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

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

Introduction

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

Method

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

Results

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

Conclusion

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

Determining the Role of Employee Engagement in Nurse Retention along with the Mediation of Organizational Culture

In today's unpredictable environment, the rapid emergence of the COVID-19 pandemic has shaken the world and its healthcare infrastructure immensely. As nurses are the building blocks of the healthcare personnel labor market, organizations should develop tactics that aid in their retention. With a solid theoretical foundation in self-determination theory, this study aims to understand the role of employee engagement in keeping nurses in 51 hospitals in the Northern Indian region, along with the mediation of organizational culture through smart PLS. In a complementary mediation relationship with organizational culture, nurse retention is positively correlated with employee engagement.

Accreditation of primary health care centres in the KSA: Lessons from developed and developing countries

Background/Objectives

In 2013, the KSA made Central Board for Accreditation of Healthcare Institutions (CBAHI) accreditation mandatory for all healthcare facilities, including primary health care centres (PHCs) and set a target to have 502 PHCs accredited by 2020. However, there is a real gap in knowledge and research on the impact of CBAHI accreditation on PHCs. This absence of research has been linked to the lack of understanding of the accreditation programme. Therefore, it was recommended by scholars that the KSA could learn from the experience of other countries to improve policy implementation and avoid future complications.

Methods

This study aimed to explore lessons that KSA can draw from developed and developing countries that have implemented accreditation programmes for PHCs. We performed a literature review using a systematic approach to identify articles related to the accreditation of PHCs. The identified articles were examined by applying evaluation criteria in respect of prospective policy transfer.

Results

The research results yielded 22 publications from different countries. There were variations among the countries in the specific information acquired. However, Denmark had the highest number of articles providing detailed information. Regarding their aims, most studies shared the same goal of improving quality and patient safety. Generally, there was limited discussion of policy failure compared with policy success. In addition, most of the countries were in the process of implementing local accreditation. Almost all of the countries that had implemented external programmes were developing countries. In terms of application criteria, most cases made recommendations for the programme or for PHCs.

Conclusion

Analysis indicated that because of the differences in information between countries and settings, there is no ideal country-based experience from which the KSA can transfer lessons. Lessons from outside the KSA would need careful consideration when adopting them in the local context of the Kingdom.

The perceptions of healthcare professionals about accreditation and its impact on quality of healthcare in Kuwait: a qualitative study

RATIONALE, AIMS, AND OBJECTIVES

The accreditation of healthcare organizations has been applied as a quality assurance mechanism of healthcare services. Kuwait health authorities implemented a national healthcare accreditation program at the governmental healthcare system. This study aimed to explore the perceptions of healthcare professionals (HCPs) about healthcare accreditation, perceived challenges to implementing accreditation, and views on how to overcome these challenges.

METHODS

A phenomenological qualitative framework was adopted to conduct focus group interviews to explore perceptions of HCPs about accreditation in governmental healthcare system. Data were collected from 30 HCPs using seven focus group interviews. The verbatim transcripts of the interviews were analysed using the framework approach.

RESULTS

The HCPs indicated that accreditation enhanced patient safety culture at their organizations through staff adherence to good practices, improved documentation and patient handover practices, and incident reporting. The facilitators to the implementation of accreditation that emerged from interviews included administrative support, staff training about accreditation, and expansion in application of electronic systems. Participants reported several challenges to implementing accreditation including challenges related to staff (eg, high workload, burdens imposed by accreditation requirements), challenges related to organizational system and resources (eg, poor teamwork among HCPs, inadequate infrastructure in some facilities), and challenges related to patients (eg, poor understanding about accreditation). However, most participants expressed positive attitudes towards accreditation and appreciated its impact on quality of healthcare. Participants suggested ways to support accreditation such as increasing staff numbers to reduce workload, enhancing staff motivation and education about accreditation, developing proactive leadership and staff teamwork, and improving patients' awareness about accreditation.

CONCLUSIONS

HCPs in Kuwait expressed positive attitudes towards accreditation while also recognizing the challenges that may hinder its implementation. The collaboration between different stakeholders in this process is essential to overcome these challenges and support HCPs to meet accreditation standards and improve quality of healthcare services.

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.

Quality management systems in Aboriginal Community Controlled Health Services: a review of the literature

BACKGROUND

A national accreditation policy for the Australian primary healthcare (PHC) system was initiated in 2008. While certification standards are mandatory, little is known about their effects on the efficiency and sustainability of organisations, particularly in the Aboriginal Community Controlled Health Service (ACCHS) sector.

AIM

The literature review aims to answer the following: to what extent does the implementation of the International Organisation for Standardization 9001:2008 quality management system (QMS) facilitate efficiency and sustainability in the ACCHS sector?

METHODS

Thematic analysis of peer-reviewed and grey literature was undertaken from Australia and New Zealand PHC sector with a focus on First Nations people. The databases searched included Medline, Scopus and three Informit sites (AHB-ATSIS, AEI-ATSIS and AGIS-ATSIS). The initial search strategy included quality improvement, continuous quality improvement, efficiency and sustainability.

RESULTS

Sixteen included studies were assessed for quality using the McMaster criteria. The studies were ranked against the criteria of credibility, transferability, dependability and confirmability. Three central themes emerged: accreditation (n=4), quality improvement (n=9) and systems strengthening (n=3). The accreditation theme included effects on health service expenditure and clinical outcomes, consistency and validity of accreditation standards and linkages to clinical governance frameworks. The quality improvement theme included audit effectiveness and value for specific population health. The theme of systems strengthening included prerequisite systems and embedded clinical governance measures for innovative models of care.

