David Greenfield, PhD,
Jeffrey Braithwaite, PhD, Professor and Director
Centre for Clinical Governance Research,
Faculty of Medicine,
University of New South Wales,
Email: [email protected]
There are now over 70 national accreditation agencies and an international body, the International Society for Quality in Health Care (ISQua). While there have been many calls for research into accreditation, the evidence base to support the claims of many programmes remains insufficient (Greenfield 2007; Greenfield et al. 2007; Shaw 2003). In 2004, the Centre for Clinical Governance Research (CCGR) at the University of New South Wales, Australia, in conjunction with industry partners the Australian Council on Healthcare Standards (ACHS), an industry body responsible for standards and accreditation, and Ramsay Health Care, a private health care provider, commenced a multi-faceted project to research accreditation.
Overview of Health Service Accreditation by ACHS
The ACHS has over 1000 member organisations, making it the major health service accreditation agency in Australia. The ACHS, in consultation with representatives from the health industry, has developed a continuous quality improvement programme the Evaluation and Quality Improvement Programme (EQuIP). The programme has been revised regularly and is now in its fourth edition. During the period 2003-2006, using the third edition of EQuIP, ACHS conducted 1233 accreditation surveys (AHCS 2007). The programme contains a set of standards that cover infrastructure or organisational issues as well as a continuum of patient care issues. Infrastructure standards, for example, include human resource management in addition to leadership and management functions, while continuum of care standards include consumer participation in the care process itself and care planning processes (ACHS 2002).
ACHS assesses health organisations against EQuIP standards, and when considered appropriate, participating organisations are granted accreditation status. The assessment process involves a number of activities, many of which are common to other accreditation programmes around the world. Firstly, a health organisation completes a pre-survey, self-assessment report where evidence is provided to demonstrate how standards have been achieved. Secondly, ACHS sends a team of surveyors – professionals drawn from medicine, nursing, allied health and administration who are specifically selected and trained for the task – to assess the health organisation against the standards. The visit involves interviews, document analysis and observations of the health organisation. At the conclusion of the survey, the team provides verbal feedback to the organisation and a written report to ACHS. When assessed positively, an organisation receives accreditation for a defined period, usually four years. If problems are identified, there are mechanisms in place as well as an opportunity for re-assessment.
CCGR Accreditation Research Project
The CCGR is conducting research into accreditation, using EQuIP as an exemplar of accreditation. The CCGR accreditation research programme has two aims with four studies. The research aims are: to examine the relationships between accreditation and organisational performance (clinical performance and organisational culture) and to examine the influence of surveyors on reliability and the organisations in which they work. The research protocol is outlined in Braithwaite et al. (2006).
Studies 1 and 2 used the same methods. This has involved researchers visiting health organisations and undertaking organisational (culture and climate) assessments. In addition, data about clinical indicator performance have been collected. This information is to be related to each organisation’s accreditation performance, to determine whether there is any correlation between these variables. Interim results indicate a positive correlation between accreditation outcome and organisational culture and climate, as well as leadership and clinical indicator performance. There does not appear to be any relationship between accreditation and consumer participation. A paper outlining the final results is to be released later this year.
Intra- and inter-rater reliability is being explored in study 3. There are several parts to this study. There is an investigation of the views of accreditation stakeholders about reliability of surveyors and survey teams; an examination of inter-rater reliability of survey teams using scenarios; an examination of intra-reliability of surveyors using scenarios; and a case study of two teams in one organisation. Initial assessments indicate that surveyors and sur vey teams are reliable. The accreditation programme, surveyor selection and surveyor management in particular, are recognised as factors standardising the conduct of individuals and teams. Papers describing the findings are currently being developed for publication.
Study 4 focuses upon the influence of surveyors in the organisations in which they work. Two studies are being conducted. One is using network analysis to map the connections and influence surveyors have on quality and safety issues, including accreditation activities. The other is inquiring into how surveyors enact leadership in relation to accreditation and safety and quality activities. Results from this study are expected in the next year.
for, Benefits from, and Challenges Associated with Accreditation
Research interviews with over 1,000 health professionals reveal interesting findings about the motivation for, benefits from, and challenges associated with accreditation. Health organisations seek accreditation for a host of reasons. Two of the most commonly expressed are: a desire from health professionals to improve their services and the care provided; and the requirement from governments and health funds to demonstrate attention to, and outcomes from, their quality and safety activities. Participation in an accreditation programme is considered one important way to achieve these goals. Similarly, health professionals discussed a range of benefits emerging from participating in an accreditation programme. Several of the more common ones are: improved communication, improved care, better use of resources and greater understanding of other services and professional roles.
In contrast to these positive views, health professionals also held strong views about the challenges an accreditation programme presents. In particular, undertaking and maintaining quality activities in busy clinical services and meeting documentation requirements were highlighted as most difficult. In addition, preparing for a survey visit was identified as being demanding and stressful for some participants. Nevertheless, a majority of people in our study perceived the benefits of accreditation outweigh the costs. Many professionals explained that accreditation stimulated them, and their organisations, to deal with issues that, in their hectic environments, were sometimes put to one side.
Accreditation is a major strategy by which quality and safety are being addressed. Accreditation offers benefits to providers delivering patient care and works to improve organisational processes. Research underway is illuminating the benefits and challenges associated with accreditation. The findings of these studies offer important insights for policymakers, hospital directors in addition to other healthcare managers and clinical professionals.
For references, please contact [email protected]e