The standard of healthcare accreditation standards: a review of empirical research underpinning their development and impact

Challenges of Implementing an Effective Primary Health Care Accreditation Program: a qualitative study in Iran

BACKGROUND

Accreditation is a prerequisite for scientific management of the health system, owing to its numerous benefits on health centres' performance. The current study examined Iran's primary healthcare accreditation program to ascertain the challenges to its successful implementation.

METHODS

This qualitative study examined the perspectives of 32 managers and staff members in the pilot accreditation program (from the Ministry of Health and Medical Education, Semnan University of Medical Sciences, and Aradan District Health Network). Three in-depth group interviews were conducted using a semi-structured questionnaire, and the data obtained were assessed using thematic analysis. As a result of this investigation identified six themes, 29 sub-themes, and 218 codes as challenges to the successful accreditation of primary health care in Iran.

RESULTS

Six main themes, including "organisational culture", "motivational mechanisms", "staff workload", "training system", "information systems", and "macro-executive infrastructure", were identified as the main domain of challenges, with seven, five, two, four, three, and eight sub-themes respectively.

CONCLUSION

Accreditation of PHC in Iran faces significant challenges and obstacles that, if ignored, can jeopardise the program's success and effectiveness. By identifying challenges and obstacles and making practical suggestions for overcoming them, the findings of this study can aid in the program's successful implementation and achievement of desired outcomes.

Factors that influence the implementation of (inter)nationally endorsed health and social care standards: a systematic review and meta-summary

BACKGROUND

Health and social care standards have been widely adopted as a quality improvement intervention. Standards are typically made up of evidence-based statements that describe safe, high-quality, person-centred care as an outcome or process of care delivery. They involve stakeholders at multiple levels and multiple activities across diverse services. As such, challenges exist with their implementation. Existing literature relating to standards has focused on accreditation and regulation programmes and there is limited evidence to inform implementation strategies specifically tailored to support the implementation of standards. This systematic review aimed to identify and describe the most frequently reported enablers and barriers to implementing (inter)nationally endorsed standards, in order to inform the selection of strategies that can optimise their implementation.

METHODS

Database searches were conducted in Medline, CINAHL (Cumulative Index to Nursing and Allied Health Literature), SocINDEX, Google Scholar, OpenGrey and GreyNet International, complemented by manual searches of standard-setting bodies' websites and hand searching references of included studies. Primary qualitative, quantitative descriptive and mixed methods studies that reported enablers and barriers to implementing nationally or internationally endorsed standards were included. Two researchers independently screened search outcomes and conducted data extraction, methodological appraisal and CERQual (Confidence in Evidence from Reviews of Qualitative research) assessments. An inductive analysis was conducted using Sandelowski's meta-summary and measured frequency effect sizes (FES) for enablers and barriers.

RESULTS

4072 papers were retrieved initially with 35 studies ultimately included. Twenty-two thematic statements describing enablers were created from 322 descriptive findings and grouped under six themes. Twenty-four thematic statements describing barriers were created from 376 descriptive findings and grouped under six themes. The most prevalent enablers with CERQual assessments graded as high included: available support tools at local level (FES 55%); training courses to increase awareness and knowledge of the standards (FES 52%) and knowledge sharing and interprofessional collaborations (FES 45%). The most prevalent barriers with CERQual assessments graded as high included: a lack of knowledge of what standards are (FES 63%), staffing constraints (FES 46%), insufficient funds (FES 43%).

CONCLUSIONS

The most frequently reported enablers related to available support tools, education and shared learning. The most frequently reported barriers related to a lack of knowledge of standards, staffing issues and insufficient funds. Incorporating these findings into the selection of implementation strategies will enhance the likelihood of effective implementation of standards and subsequently, improve safe, quality care for people using health and social care services.

A framework for assessing clinical trial site readiness

Clinical trial processes are unnecessarily inefficient and costly, slowing the translation of medical discoveries into treatments for people living with disease. To reduce redundancies and inefficiencies, a group of clinical trial experts developed a framework for clinical trial site readiness based on existing trial site qualifications from sponsors. The site readiness practices are encompassed within six domains: research team, infrastructure, study management, data collection and management, quality oversight, and ethics and safety. Implementation of this framework for clinical trial sites would reduce inefficiencies in trial conduct and help prepare new sites to enter the clinical trials enterprise, with the potential to improve the reach of clinical trials to underserved communities. Moreover, the framework holds benefits for trial sponsors, contract research organizations, trade associations, trial participants, and the public. For novice sites considering future trials, we provide a framework for site preparation and the engagement of stakeholders. For experienced sites, the framework can be used to assess current practices and inform and engage sponsors, staff, and participants. Details in the supplementary materials provide easy access to key regulatory documents and resources. Invited perspective articles provide greater depth from a systems, DEIA (diversity, equity, inclusion, and accessibility) and decentralized trials perspective.

Mapping service standards and guidelines to support accreditation processes – a case study of a collaborative effort worth replicating

Health services respond to myriad practice standards and guidelines that regulate, monitor, and improve the safety and quality of healthcare. Although important, information overload and compliance fatigue for accreditation can be burdensome for service managers and clinicians. To address this, and ultimately improve the safety and quality of care, this case study demonstrates how a mapping exercise was completed to synthesise seven practice standards and guidelines relevant to palliative care; and develop an online resource to aid accreditation efforts and improve palliative care. A working group, comprised of service managers, clinicians, and academics, mapped a state-wide blueprint to improve palliative care against seven unique practice standards and guidelines, most of which were national in scope. This project culminated with a freely available online resource to translate the standards and guidelines for accreditation - a resource that supports service managers and clinicians across public and private health sectors to readily determine whether and how they demonstrated safety and quality in the context of palliative care and pursue accreditation. By developing one matrix, there is opportunity to alleviate information overload and compliance fatigue for service managers and clinicians. Despite its focus on palliative care, this case study demonstrates how to collaboratively map distinct practice standards and guidelines and form a resource to aid accreditation efforts to improve healthcare.

Development of accreditation standards for midwifery clinical education in Iran

BACKGROUND

Accreditation is one of the most important methods of quality assurance and improvement in medical education. In Iran, there are no specific midwifery education accreditation standards. This study was designed to develop accreditation standards for midwifery clinical education in Iran.

METHODS

This study was performed in Iran in 2021. It consisted of two phases. In the first phase, accreditation standards for midwifery education in the United Kingdom, the United States, Australia and the International Confederation of Midwives were thoroughly examined through a narrative review. The domains obtained from this phase were used as a framework for coding in the second phase. In the second phase, a qualitative study was conducted with a directed content analysis approach to determine standards and criteria for clinical midwifery education accreditation in Iran. Participants were policymakers and senior managers of midwifery education, faculty members of midwifery departments with clinical teaching experience, and final year undergraduate midwifery students. The participants were selected by purposive sampling method, and data collection continued until data saturation.

RESULTS

The standards and accreditation criteria of midwifery education from the review study were formed 6 domains: Mission and goals; Curricula; Clinical instructors; Students, Clinical setting; and Assessment. In the second phase, data analysis led to the extraction of 131 codes, which were divided into 35 sub-subcategories, 15 sub-categories, and 6 main categories.

CONCLUSION

Implementing the specific and localized standards of clinical midwifery education in Iran can lead to improved quality of clinical education programs.

From assurance to coproduction: a century of improving the quality of health-care service

BACKGROUND

Over the last century, the invitation to improve health-care service quality has taken many different forms: questions, observations, methods, tools and actions have emerged and evolved to create relevant 'improvement work.' In this paper we present three phases of this work. The basic frameworks used in these phases have not supplanted each other, but they have been layered one upon the next over time. Each brought important new thinking, new change opportunities and a new set of limits. The important messages of each need to be carried together into the future, as must the sense of curiosity and possibility about the commonalities that has driven this evolution.

METHODS

Literature, personal experience and other artifacts were reviewed to develop this description of how the focus on quality work has evolved (and continues to evolve) over the last century.

