Impact of repeated hospital accreditation surveys on quality and reliability, an 8-year interrupted time series analysis

A review of the United Arab Emirates healthcare systems on medical tourism and accreditation

This paper aims to review the healthcare system in the United Arab Emirates (UAE) and the utilisation of international accreditation to improve the quality of healthcare services and to grow its medical tourism industry. Medical tourism has contributed to the UAE's economy. Hence, the country mandated international accreditation in public and private facilities to attract patients and boost medical tourism. Accreditation is recognised worldwide as one of the main drivers for implementing quality and patient safety standards, which has sparked considerable interest in studying the effects and outcomes of such assessments. Therefore, the second aim of this paper is to review the UAE's strategic goals to improve the quality of healthcare services using international accreditation. Although striving to achieve global accreditation attracts tourists, it is essential to understand the needs and outcomes of such assessments. This review showed how the UAE healthcare sector has evolved to improve the quality of its healthcare services through accreditation. While enhancing the quality of such services and increasing the medical tourism industry provided many opportunities for expatriates to move to the UAE, the country should aim to strengthen its medical services by expanding to other Middle Eastern countries. This paper could influence policymakers implementing international accreditation in the UAE and the Middle Eastern region.

The Effects of Quality Assurance System Implementation on Work Well-Being and Patient Safety: Protocol for a Mixed Methods Study

BACKGROUND

Systematic monitoring of work atmosphere and patient safety incidents is a necessary part of a quality assurance system, particularly an accredited system like the Joint Commission International (JCI). How the implementation of quality assurance systems affects well-being at work and patient safety is unclear. Evidence shows that accreditation improves workplace atmosphere and well-being. Thus, the assumption that an increase in employees' well-being at work improves patient safety is reasonable.

OBJECTIVE

This study aims to describe the protocol for monitoring the effects of implementing the quality assurance system of JCI at Orton Orthopedic Hospital on employees' well-being (primary outcome) and patient safety (secondary outcome).

METHODS

Quantitative (questionnaires and register data) and qualitative (semistructured interviews) methods will be used. In addition, quantitative data will be collected from register data. Both quantitative and register data will be analyzed. Register data analysis will be performed using generalized linear models with an appropriate distribution and link function. The study timeline covers the time before, during, and after the start of the accreditation process. The collected data will be used to compare job satisfaction, as a part of the well-being questionnaire, and the development of patient safety during the accreditation process.

RESULTS

The results of the quality assurance system implementation illuminate its possible effects on the patient's safety and job satisfaction. The repeatability and internal consistency reliability of the well-being questionnaire will be reported. Data collection will begin in May, 2024. It will be followed by data analysis and the results are expected to be published by 2025.

CONCLUSIONS

The planned study will contribute to the evaluation of the effects of JCI accreditation in terms of well-being at work and patient safety.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/45200.

Enabling Factors for the Successful Implementation of the CBAHI Accreditation Program

Background

Healthcare organizations worldwide tend to implement hospital accreditation programs to improve the quality of care they provide. However, the literature shows inconsistent findings on the impact of such programs on the quality of care due to improper implementation of accreditation programs.

Purpose

This study explored the enabling factors for the effective implementation of the Saudi Central Board for Accreditation of Healthcare Institutions (CBAHI) program in the Ministry of Health (MOH) hospitals in Madinah, Saudi Arabia.

Methods

This qualitative study involved 22 professionals from five CBAHI-accredited MOH hospitals in Madinah, Saudi Arabia. A purposive sampling technique was applied, and data were collected through in-depth, semi-structured interviews. A thematic analysis approach was applied to the interview transcripts.

Results

Four themes and 11 subthemes emerged. The emerging themes included the development of human capital, resolving quality management issues, ensuring the availability of resources, and strategizing CBAHI-specific solutions.

