Accreditation in 2030

With the rapid acceleration of changes being experienced throughout the world and in particular within health and health and social care, accreditation programmes must keep pace or go the way of the dinosaur. While accreditation has deep roots in some countries, in the past 30 years, it has spread to a considerably larger range of countries in a mix of mandatory and voluntary systems. Accreditation is a tool to improve the quality of healthcare and social care, and in particular, there is recent recognition of its value in low- and middle-income countries, with promotion by the World Health Organization (WHO). The challenge is that with the rapid pace of change, how does accreditation reframe and reposition itself to ensure relevance in 2030? Accreditation must adapt and be relevant in order to be sustainable. This article outlines the fundamental principles, reviews the global trends' impact on accreditation and the challenges with the existing model and, through the lens of living in 2030, outlines how accreditation programmes will be structured and applied 10 years from now.

Letters to the Editor

This article contains Letters from the Readears.

Transformational improvement in quality care and health systems: the next decade

BACKGROUND

Healthcare is amongst the most complex of human systems. Coordinating activities and integrating newer with older ways of treating patients while delivering high-quality, safe care, is challenging. Three landmark reports in 2018 led by (1) the Lancet Global Health Commission, (2) a coalition of the World Health Organization, the Organisation for Economic Co-operation and Development and the World Bank, and (3) the National Academies of Sciences, Engineering and Medicine of the United States propose that health systems need to tackle care quality, create less harm and provide universal health coverage in all nations, but especially low- and middle-income countries. The objective of this study is to review these reports with the aim of advancing the discussion beyond a conceptual diagnosis of quality gaps into identification of practical opportunities for transforming health systems by 2030.

MAIN BODY

We analysed the reports via text-mining techniques and content analyses to derive their key themes and concepts. Initiatives to make progress include better measurement, using the capacities of information and communications technologies, taking a systems view of change, supporting systems to be constantly improving, creating learning health systems and undergirding progress with effective research and evaluation. Our analysis suggests that the world needs to move from 2018, the year of reports, to the 2020s, the decade of action. We propose three initiatives to support this move: first, developing a blueprint for change, modifiable to each country's circumstances, to give effect to the reports' recommendations; second, to make tangible steps to reduce inequities within and across health systems, including redistributing resources to areas of greatest need; and third, learning from what goes right to complement current efforts focused on reducing things going wrong. We provide examples of targeted funding which would have major benefits, reduce inequalities, promote universality and be better at learning from successes as well as failures.

CONCLUSION

The reports contain many recommendations, but lack an integrated, implementable, 10-year action plan for the next decade to give effect to their aims to improve care to the most vulnerable, save lives by providing high-quality healthcare and shift to measuring and ensuring better systems- and patient-level outcomes. This article signals what needs to be done to achieve these aims.

Patient Safety: We've Come a Long Way

Patient safety has come a long way since the release of the 1999 Institute of Medicine report To Err Is Human. This report revealed the immense size of the problem of preventable adverse events - events that in the past we assumed were "just complications" occurring in the normal course of diagnosis and treatment. Simultaneously, shining the light on patient safety "took the lid off quality." Those of us involved in healthcare provision always had a commitment to providing high-quality care, yet the focus of many key stakeholders on the importance of high-quality healthcare had been limited. The focus tended to be disproportionately on the rising cost of healthcare rather than a balanced focus on quality. Now, we respect the imperative of achieving high-quality healthcare.

The unrecognized power of health services accreditation: more than external evaluation

While it is widely recognized that accreditation enables an organization to improve its performance and sustain a culture of quality, changing healthcare practices to align with evidence-informed guidelines (clinical and administrative) is a complex process that takes time. The true value of accreditation lies in its contribution to healthcare safety and quality as a means to prompt and support 'knowledge to action', a key value of accreditation that 'has yet to be articulated'. Using the 'knowledge to action' cycle, a planned action framework, we illustrate that accreditation is a knowledge translation (KT) or implementation intervention that seeks to improve and increase the uptake of evidence in healthcare organizations. The accreditation components, including the quality framework, standards, self-assessment process and on-site survey visit, ultimately serve to improve quality, decreasing variation in practice and strengthening a culture of quality. With a unique perspective and alignment obtained through the implementation lens, we examine the accreditation process and components relative to the 'knowledge to action cycle' with implications for enhancing the value of accreditation beyond current appreciation to both accreditation bodies worldwide and those organizations that participate in accreditation programs. Until organizations and accreditation bodies embrace the accreditation process as a knowledge to action intervention to bring about meaningful and sustained change, the full benefits of the process will not be optimized nor achieved.