RESULTS

We describe three phases. Quality 1.0 seeks to answer the question 'How might we establish thresholds for good healthcare services?' It described certain 'basic' standards that should be used to certify acceptable performance and capability. This led to the formation of formal processes for review, documentation and external audits and a system for public notice and recognition. Over time, the limits and risks of this approach also became more visible: a 'micro-accounting compliance' sometimes triumphed over what might be of even greater strategic importance in the development and operations of effective systems of disease prevention and management to improve outcomes for patients and families. Quality 2.0 asked 'How might we use enterprise-wide systems for disease management?' It added a focus on the processes and systems of production, reduction of unwanted variation, the intrinsic motivation to take pride in work, outcome measurement and collaborative work practices as ways to improve quality, modeled on experiences in other industries. Quality 3.0 asks 'How might we improve the value of the contribution that healthcare service makes to health?' It requires careful consideration of the meaning of 'service' and 'value', service-creating logic, and prompts us to consider both relationships and activities in the context of the coproduction of health-care services.

CONCLUSION

Efforts to improve the quality and value of health-care services have evolved over the last century. With each success have come new challenges and questions, requiring the addition of new frames and approaches.

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.

Chiropractic program changes facilitated by the European Council on Chiropractic Education Accreditation reports

OBJECTIVE

The European Council on Chiropractic Education (ECCE) currently accredits 10 programs throughout Europe and South Africa. It is assumed that ECCE evaluation activities lead to changes to the chiropractic programs but no systematic evaluation as to whether this is true, and the extent of changes has previously been done. The purpose of this study was to obtain feedback from program heads as to whether ECCE evaluation reports facilitated changes/improvements to their programs and to identify their reported changes.

METHODS

This was a mixed methods audit study using questionnaires with 2 sections. Closed statements requesting the degree of change to each section of the "Standards" based on ECCE evaluation reports (substantial, some, none) were analyzed using frequencies. Written responses identifying the specific changes made based on previous evaluation reports were evaluated independently by 3 researchers using a modified "thematic analysis" approach.

RESULTS

All 10 accredited programs responded. Seven of the 10 programs (70%) reported "some" or "substantial" changes to ≥ 6 sections of the ECCE Standards. The most common section with reported changes was "Educational Program" (8 of 10). "Educational Resources" had the largest number of programs reporting "substantial changes" (4) and was the second most common section to have reported changes. The main themes identified emphasized changes in "infrastructure, equipment and faculty," "increasing evidence-based practice," and "instilling a research culture in faculty and students."

CONCLUSION

ECCE accreditation processes facilitate changes to the chiropractic programs, particularly in the areas of improved infrastructure and faculty, research, and evidence-based practice.

Australian chiropractic students' perceptions of education: validation of a questionnaire

BACKGROUND

This study aimed to validate a questionnaire to address an absence of a measure to evaluate Australian chiropractic students' perceptions of the quality of chiropractic programs.

METHOD

Potential relevant questionnaire items were selected from the Australian chiropractic accreditation standards. Chiropractic students rated these items for clarity and relevance, which resulted in a pilot questionnaire of 47 items. Principal components analysis was used to establish the structure of the scales. Finally, intra-class correlation coefficients were used to establish the scales' test-retest reliability.

RESULTS

Thirty-four items were omitted resulting in the retention of 13 items that strongly loaded onto five factors. Internal consistency was adequate. The test-retest reliability ranged from adequate to good for four of the derived factors. The fifth was poor and omitted.

CONCLUSION

A valid questionnaire for assessing Australian chiropractic programs has been developed comprising four scales that enquire about: 1) quality of the educational program; 2) provision of student support services; 3) enablement of independent learning; and 4) adequacy of teaching resources.

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.

Developing National Functional Accreditation Model for Primary Healthcares with Emphasis on Family Practice in Iran

BACKGROUND

Accreditation is an approach toward quality improvement which has been increasingly implemented in healthcare. This study aimed at developing a national functional accreditation model for primary healthcare with emphasis on family practice in Iran.

METHODS

This mixed-method study utilizes a set of research methods purposefully. Initially, the reference models were used for benchmarking accreditation standards through a systematic review. Then, the primary accreditation standards were developed and then they were assessed and approved by the experts of the field via Delphi technique. In the following and after developing essential parts of the standards, the necessary changes in developed model were done according to the pilot test results.

RESULTS

The results of systematic review suggested the superiority of accreditation models of the United States, Australia, Canada, and the United Kingdom globally; and the models of Jordan, Saudi Arabia, Lebanon, and Egypt in Eastern-Mediterranean region. Then, the primary standards including 39 functional standards with 231 measures were developed according to the benchmarked models, and were approved by the experts in Delphi-based study. In pilot test step, the compliance rate of developed standards by primary healthcare centers was calculated 61.61% and 26.37% for self-evaluation and external evaluation phases, respectively.

CONCLUSION

Regarding the comprehensiveness of developed accreditation model due to its focus on all functional dimensions and the consensus over the developed standards by the experts, it can be an underlying ground for the establishment and evaluation of functional improvement programs in Iranian primary healthcare system.

Reference to nutrition in medical accreditation and curriculum guidance: a comparative analysis

Objective

Poor diet is a leading cause of death worldwide. Doctors are well placed to provide dietary advice, yet nutrition remains insufficiently integrated into medical education. Enforcement of curriculum or accreditation requirements such as nutrition requires relevant regulatory frameworks. The aim of this review was to identify nutrition content or requirements for nutrition education in accreditation standards or formal curriculum guidance for medical education internationally.

Design

Non-systematic comparative analysis.

Data sources

An internet search using the Google Search engine, the WHO Directory of Medical Schools and Foundation for Advancement of International Medical Education and Research Directory of Organizations that Recognise/Accredit Medical Schools was conducted through September 2020 to identify government and organisational reports as well as publications from regulatory and professional bodies relevant to medical education.

Eligibility criteria

Eligible publications included (A) accreditation standards, (B) competency standards or a framework, (C) curricula, and (D) assessment content.

Data extraction and synthesis

We stratified findings by country or region and both preregistration and postregistration education. Findings were synthesised based on the existence of nutrition content or requirements for nutrition education within systems used to guide medical education internationally.

Results

This review found that despite an emphasis on meeting the needs of the community and the demands of the labour market, only 44% of accreditation and curriculum guidance included nutrition. Nutrition remains inadequately represented in accreditation and curriculum guidance for medical education at all levels internationally. Accreditation standards provide a mandated framework for curricula and inclusion of nutrition in accreditation frameworks provides an incentive for the integration of nutrition into medical education.

Conclusions

This review is a call to action for the medical profession including government, health agencies and educational and accreditation entities. The inclusion of nutrition in medical education has appeared throughout medical education literature for more than five decades, yet without consensus standards there is little likelihood of uniform adoption.

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

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

Effectiveness of trauma centre verification: a systematic review and meta-analysis

Background

There is a growing trend toward verification of trauma centres, but its impact remains unclear. This systematic review aimed to synthesize available evidence on the effectiveness of trauma centre verification.

Methods

We conducted a systematic search of the CINAHL, Embase, HealthStar, MEDLINE and ProQuest databases, as well as the websites of key injury organizations for grey literature, from inception to June 2019, without language restrictions. Our population consisted of injured patients treated at trauma centres. The intervention was trauma centre verification. Comparison groups comprised nonverified trauma centres, or the same centre before it was first verified or re-verified. The primary outcome was in-hospital mortality; secondary outcomes included adverse events, resource use and processes of care. We computed pooled summary estimates using random-effects meta-analysis.

Results

Of 5125 citations identified, 29, all conducted in the United States, satisfied our inclusion criteria. Mortality was the most frequently investigated outcome (n = 20), followed by processes of care (n = 12), resource use (n = 12) and adverse events (n = 7). The risk of bias was serious to critical in 22 studies. We observed an imprecise association between verification and decreased mortality (relative risk 0.74, 95% confidence interval 0.52 to 1.06) in severely injured patients.