CONCLUSION

The ACCHS sector warrants reliable evidence to understand the value of QMSs and enhancement tools, particularly given ACCHS (client-centric) services and their specialist status. Limited evidence exists for the value of standards on health system sustainability and efficiency in Australia. Despite a mandatory second certification standard, no studies reported on sustainability and efficiency of a QMS in PHC.

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.

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

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

Challenges of implementation of hospital accreditation in Iran: an exploratory factor analysis

BACKGROUND

Today, accreditation is considered as the most commonly used health assessment approach. Considering the importance and application of the process of this approach in the hospital, this study aimed to investigate the challenges of implementation of hospital accreditation in Iran using exploratory factor analysis.

METHODS

A cross-sectional study design was carried out from July to December 2017, consisting of 200 managers in the seven hospitals accredited by the MOH in Tehran, Iran. Samples were selected through the purposive sampling method, and data were collected using a structured questionnaire in which validity and reliability were confirmed. Likert's five-choice range was used for the rating of items. Exploratory factor analysis was used to categorize the identified challenges and extract the mathematical model on them.

RESULTS

Exploratory factor analysis identified six dimensions (implementation, evaluation, content, structural, psychological, and managerial) with 40 items using a 5-point Likert scale. Each dimension accounted for greater than 63.20% of the total variance. The scale had strong content validity (indices = 0.84). Each dimension of Cronbach's alpha ranged from 0.74 to 0.94. Implementation, evaluation, content, structural, psychological, and managerial components also formed the final identified areas.

CONCLUSION

The present study showed that there were major challenges in the path to successful deployment of Iranian hospital accreditation, requiring serious action by managers and policymakers in this field.

Implementation and data-related challenges in the Deepening our Understanding of Quality in Australia (DUQuA) study: implications for large-scale cross-sectional research

Healthcare organisations vary in the degree to which they implement quality and safety systems and strategies. Large-scale cross-sectional studies have been implemented to explore whether this variation is associated with outcomes relevant at the patient level. The Deepening our Understanding of Quality in Australia (DUQuA) study draws from earlier research of this type, to examine these issues in 32 Australian hospitals. This paper outlines the key implementation and analysis challenges faced by DUQuA. Many of the logistical difficulties of implementing DUQuA derived from compliance with the administratively complex and time-consuming Australian ethics and governance system designed principally to protect patients involved in clinical trials, rather than for low-risk health services research. The complexity of these processes is compounded by a lack of organizational capacity for multi-site health services research; research is expected to be undertaken in addition to usual work, not as part of it. These issues likely contributed to a relatively low recruitment rate for hospitals (41% of eligible hospitals). Both sets of issues need to be addressed by health services researchers, policymakers and healthcare administrators, if health services research is to flourish. Large-scale research also inevitably involves multiple measurements. The timing for applying these measures needs to be coherent, to maximise the likelihood of finding real relationships between quality and safety systems and strategies, and patient outcomes; this timing was less than ideal in DUQuA, in part due to administrative delays. Other issues that affected our study include low response rates for measures requiring recruitment of clinicians and patients, missing data and a design that necessarily included multiple statistical comparisons. We discuss how these were addressed. Successful completion of these projects relies on mutual and ongoing commitment, and two-way communication between the research team and hospital staff at all levels. This will help to ensure that enthusiasm and engagement are established and maintained.

Can hospital accreditation enhance patient experience? Longitudinal evidence from a Hong Kong hospital patient experience survey

BACKGROUND

Hospital accreditation is expected to improve health care quality and patient satisfaction. However, little and conflicting evidence is currently available to support its effect on patient outcomes, particularly patient experience. Hong Kong recently launched a pilot programme to test an infrastructure for accreditation of both private and public hospitals with the Australian Council on Healthcare Standards. This study aims to evaluate the longitudinal impact of hospital accreditation on patient experience in a publicly-funded university teaching hospital in Hong Kong.

METHODS

Three cross-sectional surveys were conducted at three time points: 9 months pre- accreditation as baseline (T1), three (T2) and fifteen months (T3) post-accreditation. Acute care inpatients aged 18 to 80 were recruited on the second day of hospital admission to complete the Picker Patient Experience Questionnaire-15 (PPE-15). Baseline data was first compared to the 2005 Hong Kong average for public hospitals using t-tests. Data was then analyzed using ANOVA and multiple linear regression to evaluate differences across the three cross-sections and examine the effect of accreditation over time while controlling for covariates.

RESULTS

3083 patients (T1 = 896, T2 = 1093, T3 = 1094) completed the survey for a response rate of 83.5, 86.1, and 83.8%, respectively. The hospital baseline domain and summary patient experience scores differed from the Hong Kong public hospital average obtained from the 2005 Thematic Household Survey. All domain and summary patient experience scores declined (improved) over the study period (T1 to T3). The multiple regression results confirmed the time point score comparisons with declining (improving) parameter estimates for T2 and T3 for all domain and summary scores except the 'continuity and transition' domain, for which the declining coefficient was only significant at T3.

CONCLUSIONS

While hospital accreditation has not been shown to improve patient outcomes, this study suggests the accreditation exercise may enhance patient experience. Moreover, it suggests the quality improvement initiatives associated with accreditation may address areas of concern emphasized by Hong Kong patients, such as involvement in care and emotional support from providers.

