Preventing deaths from infection and tackling antimicrobial resistance by supporting and accrediting effective antimicrobial stewardship programmes globally

Accreditation in healthcare – background information

Definition and scope
Accreditation has been defined as, “A self-assessment and external peer review process used by health and social care organisations to accurately assess their level of performance in relation to established standards and to implement ways to continuously improve the health or social care system”. (The International Society for Quality in Health Care (ISQua), 2015)

Accreditation is an external review of quality with four principal components:
• It is based on written and published standards
• Reviews are conducted by professional peers
• The accreditation process is administered by an independent body
• The aim of accreditation is to encourage organisational development.
(Montagu D, 2003)

Four components have been identified in an accreditation programme – the accreditation body, the standards used to assess healthcare quality, the inspection process including the surveyors, and incentives for engaging in accreditation. (Mansour W et al, 2020). The wide variation in healthcare organisation settings, availability of resources and differences between patient populations are additional important considerations.

The purpose of accreditation is to establish the delivery of a baseline level of safe healthcare followed by incremental quality improvement through evolving standards. The ambition to drive improvements in healthcare sets accreditation apart from external review programmes such as regulatory inspection against a set of minimum standards.

Accreditation has been differentiated from certification and licensure – two other types of external peer review exercises:

Accreditation Public recognition by a national 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.
Certification Formal recognition of compliance with set standards (e.g. ISO 9000 series for quality systems) validated by external evaluation by an authorised auditor.
Licensure Process by which a government authority grants permission, usually following inspection against minimal statutory standards, to an individual practitioner or healthcare organisation to operate or to engage in an occupation or profession.

(Shaw CD, 2006)

In principle, accreditation programmes can cover any or all aspects of health and social care, but the majority of programmes focus on secondary care settings and cover all aspects of the inspected organisation.

Origins and global spread of accreditation
Healthcare accreditation has its origins in the “Minimum Standard for Hospitals” developed by the American College of Surgeons in 1917. Subsequent milestones include the establishment of the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) in 1951 in the United States, followed by the development in Canada (Accreditation Canada was launched in 1958) and Australia.
The first accreditation programme in Europe started in Catalonia, Spain, in the 1980s, and subsequently programmes across Europe followed suit.
Accreditation has been taken up by low and middle income countries (LMICs) in South America (including Brazil, Chile, Argentina), the Middle East (e.g. Lebanon, Jordan, Egypt, Iran), Africa (e.g. South Africa, Kenya, Tanzania, Uganda) and Asia (including India, Indonesia, South Korea, China, Thailand, Philippines), often through the initiatives of a country’s Ministry of Health but sometimes supported by non-governmental organisations (NGOs). These include the World Health Organisation (WHO), the Pan American Health Organisation (PAHO) and the World Bank, accreditation bodies such as Joint Commission International (JCI) and International Society for Quality in Healthcare (ISQua). Aid organisations such as the United States Agency for International Development (USAID) have also contributed to the spread of accreditation to LMICs. (Mansour W et al, 2020)

Why accreditation has evolved
There are varied reasons for the proliferation of accreditation programmes. The global push for the provision of universal health coverage (health services that are of sufficient quality to be effective without creating financial hardship for the patient) has been a major driver for accreditation, especially in low- and middle-income countries (LMICs). Accreditation has been seen as a useful tool for ensuring the quality and cost-effectiveness of healthcare in both public and private hospitals by governments. There are also many financial incentives including:

  • Reimbursement differentials
  • Participation in insurance schemes
  • Preferred provider status
  • Designation as medical travel destinations
  • Favourable reputation leading to increased market share

Mate and colleagues report that in India hospitals accredited by the National Accreditation Board for Hospitals and Healthcare Providers receive 15% extra remuneration from the Central Government Health Scheme (Mate KS et al, 2014)
Health insurance companies have also encouraged or required their provider hospitals to be accredited to contain costs as well as to guarantee quality. Accreditation can be used as a due process mechanism when carrying out their own inspection would be too burdensome for insurers or other healthcare payers. Some aid providers make accreditation a condition of support.