Conclusion

Our review showed mixed and inconsistent associations between verification and processes of care or patient outcomes. The validity of the published literature is limited by the lack of robust controls, as well as any evidence from outside the US, which precludes extrapolation to other health care jurisdictions. Quasiexperimental studies are needed to assess the impact of trauma centre verification.

Systematic reviews registration

PROSPERO no. CRD42018107083

Trauma system accreditation and patient outcomes in British Columbia: an interrupted time series analysis

OBJECTIVE

We aim to assess the impact of several accreditation cycles of trauma centers on patient outcomes, specifically in-hospital mortality, complications and hospital length of stay.

DESIGN

Interrupted time series.

SETTING

British Columbia, Canada.

PARTICIPANTS

Trauma patients admitted to all level I and level II trauma centers between January 2008 and March 2018.

EXPOSURE

Accreditation.

MAIN OUTCOMES AND MEASURES

We first computed quarterly estimates of the proportions of in-hospital mortality, complications and survival to discharge standardized for change in patient case-mix using prognostic scores and the Aalen-Johansen estimator of the cumulative incidence function. Piecewise regressions were then used to estimate the change in levels and trends for patient outcomes following accreditation.

RESULTS

For in-hospital mortality and major complications, the impact of accreditation seems to be associated with short- and long-term reductions after the first cycle and only short-term reductions for subsequent cycles. However, the 95% confidence intervals for these estimates were wide, and we lacked the precision to consistently conclude that accreditation is beneficial.

CONCLUSIONS

Applying a quasi-experimental design to time series accounting for changes in patient case-mix, our results suggest that accreditation might reduce in-hospital mortality and major complications. However, there was uncertainty around the estimates of accreditation. Further studies looking at clinical processes of care and other outcomes such as patient or health staff satisfaction are needed.

The applicability of COBIT processes representation structure for quality improvement in healthcare: a Delphi study

OBJECTIVES

In healthcare, a variety of quality management practices are used. Although they are important sources for quality improvement initiatives, they do not focus on each particular process. On the other hand, 'Control Objectives for Information and Related Technologies' (COBIT) offers a well-defined process representation structure for representing potential process improvements. The objective of this study was to adopt the COBIT structure for healthcare processes and assess the applicability of such process representations.

DESIGN

A two-round Delphi technique was applied: in round 1, open-ended interviews were performed with the participants; in round 2, the participants responded to the web questionnaire.

SETTINGS

The participants provided their opinion between 11 September 2018 and 26 June 2019.

PARTICIPANTS

It included 37 members of an expert panel from 8 European countries.

INTERVENTION

N/A.

MAIN OUTCOME MEASURES

In round 1, strengths, weaknesses, opportunities and threats indicators of using the proposed structure in healthcare were identified. These were evaluated on a 9-point Likert scale in round 2.

RESULTS

All participants noted that elements of the COBIT process representation structure were suitable for representing healthcare processes. The consensus was reached only for strengths and opportunities indicators.

CONCLUSIONS

A set of processes represented with the suggested structure has the potential to become a valid reference in healthcare quality improvements initiatives, as COBIT in IT domain. Despite the fact that the expert panel members confirmed the applicability of the COBIT process representation structure for healthcare processes, the identified weaknesses and threats cannot be ignored.

Using accreditation surveyors to conduct health services research: a qualitative, comparative study in Australia

OBJECTIVE

Healthcare accreditation surveyors are well positioned to gain access to hospitals and apply their existing data collection skills to research. Consequently, we contracted and trained a surveyor cohort to collect research data for the Deepening our Understanding of Quality in Australia (DUQuA) project. The aim of this study is to explore and compare surveyors' perceptions and experiences in collecting quality and safety data for accreditation and for health services research.

DESIGN

A qualitative, comparative study.

SETTING AND PARTICIPANTS

Ten surveyors participated in semi-structured interviews, which were audio recorded, transcribed and coded using Nvivo11. Interview transcripts of participants were analysed thematically and separately, providing an opportunity for comparison and for identifying common themes and subthemes.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Topics addressed data collection for healthcare accreditation and research, including preparation and training, structure, organization, attitudes and behaviours of staff and perceptions of their role.

RESULTS

Five themes and ten subthemes emerged from the interviews: (1) overlapping facilitators for accreditation and research data collection, (2) accreditation-specific facilitators, (3) overlapping barriers for accreditation and research data collection, (4) research data collection-specific barriers and (5) needs and recommendations. Subthemes were (1.1) preparation and training availability, (1.2) prior knowledge and experiences; (2.1) ease of access, (2.2) high staff engagement, (3.1) time, (4.1) poor access and structure, (4.2) lack of staff engagement, (4.3) organizational changes; (5.1) short-notice accreditation and (5.2) preparation for future research.

CONCLUSIONS

Although hospital accreditation and research activities require different approaches to data collection, we found that suitably trained accreditation surveyors were able to perform both activities effectively. The barriers surveyors encountered when collecting data for research provide insight into the challenges that may be faced when visiting hospitals for short-notice accreditation.

'All hands-on deck', working together to develop UK standards for public involvement in research

BACKGROUND

Public involvement in research is an established part of the research process in the UK, however there remain questions about what good public involvement in research looks and feels like. Until now public involvement practitioners, researchers and members of the public have looked for answers in examples shared across networks, published case studies, guidance and research articles. Pulling these strands together, the UK Standards for Public Involvement provides six statements (standards) about public involvement in research. They were produced by a partnership of organisations from Scotland, Northern Ireland, Wales and England with contributions from involvement practitioners, public partners, researchers and research funders.

MAIN BODY

Each standard has reflective questions, which are designed to encourage standard users to use approaches and behaviours that improve involvement, over time. The standards are designed to be used as a practical tool, and reflect the agreed hallmarks of good public involvement in research for example, flexibility in approaches used, shared learning, and mutual respect.The standards development process is described from the initial idea and scoping, via the appraisal of existing standard sets and integration of values and principles in public involvement in research. The collaborative writing process of and consultation on the draft standard set is described, together with what changed as a result of feedback. The initiation of a year-long testing programme with forty participating research organisations, the experiential feedback and the resulting changes to the standards is summarised.

CONCLUSION

This commentary paper describes, in some detail, a process to develop a set of six standards for public involvement in research in the UK. Producing a complex, national public involvement initiative is not without its challenges, and in supplementary material partnership members reflect on and share their experiences of standards development. The next phase of integration and implementation is explored with concluding comments from those that tested and helped improve the standards.

Accreditation of nursing clinical services: Development of an appraisal tool

Aim

This study aimed to determine comprehensive and applicable indicators for assessing the quality of nursing clinical services.

Design

Methodological research.

Methods

The checklist was designed in three phases (conceptualization, item generation and item reduction). In the first phase, a qualitative study using conventional content analysis was performed to clarify the concept of accreditation of clinical nursing services. In the second phase, using the views of experts was obtained in phase 1 and then by a review of the literature, related items were extracted, and item pool was formed. In the last phase, validity and reliability of the checklist were examined.

Result

Based on three phases (Conceptualization, Item Generation and Item Reduction), the accreditation indicators of clinical nursing services were extracted in three dimensions including structure, process and outcome at two levels of organizational (including structural and outcome indicators) and individual performance appraisal (process indicators) in 19 main categories.

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.

Management and treatment outcomes of patients undergoing endovenous ablation are significantly different between Intersocietal Accreditation Commission-accredited and nonaccredited vein centers

OBJECTIVE

The Intersocietal Accreditation Commission of vein centers was instituted in 2014, yet data regarding impact of accreditation on patients undergoing superficial vein interventions are lacking. This study was undertaken to identify differences in patient outcomes and utilization index as a measure of appropriate use in accredited compared with nonaccredited centers.

METHODS

This study was performed with a matched control design using prospectively collected data from two major U.S.-based venous registries: the Society for Vascular Surgery Vascular Quality Initiative Varicose Vein Registry and the American Vein & Lymphatic Society PRO Venous Registry.

