality management systems in European hospitals: a quantitative analysis

Objective

To assess whether there is a relationship between having quality as an item on the board's agenda, perceived external pressure (PEP) and the implementation of quality management in European hospitals.

Design

A quantitative, mixed method, cross-sectional study in seven European countries in 2011 surveying CEOs and quality managers and data from onsite audits.

Participants

One hundred and fifty-five CEOs and 155 quality managers.

Setting

One hundred and fifty-five randomly selected acute care hospitals in seven European countries (Czech Republic, France, Germany, Poland, Portugal, Spain and Turkey).

Main outcome measure(s)

Three constructs reflecting quality management based on questionnaire and audit data: (i) Quality Management System Index, (ii) Quality Management Compliance Index and (iii) Clinical Quality Implementation Index. The main predictor was whether quality performance was on the executive board's agenda.

Results

Discussing quality performance at executive board meetings more often was associated with a higher quality management system score (regression coefficient b = 2.53; SE = 1.16; P = 0.030). We found a trend in the associations of discussing quality performance with quality compliance and clinical quality implementation. PEP did not modify these relationships.

Conclusions

Having quality as an item on the executive board's agenda allows them to review and discuss quality performance more often in order to improve their hospital's quality management. Generally, and as this study found, having quality on the executive board's agenda matters.

Implications for the NHS of inward and outward medical tourism: a policy and economic analysis using literature review and mixed-methods approaches

Background

The study examined the implications of inward and outward flows of private patients for the NHS across a range of specialties and services.

Objectives

To generate a comprehensive documentary review; to better understand information, marketing and advertising practices; examine the magnitude and economic and health-related consequences of travel; understand decision-making frames and assessments of risk; understand treatment experience; elicit the perspectives of key stakeholder groups; and map out medical tourism development within the UK.

Design and participants

The study integrated policy analysis, desk-based work, economic analysis to estimate preliminary costs, savings and NHS revenue, and treatment case studies. The case studies involved synthesising data sources around bariatric, fertility, cosmetic, dental and diaspora examples. Overall, we drew on a mixed-methods approach of qualitative and quantitative data collection. The study was underpinned by a systematic overview and a legal and policy review. In-depth interviews were carried out with those representing professional associations, those with clinical interests and representative bodies (n = 16); businesses and employees within medical tourism (n = 18); NHS managers (n = 23); and overseas providers. We spoke to outward medical travellers (46 people across four treatment case studies: bariatric, fertility, dental and cosmetic) and also 31 individuals from UK-resident Somali and Gujarati populations.

Results

The study found that the past decade has seen an increase in both inward and outward medical travel. Europe is both a key source of travellers to the UK and a destination for UK residents who travel for medical treatment. Inward travel often involves either expatriates or people from nations with historic ties to the UK. The economic implications of medical tourism for the NHS are not uniform. The medical tourism industry is almost entirely unregulated and this has potential risks for those travelling out of the UK. Existing information regarding medical tourism is variable and there is no authoritative and trustworthy single source of information. Those who travel for treatment are a heterogeneous group, with people of all ages spread across a range of sociodemographic groups. Medical tourists do not appear to inform their decision-making with hard information and consequently often do not consider all risks. They make use of extensive informal networks such as treatment-based or cultural groups. Motivations to travel are in line with the findings of other studies. Notably, cost is never a sole motivator and often not the primary motivation for seeking treatment abroad.

Limitations

One major limitation of the study was the abandonment of a survey of medical tourists. We sought to avoid an extremely small survey, which offers no real insight. Instead we redirected our resources to a deeper analysis of qualitative interviews, which proved remarkably fruitful. In a similar vein, the economic analysis proved more difficult and time consuming than anticipated. Data were incomplete and this inhibited the modelling of some important elements.