Student and Graduate Perceptions Regarding Canadian-based Accreditation of a Pharmacy Program in Qatar

Objective. To determine student and alumni perceptions of a Canadian-based pharmacy degree accreditation in a Middle Eastern setting and to explore the impact on patient care practices. Methods. Current and former Doctor of Pharmacy students from Qatar University were recruited to participate in the study. Three focus groups were conducted with a total of 14 participants (39% of total population). Focus group discussions were recorded and transcribed verbatim. Transcripts were coded using a bottom-up, grounded theory approach to identify overarching themes related to the study objectives. Results. Data analysis of participants' comments revealed three key themes regarding university accreditation by an international organization: influence on education, influence on patient care, and influence on the individual. Overall, participants responded positively toward international accreditation, as it was perceived to ensure the quality of education by meeting international standards, improve patient care through clinical training, and provide greater individual career opportunities through reputability. Participants responded negatively toward some aspects of accreditation: it was perceived to increase student workload, lacked recognition and did not result in differentiation in job-related duties, and was perceived to be the reason for training gaps related to culture and language within the accredited curriculum. Conclusion. Participants perceived international accreditation positively for its influence on education and patient care; however, some misconceptions and negative perceptions existed regarding its influence on the individual practitioner.

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.

Understanding accreditation standards in general practice - a qualitative study

Background

Accreditation is a widely adopted tool for quality control and quality improvement in health care, which has increasingly been employed for general practice. However, there is lack of knowledge of how accreditation is received and experienced by health professionals in general practice. This study explores how general practitioners (GPs) and their staff experienced the comprehensibility of accreditation standards and how they worked to increase their understanding of the standards. The study was conducted in Denmark where accreditation was mandatory in general practice from 2016 to 2018.

Methods

The study consists of qualitative interviews with general practitioners and staff from 11 general practices that were strategically sampled among practices set to receive their survey visit in 2017. Participants were interviewed twice; once during the preparation phase and once after the survey visit. GPs and staff were interviewed separately. The interviews were analysed inductively using thematic analysis.

Results

Understanding the requirements of the accreditation standards was a major challenge for the professionals when preparing for the accreditation survey visit. The participants attempted to increase their understanding of the standards in several ways including the use of regional support options and seeking out experts and colleagues. However, participants had mixed experiences with the various support options and many found the sense making work frustrating and time consuming.

Conclusion

The results point to the importance of considering the level of specificity in accreditation standards and how to ensure an organisational set-up that can offer appropriate support to primary care clinics in terms of understanding what is required to meet the standards.

Electronic supplementary material

The online version of this article (10.1186/s12875-019-0910-2) contains supplementary material, which is available to authorized users.

Albuminuria measurement in diabetic care: a multilevel analysis measuring the influence of accreditation on institutional performance

Background

Studies assessing institutional performance regarding quality of care are frequently performed using single-level statistical analyses investigating differences between provider averages of various quality indicators. However, such analyses are insufficient as they do not consider patients’ heterogeneity around those averages. Hence, we apply a multilevel analysis of individual-patient heterogeneity that distinguishes between ‘general’ (‘latent quality’ or measures of variance) and ‘specific’ (measures of association) contextual effects. We assess general contextual effects of the hospital departments and the specific contextual effect of a national accreditation programme on adherence to the standard benchmark for albuminuria measurement in Danish patients with diabetes.

Methods

From the Danish Adult Diabetes Database, we extracted data on 137 893 patient cases admitted to hospitals between 2010 and 2013. Applying multilevel logistic and probit regression models for every year, we quantified general contextual effects of hospital department by the intraclass correlation coefficient (ICC) and the area under the receiver operating characteristic curve (AUC) values. We evaluated the specific effect of hospital accreditation using the ORs and the change in the department variance.

Results

In 2010, the department context had considerable influence on adherence with albuminuria measurement (ICC=21.8%, AUC=0.770), but the general effect attenuated along with the implementation of the national accreditation programme. The ICC value was 16.5% in 2013 and the rate of compliance with albuminuria measurement increased from 91.6% in 2010 to 96% in 2013.

Conclusions

Parallel to implementation of the national accreditation programme, departments’ compliance with the standard benchmark for albuminuria measurement increased and the ICC values decreased, but remained high. While those results indicate an overall quality improvement, further intervention focusing on departments with the lowest compliance could be considered.

Characteristics and behaviours of formal versus informal nurse champions and their relationship to innovation success

AIMS

To identify the sociodemographic attributes, project characteristics and champion strategies that differentiate formal from informal nursing champions, and to test their success in terms of project spread and novelty.

BACKGROUND

Champions spread innovation in healthcare organizations. Empirical research has not explored the differences between formal and informal champions in terms of their antecedents and success.

DESIGN

A quantitative cross-sectional design.

METHOD

Data were collected on 93 nursing champions in three hospitals from 2015 - 2016. Champions were identified according to a validated approach; data on their sociodemographic attributes, project characteristics and strategies were assembled through interviews and validated questionnaires. Their success in terms of novelty and spread was assessed via expert ratings and validated questionnaire.

FINDINGS

Informal champions had longer tenure and were involved mainly in bottom-up projects aimed mostly at improving human resources and services; formal champions were mostly involved in top-down projects aimed at quality control. Informal champions expressed more enthusiasm and confidence about the innovation; formal champions tended to use more online resources and peer-monitoring strategies. Projects of informal champions were more novel than those of formal champions. Project spread did not differ between the two groups.

CONCLUSION

Formal and informal champions differ in their characteristics and implementation strategies. To encourage project's innovation, the organizational climate should encourage the emergence of informal champions; formal and informal champions should be chosen wisely, assuring that they possess enough organizational resources; and coaching programmes for junior champions should be planned to equip them with championing behaviours.

Predictors of the effectiveness of accreditation on hospital performance: A nationwide stepped-wedge study

Objective

To identify predictors of the effectiveness of hospital accreditation on process performance measures.

Design

A multi-level, longitudinal, stepped-wedge, nationwide study.

Participants

All patients admitted for acute stroke, heart failure, ulcers, diabetes, breast cancer and lung cancer at Danish hospitals.

Intervention

The Danish Healthcare Quality Programme that was designed to create a framework for continuous quality improvement.