RESULTS

A total of 39,001 patients treated between 2015 and 2018 in 192 centers were included in the study. The Vascular Quality Initiative Varicose Vein Registry provided information on 19,810 (50.8%) patients, and the American Vein & Lymphatic Society PRO Venous Registry provided information on 19,191 (49.2%) patients. Accredited centers were significantly more likely to treat patients with advanced venous disease as characterized by trophic skin changes (C4-C6, 38.1% vs 25.2%; P < .001). Percentage of patients treated 2 standard deviations above the Medicare-reported mean (3.4 utilization index) was significantly higher among patients treated at nonaccredited centers (3.3% vs 0.1%; P < .001). Venous Clinical Severity Score of those who were assessed between 1 month and 1 year after ablation decreased by 4.98 ± 4.01 in nonaccredited centers compared with 5.61 ± 3.64 in accredited centers (P < .001). Complications were low in both cohorts (nonaccredited centers, 71 [0.4%]; accredited centers, 17 [0.1%]; P < .001). One-year clinical follow-up was higher in nonaccredited centers (76.4% vs 31.5%; P < .001).

CONCLUSIONS

Venous registries are a powerful tool for capturing and identifying significant variations in procedure utilization and complications in low-risk procedures. Intersocietal Accreditation Commission accreditation was associated with reduced use of endovenous therapies, slightly lower complication rates, lower 1-year follow up, and greater improvement in Venous Clinical Severity Score.

Are Councils on Chiropractic Education expectations of chiropractic graduates changing for the better: a comparison of similarities and differences of the graduate competencies of the Chiropractic Council on Education-Australasia from 2009 to 2017

BACKGROUND

The Council on Chiropractic Education Australasia (CCE-A) is tasked with assessment and accreditation of chiropractic programs (CPs) in the Australasian community. To achieve this process the CCE-A has developed educational standards and graduate competencies which include minimum expectations of graduates prior to entry into the workforce. We sought to explore if these are changing overtime, and if so are these changes for the better.

METHOD

The CCE-A 2009 and 2017 Competency Standards were located and downloaded. The competencies were placed into tables for a comparative analyses in a systematic manner to enable the identification of similarities and differences. In addition, word counts were conducted for the most commonly occurring words and this took place in December 2019.

RESULTS

The 2017 competency standards were over three times smaller than the previous standards 2009 standards. More similarities than differences between the old and the new standards were found. There were 18 additions to the 2017 graduate competencies with many that were in unison with contemporary aspects of healthcare such as patient centred-care, respect for practitioner-patient boundaries and patient sexual orientation, transitioning patients to self-management, and consideration of improving lifestyle options. Some competencies were not bought forward to the new standards and included, among others, students being competent in screening for mental health conditions, an expectation to discuss cost of care, re-evaluating and monitoring patients at each visit, and knowing when to discharge patients. The competencies continued to be silent on known issues within the chiropractic profession of a lack of a definition for chiropractic that would inform scope of practice and the presence of vitalism within CPs.

CONCLUSION

There have been positive changes which reflect contemporary mainstream health care standards between CCE-A graduate competency revisions. The absence of a clear definition of chiropractic and its attendant scope of practice as well as continued silence on vitalism reflect known issues within the chiropractic profession. Recommendations are made for future accreditation standards to inform the required competencies and aid the integration of chiropractic into the broader health care community.

Development and upgrading of public primary healthcare facilities with essential surgical services infrastructure: a strategy towards achieving universal health coverage in Tanzania

BACKGROUND

Infrastructure development and upgrading to support safe surgical services in primary health care facilities is an important step in the journey towards achieving Universal Health Coverage (UHC). Quality health service provision together with equitable geographic access and service delivery are important components that constitute UHC. Tanzania has been investing in infrastructure development to offer essential safe surgery close to communities at affordable costs while ensuring better outcomes. This study aimed to understand the public sector's efforts to improve the infrastructure of primary health facilities between 2005 and 2019. We assessed the construction rates, geographic coverage, and physical status of each facility, surgical safety and services rendered in public primary health facilities.

METHODS

Data was collected from existing policy reports, the Services Availability and Readiness Assessment (SARA) tool (physical status), the Health Facility Registry (HFR), implementation reports on infrastructure development from the 26 regions and 185 district councils across the country (covering assessment of physical infrastructure, waste management systems and inventories for ambulances) and Comprehensive Emergence Obstetric Care (CEMONC) signal functions assessment tool. Data was descriptively analyzed so as to understand the distribution of primary health care facilities and their status (old, new, upgraded, under construction, renovated and equipped), and the service provided, including essential surgical services.

RESULTS

Of 5072 (518 are Health Centers and 4554 are Dispensaries) existing public primary health care facilities, the majority (46%) had a physical status of A (good state), 33% (1693) had physical status of B (minor renovation needed) and the remaining facilities had physical status of C up to F (needing major renovation). About 33% (1673) of all health facilities had piped water and 5.1% had landline telecommunication system. Between 2015 and August 2019, a total of 419 (8.3%) health facilities (Consisting of 350 health centers and 69 District Council Hospitals) were either renovated or constructed and equipped to offer safe surgery services. Of all Health Centers only 115 (22.2%) were offering the CEMONC services. Of these 115 health facilities, only 20 (17.4%) were offering the CEMONC services with all 9 - signal functions and only 17.4% had facilities that are offering safe blood transfusion services.

CONCLUSION

This study indicates that between 2015 and 2019 there has been improvement in physical status of primary health facilities as a result constructions, upgrading and equipping the facilities to offer safe surgery and related diagnostic services. Despite the achievements, still there is a high demand for good physical statuses and functioning of primary health facilities with capacity to offer essential and safe surgical services in the country also as an important strategy towards achieving UHC. This is also inline with the National Surgical, Obstetrics and Anesthesia plan (NSOAP).

Hospital accreditation: Driving best outcomes through continuity of midwifery care? A scoping review

PROBLEM

Continuity of midwifery care models are the gold standard of maternity care. Despite being recommended by the Australian Health Ministers' Advisory Council, few women in Australia have access to such models.

BACKGROUND

Extensive research shows that if all women had access to continuity of midwifery care, maternal and neonatal outcomes would improve. Hospital accreditation, the main national safety and quality system in Australia, aims to encourage and enable the translation of healthcare quality and safety standards into practice.

AIM

This paper explored the realities and possibilities of a health care accreditation system driving health service re-organisation towards the provision of continuity of midwifery care for childbearing women.

METHODS

A scoping review sought literature at the macro (policy) level. From 3036 records identified, the final number of sources included was 100:73 research articles and eight expert opinion pieces/editorials from journals, 15 government/accreditation documents, three government/accreditation websites, and one thesis.

FINDINGS

Two narrative themes emerged: (1) Hospital accreditation: 'Here to stay' but no clear evidence and calls for change. (2) Measuring and implementing quality and safety in maternity care.

DISCUSSION

Regulatory frameworks drive hospitals' priorities, potentially creating conditions for change. The case for reform in the hospital accreditation system is persuasive and, in maternity services, clear. Mechanisms to actualise the required changes in maternity care are less apparent, but clearly possible.

CONCLUSIONS

Structural changes to Australia's health accreditation system are needed to prioritise, and mandate, continuity of midwifery care.

Integrating Safety Attitudes and Safety Stressors into Safety Climate and Safety Behavior Relations: The Case of Healthcare Professionals in Abu Dhabi

Objectives

How safety climates, safety attitudes, and safety behaviors are related remains unexplored in the literature, with no study so far investigating the moderating path of safety stressors between these variables. We sought to understand the path through which safety climates may affect safety-behavior-related outcomes, such as safety compliance and participation, through the integration of safety attitudes. Since this study is related to the safety-related perception-intention-behavior relationship, safety stressors are proposed as a moderator of this relationship.