Conclusions

In 2010 at least 63,000 residents of the UK travelled abroad for medical treatment and at least 52,000 residents of foreign countries travelled to the UK for treatment. Inward referral and flows of international patients are shaped by clinical networks and longstanding relationships that are fostered between clinicians within sender countries and their NHS counterparts. Our research demonstrated a range of different models that providers market and by which patients travel to receive treatment. There are clearly legal uncertainties at the interface of these and clinical provision. Patients are now travelling to further or ‘new’ markets in medical tourism. Future research should: seek to better understand the medium- and long-term health and social outcomes of treatment for those who travel from the UK for medical treatment; generate more robust data that better capture the size and flows of medical travel; seek to better understand inward flows of medical travellers; gather a greater level of information on patients, including their origins, procedures and outcomes, to allow for the development of better economic costing; explore further the issues of clinical relationships and networks; and consider the importance of the NHS brand.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Impact of guideline-concordant microbiological testing on outcomes of pneumonia

OBJECTIVE

Clinical practice guidelines recommend standardized diagnostic microbiological testing for community-acquired pneumonia on hospital admission, although evidence of its impact on quality is limited. This study evaluated the relationship between guideline-concordant microbiological testing (GCMT) and both in-hospital mortality and length of stay.

DESIGN

/st> Retrospective cohort study using a multicenter claims-based inpatient database linked to a government hospital census database in Japan.

SETTING AND PARTICIPANTS

/st> Patients who were diagnosed with and treated for pneumonia, and were discharged between 1 July 2010 and 30 September 2011 (n = 65 145).

METHODS

and

MAIN OUTCOME MEASURES

/st> GCMT was defined to include sputum tests, blood cultures and urine antigen tests conducted on the first day of hospitalization. We examined the association between 30-day in-hospital mortality and both the performance of each test and the number of tests performed using multivariable logistic regression analysis, adjusting for patient demographics, pneumonia severity and hospital characteristics. Length of stay was analyzed using a Cox proportional hazards model.

RESULTS

/st> Simultaneous conduct of all three tests was significantly associated with reduced 30-day mortality (odds ratio: 0.64; 95% confidence interval (CI): 0.56-0.74) and with increased likelihood of discharge (hazard ratio: 1.04; 95% CI: 1.00-1.07), after adjusting for patient and hospital characteristics. The association was more marked as the level of disease severity increased.

CONCLUSIONS

/st> Performance of GCMT was significantly associated with lower mortality and shorter length of stay. These results suggest that hospitals should assure performance of GCMT in patients with severe community-acquired pneumonia.

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.

Quality assurance and quality improvement in medical practice – Part 1. Definition and importance of quality in medical practice

In Hungary healthcare finance has decreased in proportion with the GDP, while the health status of the population is still ranks among the worst in the European Union. Since healthcare finance is not expected to increase, the number of practicing doctors per capita is continuously decreasing. In the coming years it is an important question that in this situation what methods can be used to prevent further deterioration of the health status of the Hungarian population, and within this is the role of the quality approach, and different methods of quality management. In the present and the forthcoming two articles those standpoints will be summarized which support the need for the integration of quality assurance in the everyday medical practice. In the first part the importance of quality thinking, quality management, quality assurance, necessity of quality measurement and improvement, furthermore, advantages of the quality systems will be discussed. Orv. Hetil., 2012, 153, 83–92.

Is the maturity of hospitals' quality improvement systems associated with measures of quality and patient safety?

Background

Previous research addressed the development of a classification scheme for quality improvement systems in European hospitals. In this study we explore associations between the 'maturity' of the hospitals' quality improvement system and clinical outcomes.

Methods

The maturity classification scheme was developed based on survey results from 389 hospitals in eight European countries. We matched the hospitals from the Spanish sample (113 hospitals) with those hospitals participating in a nation-wide, voluntary hospital performance initiative. We then compared sample distributions and explored associations between the 'maturity' of the hospitals' quality improvement system and a range of composite outcomes measures, such as adjusted hospital-wide mortality, -readmission, -complication and -length of stay indices. Statistical analysis includes bivariate correlations for parametrically and non-parametrically distributed data, multiple robust regression models and bootstrapping techniques to obtain confidence-intervals for the correlation and regression estimates.