Conclusion

The current study fills this knowledge gap by identifying the factors leading to the effective implementation of the CBAHI accreditation program in the MOH hospitals. Only the effective execution of the CBAHI will increase healthcare quality and, as a result, justify the significant resources and efforts invested in these programs. Future research should replicate similar study in other governments or private hospitals.

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.

Impact of the Accreditation Program of the Saudi Central Board for Accreditation of Healthcare Institutions on the Safety Dimension of the Institute of Medicine Quality

Background

Although hospital accreditation is recognized as a tool for improving healthcare, there are inconsistent results regarding its impact on healthcare quality. In Saudi Arabia, it is mandatory for all Ministry of Health (MOH) hospitals to be accredited by the Central Board for Accreditation of Healthcare Institutions (CBAHI).

Purpose

This study measured the impact of the CBAHI accreditation program on the Institute of Medicine's (IOM) safety dimension in Madinah.

Methods

A cross-sectional study was conducted using retrospective data gathered from a review of hospital records over 60 months (ie, 12 months before, 36 during, and 12 post-accreditation). The data were analyzed using piecewise (segmented) regression analysis.

Results

The three indicators (ie: incident reports, medication errors, and nosocomial infection) were continuously improved compared to the data before accreditation, as a results of implementing the CBAHI accreditation program. Therefore, the CBAHI had a significantly positively impacts on MOH hospitals' safety dimension.

Conclusion

Complying with the CBAHI standards can help reduce the rates of incident reports, medication errors, nosocomial infections, and post-admission mortality. This study provides insight for MOH hospitals and opportunities to expand the accreditation program to improve the quality of healthcare services.

The Attitude of Hospital Directors Towards Normalising Accreditation Standards: A Qualitative Descriptive Study for Saudi Arabia

Background

Accreditation is an important performance management tool. The engagement of stakeholders in pursuing accreditation plays a critical role in integrating standards into routine practice.

Objective

This study explores the attitude of hospital directors towards accreditation and investigates the mechanisms of normalising standards in Saudi Arabian hospitals.

Methods

Fifteen hospital directors across Saudi Arabia participated in semi-structured qualitative interviews. The interviews were conducted virtually, audiotaped, transcribed verbatim, and then analysed thematically using the NVivo-12 software package. The normalisation process theory (i.e. coherence, participation, actions and monitoring) was adopted to frame the study and describe the findings on normalising accreditation standards heuristically.

Results

Overall, the hospital directors perceived accreditation favourably, particularly by those with more experience or previous exposure to accreditation. This attitude was a factor in normalising standards into daily operations. The clarity of standards, availability of full-time quality professionals and alignment of accreditation standards with hospital strategies assisted hospital directors in making sense of accreditation (coherence) and moving towards engaging hospital teams in the process (cognitive participation). This motivation-driven engagement catalysed the initiation of purposeful operational activities to integrate standards in operations (collective actions). The integration included distributing standard sets to relevant owners, conducting gap analysis, constructing a corrective plan and prioritising tasks within timeframes. Despite the financial and structural constraints experienced, the integration resulted in enhanced organisational safety culture, team spirit, communication, public trust, reporting of safety concerns and standardising of procedures. Following the integration, the objective appraisal of accreditation benefits (reflexive monitoring) was critical in addressing what went wrong, what worked well, and subsequently in sustaining performance gains.

Conclusion

The effectiveness of integrating accreditation standards heavily relies on making sense of accreditation and understanding the mechanisms through which standards are routinised into operations. This study, using normalisation process theory constructs, indicates that standards integration phases are sequential, interlinked and influenced by culture, teamwork and leadership engagement. The findings helped in clarifying the accreditation operating process which may provide advantages to policymakers and stakeholders in making informed decisions on the implementation of accreditation.

