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

Accreditation of Quality in Primary Health Care in Chile: Perception of the Teams from Accredited Family Healthcare Centers

This study aimed to investigate the perception of the health teams belonging to the Family Healthcare Centers (CESFAMs) that are accredited, regarding the process of implementation and the achievement of accreditation. A qualitative approach was applied, with contributions from grounded theory, through the technique of individual in-depth interviews and focus groups. The interviews were carried out in nine accredited CESFAMs. For the presentation, organization and analysis of the data, Atlas.ti V9 software was used. From the results, derived from the open phase of the analysis, obtained from the opinions of the participants, a total of 26 categories emerged relating to the facilitating and hindering factors of the process. From the axial phase, it was possible to establish central categories that were related to quality management policies, the structure of Primary Health Care (PHC), participation and co-construction, and leadership and change management. In conclusion, the discourse of the teams reveals the need to have necessary conditions for the accreditation process, which are mainly related to training, characteristics of the types of leadership and teamwork in harmony with the process. Finally, the study reveals a gap in the community participation in this process, which suggests continuing this line of research.

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.

From accreditation to quality improvement-The Danish National Quality Programme

The Danish government launched a new National Quality Programme (NQP) in healthcare in 2015. It has changed the focus from old public management in terms of accreditation, regulation, rules and standards to new public governance focusing on delivering high quality healthcare and outcomes of value for the patients, health professionals and the Danish healthcare system. The NQP aims to strengthen the focus on continuous quality improvement and the launch of the programme was accompanied by a decision to phase out accreditation of public hospitals. The NQP includes 1) eight specific national quality goals, 2) a national educational programme for quality management, and 3) establishment of quality improvement collaboratives. Since the establishment of the NQP the indicator results have improved in several important clinical areas. However, causal conclusions related to the effect of the NQP cannot yet be made. This perspective on quality paper aims to give a short introduction to the NQP and documented outcomes.

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.

Burnout of intrinsically motivated GPs when exposed to external regulation: A combined panel data survey and cluster randomized field experiment

Burnout among general practitioners (GPs) is a problem in many countries. Research indicates that burnout is less likely to occur among intrinsically motivated employees. Based on self-determination theory, we investigate 1) whether intrinsically motivated GPs are less burned out than their colleagues, and 2) whether the most intrinsically motivated GPs are more likely to burn out when exposed to an external regulatory accreditation programme. General practices in Denmark were cluster randomized to mandatory accreditation in 2016, 2017 or 2018. We measure GPs' intrinsic motivation and burnout levels one and two years into the accreditation process. We use a balanced panel of GPs (n = 846) to estimate mixed effects ordered logit models. We find that GPs with high intrinsic motivation are less burned out than their colleagues. However, the most intrinsically motivated GPs are significantly more burned out when exposed to accreditation compared to their colleagues. We conclude that being intrinsically motivated may not shield from burnout when external regulation is imposed.

Does accreditation of general practice promote patient-reported quality of care? A natural cluster randomised experiment

OBJECTIVE

To investigate whether accreditation of general practice in Denmark promotes patient-reported quality of care and patient satisfaction.

DESIGN

A national cluster randomised case control study based on an online version of the Danish Patients Evaluate Practice questionnaire. Mixed effects ordered logit regression models taking account of clustering of patients in different municipalities were used in the analyses.

SETTING

General practice in Denmark.

PARTICIPANTS

A representative sample of the Danish population.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome measure was patient-reported quality of care, and patient satisfaction with general practice and patient satisfaction with the general practitioner served as secondary outcome measures.

RESULTS

In total, 3609 respondents answered the survey. We found no statistically significant relationships between patient-reported quality of care and practice accreditation (2016: OR=0.89, 95% CI 0.73 to 1.07 and 2017: OR=0.85, 95% CI 0.71 to 1.02) and between patient satisfaction with the general practitioner and accreditation (2016: OR=0.93, 95% CI 0.76 to 1.13 and 2017: OR=0.86, 95% CI 0.70 to 1.04). However, there was a statistically significant negative relationship between patient satisfaction with the general practice and recent practice accreditation compared with satisfaction with practices not yet accredited (OR=0.81, 95% CI 0.67 to 0.97) but no significant relationship between patient satisfaction with the general practice and previous accreditation (OR=0.91, 95% CI 0.76 to 1.09).