Main outcome Measure(s)

Changes in week-by-week trends of hospitals' process performance measures during the study period of 269 weeks prior to, during and post-accreditations. Process performance measures were based on 43 different processes of care obtained from national clinical quality registries. Analyses were stratified according to condition, type of care (i.e. treatment, diagnostics, secondary prevention and patient monitoring) and hospital characteristics (i.e. university affiliation, location, size, experience with accreditation and accreditation compliance).

Results

A total of 1 624 518 processes of care were included. The impact of accreditation differed across the conditions. During accreditation, heart failure and breast cancer showed less improvement than other disease areas. Across all conditions, diagnostic processes improved less rapidly than other types of processes. However, after stratifying the data by hospital characteristics, process performance measures improved more uniformly. In respect of the measures that had an unsatisfactory level of quality, the processes related to diabetes, diagnostics and patient monitoring all responded to accreditation and showed an increased improvement during the preparatory work.

Conclusion

Hospital characteristics were not found to be predictors for the effects of accreditation, whereas conditions and types of care to some extent predicted the effectiveness.

Perception of hospital accreditation among health professionals in Saudi Arabia

BACKGROUND

Hospital accreditation assesses hospital performance against explicit standards. Studies of the efficacy of accreditation are limited, but suggest that Joint Commission International (JCI) accreditation is efficient in improving the safety and quality of care in accredited hospitals.

OBJECTIVES

This study aimed to assess the perceptions of health professionals on the impact of JCI accreditation and implementation of change towards the delivery of quality patient care.

DESIGN

Cross-sectional survey.

SETTINGS

King Abdulaziz Medical City in Jeddah, Saudi Arabia.

SUBJECTS

Between June 2016 and September 2016, a validated questionnaire was distributed to physicians, nurses, medical technologists, dietitians, and other allied healthcare professionals. The questionnaire consisted of 19 items covering participation in accreditation, benefits of accreditation, and the quality of results of accreditation. Demographic data collected on the participants included age, gender, educational attainment, profession, length of service, and department.

MAIN OUTCOME MEASURE(S)

Participation in accreditation, benefits of accreditation, and quality of results of accreditation.

RESULTS

Hospital accreditation was given a worthy response from the general view of 901 health professionals. The mean (standard deviation) of scores on a 5-point Likert scale were 3.79 (0.68) for participation in accreditation, 3.85 (0.84) for benefits, and 3.54 (1.01) for quality of results.

CONCLUSION

As perceived by health professionals in our survey, accrediation had a positive impact on the process and implementation of change in the hospital that resulted in improvement in the delivery of patient care and other health services.

LIMITATIONS

Single institution study with no comparison made to other small, medium, or large-sized JCI-accredited hospitals in Saudi Arabia. Patient satisfaction before and after accreditation was not included.

How does accreditation influence staff perceptions of quality in residential aged care?

Purpose

Quality of care in the residential aged sector has changed over the past decade. The purpose of this paper is to examine these changes from the perspectives of staff to identify factors influencing quality of residential aged care, and the role and influence of an aged care accreditation programme.

Design/methodology/approach

Focus groups were held with 66 aged care staff from 11 Australian aged care facilities. Data from semi-structured interviews were analysed to capture categories representing participant views.

Findings

Participants reported two factors stimulating change: developments in the aged care regulatory and policy framework, and rising consumer expectations. Four corresponding effects on service quality were identified: increasing complexity of resident care, renewed built environments of aged care facilities, growing focus on resident-centred care and the influence of accreditation on resident quality of life. The accreditation programme was viewed as maintaining minimum standards of quality throughout regulatory and social change, yet was considered to lack capacity of itself to explicitly promote or improve resident quality of life.

Research limitations/implications

For an increasingly complex aged care population, regulatory and societal change has led to a shift in service provision from institutional care models to one that is becoming more responsive to consumer expectations. The capacity of long-established and relatively static accreditation standards to better accommodate changing consumer needs comes into question.

Originality/value

This is the first study to examine the relationship between accreditation and residential aged care service quality from the perspectives of staff, and offers a nuanced view of “quality” in this setting.

Accreditation in general practice in Denmark: study protocol for a cluster-randomized controlled trial

Background

Accreditation is used increasingly in health systems worldwide. However, there is a lack of evidence on the effects of accreditation, particularly in general practice. In 2016 a mandatory accreditation scheme was initiated in Denmark, and during a 3-year period all practices, as default, should undergo accreditation according to the Danish Healthcare Quality Program. The aim of this study is primarily to evaluate the effects of a mandatory accreditation scheme.

Methods/design

The study is conducted as a cluster-randomized controlled trial among 1252 practices (clusters) with 2211 general practitioners in Denmark. Practices allocated to accreditation in 2016 serve as the intervention group, and practices allocated to accreditation in 2018 serve as controls. The selected outcomes should meet the following criteria: (1) a high degree of clinical relevance; (2) the possibility to assess changes due to accreditation; (3) availability of data from registers with no self-reporting data. The primary outcome is the number of prescribed drugs in patients older than 65 years. Secondary outcomes are changes in outcomes related to other perspectives of safe medication, good clinical practice and mortality. All outcomes relate to quality indicators included in the Danish Healthcare Quality Program, which is based on general principles for accreditation.

Discussion

The consequences of accreditation and standard-setting processes are generally under-researched, particularly in general practice. This is the largest study in general practice with a randomized implementation approach to evaluate the clinical effects of a nation-wide mandatory accreditation scheme in general practice.

Trial registration

ClinicalTrials.gov, NCT02762240. Registered on 24 May 2016.

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-017-1818-6) contains supplementary material, which is available to authorized users.