Accreditation standards
Standards are at the heart of accreditation and are a critical factor in determining the uptake and longevity of an accreditation programme. Accreditation standards should be “optimal and achievable, more rigorous than the minimum standards of licensure, and with a stated intent to foster a culture of improvement.” (Mate KS et al, 2014)

Shaw, in his outline of standards development, stated that standards need to be:

  • Relevant (to the candidate healthcare organisation)
  • Understandable (by healthcare organisation staff as well as assessors)
  • Measurable (by direct observation, by interviewing staff or by reading documented evidence)
  • Behavioural (referring to what people do and how activity is organized)
  • Achievable (now or within the near future),

giving the acronym RUMBA. (Shaw CD, 2006)

Mate and colleagues (Mate KS et al, 2014) describe a standards development pathway for starting a new national accreditation programme:

  1. Review current set standards from within the country, relevant national programmes and global accreditation organisations
  2. Identify all quality and safety critical elements (patient care processes, management components)
  3. Engage subject matter experts in standards development
  4. Seek stakeholder feedback from as many sources as possible (providers, healthcare professional societies, public, employers, consumer advocacy groups).
  5. Carry out a pilot test of new standards – ensure that standards can be measured in a comprehensive, reliable, and consistent manner.
  6. Carry out periodic reviews.

The Guidelines and Principles for the Development of Health and Social Care Standards (ISQua, 2018) sets out the following principles for standard development, measurement, structure, and content, noting that standards require review and revision at least every four years.

Standards Development The standards are planned, developed and evaluated through a defined and rigorous process
Standards Measurement There is a transparent measurement or rating methodology used by organisations and surveyors to aid consistent rating of achievement.
Organisational Role, Planning and Performance The standards require the assessment of the capacity and efficiency of health and social care organisations.
Safety Risk The standards include processes to manage risk and to protect the safety of patients/service users, staff and visitors.
Person-Centred Approach The standards are person-centred, reflect the continuum of care and encourage partnerships between patients/service users and professionals.
Quality Performance The standards require service organisations to evaluate, monitor and improve the quality of service.

Standards have tended to focus on organisational structure and process. A recently published paper envisions that by 2030 standards will concentrate on outcomes, with each standard including a description of the outcome that the standard sets out to achieve (Nicklin W et al, 2021).

Assessment against agreed standards
Standard accreditation assessment begins with the candidate healthcare organisation carrying out an internal baseline assessment against published standards. Standards should be sufficiently clear for organisations to be able to understand the aim of the standard and the evidence that is required to demonstrate compliance. The accrediting organisation can help with detailed supplementary guidance such as teaching material, case reports, sample data and analysis examples. Further support can be provided through e-mail or videoconferencing.

Standard assessment practice is for on-site reviews or inspections to be carried out by ‘surveyors’. It is vital that these surveyors are appropriately trained, “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” (Mate KS et al, 2014). In one survey of accrediting organisations, the vast majority provided formal certification of trained surveyors (Braithwaite J et al. 2012).

On-site surveyor visits may pose significant logistical challenges, especially in LMICs and virtual visits through videoconferencing could be considered. The forecast of accreditation in 2030 by Nicklin and colleagues describes a totally automated process, with online data collection and automated monitoring by the accreditation organisation, within the context of accreditation as a process rather than an event marked by the arrival of surveyors. (Nicklin W et al, 2021).

Evidence that accreditation improves healthcare quality
While accreditation programmes have burgeoned since their origins just over a century ago, based on a perception that they deliver on their promise of quality assurance and improvement, the paucity of peer-reviewed, published evidence demonstrating their impact is noteworthy.
This gap between perception and evidence prompted Greenfield and Braithwaite in 2009 to write, “So while it is accepted that accreditation programmes have been an important driver to improve quality and safety in healthcare organisations, a rigorous, transparent examination of different aspects of accreditation, and publication of the subsequent results, has not become the norm.” (Greenfield D, Braithwaite J., 2009). A more sceptical view was presented by Grepperud who listed a number of reasons why policy makers and third-party payers should hold back their enthusiasm for accreditation, including; lack of convincing evidence that accreditation results in quality improvements; that although hospitals may seek accreditation for reasons of moral hazard, consumer misperceptions and non-profit motivations, doing so is socially inefficient; hospitals undertaking accreditation may be insincere and not believe that the process will deliver quality improvements. (Grepperud S., 2015)