Development and Evaluation of Interactive Flipped e-Learning (iFEEL) for Pharmacy Students during the COVID-19 Pandemic

Background: Distance learning has come to the forefront of educational delivery throughout the world due to the COVID-19 pandemic. Presently, there is a paucity of studies that have utilized interactive e-lectures as a model for remote flipped learning. Objectives: To compare educational outcomes for the remote interactive flipped e-learning (iFEEL) activity versus paper-based in-class group learning (PICkLE). Methods: During the spring 2021 semester, tutorials in pharmaceutical quality control and good manufacturing practice were remotely delivered to students by two different approaches: PICkLE and iFEEL. In the latter activity, interactive e-lectures were software-designed and included several audiovisual enhanced illustrations to encourage students to interact with the lecture material prior to attending the virtual class. The class time was reserved for in-class quizzes and discussion. Mean exam scores were compared and voluntary questionnaires were distributed among the participating students as well as healthcare faculty members in 29 Saudi universities. Data from the remotely-delivered course was compared with data from previous course offerings (2018−2020) that used the live PICkLE method. Results: The mean score of post-lecture tests significantly (p < 0.05) increased compared to pre-lecture tests in remote PICkLE and iFEEL, respectively. iFEEL activity showed higher mean post-tests score (95.2%) compared to live PICkLE (90.2%, p = 0.08) and remote PICkLE (93.5%, p = 0.658). Mean comprehensive exam scores increased from 83.8% for remote PICkLE to 89.2% for iFEEL (p = 0.449). On average, 92% of students and 85% of faculty members reported positive feedback on the five quality attributes of the e-lecture. Over 75% of students preferred the iFEEL over PICkLE activity for future course offerings and 84% of faculty members recommend the integration of interactive e-lectures in their future courses. Conclusion: iFEEL represents a novel model of remote flipped learning and shows promising potential to be incorporated into live blended-learning classroom activities.

Accreditation program for gastrointestinal endoscopes reprocessing in Italy: An on-site survey

Background and study aims  Endoscope reprocessing has been associated with a variable failure rate. Our aim was to present an overview on current practices for reprocessing in Italian facilities and discuss the principle critical points. Methods  In 2014 the Italian Society for Digestive Diseases implemented an accreditation program in collaboration with an independent organization for certification and with the Italian Association for Endoscopy Technical Operators. During a 1-day site visit of the endoscopy center, two endoscopists, one nurse, and the representative of the certification body evaluated the endoscope reprocessing. Results  As of July 1, 2020, 28 endoscopy centers had been accredited. Ten centers are completing the measures to correct deficiencies found at the visit. Three centers withdrew from the program. The accreditation program has found variations between the various centers, confirming the poor compliance with guidelines. Major deviations from the standards, established by the model before the site visit according to national and international guidelines, concerned instrument cleaning (44.7 % of the centers), instrument storage (23.7 %), and microbiological tests (31.6 %). Conclusions  Our overview demonstrated the lack of many reprocessing phases, which are important to prevent endoscopy-associated infections. Accreditation can achieve a transformation in quality and safety of reprocessing with the Italian centrally-led approach.

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 decade of commitment to hospital quality of care: overview of and perceptions on multicomponent quality improvement policies involving accreditation, public reporting, inspection and pay-for-performance

Background

Quality improvement (QI) initiatives such as accreditation, public reporting, inspection and pay-for-performance are increasingly being implemented globally. In Flanders, Belgium, a government policy for acute-care hospitals incorporates aforementioned initiatives. Currently, questions are raised on the sustainability of the present policy.

Objective

First, to summarise the various initiatives hospitals have adopted under government encouragement between 2008 and 2019. Second, to study the perspectives of healthcare stakeholders on current government policy.

Methods

In this multi-method study, we collected data on QI initiative implementation from governmental and institutional sources and through an online survey among hospital quality managers. We compiled an overview of QI initiative implementation for all Flemish acute-care hospitals between 2008 (n = 62) and 2019 (n = 53 after hospital mergers). Stakeholder perspectives were assessed via a second survey available to all healthcare employees and a focus group with healthcare policy experts was consulted. Variation between professions was assessed.