Avaliação do Programa de Acreditação Hospitalar: validação de face e conteúdo

RESUMO Objetivo: descrever os resultados da validação de face e conteúdo do questionário intitulado Quality Improvement Implementation Survey e de duas escalas complementares, como parte do processo de adaptação ao idioma e à cultura brasileira. Método: incluiu os seguintes estágios: (1) tradução e síntese das traduções; (2) apreciação pelo comitê de especialistas; (3) retrotradução; (4) avaliação da compreensão verbal pela população-alvo. Resultados: o questionário foi traduzido para o português e sua versão final incluiu 90 itens. No pré-teste, a população-alvo avaliou todos os itens como de fácil compreensão, apresentando média global de 4,58 (valor máximo=5). Conclusão: o questionário encontra-se traduzido para o português e adaptado ao contexto brasileiro. A versão adaptada manteve a equivalência semântica, idiomática, conceitual e cultural, segundo a avaliação do comitê de especialistas assim como pelas informações fornecidas pela população-alvo, confirmando a validade de face e de conteúdo.

Counting the costs of accreditation in acute care: an activity-based costing approach

OBJECTIVES

To assess the costs of hospital accreditation in Australia.

DESIGN

Mixed methods design incorporating: stakeholder analysis; survey design and implementation; activity-based costs analysis; and expert panel review.

SETTING

Acute care hospitals accredited by the Australian Council for Health Care Standards.

PARTICIPANTS

Six acute public hospitals across four States.

RESULTS

Accreditation costs varied from 0.03% to 0.60% of total hospital operating costs per year, averaged across the 4-year accreditation cycle. Relatively higher costs were associated with the surveys years and with smaller facilities. At a national level these costs translate to $A36.83 million, equivalent to 0.1% of acute public hospital recurrent expenditure in the 2012 fiscal year.

CONCLUSIONS

This is the first time accreditation costs have been independently evaluated across a wide range of hospitals and highlights the additional cost burden for smaller facilities. A better understanding of the costs allows policymakers to assess alternative accreditation and other quality improvement strategies, and understand their impact across a range of facilities. This methodology can be adapted to assess international accreditation programmes.

Accreditation and improvement in process quality of care: a nationwide study

OBJECTIVE

To examine whether performance measures improve more in accredited hospitals than in non-accredited hospital.

DESIGN AND SETTING

A historical follow-up study was performed using process of care data from all public Danish hospitals in order to examine the development over time in performance measures according to participation in accreditation programs.

PARTICIPANTS

All patients admitted for acute stroke, heart failure or ulcer at Danish hospitals.

INTERVENTION

Hospital accreditation by either The Joint Commission International or The Health Quality Service.

MEASUREMENTS

The primary outcome was a change in opportunity-based composite score and the secondary outcome was a change in all-or-none scores, both measures were based on the individual processes of care. These processes included seven processes related to stroke, six processes to heart failure, four to bleeding ulcer and four to perforated ulcer.

RESULTS

A total of 27 273 patients were included. The overall opportunity-based composite score improved for both non-accredited and accredited hospitals (13.7% [95% CI 10.6; 16.8] and 9.9% [95% 5.4; 14.4], respectively), but the improvements were significantly higher for non-accredited hospitals (absolute difference: 3.8% [95% 0.8; 8.3]). No significant differences were found at disease level. The overall all-or-none score increased significantly for non-accredited hospitals, but not for accredited hospitals. The absolute difference between improvements in the all-or-none score at non-accredited and accredited hospitals was not significant (3.2% [95% -3.6:9.9]).

CONCLUSIONS

Participating in accreditation was not associated with larger improvement in performance measures for acute stroke, heart failure or ulcer.

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

Background

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

Methods

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

Results

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

Conclusion

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

Electronic supplementary material

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

The impact of hospital accreditation on quality measures: an interrupted time series analysis

Background

Developing countries frequently use hospital accreditation to guarantee quality and patient safety. However, implementation of accreditation standards is demanding on organisations. Furthermore, the empirical literature on the benefits of accreditation is sparse and this is the first empirical interrupted time series analysis designed to examine the impact of healthcare accreditation on hospital quality measures.

Methods

The study was conducted in a 150-bed multispecialty hospital in Abu Dhabi, United Arab Emirates. The quality performance outcomes were observed over a 48 month period. The quality performance differences were compared across monthly intervals between two time segments, 1 year pre- accreditation (2009) and 3 years post-accreditation (2010, 2011 and 2012) for the twenty-seven quality measures. The principal data source was a random sample of 12,000 patient records drawn from a population of 50,000 during the study period (January 2009 to December 2012). Each month (during the study period), a simple random sample of 24 percent of patient records was selected and audited, resulting in 324,000 observations. The measures (structure, process and outcome) are related to important dimensions of quality and patient safety.

Results

The study findings showed that preparation for the accreditation survey results in significant improvement as 74% of the measures had a significant positive pre-accreditation slope. Accreditation had a larger significant negative effect (48% of measures) than a positive effect (4%) on the post accreditation slope of performance. Similarly, accreditation had a larger significant negative change in level (26%) than a positive change in level (7%) after the accreditation survey. Moreover, accreditation had no significant impact on 11 out of the 27 measures. However, there is residual benefit from accreditation three years later with performance maintained at approximately 90%, which is 20 percentage points higher than the baseline level in 2009.

Conclusions

Although there is a transient drop in performance immediately after the survey, this study shows that the improvement achieved from accreditation is maintained during the three year accreditation cycle.

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.

A multicenter prospective comparative effectiveness study of the effect of physician certification and center accreditation on patient-centered outcomes in obstructive sleep apnea

OBJECTIVES

To study the effect of sleep center accreditation and Sleep Medicine board certification of physicians on patient-centered outcomes in obstructive sleep apnea (OSA).

DESIGN

Prospective, multicenter, comparative effectiveness study.

SETTING

Four sleep centers.

PATIENTS

502 patients with OSA.

INTERVENTIONS

None.