Results

Overall, 43 hospitals were included. Compared to the original sample of 113, this sample was characterized by a higher representation of university hospitals. Maturity of the quality improvement system was similar, although the matched sample showed less variability. Analysis of associations between the quality improvement system and hospital-wide outcomes suggests significant correlations for the indicator adjusted hospital complications, borderline significance for adjusted hospital readmissions and non-significance for the adjusted hospital mortality and length of stay indicators. These results are confirmed by the bootstrap estimates of the robust regression model after adjusting for hospital characteristics.

Conclusions

We assessed associations between hospitals' quality improvement systems and clinical outcomes. From this data it seems that having a more developed quality improvement system is associated with lower rates of adjusted hospital complications. A number of methodological and logistic hurdles remain to link hospital quality improvement systems to outcomes. Further research should aim at identifying the latent dimensions of quality improvement systems that predict quality and safety outcomes. Such research would add pertinent knowledge regarding the implementation of organizational strategies related with quality of care outcomes.

Strengthening organizational performance through accreditation research-a framework for twelve interrelated studies: the ACCREDIT project study protocol

BACKGROUND

Service accreditation is a structured process of recognising and promoting performance and adherence to standards. Typically, accreditation agencies either receive standards from an authorized body or develop new and upgrade existing standards through research and expert views. They then apply standards, criteria and performance indicators, testing their effects, and monitoring compliance with them. The accreditation process has been widely adopted. The international investments in accreditation are considerable. However, reliable evidence of its efficiency or effectiveness in achieving organizational improvements is sparse and the value of accreditation in cost-benefit terms has yet to be demonstrated. Although some evidence suggests that accreditation promotes the improvement and standardization of care, there have been calls to strengthen its research base.In response, the ACCREDIT (Accreditation Collaborative for the Conduct of Research, Evaluation and Designated Investigations through Teamwork) project has been established to evaluate the effectiveness of Australian accreditation in achieving its goals. ACCREDIT is a partnership of key researchers, policymakers and agencies.

FINDINGS

We present the framework for our studies in accreditation. Four specific aims of the ACCREDIT project, which will direct our findings, are to: (i) evaluate current accreditation processes; (ii) analyse the costs and benefits of accreditation; (iii) improve future accreditation via evidence; and (iv) develop and apply new standards of consumer involvement in accreditation. These will be addressed through 12 interrelated studies designed to examine specific issues identified as a high priority. Novel techniques, a mix of qualitative and quantitative methods, and randomized designs relevant for health-care research have been developed. These methods allow us to circumvent the fragmented and incommensurate findings that can be generated in small-scale, project-based studies. The overall approach for our research is a multi-level, multi-study design.

DISCUSSION

The ACCREDIT project will examine the utility, reliability, relevance and cost effectiveness of differing forms of accreditation, focused on general practice, aged care and acute care settings in Australia. Empirically, there are potential research gains to be made by understanding accreditation and extending existing knowledge; theoretically, this design will facilitate a systems view of accreditation of benefit to the partnership, international research communities, and future accreditation designers."Accreditation of health-care organisations is a multimillion dollar industry which shapes care in many countries. Recent reviews of research show little evidence that accreditation increases safety or improves quality. It's time we knew about the cost and value of accreditation and about its future direction." [Professor John Øvretveit, Karolinska Institute, Sweden, 7 October 2009].

[Indicators for quality of care: who profits: patients or managers?]

In the Netherlands and abroad detailed indicators are developed to measure quality of care for a variety of treatments and care systems. These days the development of quality indicators is a profession and business in itself. The significance of these indicators is often not related to the primary care process, but based on (administrative) data for 'quality management'. The consequence is a gap between 'real' and 'measured' quality of care. Improvement in quality of care is therefore problematic. There is a need to return to the essence of care, i.e. the patient and the care professional, to develop appropriate indicators for quality of care.