CONCLUSION

Accreditation does not promote patient-reported quality of care or patient satisfaction. On the contrary, patient satisfaction with the general practice decreases when general practice is recently accredited.

Does accreditation affect the job satisfaction of general practitioners? A combined panel data survey and cluster randomised field experiment

A critical question for policy makers in health care is whether external interventions have unintended consequences such as lowering professionals' job satisfaction. We investigate whether a non-monetary incentive, in the form of mandatory accreditation, affects the job satisfaction of Danish GPs. Accreditation of general practice in Denmark was introduced as a cluster randomised stepwise implementation from 2016 to 2018. We measure job satisfaction at three time points: before the randomisation took place, one year into the accreditation process and two years into the accreditation process. We use a balanced panel of GPs who have completed all three waves of the survey (n = 846) and estimate a series of random and mixed effects ordered logit models. Despite many GPs having negative attitudes towards accreditation, we find no evidence of accreditation affecting GP job satisfaction. However, there are negative associations between job satisfaction and perceiving accreditation as a tool for external control. Policy makers are therefore encouraged to carefully inform about new interventions and identify barriers to diminish pre-existing negative perceptions about the incentive.

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.

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.

How Does ISO 15189 Laboratory Accreditation Support the Delivery of Healthcare in Ethiopia? A Systematic Review

BACKGROUND

Assessing quality by considering input, process and output level quality variables is important to ensure improved quality services. Designing and execution of an effective quality management system are aimed for the purpose of quality improvement, error reduction and associated risks. Therefore, this review is designed to assess the value of accreditation on the performance of healthcare institutions in ensuring quality improvement interventions. Moreover, this review presents important concepts of accreditation and the aspects of quality.

METHODS

Published articles were downloaded using EndNote® application software program from PubMed (NML) database, Web of Sciences (TS) and Google Scholar. From a total of 883 downloaded full-text published materials, only 28 journals and 1 report issued from 2010 to 2017 were used for the development of this review.

RESULT

The overall quality of healthcare services in developing countries was error-prone and suffered from limitations. These could be associated with wrong interventions and increased risks. Accreditation schemes have been implemented to provide quality care and ensure safety.

CONCLUSION

Evaluation feedback induces interventions aimed at quality improvement and ensures better management systems, good process design, wise resource utilization, meeting patients' need and increased satisfaction. Hence, stakeholders must be engaged in the provision of improve quality patient care and reduce associated risks. Hence, giving special quality improvement attention helps to improve quality healthcare services.

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.

The impact of accreditation on nurses' perceptions of quality of care in Iran and its barriers and facilitators

BACKGROUND

Iran national hospital accreditation was initiated as a government and mandatory program in 2012. The aim of this study was to examine the impact of accreditation on nurses' perceptions of quality of care and to determine those barriers and facilitators needed for effective implementation of accreditation.

METHODS

A cross-sectional survey conducted in 43 tertiary public hospitals in 5 metropolises, Iran, which successfully passed national accreditation surveys. Participants included nurses with at least 5-year work experience. Overall response rate was 76%, with 1312 of 1706 valid responses included in the data analysis. A questionnaire was applied using a 5-point Likert scale ranging from 1 "strongly disagree" to 5 "strongly agree". In addition, the questionnaire included 2 open-ended questions allowing the respondent to identify barriers and facilitators to the process of for improving accreditation implementation. The relationship between the quality of results and the independent variables was tested using multiple regression analysis.

RESULTS

The scales measuring benefits of accreditation had the highest mean score followed by strategic quality planning, education and training, and staff involvement. Regression analysis indicated that leadership, commitment, and support; education and training; rewards and recognition; and staff involvement were factors affecting quality results. Barriers encountered included financial and capital resources, staff, institutional, and patients. Hospital accreditation has a positive impact on quality of care.

CONCLUSIONS

The findings of this study provide valuable information to policymakers and hospital managers on which to base the process of accreditation and its requirements, and to help reap its benefits.