Accreditation and Clinical Outcomes: Shorter Length of Stay After First-Time Hospital Accreditation in the Faroe Islands

BACKGROUND

The aim of accreditation is to improve quality of care and patient safety. However, studies on the effectiveness of accreditation on clinical outcomes are limited and inconsistent. Comparative studies have contrasted accredited with non-accredited hospitals or hospitals without a benchmark, but assessments of clinical outcomes of patients treated at hospitals undergoing accreditation are sparse. The Faroe Islands hospitals were accredited for the first time in 2017, making them an ideal place to study the impact of accreditation. The objective was to investigate the association between first-time hospital accreditation and length of stay (LOS), acute readmission (AR) and 30-day mortality in the unique setting of the Faroe Islands.

METHODS

A before and after study based on medical record audits in relation to first-time accreditation. All three Faroese hospitals were voluntarily accredited using a modified second version of the Danish Healthcare Quality Program (DDKM) encompassing 76 standards. We included in-patients 18 years or older treated at a Faroese hospital with one of six clinical conditions (stroke/TIA, bleeding gastric ulcer, COPD, childbirth, heart failure and hip fracture) in 2012-2013 designated 'before accreditation' or 2017-2018 'after accreditation'. Main outcome measures were LOS, all-cause AR and all-cause 30-day mortality. We computed adjusted cause specific hazard rate ratios (HR) using Cox Proportional Hazard regression with before accreditation as reference. The analyses were controlled for age, sex, cohabitant status, in-hospital rehabilitation, type of admission, diagnosis and cluster effect at patient and hospital level.

RESULTS

The mean LOS was 13.4 days (95%CI: 10.8, 15.9) before accreditation and 7.5 days (95%CI: 6.10, 8.89) after accreditation. LOS of patients hospitalized after accreditation was significantly shorter (overall, adjusted HR=1.23 (95% confidence interval (CI): 1.04, 1.46)). By medical condition, only women in childbirth had a significantly shorter LOS (adjusted HR=1.30 (95%CI: 1.04, 1.62)). In total, 12.3% of in-patients before and 9.5% after accreditation were readmitted acutely within 30 days of discharge, and 30-day mortality was 3.3% among in-patients before and 2.8% after accreditation, respectively. No associations were found overall or by medical condition for AR (overall, adjusted HR=1.34 (95%CI: 0.82, 2.18)) or 30-day mortality (overall, adjusted HR=1.33 (95%CI: 0.55, 3.21)) after adjustment for potential confounding factors.

CONCLUSION

First-time hospital accreditation in the Faroe Islands was associated with significant reduction in LOS, especially of women in childbirth. Notably,shorter LOS was not followed by increased AR. There was no evidence that first-time accreditation lowered the risk of AR or 30-day mortality.

Patients experience more support, information and involvement after first-time hospital accreditation: a before and after study in the Faroe Islands

BACKGROUND

The impact of hospital accreditation on the experiences of patients remains a weak point in quality improvement research. This is surprising given the time and cost of accreditation and the fact that patient experiences influence outcomes. We investigated the impact of first-time hospital accreditation on patients' experience of support from health-care professionals, information and involvement in decisions.

OBJECTIVE

We aimed to examine the association between first-time hospital accreditation and patient experiences.

METHODS

We conducted a longitudinal study in the three Faroese hospitals that, unlike hospitals on the Danish mainland and elsewhere internationally, had no prior exposure to systematic quality improvement. The hospitals were accredited in 2017 according to a modified second version of the Danish Healthcare Quality program. Study participants were 18 years or older and hospitalized for at least 24 h in 2016 before or 2018 after accreditation. We administered the National Danish Survey of Patient Experiences for acute and scheduled hospitalization. Patients rated their experiences of support, information and involvement in decision-making on a 5-point Likert scale. We calculated individual and grouped mean item scores, the percentages of scores ≥4, the mean score difference, the relative risk (RR) for high/very high scores (≥4) using Poisson regression and the risk difference. Patient experience ratings were compared using mixed effects linear regression.

RESULTS

In total, 400 patients before and 400 after accreditation completed the survey. After accreditation patients reported increased support from health professionals; adjusted mean score difference (adj. mean diff.) = 1.99 (95% confidence interval (CI): 1.89, 2.10), feeling better informed before and during the hospitalization; adj. mean diff. = 1.14 (95% CI: 1.07; 1.20) and more involved in decision-making; adj. mean diff. = 1.79 (95% CI: 1.76; 1.82). Additionally, the RR for a high/very high score (≥4) was significantly greater on 15 of the 16 questionnaire items. The greatest RR for a high/very high score (≥4) after accreditation, was found for the item 'Have you had a dialogue with the staff about the advantages and disadvantages of the examination/treatment options available?'; RR= 5.73 (95% CI: 4.51, 7.27).