Effectively leading for quality

Although significant advances have occurred in medical and related sciences, the quality improvement and patient safety movements have been slow to gain traction. There are many "pockets" of progress around the globe; however, the scale and spread has been slow. Stimulating culture and system change in healthcare requires a definitive change in leadership style and approach. Health leaders of today must commit to the critical success factors and demonstrate the attributes necessary to create change and raise the bar for quality improvement and safety.

Coping with more people with more illness. Part 1: the nature of the challenge and the implications for safety and quality

Health systems are under more pressure than ever before, and the challenges are multiplying and accelerating. Economic forces, new technology, genomics, AI in medicine, increasing demands for care-all are playing a part, or are predicted to increasingly do so. Above all, ageing populations in many parts of the world are exacerbating the disease burden on the system and intensifying the requirements to provide effective care equitably to citizens. In this first of two companion articles on behalf of the Innovation and Systems Change Working Group of the International Society for Quality in Health Care (ISQua), in consultation with representatives from over 40 countries, we assess this situation and discuss the implications for safety and quality. Health systems will need to run ahead of the coming changes and learn how to cope better with more people with more chronic and acute illnesses needing care. This will require collective ingenuity, and a deep desire to reconfigure healthcare and re-engineer services. Chief amongst the successful strategies, we argue, will be preventative approaches targeting both physical and psychological health, paying attention to the determinants of health, keeping people at home longer, experimenting with new governance and financial models, creating novel incentives, upskilling workforces to fit them for the future, redesigning care teams and transitioning from a system delivering episodic care to one that looks after people across the life cycle. There are opportunities for the international community to learn together to revitalise their health systems in a time of change and upheaval.

The future of health systems to 2030: a roadmap for global progress and sustainability

Most research on health systems examines contemporary problems within one, or at most a few, countries. Breaking with this tradition, we present a series of case studies in a book written by key policymakers, scholars and experts, looking at health systems and their projected successes to 2030. Healthcare Systems: Future Predictions for Global Care includes chapters on 52 individual countries and five regions, covering a total of 152 countries. Synthesised, two key contributions are made in this compendium. First, five trends shaping the future healthcare landscape are analysed: sustainable health systems; the genomics revolution; emerging technologies; global demographics dynamics; and new models of care. Second, nine main themes arise from the chapters: integration of healthcare services; financing, economics and insurance; patient-based care and empowering the patient; universal healthcare; technology and information technology; aging populations; preventative care; accreditation, standards, and policy; and human development, education and training. These five trends and nine themes can be used as a blueprint for change. They can help strengthen the efforts of stakeholders interested in reform, ranging from international bodies such as the World Health Organization, the International Society for Quality in Health Care and the World Bank, through to national bodies such as health departments, quality and safety agencies, non-government organisations (NGO) and other groups with an interest in improving healthcare delivery systems. This compendium offers more than a glimpse into the future of healthcare-it provides a roadmap to help shape thinking about the next generation of caring systems, extrapolated over the next 15 years.

Accomplishing reform: successful case studies drawn from the health systems of 60 countries