Methods

A total of 770 healthcare professionals working in public hospitals across Abu Dhabi were randomly selected for this study. We used questionnaires covering demographic details, safety behaviors, safety climates, safety attitudes, and safety stressors to obtain the data.

Results

The results revealed the partial mediating role of safety attitudes in the relationship between safety climate and safety behavior. Additionally, safety stressors did not moderate the relationship between safety climates, safety attitudes, and safety behaviors, which has some interesting implications for healthcare professionals.

Conclusions

The study suggests that safety attitudes may also regulate the impact of perceptions of management values regarding safety, policies, and procedures. It is highly likely that healthcare professionals who experience a positive workplace safety climate will form positive safety attitudes that encourage safety behavior. In addition, the homogeneous characteristics of healthcare professionals' in the UAE may also offer the positive coping strategy that caused the insignificant moderating effect of safety stressors on the relationship between safety climates, safety attitudes, and safety behaviors.

A Comparison of Three Models of Hospital Performance Assessment Using IPOCC Approach

Background

Hospital performance measurement is an essential component of providing feedback on the efficacy and effectiveness of service. The purpose of this study was to compare three models of performance assessment through the IPOCC approach.

Methods

This descriptive-analytical study was conducted in 2018 in Sari educational hospital. The data collection instrument was BSC, EFQM and accreditation questionnaire which was filled out through census. The validity of the BSC questionnaire and EFQM was based on expert opinion, and its reliability was found to be 0.97 and 0.92 using Cronbach's alpha coefficient. The accreditation questionnaire was developed using a checklist of the Ministry of Health. Using the expert panel, the components of the questionnaires were classified into dimensions of input, process, output, control, and context. Data analysis was done applying descriptive statistics and one way ANOVA.

Results

The highest distribution of components and acquired points through the IPOCC approach were found in the BSC in the process dimension (58.8%) and control dimension (3.62 ± 0.56), in the EFQM, in the result dimension (40.2%) and structure dimension (3.25 ± 0.44), and in the accreditation, in the process dimension (64.4%) and control dimension (3.45 ± 0.72), respectively. The results of one-way ANOVA showed that there was a significant difference between different quality models (P <0.001).

Conclusion

The results of the present study showed that in evaluating the hospital through the IPOCC approach, the distribution of components was more in the dimensions of the process. Therefore, having a robust systematic approach was considered to be effective for hospitals.

Recognising and responding to deteriorating patients: what difference do national standards make?

Background

The Australian Commission on Safety and Quality in Health Care released a set of national standards which became a mandatory part of accreditation in 2013. Standard 9 focuses on the identification and treatment of deteriorating patients. The objective of the study was to identify changes in the characteristics and perceptions of rapid response systems (RRS) since the implementation of Standard 9.

Methods

Cross-sectional study of Australian hospitals. Baseline data was obtained from a pre-implementation survey in 2010 (220 hospitals). A follow-up survey was distributed in 2015 to staff involved in implementing Standard 9 in public and private hospitals (276 responses) across Australia.

Results

Since 2010, the proportion of hospitals with formal RRS had increased from 66 to 85. Only 7% of sites had dedicated funding to operate the RRS. 83% of respondents reported that Standard 9 had improved the recognition of, and response to, deteriorating patients in their health service, with 51% believing it had improved awareness at the executive level and 50% believing it had changed hospital culture.

Conclusions

Implementing a national safety and quality standard for deteriorating patients can change processes to deliver safer care, while raising the profile of safety issues. Despite limited dedicated funding and staffing, respondents reported that Standard 9 had a positive impact on the care for deteriorating patients in their hospitals.

Electronic supplementary material

The online version of this article (10.1186/s12913-019-4339-z) contains supplementary material, which is available to authorized users.

The influence of hospital accreditation: a longitudinal assessment of organisational culture

BACKGROUND

A growing body of evidence supports the link between hospital organisational culture and health outcomes. Organisational culture is thus an essential consideration for hospital accreditation, a practice of systematically assessing the quality of hospital care against accepted standards. This study assesses the interplay between accreditation and hospital professional staff perception of organisational culture.

METHODS

A prospective cohort study design was used to explore the influence of accreditation on organisational culture within a large, publicly-funded, university teaching hospital in Hong Kong. All full-time hospital and academic physicians, nurses and allied health professionals were invited to participate. Organisational culture was evaluated using the Competing Values Framework through the Quality Improvement Implementation Survey. Organisational culture was assessed longitudinally at 9 months prior to accreditation, 3 months following and 15 months after accreditation. To capture potential shifts in staff perception of organisational culture through the accreditation process, we conducted a between time-point comparison using a linear trend model.

RESULTS

545 clinical staff completed the organisational culture survey pre-accreditation, 378 three- months post-accreditation and 141 15-months post-accreditation. Hierarchical culture was the dominant organisational culture domain pre-accreditation, followed by rational, developmental and group culture, respectively. Following accreditation, hierarchical culture declined but remained dominant, while group and developmental culture increased. However, the decline in hierarchical culture was U-shaped with scores increasing at 15-months post-accreditation, though not to pre-accreditation levels. When stratified by professional group, hierarchical culture declined following accreditation with corresponding increases in group culture and developmental culture among physicians and nurses, respectively. While allied health professionals did not perceive any significant cultural differences directly following accreditation, a significant increase in hierarchical culture and corresponding decrease in group culture was found 15-months post-accreditation.

CONCLUSIONS

This study suggests the hospital accreditation process may contribute to shifts in staff perception of organisational culture. Our findings also indicate differential views of organisational culture across professional groups. Finally, we note the striking dominance of hierarchical culture in this Hong Kong hospital across all time points, far surpassing other studies, even those in which hierarchical culture prevailed.

A process for developing standards to promote quality in general practice

BACKGROUND

Since 1991, the Royal Australian College of General Practitioners' (RACGP) Standards for General Practices (the Standards) have provided a framework for quality care, risk management and best practice in the operation of Australian general practices. The Standards are also linked to incentives for general practice remuneration. These Standards were revised in 2017.

OBJECTIVE

The objective of this study is to describe the process undertaken to develop the fifth edition Standards published in 2017 to inform future standards development both nationally and internationally.

METHOD

A modified Delphi process was deployed to develop the fifth edition Standards. Development was directed by the RACGP and led by an expert panel of GPs and representatives of stakeholder groups who were assisted and facilitated by a team from RACGP. Each draft was released for stakeholder feedback and tested twice before the final version was submitted for approval by the RACGP board.

RESULTS

Four rounds of consultation and two rounds of piloting were carried out over 32 months. The Standards were redrafted after each round. One hundred and fifty-two individuals and 225 stakeholder groups participated in the development of the Standards. Twenty-three new indicators were recommended and grouped into three sections in a new modular structure that was different from the previous edition.

CONCLUSION

The Standards represent the consensus view of national stakeholders on the indicators of quality and safety in Australian general practice and primary care.

A WHO-HPH operational program versus usual routines for implementing clinical health promotion: an RCT in health promoting hospitals (HPH)

BACKGROUND

Implementation of clinical health promotion (CHP) aiming at better health gain is slow despite its effect. CHP focuses on potentially modifiable lifestyle risks such as smoking, alcohol, diet, and physical inactivity. An operational program was created to improve implementation. It included patients, staff, and the organization, and it combined existing standards, indicators, documentation models, a performance recognition process, and a fast-track implementation model. The aim of this study was to evaluate if the operational program improved implementation of CHP in clinical hospital departments, as measured by health status of patients and staff, frequency of CHP service delivery, and standards compliance.

METHODS

Forty-eight hospital departments were recruited via open call and stratified by country. Departments were assigned to the operational program (intervention) or usual routine (control group). Data for analyses included 36 of these departments and their 5285 patients (median 147 per department; range 29-201), 2529 staff members (70; 10-393), 1750 medical records (50; 50-50), and standards compliance assessments. Follow-up was measured after 1 year. The outcomes were health status, service delivery, and standards compliance.

