Understanding accreditation standards in general practice - a qualitative study

The co-production process of an assessment programme: Between clarifying identity and developing the quality of French-speaking Belgian community health centres

BACKGROUND

The assessment of primary care organizations is considered to be essential for improving care. However, the assessments' acceptability to professionals poses a challenge. Developing assessment programmes in collaboration with the end-users is a strategy that is widely encouraged to make interventions better targeted. By doing so, it can help to prevent resistance and encourage adherence to the assessment. This process, however, is rarely reported. This paper aims to fill this gap by describing the process of the co-production of an assessment programme for community health centres (CHCs) affiliated to the Federation of Community Health Centres (FCHC) in French-speaking Belgium.

METHODS

We conducted a documentary study on the co-production of the assessment programme before carrying out semi-structured interviews with the stakeholders involved in its development.

RESULTS

CHCs in French-speaking Belgium are increasing in number and are becoming more diverse. For the FCHC, this growth and diversification pose challenges for the meaning of CHC (an identity challenge) and what beneficiaries can expect in terms of the quality of organizations declaring themselves CHC (a quality challenge). Faced with this double challenge, the FCHC decided to develop an assessment programme, initially called Label, using participatory action research. During the co-production process, this initial programme version was abandoned in favour of a new name "DEQuaP". This new name embodies new objectives and new design regarding the assessment programme. When studying the co-production process, we attributed these changes to two controversies. The first concerns how much and which type of variety is desired among CHCs part of the FCHC. The second concerns the organization of the FCHC in its capacity as a federation. It shed light on tensions between two professional segments that, in this paper, we called "political professionalism" and "pragmatic professionalism".

CONCLUSIONS

These controversies show the importance of underlying challenges behind the development of an assessment programme for CHCs. This provided information about the evolution of the identity of multidisciplinary organizations in primary care. Issues raised in the development of this assessment programme also show the importance of considering assessment methods that reflect and embody the current realities of these organizations and the way of developing these assessment methods.

The Prerequisites of Executing the Accreditation Program for Primary Healthcare: A Systematic Review and Meta-Synthesis

Background

In Iran, the primary healthcare system is the front-line for society's encounter with healthcare. Health planners aim to enhance quality and administer an accreditation program. This study examined program administration prerequisites through systematic review and meta-synthesis.

Methods

We conducted a systematic review and meta-synthesis of qualitative literature using Thomas and Hudson's framework. Peer-reviewed papers were searched in Scopus, PubMed, Web of Science, Google, and Google Scholar up to 2023.

Results

The search found 1308 articles, with 37 relevant ones selected for review. Data extraction included setting, participants, study design, data collection, analysis, and themes. Thirteen qualitative subthemes were identified and were categorized under three elements of the Donabedian model.

Conclusion

Before implementing a plan, it is crucial to consider its executive prerequisites. Revision and trial-and-error approaches can be costly and time-consuming, potentially hindering the plan's effectiveness and diverting organizations from their primary goal, leading to failure.

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.

What GPs do to meet accreditation standards - implementation activities and perceived improvements attributed to general practice accreditation

BACKGROUND

Healthcare accreditation is a widely implemented tool used to enhance the quality of care and underpin quality control. However, research is sparse on the accreditation process in general practice. The aim of this study was to explore how team-based implementation activities preceding accreditation were associated with self-perceived improvements in emergency preparedness (preparedness for urgent disease and cardiac arrest) and handling of prescription renewals in Danish general practice.

METHODS

GPs (general practitioners) completed a questionnaire exploring practice-team activities conducted to implement two specific accreditation standards and the related improvements as perceived by the GPs. The following implementation activities were selected, inspired by Normalization Process Theory: Common understanding (obtaining a common understanding of the purpose of implementing changes according to the accreditation standard), key person (assigning a key person responsible for working with the standard), and easy integration (finding it easy to integrate changes into existing working procedures). Data were analysed with logistic regression, and adjusted analyses included practice type, number of GP partners, number of staff, training site for junior GPs and administrative region.

RESULTS

The total response rate was 74% (n = 920). Around 80% of the clinics reported having conducted team-based implementation activities. Almost half of the clinics (48%) reported perceived improvements in the emergency preparedness, and 30% reported perceived improvements in the handling of prescription renewals. Obtaining a common understanding was found to have a strong, significant association with perceived improvements in the emergency preparedness (OR = 5.07 (3.06-8.40)) and handling of prescription renewals (OR = 3.66 (2.07-6.46)). Easy integration of changes was also significantly associated with improvements in both emergency preparedness (OR = 1.88 (1.24-2.85)) and handling of prescription renewals (OR = 2.34 (1.44-3.79)), whereas assigning a key person was only significantly associated with improved emergency preparedness (OR = 1.95 (1.19-3.19)).

CONCLUSION

Clinical quality initiatives that involve collaboration within a practice team are more likely to cause improvements if specific team-based implementation activities are conducted. It is particularly important to facilitate a common understanding of the purpose of the initiative. Therefore, external support for quality initiatives aiming at the practice level in general practice should facilitate such team-based activities.