Healthcare reform typically involves orchestrating a policy change, mediated through some form of operational, systems, financial, process or practice intervention. The aim is to improve the ways in which care is delivered to patients. In our book 'Health Systems Improvement Across the Globe: Success Stories from 60 Countries', we gathered case-study accomplishments from 60 countries. A unique feature of the collection is the diversity of included countries, from the wealthiest and most politically stable such as Japan, Qatar and Canada, to some of the poorest, most densely populated or politically challenged, including Afghanistan, Guinea and Nigeria. Despite constraints faced by health reformers everywhere, every country was able to share a story of accomplishment-defining how their case example was managed, what services were affected and ultimately how patients, staff, or the system overall, benefited. The reform themes ranged from those relating to policy, care coverage and governance; to quality, standards, accreditation and regulation; to the organization of care; to safety, workforce and resources; to technology and IT; through to practical ways in which stakeholders forged collaborations and partnerships to achieve mutual aims. Common factors linked to success included the 'acorn-to-oak tree' principle (a small scale initiative can lead to system-wide reforms); the 'data-to-information-to-intelligence' principle (the role of IT and data are becoming more critical for delivering efficient and appropriate care, but must be converted into useful intelligence); the 'many-hands' principle (concerted action between stakeholders is key); and the 'patient-as-the-pre-eminent-player' principle (placing patients at the centre of reform designs is critical for success).

Preparing national health systems to cope with the impending tsunami of ageing and its associated complexities: Towards more sustainable health care

Healthcare systems across the world are experiencing increased financial, organizational and social pressures attributable to a range of critical issues including the challenge of ageing populations. Health systems need to adapt, in order to sustainably provide quality care to the widest range of patients, particularly those with chronic and complex diseases, and especially those in vulnerable and low-income groups. We report on a workshop designed to tackle such issues under the auspices of ISQua, with representatives from Argentina, Australia, Canada, Columbia, Denmark, Emirates, France, Ireland, Jordan, Qatar, Malaysia, Norway, Oman, UK, South Africa and Switzerland. We discuss some of the challenges facing healthcare systems in countries ageing rapidly, to those less so, and touch on current and future reform options.

The Accreditation Canada program: a complementary tool to promote accountability in Canadian healthcare

Across Canada and internationally, the public and governments at all levels have increasing expectations for quality of care, value for healthcare dollars and accountability. Within this reality, there is increasing recognition of the value of accreditation as a barometer of quality and as a tool to assess and improve accountability and efficiency in healthcare delivery. In this commentary, we show how three key attributes of the Accreditation Canada Qmentum accreditation program--measurement, scalability and currency - promote accountability in healthcare.

Alberta Health Services: journey to accreditation

In October 2010, Alberta Health Services (AHS) successfully completed phase one of its journey to accreditation, meeting 683 of 774 criteria and earning Accreditation with Condition. AHS entered accreditation during its infancy (18 months, to be exact) in an environment shaped by seismic organizational and structural changes. In this article, the authors share some of the successes, challenges and ongoing opportunities that have emerged during the first years of AHS's accreditation journey, as well as details of the strong collaborative relationship between AHS and Accreditation Canada.

Profiling health-care accreditation organizations: an international survey

OBJECTIVE

To describe global patterns among health-care accreditation organizations (AOs) and to identify determinants of sustainability and opportunities for improvement.

DESIGN

Web-based questionnaire survey.

PARTICIPANTS

Organizations offering accreditation services nationally or internationally to health-care provider institutions or networks at primary, secondary or tertiary level in 2010.

MAIN OUTCOME MEASURE

s) External relationships, scope and activity public information.

RESULTS

Forty-four AOs submitted data, compared with 33 in a survey 10 years earlier. Of the 30 AOs that reported survey activity in 2000 and 2010, 16 are still active and stable or growing. New and old programmes are increasingly linked to public funding and regulation.

CONCLUSIONS

While the number of health-care AOs continues to grow, many fail to thrive. Successful organizations tend to complement mechanisms of regulation, health-care funding or governmental commitment to quality and health-care improvement that offer a supportive environment. Principal challenges include unstable business (e.g. limited market, low uptake) and unstable politics. Many organizations make only limited information available to patients and the public about standards, procedures or results.

The determinants of quality healthcare: implications for Canadian health leaders

The Accreditation Canada program supports organizations in delivering quality healthcare using a quality framework that recognizes the complex interplay of multiple factors that define quality. This article highlights the Accreditation Canada quality framework and how these dimensions of quality together promote quality care. Using three dimensions of quality--population focus, safety, and worklife--we discuss how these quality dimensions can be utilized by healthcare leaders to improve quality in their organizations.