MEASUREMENTS AND RESULTS

Patients at two accredited and two non-accredited centers underwent polysomnography at participating locations and completed validated questionnaires, with objective measurement of positive airway pressure (PAP) therapy adherence performed three months after therapy initiation. The proportion of patients (age 53 ± 13[SD] years; 26% women; and body mass index 33.6 ± 7.2 kg/m(2)) who were adherent to PAP therapy by Medicare guidelines (> 70% of nights with ≥ 4 h use over a 30-day period) was greater in accredited (79%) than non-accredited sites (64%; p = 0.004). After adjustment for confounding variables, patients who received care from accredited centers (odds ratio [OR] 2.2, 95% confidence interval [CI], 1.2-4.2; p = 0.016) and certified physicians (OR 2.3, 95% CI, 1.3-4.0; p = 0.005) were more likely to be adherent to PAP therapy than those who received care from non-accredited centers and non-certified physicians. Patient satisfaction was associated with greater education received from physician (OR 4.6; 95% CI 2.3-9.3); greater risk perception (OR 2.7; 95% CI 1.0-7.4); physician certification (OR 2.1; 95% CI 1.1-4.2); and inversely related to delays in care (OR 0.5; 95% CI 0.3-0.9; p < 0.05). Such delays were inversely related to accreditation-certification status (p < 0.0001).

CONCLUSIONS

In patients with OSA, accreditation-certification status of sleep centers and physicians was associated with better PAP adherence, better patient education, better patient satisfaction, and greater timeliness.

COMMENTARY

A commentary on this article appears in this issue on page 251.

CITATION

Parthasarathy S; Subramanian S; Quan SF. A multicenter prospective comparative effectiveness study of the effect of physician certification and center accreditation on patient-centered outcomes in obstructive sleep apnea.

Local perceptions on factors influencing the introduction of international healthcare accreditation in Pakistan

One contributor to poor health outcomes in developing countries is weak health systems; key to strengthening them are interventions to improve quality of health services. Though the value of healthcare accreditation is increasingly recognized, there are few case studies exploring its adaptation in developing countries. The aim of our study in Pakistan was to identify perceived factors influencing the adaptation of international healthcare accreditation within a developing country context. We used qualitative methods including semi-structured interviews, a structured group discussion, focus groups and non-participant observation of management meetings. Data analysis used a grounded theory approach and a conceptual framework adapted from implementation science. Using our conceptual framework categories of 'inner' and 'outer' setting, we found six perceived inner health system factors that could influence the introduction of healthcare accreditation and two 'outer' setting factors, perceived as external to the health system but able to influence its introduction. Our research identified that there is no 'one size fits all' approach to introducing healthcare accreditation as a means to improve healthcare quality. Those planning to support healthcare accreditation, such as national and provincial ministries and international development partners, need to understand how the three components of healthcare accreditation fit into the local health system and into the broader political and social environment. In our setting this included moving to supportive and transparent external evaluation mechanisms, with a first step of using locally developed and agreed standards. In addition, sustainable implementation of the three components was seen as a major challenge, especially establishment of a well-managed, transparent accreditation agency able to lead processes such as training and support for peer surveyors. Consideration of local change mechanisms and cultural practices is important in designing a local accreditation approach. The results of our study are important for health systems strengthening in Pakistan and in other developing countries.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Health services accreditation: what is the evidence that the benefits justify the costs?

PURPOSE

To identify and analyse research on the use of economic evaluation in health services accreditation.

DATA SOURCES

Seven online health and economic databases, and key accreditation agency and health department websites were searched between June and December 2011.

STUDY SELECTION

The selection criteria were English language and published empirical research studies on the topic of economic evaluation of health service accreditation. No formal economic evaluation of health services accreditation has been carried out to date. Empirical data on costs and benefits were analysed in 6 and 15 studies, respectively. Data extraction Meta-analysis was unsuitable due to output variability. Attributes relating to

STUDY DESIGN

scalability and independence of outcome data were collected. For the benefit studies, we also assessed the strength of claim that accreditation improved patient safety and quality, and sources of potential bias.

RESULTS OF DATA SYNTHESIS

The incremental costs ranged from 0.2 to 1.7% of total costs averaged over the accreditation cycle. The benefit studies were inconclusive in terms of showing clear evidence that accreditation improves patient safety and quality of care.

CONCLUSION

The lack of formal economic appraisal makes it difficult to evaluate accreditation in comparison to other methods to improve patient safety and quality of care. The lack of a clear relationship between accreditation and the outcomes measured in the benefit studies makes it difficult to design and conduct such appraisals without a more robust and explicit understanding of the costs and benefits involved.

Parallel quality assessment of emergency departments by European foundation for quality management model and Iranian national program for hospital evaluation

BACKGROUND

European Foundation for Quality Management (EFQM) model is a widely used quality management system (QMS) worldwide, including Iran. Current study aims to verify the quality assessment results of Iranian National Program for Hospital Evaluation (INPHE) based on those of EFQM.

METHODS

This cross-sectional study was conducted in 2012 on a sample of emergency departments (EDs) affiliated with Tehran University of Medical Sciences (TUMS), Iran. The standard questionnaire of EFQM (V-2010) was used to gather appropriate data. The results were compared with those of INPHE. MS Excel was used to classify and display the findings.

RESULTS

The average assessment score of the EDs based on the INPHE and EFQM model were largely different (i.e. 86.4% and 31%, respectively). In addition, the variation range among five EDs' scores according to each model was also considerable (22% for EFQM against 7% of INPHE), especially in the EDs with and without prior record of applying QMSs.

CONCLUSION

The INPHE's assessment results were not confirmed by EFQM model. Moreover, the higher variation range among EDs' scores using EFQM model could allude to its more differentiation power in assessing the performance comparing with INPHE. Therefore, a need for improvement in the latter drawing on other QMSs' (such as EFQM) strengths, given the results emanated from its comparison with EFQM seems indispensable.