RESULTS

No health differences between groups were found, but the intervention group had higher identification of lifestyle risk (81% versus 60%, p < 0.01), related information/short intervention and intensive intervention (54% versus 39%, p < 0.01 and 43% versus 25%, p < 0.01, respectively), and standards compliance (95% versus 80%, p = 0.02).

CONCLUSIONS

The operational program improved implementation by way of lifestyle risk identification, CHP service delivery, and standards compliance. The unknown health effects, the bias, and the limitations should be considered in implementation efforts and further studies.

TRIAL REGISTRATION

ClinicalTrials.gov : NCT01563575. Registered 27 March 2012. https://clinicaltrials.gov/ct2/show/NCT01563575.

Development of a System Measurement Model of the Brazilian Hospital Accreditation System

The purpose of this study is to develop and validate a measurement model that evaluates the Brazilian hospital accreditation methodology (ONA), based on a multivariate model using structural equation modeling (SEM). The information used to develop the model was obtained from a questionnaire sent to all organizations accredited by the ONA methodology. A model was built based on the data obtained and tested through a structural equation modeling (SEM) technique using the LISREL® software (Scientific Software International, Inc., Skokie, IL, USA). Four different tests were performed: Initial, calibrated, simulated, and cross-validation models. By analyzing and validating the proposed measurement model, it can be verified that the selected factors satisfy the required criteria for the development of a structural model. The results show that leadership action is one of the most important factors in the process of health services accredited by ONA. Although, leadership, staff management, quality management, organizational culture, process orientation, and safety are strongly linked to the development of health organizations, and directly influence the accreditation process.

Comparing the old to the new: A comparison of similarities and differences of the accreditation standards of the chiropractic council on education-international from 2010 to 2016

Background

Chiropractic programs are accredited and monitored by regional Councils on Chiropractic Education (CCE). The CCE-International has historically been a federation of regional CCEs charged with harmonising world standards to produce quality chiropractic educational programs. The standards for accreditation periodically undergo revision. We conducted a comparison of the CCE-International 2016 Accreditation Standards with the previous version, looking for similarities and differences, expecting to see some improvements.

Method

The CCE-International current (2016) and previous versions (2010) were located and downloaded. Word counts were conducted for words thought to reflect content and differences between standards. These were tabulated to identify similarities and differences. Interpretation was made independently followed by discussion between two researchers.

Results

The 2016 standards were nearly 3 times larger than the previous standards. The 2016 standards were created by mapping and selection of common themes from member CCEs' accreditation standards and not through an evidence-based approach to the development and trialling of accreditation standards before implementation. In 2010 chiropractors were expected to provide attention to the relationship between the structural and neurological aspects of the body in health and disease. In 2016 they should manage mechanical disorders of the musculoskeletal system. Many similarities between the old and the new standards were found. Additions in 2016 included a hybrid model of accreditation founded on outcomes-based assessment of education and quality improvement. Both include comprehensive competencies for a broader role in public health. Omissions included minimal faculty qualifications and the requirement that students should be able to critically appraise scientific and clinical knowledge. Another omission was the requirement for chiropractic programs to be part of a not-for-profit educational entity. There was no mention of evidence-based practice in either standards but the word 'evidence-informed' appeared once in the 2016 standards.

Conclusions

Some positive changes have taken place, such as having bravely moved towards the musculoskeletal model, but on the negative side, the requirement to produce graduates skilled at dealing with scientific texts has been removed. A more robust development approach including better transparency is needed before implementation of CCE standards and evidence-based concepts should be integrated in the programs. The CCE-International should consider the creation of a recognition of excellence in educational programs and not merely propose minimal standards.

Governance arrangements for health systems in low-income countries: an overview of systematic reviews

BACKGROUND

Governance arrangements include changes in rules or processes that determine authority and accountability for health policies, organisations, commercial products and health professionals, as well as the involvement of stakeholders in decision-making. Changes in governance arrangements can affect health and related goals in numerous ways, generally through changes in authority, accountability, openness, participation and coherence. A broad overview of the findings of systematic reviews can help policymakers, their technical support staff and other stakeholders to identify strategies for addressing problems and improving the governance of their health systems.

OBJECTIVES

To provide an overview of the available evidence from up-to-date systematic reviews about the effects of governance arrangements for health systems in low-income countries. Secondary objectives include identifying needs and priorities for future evaluations and systematic reviews on governance arrangements and informing refinements of the framework for governance arrangements outlined in the overview.

METHODS

We searched Health Systems Evidence in November 2010 and PDQ Evidence up to 17 December 2016 for systematic reviews. We did not apply any date, language or publication status limitations in the searches. We included well-conducted systematic reviews of studies that assessed the effects of governance arrangements on patient outcomes (health and health behaviours), the quality or utilisation of healthcare services, resource use (health expenditures, healthcare provider costs, out-of-pocket payments, cost-effectiveness), healthcare provider outcomes (such as sick leave), or social outcomes (such as poverty, employment) and that were published after April 2005. We excluded reviews with limitations that were important enough to compromise the reliability of the findings of the review. Two overview authors independently screened reviews, extracted data and assessed the certainty of evidence using GRADE. We prepared SUPPORT Summaries for eligible reviews, including key messages, 'Summary of findings' tables (using GRADE to assess the certainty of the evidence) and assessments of the relevance of findings to low-income countries.

MAIN RESULTS

We identified 7272 systematic reviews and included 21 of them in this overview (19 primary reviews and 2 supplementary reviews). We focus here on the results of the 19 primary reviews, one of which had important methodological limitations. The other 18 were reliable (with only minor limitations).We grouped the governance arrangements addressed in the reviews into five categories: authority and accountability for health policies (three reviews); authority and accountability for organisations (two reviews); authority and accountability for commercial products (three reviews); authority and accountability for health professionals (seven reviews); and stakeholder involvement (four reviews).Overall, we found desirable effects for the following interventions on at least one outcome, with moderate- or high-certainty evidence and no moderate- or high-certainty evidence of undesirable effects. Decision-making about what is covered by health insurance- Placing restrictions on the medicines reimbursed by health insurance systems probably decreases the use of and spending on these medicines (moderate-certainty evidence). Stakeholder participation in policy and organisational decisions- Participatory learning and action groups for women probably improve newborn survival (moderate-certainty evidence).- Consumer involvement in preparing patient information probably improves the quality of the information and patient knowledge (moderate-certainty evidence). Disclosing performance information to patients and the public- Disclosing performance data on hospital quality to the public probably encourages hospitals to implement quality improvement activities (moderate-certainty evidence).- Disclosing performance data on individual healthcare providers to the public probably leads people to select providers that have better quality ratings (moderate-certainty evidence).

AUTHORS' CONCLUSIONS

Investigators have evaluated a wide range of governance arrangements that are relevant for low-income countries using sound systematic review methods. These strategies have been targeted at different levels in health systems, and studies have assessed a range of outcomes. Moderate-certainty evidence shows desirable effects (with no undesirable effects) for some interventions. However, there are important gaps in the availability of systematic reviews and primary studies for the all of the main categories of governance arrangements.

Hospital quality measures: are process indicators associated with hospital standardized mortality ratios in French acute care hospitals?

Background

Results of associations between process and mortality indicators, both used for the external assessment of hospital care quality or public reporting, differ strongly across studies. However, most of those studies were conducted in North America or United Kingdom. Providing new evidence based on French data could fuel the international debate on quality of care indicators and help inform French policy-makers. The objective of our study was to explore whether optimal care delivery in French hospitals as assessed by their Hospital Process Indicators (HPIs) is associated with low Hospital Standardized Mortality Ratios (HSMRs).

Methods

The French National Authority for Health (HAS) routinely collects for each hospital located in France, a set of mandatory HPIs. Five HPIs were selected among the process indicators collected by the HAS in 2009. They were measured using random samples of 60 to 80 medical records from inpatients admitted between January 1st, 2009 and December 31, 2009 in respect with some selection criteria. HSMRs were estimated at 30, 60 and 90 days post-admission (dpa) using administrative health data extracted from the national health insurance information system (SNIIR-AM) which covers 77% of the French population. Associations between HPIs and HSMRs were assessed by Poisson regression models corrected for measurement errors with a simulation-extrapolation (SIMEX) method.