Activating knowledge for patient safety practices: a Canadian academic-policy partnership

BACKGROUND

Over the past decade, the need for healthcare delivery systems to identify and address patient safety issues has been propelled to the forefront. A Canadian survey, for example, demonstrated patient safety to be a major concern of frontline nurses (Nicklin & McVeety 2002). Three crucial patient safety elements, current knowledge, resources, and context of care have been identified by the World Health Organization (WHO 2009). To develop strategies to respond to the scope and mandate of the WHO report within the Canadian context, a pan-Canadian academic-policy partnership has been established.

APPROACH

This newly formed Pan-Canadian Partnership, the Queen's Joanna Briggs Collaboration for Patient Safety (referred throughout as "QJBC" or "the Partnership"), includes the Queen's University School of Nursing, Accreditation Canada, the Canadian Patient Safety Institute (CPSI), the Canadian Institutes of Health Research, and is supported by an active and committed advisory council representing over 10 national organizations representing all sectors of the health continuum, including patients/families advocacy groups, professional associations, and other bodies. This unique partnership is designed to provide timely, focused support from academia to the front line of patient safety. QJBC has adopted an "integrated knowledge translation" approach to identify and respond to patient safety priorities and to ensure active engagement with stakeholders in producing and using available knowledge. Synthesis of evidence and guideline adaptation methodologies are employed to access quantitative and qualitative evidence relevant to pertinent patient safety questions and subsequently, to respond to issues of feasibility, meaningfulness, appropriateness/acceptability, and effectiveness.

SUMMARY

This paper describes the conceptual grounding of the Partnership, its proposed methods, and its plan for action. It is hoped that our journey may provide some guidance to others as they develop patient safety models within their own arenas.

What's on the quality agenda? Acknowledging progress, respecting the challenges

While many quality improvement and performance measurement initiatives are under way in Canada and beyond, there are challenges to be met around effectively coordinating the national quality agenda, sharing expertise and reducing duplication. An important first step has been recognizing the vital connection between quality and efficiency.While many provinces and territories have embraced the quality challenge, the national quality agenda remains less than coordinated. Reaching agreement on goals must be done in full collaboration with the provinces and territories, respecting their unique priorities while also providing the benefits of a national measurement and performance system and broader-level strategies.Workplace culture affects the ability to deliver safe care. Creating an integrated culture of quality results in measurable improvements in staff satisfaction and patient outcomes. However, this process requires long-term commitments from governments, boards, chief executive officers (CEOs) and staff, and involvement at all levels in design, initiation and implementation.There is frustration with the extensive and growing number of bodies to whom health organizations must submit data. This duplication could be reduced through consistent definitions, measurement priorities and reporting mechanisms, as well as national agreement on core performance measures. Ongoing collaboration at many levels is increasing the sharing of information and aligning of definitions in this regard.

The quality journey--in fast forward

Healthcare providers have always focused on the quality of healthcare. However, the escalating focus of government on quality and the connection between quality and efficiency signals a significant positive change in the health quality journey. Given accreditation's contribution to quality and efficiency, quality discussions and initiatives inherently include accreditation in a renewed way.

Strengthening the value of accreditation: Qmentum - one year later

Accreditation is recognized as one of the most effective ways for health services organizations to systematically examine and improve the quality of their services. Accreditation Canada released the Qmentum accreditation program in February 2008. This article outlines the progress made during the first year of implementation, discusses the current challenges and provides insight into what lies ahead.

Healthcare-associated infections: infection prevention and control within the Accreditation Canada Qmentum Program

Gardam, Lemieux, Reason, van Dijk and Goel argue that healthcare-associated infections (HAIs) are "a pressing and imminent concern in the context of patient safety." Accreditation Canada supports the position taken by these authors. The prevention and control of two HAIs of great concern, methicillin-resistant Staphylococcus aureus and Clostridium difficile, are an integral part of the Accreditation Canada program. A coordinated approach to combating HAIs and developing a culture of infection prevention and control is necessary, one that involves front-line healthcare professionals, senior leadership, national and provincial partners and the public. Since 2005, Accreditation Canada has increasingly strengthened the accreditation program in this area through a number of new strategies, including enhanced standards, required organizational practices, performance measures and indicators and the introduction of education programs. Optimizing the value of accreditation through an integrative approach with organizations' quality improvement programs will contribute to effectively combating HAIs and developing a culture of infection prevention and control.