A multimethod research investigation of consumer involvement in Australian health service accreditation programmes: the ACCREDIT-SCI study protocol

INTRODUCTION

Health service accreditation programmes are a regulatory mechanism adopted to drive improvements inpatient safety and quality. Research investigating the benefits or limitations, of consumer involvement in accreditation programmes is negligible. To develop our knowledge in this area the ACCREDIT collaboration (Accreditation Collaborative for the Conduct of Research, Evaluation and Designated Investigations through Teamwork) has developed a research plan, known as the ACCREDIT-SCI (Standards of Consumer Involvement) study protocol. Two complementary studies have been designed: one, to examine the effectiveness of a standard for consumer participation and two, to explore how patient experiences vary across a range of settings with differing accreditation results.

METHODS AND DESIGN

The research setting is the Australian healthcare system, and the two studies focus on three accreditation programmes in the primary, acute and aged care domains. The studies will use multimethods: document analysis; interviews and surveys. Participants will be stakeholders across the three domains including: policy officers; frontline healthcare professionals; accreditation agency personnel, including surveyors and healthcare consumers. Drawing on previous experience, the research team has developed purpose-designed tools. Data will be analysed using thematic, narrative and statistical (descriptive and inferential) procedures.

ETHICS AND DISSEMINATION

The University of New South Wales Human Research Ethics Committee has approved the two studies (HREC 10274). Findings will be disseminated through seminars, conference presentations, academic publications and research partner websites. The findings will be formulated to facilitate uptake by policy and accreditation agency professionals, researchers and academics, and consumers, nationally and internationally.

Narrative synthesis of health service accreditation literature

AIMS

To systematically identify and synthesise health service accreditation literature.

METHODS

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

RESULTS

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

CONCLUSIONS

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

An empirical test of accreditation patient journey surveys: randomized trial

OBJECTIVE

To evaluate the effectiveness of utilizing the patient journey survey (PJS) method in healthcare accreditation processes.

DESIGN

Randomized trial of the PJS method in parallel with the current accreditation survey (CAS) method of the Australian Council on Healthcare Standards (ACHS).

SETTING

Acute healthcare organizations in Australia.

PARTICIPANTS

Seventeen organizations, 28 organizational staff, nine surveyors and 38 patients.

MAIN OUTCOME MEASURES

The results of each surveying method were compared. Participants provided feedback, via 18 interviews and 40 questionnaire surveys, about the benefits and disadvantages of a PJS compared to a CAS.

RESULTS

The PJS method is not as comprehensive as the CAS method for accreditation assessment. In matched assessments the majority of items were rated lower by the PJS method than by the CAS. PJSs were shown to be appropriate for assessing mandatory clinical criteria, but were less effective for assessing corporate and support criteria. The two methods diverged in their final assessments of which organizations met the accreditation threshold. Participants endorsed the use of PJSs within accreditation processes.

CONCLUSIONS

The PJS methodology complements but is not a substitute for existing accreditation methods. There is significant stakeholder support for the inclusion of the PJS method within the current accreditation programme.

Public health department accreditation implementation: transforming public health department performance

In response to a call for improved quality and consistency in public health departments, the Public Health Accreditation Board (PHAB) is leading a voluntary public health accreditation initiative in the United States. The public health department accreditation system will implement a comprehensive set of standards that set uniform performance expectations for health departments to provide the services necessary to keep communities healthy. Continuous quality improvement is a major component of PHAB accreditation, demonstrating a commitment to empower and encourage public health departments to continuously improve their performance. The accreditation process was tested in 30 health departments around the country in 2009 and 2010, and was launched on a national level in September 2011 at the National Press Club in Washington, DC.

Evaluation of current Australian health service accreditation processes (ACCREDIT-CAP): protocol for a mixed-method research project

INTRODUCTION

Accreditation programmes aim to improve the quality and safety of health services, and have been widely implemented. However, there is conflicting evidence regarding the outcomes of existing programmes. The Accreditation Collaborative for the Conduct of Research, Evaluation and Designated Investigations through Teamwork-Current Accreditation Processes (ACCREDIT-CAP) project is designed to address key gaps in the literature by evaluating the current processes of three accreditation programmes used across Australian acute, primary and aged care services.

METHODS AND DESIGN

The project comprises three mixed-method studies involving documentary analyses, surveys, focus groups and individual interviews. Study samples will comprise stakeholders from across the Australian healthcare system: accreditation agencies; federal and state government departments; consumer advocates; professional colleges and associations; and staff of acute, primary and aged care services. Sample sizes have been determined to ensure results allow robust conclusions. Qualitative information will be thematically analysed, supported by the use of textual grouping software. Quantitative data will be subjected to a variety of analytical procedures, including descriptive and comparative statistics. The results are designed to inform health system policy and planning decisions in Australia and internationally.

ETHICS AND DISSEMINATION

The project has been approved by the University of New South Wales Human Research Ethics Committee (approval number HREC 10274). Results will be reported to partner organisations, healthcare consumers and other stakeholders via peer-reviewed publications, conference and seminar presentations, and a publicly accessible website.

An empirical test of short notice surveys in two accreditation programmes

OBJECTIVE

To evaluate short notice surveys in accreditation programmes.

DESIGN

Two trials using short notice surveys were conducted independently: a study of 20 healthcare organizations with the Australian Council on Healthcare Standards (ACHS) and a study of 7 general practices with the Australian General Practice Accreditation Limited (AGPAL). Participating organizations volunteered. ACHS and AGPAL selected 17 and 13 surveyors, respectively, and provided training for them on short notice surveys.