Results

QI initiatives have been increasingly implemented, especially from 2016 onwards, with the majority (87%) of hospitals having obtained a first accreditation label and all hospitals publicly reporting performance indicators, receiving regular inspections and having entered the pay-for-performance initiative. On the topic of external international accreditation, overall attitudes within the survey were predominantly neutral (36.2%), while 34.5% expressed positive and 29.3% negative views towards accreditation. In examining specific professional groups in-depth, we learned 58% of doctors regarded accreditation negatively, while doctors were judged to be the largest contributors to quality according to the majority of respondents.

Conclusions

Hospitals have demonstrated increased efforts into QI, especially since 2016, while perceptions on currently implemented QI initiatives among healthcare stakeholders are heterogeneous. To assure quality of care remains a top-priority for acute-care hospitals, we recommend a revision of the current multicomponent quality policy where the adoption of all initiatives is streamlined and co-created bottom-up.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-07007-w.

Is a hospital quality policy based on a triad of accreditation, public reporting and inspection evidence-based? A narrative review

BACKGROUND

Since 2009, hospital quality policy in Flanders, Belgium, is built around a quality-of-care triad, which encompasses accreditation, public reporting (PR) and inspection. Policy makers are currently reflecting on the added value of this triad.

METHODS

We performed a narrative review of the literature published between 2009 and 2020 to examine the evidence base of the impact accreditation, PR and inspection, both individually and combined, has on patient processes and outcomes. The following patient outcomes were examined: mortality, length of stay, readmissions, patient satisfaction, adverse outcomes, failure to rescue, adherence to process measures and risk aversion. The impact of accreditation, PR and inspection on these outcomes was evaluated as either positive, neutral (i.e. no impact observed or mixed results reported) or negative.

OBJECTIVES

To assess the current evidence base on the impact of accreditation, PR and inspection on patient processes and outcomes.

RESULTS

We identified 69 studies, of which 40 were on accreditation, 24 on PR, three on inspection and two on accreditation and PR concomitantly. Identified studies reported primarily low-level evidence (level IV, n = 53) and were heterogeneous in terms of implemented programmes and patient populations (often narrow in PR research). Overall, a neutral categorization was determined in 30 articles for accreditation, 23 for PR and four for inspection. Ten of these recounted mixed results. For accreditation, a high number (n = 12) of positive research on adherence to process measures was discovered.

CONCLUSION

The individual impact of accreditation, PR and inspection, the core of Flemish hospital quality, was found to be limited on patient outcomes. Future studies should investigate the combined effect of multiple quality improvement strategies.

Comparison of Major Clinical Outcomes between Accredited and Nonaccredited Hospitals for Inpatient Care of Acute Myocardial Infarction

Hospital accreditation programs are used worldwide to improve the quality of care and improve patient safety. It is of great help in improving the structure of hospitals, but there are mixed research results on improving the clinical outcome of patients. The purpose of this study was to compare the levels of core clinical outcome indicators after receiving inpatient services from accredited and nonaccredited hospitals in patients with acute myocardial infarction (AMI). For all patients with AMI admitted to general hospitals in Korea from 2010 to 2017, their 30-day mortality and readmissions and length of stay were compared according to accreditation status. In addition, through a multivariate model that controls various patients’ and hospitals’ factors, the differences in those indicators were analyzed more accurately. The 30-day mortality of patients admitted to accredited hospitals was statistically significantly lower than that of patients admitted to nonaccredited hospitals. However, for 30-day readmission and length of stay, accreditation did not appear to yield more desirable results. This study shows that when evaluating the clinical impact of hospital accreditation programs, not only the mortality but also various clinical indicators need to be included, and a more comprehensive review is needed.

Interface between accreditation and patient safety: nursing team perspectives

OBJECTIVE

To understand the relationship between accreditation and patient safety from the perspective of the nursing team.