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

Background

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

Objective

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

Methods

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

Results

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

Conclusion

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

Introducing quality clusters in general practice – a qualitative study of the experiences of cluster coordinators

Background

In 2018, the concept of clusters was introduced as a new model for data-driven quality improvement in general practice in Denmark. However, there is little research on the development and implementation of general practice clusters. The study explores how the cluster coordinators responsible for leading the clusters forward enacted and experienced their role during the early years of the clusters with attention to the challenges and enablers perceived in the process.

Methods

Qualitative, semi-structured interviews with 25 cluster coordinators from clusters that had carried out at least two meetings on a specific professional topic. The coordinators represented clusters of varying sizes and different geographic locations. Key topics in the interview guide were the development and structure of the cluster, the role of the coordinator, obtainment of data for the meetings, the role of external support, the form and content of the meetings, the participation and engagement of the members. A thematic analysis – shaped by the original aims and categories of the study while also being open to emerging themes – was performed on the transcribed interview material.

Results

Important enablers in the process of developing the clusters included the positive engagement of the GPs, the support offered by regional quality units and a national quality organisation for general practice, and the funding provided by the formal cluster framework. Challenges initially included setting up the clusters administratively and translating the open cluster concept into a local, workable model; and later obtaining relevant data for the cluster meetings and facilitating peer discussions about the data.

Conclusion

The coordinators generally experienced that the development of the clusters had progressed relatively fast with engagement from most of the participating GPs. Still, challenges with data obtainment, data analysis, and facilitation will have to be addressed ongoingly. Future research should investigate learning processes at the cluster meetings and how the clusters impact clinical practice and collaborative relations between general practice and other health care providers.

Characterization of Communes with Quality Accredited Primary Healthcare Centers in Chile

The accreditation process of primary healthcare centers in Chile has not had the same progress as in hospitals, which show high levels of compliance. The purpose of this research is to characterize the communes that have accredited family healthcare centers (CESFAMs) through socio-economic, municipal management, clinical management, and population variables by performing a principal components analysis (PCA) with biplot analysis and a grouping of communes through a hierarchical analysis. The biplot analysis and hierarchical analysis yielded the formation of three large groups of communes with accredited CESFAMs, characterized mainly by population size, number of people registered in the municipal health system, socioeconomic indicators, and financial management and clinical management variables. It was found that the communes that have accredited CESFAMs are characterized by dissimilar behavior in relation to the variables analyzed. Through the model used, it was possible to establish at least three groups of communes according to their behavior against these variables. Of these, the variables of a municipal financial nature were not decisive in achieving the accreditation of the CESFAMs of these communes. Therefore, it is possible that there are other variables or factors that could be facilitating the achievement of accreditation processes.

Implementation of healthcare accreditation in Danish general practice: a questionnaire study exploring general practitioners' perspectives on external support

OBJECTIVE

To describe the use and perceived usefulness of implementation support provided to general practice during an accreditation process and to explore potential variations across clinic characteristics.

DESIGN

Cross-sectional questionnaire study.

SETTING AND SUBJECTS

All Danish general practice clinics undergoing an accreditation survey from 27 September 2016 to 15 December 2017 (n = 608).

MAIN OUTCOME MEASURES

Use and perceived usefulness of seven types of implementation support as reported by general practitioners (GPs). Clinic characteristics included practice type, number of GP partners and staff and employment of GP trainees.

RESULTS

The total response rate was 74% (n = 447). Most clinics (99.5%) used some type of implementation support (average: 4.8 different types). The most used types of support were peer support (80-92%) and various accreditation documents (85-92%). Support tailored to the individual clinic was most often considered useful (91-97%). However, this type of support was used relatively infrequently (16-40%). In most cases, clinic characteristics were neither significantly associated with the use of support nor with the perceived usefulness of the available support.

CONCLUSION

During the accreditation processes, each clinic used a broad variety of implementation support. Support tailored to the individual clinic was highly appreciated and should be promoted in future quality interventions in general practice. Discussions with peers were widely used, and it should be investigated further how peer discussions are best facilitated. The study calls for a multifactorial approach to future quality interventions in general practice to target the needs and capacities of the individual clinics.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Experiences of accreditation impact in general practice - a qualitative study among general practitioners and their staff

BACKGROUND

Accreditation is a widespread tool for quality management in health care. However, there is lack of research on the impact of accreditation, particularly in general practice. This study explores how general practitioners and their staff experienced the impact of a mandatory accreditation program in Denmark.

METHODS

Qualitative interviews with general practitioners and staff from 11 clinics. The respondents were interviewed twice: during preparation and after the survey visit. The interviews were analyzed using thematic analysis, and all specific changes and other types of impact were extracted from the transcribed interview data from each clinic.

RESULTS

The impact of accreditation varied markedly among the clinics as did the participants' overall assessments of accreditation. Concerning specific changes in behavior and physical infrastructure, some clinics had only implemented a few minor changes in response to accreditation, some had made a relatively moderate number of changes, and a few clinics had made relatively many changes including a few pronounced ones. Further, some participants experienced that accreditation had enhanced knowledge sharing or upgraded competencies, and increased job satisfaction. However, the workload related to accreditation was emphasized as a problem by a majority of the professionals and for a few, accreditation had influenced job satisfaction negatively.

CONCLUSION

Accreditation may affect general practice clinics in very different ways. In spite of several examples of positive impact, the results suggest that it is difficult to design a mandatory accreditation program for general practice in which most professionals experience that the benefits of accreditation equal the resources used in the process.