Results

Most associations studied were not statistically significant. Only two process indicators were found associated with HSMRs. Completeness and quality of anesthetic records was negatively associated with 30 dpa HSMR (0.72 [0.52–0.99]). Early detection of nutritional disorders was negatively associated with all HSMRs: 30 dpa HSMR (0.71 [0.54–0.95]), 60 dpa HSMR (0.51 [0.39–0.67]) and 90 dpa HSMR (0.52 [0.40–0.68]).

Conclusion

In absence of gold standard of quality of care measurement, the limited number of associations suggested to drive in-depth improvements in order to better determine associations between process and mortality indicators. A smart utilization of both process and outcomes indicators is mandatory to capture aspects of the hospital quality of care complexity.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-017-2534-3) contains supplementary material, which is available to authorized users.

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.

JACIE accreditation for blood and marrow transplantation: past, present and future directions of an international model for healthcare quality improvement

Blood and marrow transplantation (BMT) is a complex and evolving medical speciality that makes substantial demands on healthcare resources. To meet a professional responsibility to both patients and public health services, the European Society for Blood and Marrow Transplantation (EBMT) initiated and developed the Joint Accreditation Committee of the International Society for Cellular Therapy and EBMT-better known by the acronym, JACIE. Since its inception, JACIE has performed over 530 voluntary accreditation inspections (62% first time; 38% reaccreditation) in 25 countries, representing 40% of transplant centres in Europe. As well as widespread professional acceptance, JACIE has become incorporated into the regulatory framework for delivery of BMT and other haematopoietic cellular therapies in several countries. In recent years, JACIE has been validated using the EBMT registry as an effective means of quality improvement with a substantial positive impact on survival outcomes. Future directions include development of Europe-wide risk-adjusted outcome benchmarking through the EBMT registry and further extension beyond Europe, including goals to faciliate access for BMT programmes in in low- and middle-income economies (LMIEs) via a 'first-step' process.

Framework for establishing records control in hospitals as an ISO 9001 requirement

Purpose

The purpose of this paper is to present the process followed to control records in a Jordanian private community hospital as an ISO 9001:2008 standard requirement.

Design/methodology/approach

Under the hospital quality council’s supervision, the quality management and development office staff were responsible for designing, planning and implementing the quality management system (QMS) using the ISO 9001:2008 standard. A policy for records control was established. An action plan for establishing the records control was developed and implemented. On completion, a coding system for records was specified to be used by hospital staff. Finally, an internal audit was performed to verify conformity to the ISO 9001:2008 standard requirements.

Findings

Successful certification by a neutral body ascertained that the hospital’s QMS conformed to the ISO 9001:2008 requirements. A framework was developed that describes the records controlling process, which can be used by staff in any healthcare organization wanting to achieve ISO 9001:2008 accreditation.

Originality/value

Given the increased interest among healthcare organizations to achieve the ISO 9001 certification, the proposed framework for establishing records control is developed and is expected to be a valuable management tool to improve and sustain healthcare quality.

Quality of Dementia Care in the Community: Identifying Key Quality Assurance Components

BACKGROUND

Primary care-based memory clinics (PCMCs) have been established in several jurisdictions to improve the care for persons with Alzheimer's disease and related dementias. We sought to identify key quality indicators (QIs), quality improvement mechanisms, and potential barriers and facilitators to the establishment of a quality assurance framework for PCMCs.

METHODS

We employed a Delphi approach to obtain consensus from PCMC clinicians and specialist physicians on QIs and quality improvement mechanisms. Thirty-eight candidate QIs and 19 potential quality improvement mechanisms were presented to participants in two rounds of electronic Delphi surveys. Written comments were collected and descriptively analyzed.

RESULTS

The response rate for the first and second rounds were 21.3% (n = 179) and 12.8% (n = 88), respectively. The majority of respondents were physicians. Fourteen QIs remained after the consensus process. Ten quality improvement mechanisms were selected with those characterized by specialist integration, such as case discussions and mentorships, being ranked highly. Written comments revealed three major themes related to potential barriers and facilitators to quality assurance: 1) perceived importance, 2) collaboration and role clarity, and 3) implementation process.

CONCLUSION

We successfully utilized a consultative process among primary and specialty providers to identify core QIs and quality improvement mechanisms for PCMCs. Identified quality improvement mechanisms highlight desire for multi-modal education. System integration and closer integration between PCMCs and specialists were emphasized as essential for the provision of high-quality dementia care in community settings.

Recent trends in working with the private sector to improve basic healthcare: a review of evidence and interventions

The private sector provides the majority of health care in Africa and Asia. A number of interventions have, for many years, applied different models of subsidy, support and engagement to address social and efficiency failures in private health care markets. We have conducted a review of these models, and the evidence in support of them, to better understand what interventions are currently common, and to what extent practice is based on evidence. Using established typologies, we examined five models of intervention with private markets for care: commodity social marketing, social franchising, contracting, accreditation and vouchers. We conducted a systematic review of both published and grey literature, identifying programmes large enough to be cited in publications, and studies of the listed intervention types. 343 studies were included in the review, including both published and grey literature. Three hundred and eighty programmes were identified, the earliest having begun operation in 1955. Commodity social marketing programmes were the most common intervention type, with 110 documented programmes operating for condoms alone at the highest period. Existing evidence shows that these models can improve access and utilization, and possibly quality, but for all programme types, the overall evidence base remains weak, with practice in private sector engagement consistently moving in advance of evidence. Future research should address key questions concerning the impact of interventions on the market as a whole, the distribution of benefits by socio-economic status, the potential for scale up and sustainability, cost-effectiveness compared to relevant alternatives and the risk of unintended consequences. Alongside better data, a stronger conceptual basis linking programme design and outcomes to context is also required.

Surveyor Management of Hospital Accreditation Program: A Thematic Analysis Conducted in Iran

Background

The surveyors in hospital accreditation program are considered as the core of accreditation programs. So, the reliability and validity of the accreditation program heavily depend on their performance.

Objectives

This study aimed to identify the dimensions and factors affecting surveyor management of hospital accreditation programs in Iran.

Materials and Methods

This qualitative study used a thematic analysis method, and was performed in Iran in 2014. The study participants included experts in the field of hospital accreditation, and were derived from three groups: 1. Policy-makers, administrators, and surveyors of the accreditation bureau, the ministry of health and medical education, Iranian universities of medical science; 2. Healthcare service providers, and 3. University professors and faculty members. The data were collected using semi-structured in-depth interviews. Following text transcription and control of compliance with the original text, MAXQDA10 software was used to code, classify, and organize the interviews in six stages.

Results

The findings from the analysis of 21 interviews were first classified in the form of 1347 semantic units, 11 themes, 17 sub-themes, and 248 codes. These were further discussed by an expert panel, which then resulted in the emergence of seven main themes - selection and recruitment of the surveyor team, organization of the surveyor team, planning to perform surveys, surveyor motivation and retention, surveyor training, surveyor assessment, and recommendations - as well as 27 sub-themes, and 112 codes.

Conclusions

The dimensions and variables affecting the surveyors’ management were identified and classified on the basis of existing scientific methods in the form of a conceptual framework. Using the results of this study, it would certainly be possible to take a great step toward enhancing the reliability of surveys and the quality and safety of services, while effectively managing accreditation program surveyors.