CONCLUSION

Hospitalized patients experienced significantly more support from health professionals, information and involvement in decision-making after accreditation. Future research on accreditation should include the patients' perspective.

The association between first-time accreditation and the delivery of recommended care: a before and after study in the Faroe Islands

Background

Significant resources are spent on hospital accreditation worldwide. However, documentation of the effects of accreditation on processes, quality of care and outcomes in healthcare remain scarce. This study aimed to examine changes in the delivery of patient care in accordance with clinical guidelines (recommended care) after first-time accreditation in a care setting not previously exposed to systematic quality improvement initiatives.

Methods

We conducted a before and after study based on medical record reviews in connection with introducing first-time accreditation. We included patients with stroke/transient ischemic attack, bleeding gastric ulcer, diabetes, chronic obstructive pulmonary disease (COPD), childbirth, heart failure and hip fracture treated at public, non-psychiatric Faroese hospitals during 2012–2013 (before accreditation) or 2017–2018 (after accreditation). The intervention was the implementation of a modified second version of The Danish Healthcare Quality Program (DDKM) from 2014 to 2016 including an on-site accreditation survey in the Faroese hospitals. Recommended care was assessed using 63 disease specific patient level process performance measures in seven clinical conditions. We calculated the fulfillment and changes in the opportunity-based composite score and the all-or-none score.

Results

We included 867 patient pathways (536 before and 331 after). After accreditation, the total opportunity-based composite score was marginally higher though the change did not reach statistical significance (adjusted percentage point difference (%): 4.4%; 95% CI: − 0.7 to 9.6). At disease level, patients with stroke/transient ischemic attack, bleeding gastric ulcer, COPD and childbirth received a higher proportion of recommended care after accreditation. No difference was found for heart failure and diabetes. Hip fracture received less recommended care after accreditation. The total all-or-none score, which is the probability of a patient receiving all recommended care, was significantly higher after accreditation (adjusted relative risk (RR): 2.32; 95% CI: 2.03 to 2.67). The improvement was particularly strong for patients with COPD (RR: 16.22; 95% CI: 14.54 to 18.10).

Conclusion

Hospitals were in general more likely to provide recommended care after first-time accreditation.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06952-w.

The perspectives of former recipients and experts on stigmatization related to electroconvulsive therapy in Denmark: A focus group study

WHAT IS KNOWN ON THE SUBJECT?: Electroconvulsive therapy (ECT) has existed worldwide for nearly 80 years. ECT is a fast-working and potentially life-saving treatment, but it is considered controversial. Although frequently mentioned, stigmatization in relation to ECT has not been systematically explored so far. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: This paper provides new insight into both recipient and expert perspectives on ECT. It identifies several issues of stigmatization related to ECT and suggests that full recovery following ECT might be jeopardized due to both stigmatization and self-stigmatization. The study suggests that most of the stigmatizing behaviors can be ascribed to (a lack of) available knowledge of and experience with ECT. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Being aware of and listening to the needs of former ECT-recipients seems essential to increase their treatment options and support care as well as a will to prioritize this patient group. For example, by addressing the potential stigma issues in follow-up groups and helping to distribute sober, factual information about ECT in society. Providing written information and psychoeducation for patients and relatives before, during, and after ECT, in addition to supporting active use of diaries, might be valuable remedies for helping patients feel adequately informed and able to accept the pros and cons of ECT during and after treatment period. ABSTRACT: Introduction Electroconvulsive therapy (ECT) has existed worldwide for nearly 80 years. Although fast-working and potentially life-saving treatment, ECT is regarded as a strongly controversial treatment and stigmatization is frequently mentioned in relation to it. However, no systematic research in this area has taken place so far. Aim The aim of this qualitative study was to explore the experiences and attitudes of former recipients of ECT and of experts professionally involved with ECT to identify potential stigmatization. Method Two focus groups, one comprising four recipients of ECT and the other seven professional experts, were conducted. Data from each focus group were analyzed separately using a framework-analysis. Results The analysis yielded three major themes for the first focus group interview: ambivalent attitudes, discrediting and exclusion, and survival strategies and three major themes for the second focus group interview: dramatic depictions of ECT, an overlooked and rare treatment, and anti-stigmatization strategies. Discussion and implications for practice Stigmatizing attitudes and behaviors in relation to ECT are closely related to one's personal and factual knowledge, and there is a great need for multi-facetted approaches if social acceptance and recognition are to be achieved. This study provides new knowledge on a scarcely examined area while also introducing suitable methods for anti-stigmatization and empowerment.