METHOD

A descriptive-exploratory study implementing a qualitative approach. It was developed with nursing workers from two Intensive Care Units in a hospital certified in excellence by Brazilian accreditation. The participants responded to individual semi-structured interviews guided by the question: "Tell me about the relationship between accreditation and patient safety in this hospital and unit". The corpus was transcribed in full, and the thematic content analysis technique was used.

RESULTS

There were 14 professionals interviewed. There are several specific improvements in patient safety mediated by accreditation between the two emerging categories. The workers reported that at times the advances in safe care are transversally visible to the certification/maintenance of accreditation visit, and at times they point to safety as something independent of the quality seal.

CONCLUSION

It was concluded that the investigated relationship was shown to be both dependent, as accreditation is a bridge for specific improvements, as well as independent, since patient safety goes beyond the certification process itself. In this context, criticality was revealed among nursing workers.

Mediators of change in healthcare organisations subject to external assessment: a systematic review with narrative synthesis

OBJECTIVES

External inspections are widely used to improve the quality of care. The effects of inspections remain unclear and little is known about how they may work. We conducted a narrative synthesis of research literature to identify mediators of change in healthcare organisations subject to external inspections.

METHODS

We performed a literature search (1980-January 2020) to identify empirical studies addressing change in healthcare organisations subject to external inspection. Guided by the Consolidated Framework for Implementation Research, we performed a narrative synthesis to identify mediators of change.

RESULTS

We included 95 studies. Accreditation was the most frequent type of inspection (n=68), followed by statutory inspections (n=19), and external peer review (n=9). Our findings suggest that the regulatory context in which the inspections take place affect how they are acted on by those being inspected. The way inspections are conducted seem to be critical for how the inspection findings are perceived and followed up. Inspections can engage and involve staff, facilitate leader engagement, improve communication and enable the creation of new networks for reflection on clinical practice. Inspections can contribute to creating an awareness of the inspected organisation's current practice and performance gaps, and a commitment to change. Moreover, they can contribute to facilitating the planning and implementation of change, as well as self-evaluation and the use of data to evaluate performance.

CONCLUSIONS

External inspections can affect different mediators of organisational change. The way and to what extent they do depend on a range of factors related to the outer setting, the way inspections are conducted and how they are perceived and acted on by the inspected organisation. To improve the quality of care, the organisational change processes need to involve and impact the way care is delivered to the patients.

Association between Accreditation and In-Hospital Mortality in Patients with Major Cardiovascular Diseases in South Korean Hospitals: Pre-Post Accreditation Comparison

The direct impact of hospital accreditation on patients' clinical outcomes is unclear. The purpose of this study was to evaluate whether mortality within 30 days of hospitalization for acute myocardial infarction (AMI), ischemic stroke (IS), and hemorrhagic stroke (HS) differed before and after hospital accreditation. This study targeted patients who had been hospitalized for the three diseases at the general hospitals newly accredited by the government in 2014. Thirty-day mortality rates of three years before and after accreditation were compared. Mortality within 30 days of hospitalization for the three diseases was lower after accreditation than before (7.34% vs. 6.15% for AMI; 4.64% vs. 3.80% for IS; and 18.52% vs. 15.81% for HS). In addition, hospitals that meet the criteria of the patient care process domain have a statistically lower mortality rate than hospitals that do not. In the newly accredited Korean general hospital, it was confirmed that in-hospital mortality rates of major cardiovascular diseases were lower than before the accreditation.

The history of quality and safety of the surgical patient: from the initial standards to the present day

There are currently various concepts related to quality, which have been implemented by many hospitals and other healthcare institutions. The search for continuous improvement, the implementation of a quality culture and hospital accreditation have also been common, in these institutions. However, the history of hospital audits and accreditation is complex and full of dynamic concepts. The American College of Surgeons was pioneer in publishing, more than a century ago, the first document pertaining quality standards. After that, various programs and concepts have been developed and remodeled by distinct entities. In this article, we briefly review the history of quality in the world and Brazil. We also discuss related concepts regarding its assessment in healthcare.