METHODS

Each agency's short notice surveys were an abbreviated version of their current advanced notification surveys. Short notice surveys assessed accreditation programme criteria or indicators that corresponded to the Australian Commission on Safety and Quality in Health Care's priority issues. Fifteen (out of 45) ACHS criteria and 48 (out of 174) AGPAL indicators that aligned to the Commission's criteria were evaluated. Participating organizations were given 2 days notice prior to the short notice surveys. Ratings from the short notice surveys were compared with those from the most recent advanced notification surveys, and statistical tests were performed to detect differences and potential confounding factors. Surveyors and organizational staff completed a post-survey feedback questionnaire which was analysed thematically and by inferential statistics.

RESULTS

The short notice survey approach overall produced ratings congruent with the advanced notification survey for both accreditation programmes. However, for both programmes short notice surveys assessed that more organizations would not reach the accreditation threshold as compared with the previous survey. Organizations in both programmes were judged to have achieved less successful performance against clinical standards by the short notice survey than the advanced notification survey. There was support from surveyors and organizational staff for short notice survey to be adopted. However, there were mixed views about the impact of short notice surveys and whether they validated trial participants' continuous improvement efforts.

CONCLUSIONS

The study demonstrated that short notice surveys are more critical in their assessment of clinical than administrative or corporate items. Short notice surveys, while broadly comparable with existing advanced notification survey practice, produced different accreditation outcomes for a significant proportion of the study organizations. The overall value and worth of short notice surveys remains to be proved.

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

BACKGROUND

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

FINDINGS

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

DISCUSSION

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

Healthcare accreditation systems: further perspectives on performance measures

OBJECTIVE

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

METHODS

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

PARTICIPANTS

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

RESULTS

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

CONCLUSIONS

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

Quality assurance of endoscopy units

This chapter reflects on how England has led the world in service development and quality assurance of endoscopy. It draws out themes of leadership, strategic vision and organisational culture. It emphasises the pivotal importance of focussing service improvement on enhancing the quality of a patient's experience of endoscopy. It describes the processes used here for quality assurance of endoscopy units and how these have dovetailed with other strands of work in transforming the English endoscopy service. The chapter presents discussion of the responses to accreditation processes and how the design of the JAG Accreditation process maximises its effectiveness.

Market-based control mechanisms for patient safety

A new model is proposed for enhancing patient safety using market-based control (MBC), inspired by successful approaches to environmental governance. Emissions trading, enshrined in the Kyoto protocol, set a carbon price and created a carbon market--is it possible to set a patient safety price and let the marketplace find ways of reducing clinically adverse events? To "cap and trade," a regulator would need to establish system-wide and organisation-specific targets, based on the cost of adverse events, create a safety market for trading safety credits and then police the market. Organisations are given a clear policy signal to reduce adverse event rates, are told by how much, but are free to find mechanisms best suited to their local needs. The market would inevitably generate novel ways of creating safety credits, and accountability becomes hard to evade when adverse events are explicitly measured and accounted for in an organisation's bottom line.

Assessing hospitals' clinical risk management: Development of a monitoring instrument

BACKGROUND

Clinical risk management (CRM) plays a crucial role in enabling hospitals to identify, contain, and manage risks related to patient safety. So far, no instruments are available to measure and monitor the level of implementation of CRM. Therefore, our objective was to develop an instrument for assessing CRM in hospitals.

METHODS

The instrument was developed based on a literature review, which identified key elements of CRM. These elements were then discussed with a panel of patient safety experts. A theoretical model was used to describe the level to which CRM elements have been implemented within the organization. Interviews with CRM practitioners and a pilot evaluation were conducted to revise the instrument. The first nationwide application of the instrument (138 participating Swiss hospitals) was complemented by in-depth interviews with 25 CRM practitioners in selected hospitals, for validation purposes.

RESULTS

The monitoring instrument consists of 28 main questions organized in three sections: 1) Implementation and organizational integration of CRM, 2) Strategic objectives and operational implementation of CRM at hospital level, and 3) Overview of CRM in different services. The instrument is available in four languages (English, German, French, and Italian). It allows hospitals to gather comprehensive and systematic data on their CRM practice and to identify areas for further improvement.

CONCLUSIONS

We have developed an instrument for assessing development stages of CRM in hospitals that should be feasible for a continuous monitoring of developments in this important area of patient safety.

What motivates professionals to engage in the accreditation of healthcare organizations?

OBJECTIVE

Motivated staff are needed to improve quality and safety in healthcare organizations. Stimulating and engaging staff to participate in accreditation processes is a considerable challenge. The purpose of this study was to explore the experiences of health executives, managers and frontline clinicians who participated in organizational accreditation processes: what motivated them to engage, and what benefits accrued?

DESIGN/PARTICIPANTS

The setting was a large public teaching hospital undergoing a planned review of its accreditation status. A research protocol was employed to conduct semi-structured interviews with a purposive sample of 30 staff with varied organizational roles, from different professions, to discuss their involvement in accreditation. Thematic analysis of the data was undertaken.

RESULTS

The analysis identified three categories, each with sub-themes: accreditation response (reactions to accreditation and the value of surveys); survey issues (participation in the survey, learning through interactions and constraints) and documentation issues (self-assessment report, survey report and recommendations). Participants' occupational role focuses their attention to prioritize aspects of the accreditation process. Their motivations to participate and the benefits that accrue to them can be positively self-reinforcing. Participants have a desire to engage collaboratively with colleagues to learn and validate their efforts to improve.

CONCLUSION

Participation in the accreditation process promoted a quality and safety culture that crossed organizational boundaries. The insights into worker motivation can be applied to engage staff to promote learning, overcome organizational boundaries and improve services. The findings can be applied to enhance involvement with accreditation and, more broadly, to other quality and safety activities.