Accreditation: A Common Quality-Enhancing Strategy
This article describes the major considerations for health system leaders in developing and implementing a sustainable and successful national accreditation programme, using the 20-year evolution of the Thai healthcare accreditation system as a model. The authors illustrate the interface between accreditation as a continuous quality improvement strategy, health insurance and other health financing schemes, and the overall goal of achieving universal health coverage.
The study's authors use the International Society for Quality in Healthcare's (ISQua) definition for accreditation: “A public recognition by a healthcare accreditation body of the achievement of accreditation standards by a healthcare organisation, demonstrated through an independent external peer assessment of that organisation’s level of performance in relation to the standards.”
Accreditation: One of Many Regulatory or Evaluation Mechanisms
Although important, accreditation is often just one of a number of quality improvement and evaluation strategies, so differentiating it from other regulatory or evaluation mechanisms is essential. Licensure is generally considered a government regulatory responsibility, designed to set minimum standards to protect the health and safety of the public. Licensing authorities such as Ministries of Health have the authority to determine which provider organisations can operate, levy fines for deficiencies and, in some cases, even close a substandard provider.
Accreditation, on the other hand, sets standards that are considered optimal and achievable, are more rigorous than the minimum standards of licensure, and have a stated intent to foster a culture of improvement. In many countries, accreditation is a voluntary recognition programme and is administered separately from the Ministry of Health, often by a Non-Governmental Organisation (NGO) or a quasi-regulatory agency with support and recognition—but at an “arm’s length”—from the government. Even if administered independently from the Ministry of Health, it is important to note that the accreditation body plays a vital role in advancing the Ministry’s overall quality and safety agenda.
The survey profile of 44 global accreditation organisations (AOs) published by Shaw et al. in 2013 demonstrated that two-thirds of responding AOs were formally authorised by national legislation, official decree, or both. Governance of the accrediting body frequently represents a credible cross-section of health care professionals (such as professional societies, medical or nursing boards), the public at large, and other stakeholders such as financing agencies, industry, NGOs, and/or academic institutions.
Accreditation Standards and Management
The heart of any accreditation programme lies in the reliability, validity, measurability, and objectivity of its standards. Accreditation standards must encourage improved performance, while at the same time being achievable and not overly prescriptive. An excellent framework for guiding the standards development process is available free of charge from ISQua through its recently revised International Principles for Healthcare Standards.
The standards should address all critical elements of quality and safety in the specific healthcare provider category, including patient care processes such as assessment and treatment, medication management and safety. Wherever possible, the accreditation programme should engage subject matter experts in the development and review of new or revised standards. The ISQua standards require a thorough standards review and revision process at least every four years.
Leadership of an effective accreditation programme includes operational management; surveyor selection, training, credentialing, and ongoing supervision and support; operating policies and procedures; design and implementation of a credible and objective evaluation process that includes sampling criteria; the application, staffing, and scheduling processes for conducting the on-site survey; field education to providers in the standards, evaluation process, and quality improvement strategies; financial management; and information management.
Well-trained, knowledgeable, and objective surveyors are critical to the design of any successful accreditation programme. Among the 20 LMIC countries represented in the Braithwaite et al. survey of global AOs, almost 90 percent indicated they have instituted a process by which surveyors are formally certified after successful completion of training. Also, surveyors must possess a high degree of personal and professional integrity as well as an ability to teach, inspire, and motivate provider organisations to a high level of performance. If surveyors are viewed as biased or punitive, the goal of the accreditation programme in stimulating a culture of improvement will fail.
Accreditation Decision Process
Valid, reliable, and transparent decision criteria should be employed in making the determination of an accreditation award, so that the “rules” are known and understood by all and the credibility of the accreditation programme is supported. Some accreditation programmes implement a tiered or “step-wise” approach to accreditation along an improvement continuum. The accreditation award is typically renewed via a process of an on-site survey every two to four years. The criteria must also address what happens when an accredited provider experiences a significant quality or safety incident, changes ownership, or embarks on a major construction project. If the accreditation programme withdraws accreditation for some reason, under what circumstances can the provider reapply?
Accreditation, because it involves an “external peer review” that is intended to place a value judgment on the quality, safety, and cleanliness, of an institution, has often been regarded as a form of summative evaluation rather than a mechanism for formative learning. However, as described in the developmental milestones of Thailand’s Healthcare Accreditation Institute, accreditation ideally should mature towards a more formative, continuous learning environment.
Sustainability of the Accreditation Programme
Sustainability of accreditation is largely dependent on sufficient financing, not only for the initial development costs, but for ongoing governance and operations (i.e., surveyor training and management). Will the provider organisations be assessed a fee for the accreditation visit and related travel expenses? Especially in the start-up phase when there are a smaller number of participating providers, how will these fees support ongoing operations until the programme becomes self-sustaining?
In addition to the financial support to the accrediting body, it is also critical to consider how provider organisations will be supported in their accreditation and improvement efforts. For example, how will needed improvements which involve capital costs such as facility renovation or the purchase of large equipment be addressed? Without this consideration, the accreditation programme runs the risk of irrelevance, as it promotes standards and expectations that are not achievable.
An international survey of 44 global AOs found that more than 80 percent indicated “quality improvement” as the primary motivator for accreditation, although commercial incentives and benefits also played an important motivating role. Linking accreditation to securing favourable bank loans and payment terms as well as other forms of recognition such as reimbursement differentials, participation in insurance schemes, “preferred provider” status from employers, and designation as medical travel destinations have been effective mechanisms for making the “business case” for accreditation.
Increasingly, insurers and employers are relying on an objective and credible accreditation award as a prerequisite for provider participation in their healthcare reimbursement programmes. In some instances this is called “empanelment”, to represent a standard/criteria driven process whereby providers are selected to participate in the insurance programme. This is frequently done in lieu of the insurer or employer conducting its own on-site evaluation or performance data collection and analysis.
Conclusion: Realising the Promise of Accreditation
Accreditation is among the most important strategies LMICs utilise to improve quality of care. Achieving “universal quality coverage” will require alignment between government, payers and accreditors. There are many choices that opinion leaders, policy makers, and regulators face as they design healthcare systems to ensure high-quality service. This paper reviews some of the better practices that are available; however, much remains unknown about the role and ideal design of accreditation systems that will accelerate achievement of universal quality coverage. By identifying the gaps in knowledge, the authors hope to not only inform decision makers but also researchers interested in pursuing further study to help bring clarity to the field.
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Published on : Mon, 27 Oct 2014