Enabling quality improvement within primary healthcare through the CCHSA accreditation program

Progress is being made on the journey to strengthen primary healthcare within Canada. As an essential component of the healthcare continuum, primary healthcare must be more effectively linked and its role optimized for better patient/client outcomes to be realized. The Canadian Council on Health Services Accreditation (CCHSA) is an enabler to change and is committed to contributing to the strengthening of primary healthcare. During the first 20 years, the focus of CCHSA's accreditation process was on facility-based acute and long-term care. Since that time, accreditation standards have been established across a wide range of healthcare sectors and specialty areas. CCHSA's accreditation program will increasingly contribute to strengthening the essential and integral role of primary healthcare in the healthcare system.

Advancing quality healthcare: the new accreditation program

The CCHSA national accreditation program is undergoing a significant transformation. This article outlines the rationale for the changes, objectives, key enhancements, the development process, the critical path and the key messages.

CCHSA accreditation: a change catalyst toward healthier work environments

Canada has made significant progress in research and policy development regarding work environment issues that contribute to the quality of the work environment in health organizations. In order to successfully achieve the outcomes that healthier work environments can have on providers, patients and the system, more definitive action is required now. The Canadian Council on Health Services Accreditation (CCHSA) is a recognized catalyst of change in health organizations and systems in Canada and internationally. This paper reviews CCHSA's role in contributing to the improvement of the health of work environments in order to improve both the well-being of those working in healthcare and the quality of care being provided to their patients or clients.

Performance reporting: alignment with accreditation

This paper reviews the strong relationship of performance measurement and reporting with the Canadian Council on Health Services Accreditation (CCHSA) accreditation program and consistency with the direction of ongoing development. The CCHSA authors discuss the issue of public reporting of the accreditation results, the impact of public reporting on accreditation, aligning accreditation with the public reporting requirements, the measurement framework, quality improvement results and reporting and the linkage of accreditation with accountability. As public reporting gains momentum, the accreditation program must align to enable this while protecting the fundamental integrity and value of the program. Participating in the accreditation program clearly demonstrates the organization's commitment to accountability.

Nursing and patient outcomes: it's time for healthcare leadership to respond

An increasing body of research confirms the link between nursing variables (e.g. staffing ratios, skill mix) and patient outcomes including morbidity and mortality. This article presents the key themes that have emerged in this research and translates them into action for senior healthcare leaders. Immediate action is required in order for hospitals to effectively recruit and retain nurses, and to provide high quality patient care that minimizes risk.

Enhancing skills for evidence-based healthcare leadership: the Executive Training for Research Application (EXTRA) program

The Executive Training for Research Application (EXTRA) is a new training program that aims to increase the skills of health services executives and their organizations to use research evidence in healthcare management and decision-making. This paper describes the goals and rationale of the EXTRA program and its learning objectives and curriculum, and reports on some early baseline evaluative research. In particular, the authors address the opportunities that EXTRA offers to leaders in the nursing profession to transform the practice of nursing and patient care, and the unique opportunities that the program offers for collaboration across the healthcare professions and disciplines. While the EXTRA training program requires substantive investment of time and commitment by healthcare leaders and their organizations, it offers great potential for increasing research application in healthcare leadership decision-making. It is therefore a potential long-term lever of cultural decision-making change within healthcare organizations.

Patient safety culture and leadership within Canada's Academic Health Science Centres: towards the development of a collaborative position paper

Currently, the Academy of Canadian Executive Nurses (ACEN) is working with the Association of Canadian Academic Healthcare Organizations (ACAHO) to develop a joint position paper on patient safety cultures and leadership within Academic Health Science Centres (AHSCs). Pressures to improve patient safety within our healthcare system are gaining momentum daily. Because AHSCs in Canada are the key organizations that are positioned regionally and nationally, where service delivery is the platform for the education of future healthcare providers, and where the development of new knowledge and innovation through research occurs, leadership for patient safety logically must emanate from them. As a primer, ACEN provides an overview of current patient safety initiatives in AHSCs to date. In addition, the following six key areas for action are identified to ensure that AHSCs continue to be leaders in delivering quality, safe healthcare in Canada. These include: (1) strategic orientation to safety culture and quality improvement, (2) open and transparent disclosure policies, (3) health human resources integral to ensuring patient safety practices, (4) effective linkages between AHSCs and academic institutions, (5) national patient safety accountability initiatives and (6) collaborative team practice.