A hybrid health service accreditation program model incorporating mandated standards and continuous improvement: interview study of multiple stakeholders in Australian health care

The study aim was to investigate the understandings and concerns of stakeholders regarding the evolution of health service accreditation programs in Australia. Stakeholder representatives from programs in the primary, acute and aged care sectors participated in semi-structured interviews. Across 2011-12 there were 47 group and individual interviews involving 258 participants. Interviews lasted, on average, 1 h, and were digitally recorded and transcribed. Transcriptions were analysed using textual referencing software. Four significant issues were considered to have directed the evolution of accreditation programs: altering underlying program philosophies; shifting of program content focus and details; different surveying expectations and experiences and the influence of external contextual factors upon accreditation programs. Three accreditation program models were noted by participants: regulatory compliance; continuous quality improvement and a hybrid model, incorporating elements of these two. Respondents noted the compatibility or incommensurability of the first two models. Participation in a program was reportedly experienced as ranging on a survey continuum from "malicious compliance" to "performance audits" to "quality improvement journeys". Wider contextual factors, in particular, political and community expectations, and associated media reporting, were considered significant influences on the operation and evolution of programs. A hybrid accreditation model was noted to have evolved. The hybrid model promotes minimum standards and continuous quality improvement, through examining the structure and processes of organisations and the outcomes of care. The hybrid model appears to be directing organisational and professional attention to enhance their safety cultures. Copyright © 2015 John Wiley & Sons, Ltd.

Experiencing health care service quality: through patient's eyes

Objective The primary aim of the present study was to consider health care service quality from the patients’ perspective, specifically through the patient’s eyes. Method A narrative analysis was performed on 300 patient stories. This rigorous analysis of patient stories is designed to identify and describe health care service quality through patients’ eyes in an authentic and accurate, experiential manner. Results The findings show that there are variant and complex ways that patients experience health care service quality. Conclusion Patient stories offer an authentic view of the complex ways that patients experience health care service quality. Narrative analysis is a useful tool to identify and describe how patients experience health care service quality. Patients experience health care service quality in complex and varying ways. What is known about the topic? Patient satisfaction measures are increasingly used for benchmark and accreditation purposes. Measures of patient satisfaction are considered indicative measures of service quality and quality of care. However, the measurement of patient satisfaction and service quality is not an accurate reflection of what and how patients experience health care. What does this paper add? This paper takes a narrative approach and analyses 300 patient stories to demonstrate the essence of patients’ evaluation of health care service quality. What are the implications for practitioners? Health care service quality is shown to be experienced in various ways. Identifying and describing these different ways of experiencing health care service quality provides practitioners with strategic insight into improving the quality of service they provide outside the realm of objective satisfaction measures. These findings also demonstrate the value in a third-party feedback system.

A mechanism for revising accreditation standards: a study of the process, resources required and evaluation outcomes

Background

The study objective was to identify and describe the process, resources and expertise required for the revision of accreditation standards, and report outcomes arising from such activities.

Methods

Secondary document analysis of materials from an accreditation standards development agency. The Royal Australian College of General Practitioners’ (RACGP) documents, minutes and reports related to the revision of the accreditation standards were examined.

Results

The RACGP revision of the accreditation standards was conducted over a 12 month period and comprised six phases with multiple tasks, including: review methodology planning; review of the evidence base and each standard; new material development; constructing field trial methodology; drafting, trialling and refining new standards; and production of new standards. Over 100 individuals participated, with an additional 30 providing periodic input and feedback. Participants were drawn from healthcare professional associations, primary healthcare services, accreditation agencies, government agencies and public health organisations. Their expertise spanned: project management; standards development and writing; primary healthcare practice; quality and safety improvement methodologies; accreditation implementation and surveying; and research. The review and development process was shaped by five issues: project expectations; resource and time requirements; a collaborative approach; stakeholder engagement; and the product produced. The RACGP evaluation was that participants were positive about their experience, the standards produced and considered them relevant for the sector.

Conclusions

The revision of accreditation standards requires considerable resources and expertise, drawn from a broad range of stakeholders. Collaborative, inclusive processes that engage key stakeholders helps promote greater industry acceptance of the standards.

Analysing 'big picture' policy reform mechanisms: the Australian health service safety and quality accreditation scheme

BACKGROUND

Agencies promoting national health-care accreditation reform to improve the quality of care and safety of patients are largely working without specific blueprints that can increase the likelihood of success.

OBJECTIVE

This study investigated the development and implementation of the Australian Health Service Safety and Quality Accreditation Scheme and National Safety and Quality Health Service Standards (the Scheme), their expected benefits, and challenges and facilitators to implementation.

METHODS

A multimethod study was conducted using document analysis, observation and interviews. Data sources were eight government reports, 25 h of observation and 34 interviews with 197 diverse stakeholders.

RESULTS

Development of the Scheme was achieved through extensive consultation conducted over a prolonged period, that is, from 2000 onwards. Participants, prior to implementation, believed the Scheme would produce benefits at multiple levels of the health system. The Scheme offered a national framework to promote patient-centred care, allowing organizations to engage and coordinate professionals' quality improvement activities. Significant challenges are apparent, including developing and maintaining stakeholder understanding of the Scheme's requirements. Risks must also be addressed. The standardized application of, and reliable assessment against, the standards must be achieved to maintain credibility with the Scheme. Government employment of effective stakeholder engagement strategies, such as structured consultation processes, was viewed as necessary for successful, sustainable implementation.

CONCLUSION

The Australian experience demonstrates that national accreditation reform can engender widespread stakeholder support, but implementation challenges must be overcome. In particular, the fundamental role of continued stakeholder engagement increases the likelihood that such reforms are taken up and spread across health systems.

"Baby Heart Project": the Italian project for accreditation and quality management in pediatric cardiology and cardiac surgery

Optimization of the relationship between the supply and the demand for medical services should ideally be taken into consideration for the planning within each national Health System. Although government national health organizations embrace this policy specifically, the contribution of expert committees (under the scientific societies' guarantee in any specific medical field) should be advocated for their capability to collect and analyze the data reported by the various national institutions. In addition, these committees have the competence to analyze the need for the resources necessary to the operation of these centers. The field of pediatric cardiology and cardiac surgery may represent a model of clinical governance of particular interest with regard to programming and to a definition of the quality standards that may be extended to highly specialized institutions and ideally to the entire Health System. The "Baby Heart Project," which represents a model of governance and clinical quality in the field of pediatric cardiology and cardiac surgery, was born from the spontaneous aggregation of a committee of experts, supported by duly appointed Italian Scientific Societies and guided by a national agency for accreditation. The ultimate aim is to standardize both procedures and results for future planning within the national Health System.

Use of the quality management system "JACIE" and outcome after hematopoietic stem cell transplantation

Competent authorities, healthcare payers and hospitals devote increasing resources to quality management systems but scientific analyses searching for an impact of these systems on clinical outcome remain scarce. Earlier data indicated a stepwise improvement in outcome after allogeneic hematopoietic stem cell transplantation with each phase of the accreditation process for the quality management system "JACIE". We therefore tested the hypothesis that working towards and achieving "JACIE" accreditation would accelerate improvement in outcome over calendar time. Overall mortality of the entire cohort of 107,904 patients who had a transplant (41,623 allogeneic, 39%; 66,281 autologous, 61%) between 1999 and 2006 decreased over the 14-year observation period by a factor of 0.63 per 10 years (hazard ratio: 0.63; 0.58-0.69). Considering "JACIE"-accredited centers as those with programs having achieved accreditation by November 2012, at the latest, this improvement was significantly faster in "JACIE"-accredited centers than in non-accredited centers (approximately 5.3% per year for 49,459 patients versus approximately 3.5% per year for 58,445 patients, respectively; hazard ratio: 0.83; 0.71-0.97). As a result, relapse-free survival (hazard ratio 0.85; 0.75-0.95) and overall survival (hazard ratio 0.86; 0.76-0.98) were significantly higher at 72 months for those patients transplanted in the 162 "JACIE"-accredited centers. No significant effects were observed after autologous transplants (hazard ratio 1.06; 0.99-1.13). Hence, working towards implementation of a quality management system triggers a dynamic process associated with a steeper reduction in mortality over the years and a significantly improved survival after allogeneic stem cell transplantation. Our data support the use of a quality management system for complex medical procedures.