Restrictive visitor policies: feedback from healthcare workers, patients and families

With the hospital-based transmission of Severe Acute Respiratory Syndrome (SARS) in Ontario, acute care hospitals severely restricted visitor access. Now that the SARS outbreak is under control, hospitals struggle with the balance between adhering to patient- and family-centred care models, and addressing the future threat of infectious diseases. To evaluate the effect of visitor restrictions and to guide future visitation policies, the Ottawa Hospital conducted a preliminary survey of patients, next of kin, staff, physicians and volunteers. Ninety percent of staff surveyed supported some form of visitor restrictions, while 71% indicated that they felt comfortable asking visitors to leave if they had exceeded current restrictions. The majority of patients (80%) and next of kin (76%) were at least moderately satisfied with current restricted limiting hours. A disproportionate number of positive comments on current visiting restrictions were received from both patients and staff. In the absence of evidence on which to base future visitor policy development, objective input from healthcare workers, patients and families is invaluable.

Cutting healthcare costs without preventable clinical incidents--together we can improve

Medical errors are receiving increasing attention as research results reveal escalation in their numbers. Three elements of this complex issue are reviewed. A systems approach to reducing the number of errors may be less than effective until the negative connotation associated with the phraseology "medical error" is changed. Healthcare restructuring, which results in the destabilization of teams, is another factor that is related to the increase in medical errors. Stabilization of the healthcare environment and/or stronger support mechanisms during change are essential. Finally, the litigious sensitivity of the public and healthcare systems overall intensifies the "error" element. This element is counter-productive to the openness required for the systems approach.

Canadian nurses' perceptions of patient safety in hospitals

The topic of patient safety within the health care system is receiving increasing attention. The Academy of Canadian Executive Nurses conducted a national survey on nurses' perceptions of patient safety, using focus groups from Academic Health Science Centres. Over a three month time frame, 22 organizations, and 33 focus groups comprised of 503 nurses provided responses to six questions regarding patient safety in hospitals. The study was designed as a preliminary fact finding initiative resulting in this descriptive report of the concerns as identified within the focus groups. With each issue identification, they were coded and grouped into 23 themes. Nurses overwhelmingly responded that the health care environment, in which they provide care, presents escalating risk to their patients. In particular, Workload/Pace of Work, Human Resources, Nursing Shortage/Staffing, Restructuring/Bed Closures, Patients/Clients, Systems Issues, Physical Environment and Technology/Specialization were themes emphasized as contributing to increased risk in patient care. Health care leaders must play a key role in developing strategies to address the issues nurses have identified and demonstrate a commitment to controlling the situation. This study encourages research into a more explicit understanding of the issues and identification of strategies to address patient safety in health care.

Advanced nursing practice: old hat, new design

Advanced practice nurses positively impact the delivery of healthcare and client outcomes. However, in the past these positions have been seen to have variable value and were often vulnerable during budget cuts. Lack of a clear advanced nursing practice (ANP) framework probably contributed to the compromised effectiveness of these roles and evolution of roles with different titles, scopes of practice and reporting structures. To build the foundation for developing an ANP framework, a task force at The Ottawa Hospital (TOH) conducted a literature review related to ANP roles and completed a review of all clinical nursing roles at TOH. In addition, focus groups with nurses and other health professionals elicited ANP perceptions. The ANP framework includes a standardized job description that details competencies under five role components: clinical practice; consultation; research; education; and, leadership. Recommendations for assessment, implementation and evaluation of ANP roles are identified. The process undertaken by our ANP task force proved to be thorough and sound in developing a framework within which to move forward with ANP role implementation throughout TOH. This article, describing the process, may assist other organizations in defining ANP roles to better meet patient needs in changing health care environments.