Given these challenges, it is important to consider the evidence that accreditation drives improvement in healthcare quality. Part of the challenge is establishing a shared agreement on what constitutes healthcare quality and therefore what should be measured to demonstrate any change in quality consequent to accreditation. Araujo and colleagues tackled this problem by identifying seven healthcare quality dimensions (effectiveness, efficiency, access, patient-centredness, equity, timeliness, safety) and seeking evidence of impact in these dimensions in a systematic review of 36 studies that reported on the introduction of accreditation. The included studies, dating from 1988 to 2019, looked at accreditation programmes in North and South America, Europe, the Middle East and Asia and reported on a variety of outcomes including whole hospital performance and improvements in specific clinical services such as radiology and out-patient practice. Overall, Araujo and colleagues concluded that there was evidence that accreditation improved the quality of healthcare in the following dimensions: efficiency, safety, effectiveness, patient-centredness and timeliness dimensions; but there was no evidence for impact on access to healthcare. This may not be surprising since access depends heavily on where healthcare is located and changing the location of a healthcare provider to improve access is a long-term project, at least for in-patient care. (Araujo CA et al., 2020)

Almost all the studies reviewed by Araujo and colleagues were observational studies, comparing quality dimensions in the same hospitals before and after the introduction of accreditation, or comparing accredited hospitals to non-accredited hospitals. Only one study used a randomised controlled trial design which highlights the difficulty inherent in investigating the effectiveness of accreditation, namely the practical challenges in rigorous study design where the unit of investigation is a whole healthcare organisation. Ideally, a cluster randomised controlled trial design should be used, where hospitals are randomly assigned to one of two treatments, accreditation or no accreditation, and pre and post intervention quality indicator measures compared. However, this sort of study is logistically and financially demanding and infrequently performed. An alternative experimental design is a stepped wedge approach which, if applied to accreditation, would introduce accreditation to all hospitals but in a phased stepped manner with the starting date of each hospital being decided by random allocation. This design has the advantage of including comparator controls while allowing all organisations to eventually join accreditation programmes.

Sustaining accreditation programmes
Accreditation programmes require investment by both the accrediting organisation and the candidate healthcare organisation. The preparatory work prior to the accreditation assessment/inspection, the inspection itself and subsequent collection and review of data requires healthcare personnel who have the time and skills to carry out this work and this costs money. Similarly, accreditation organisations need resources to develop standards, train surveyors, carry out inspections and review results. Unless all these resource requirements are provided, there is a danger that accreditation programmes can grind to a halt. Shaw highlights out that of 15 accreditation programmes in the UK in 2002, only 3 were still active in 2015 (Shaw CD. 2015)
Sufficient resources are not enough to guarantee effective accreditation. Desveaux and colleagues carried out a grounded theory study which interviewed Canadian healthcare organisation leaders, managers and clinicians who had been involved in the accreditation of their organisations by Accreditation Canada. They identified three key stages that healthcare organisations must transition in order to maximise benefit from accreditation. The first, coherence, refers to the perception of the healthcare organisation that its beliefs, context and model of service delivery align with accreditation. The second key stage is organisational buy-in, which depends on the candidate organisation having a conceptual champion, who can communicate the idea and value of accreditation to their organisation, and an operational champion who liaises with the accrediting body and oversees the individuals and processes involved in preparation for the on-site survey. The final key stage is collective quality improvement action when organisations reflect and act on accreditation process feedback. These three stages, and the consequences of not achieving them, are detailed in the table below. (Desveaux L et al., 2017)

Factors Achieved when: When not achieved: How an accrediting body can help:
Coherence An organisation and its staff perceive that accreditation standards and required organisational practices align with the organisation’s collective beliefs, context and model of service delivery. Organisations fail to buy-in to the accreditation process beyond pursuing accreditation as an external ‘stamp of approval’ possibly a required condition of certain funding streams. Provide a supportive, flexible relationship with the organisation.
Organisational buy-in
  • Established when there is both a conceptual champion and an operational champion.
  • Conceptual champion is often a credible leader within the organisation, who clearly communicates the value of the accreditation, but may or may not be actively involved in preparing the organisation for the accreditation process. In addition to supporting the process, the conceptual champion identified features of accreditation that resonated with organisational priorities.
  • Operational champion is responsible for liaising with the accrediting body and overseeing the individuals and processes involved in preparation for the on-site survey. Individuals in this role were described as actively supporting the progress of the organisation’s quality agenda; understanding the meaning behind accreditation standards and applying it to the context of the organisation; and communicating the meaning behind the standards to individuals and departments across the organisation, ensuring a consistent approach.
  • As participation in an accreditation process is mandatory in some sectors, organisations often progress to organisational buy-in before coherence was fully established.
  • Organisations are unlikely to use the results of the accreditation process to inform quality improvement initiatives.
  • Competing external factors: incentives and accountabilities, e.g. need to meet a range of quality requirements for different stakeholders. The structure of these requirements, most notably the definitions of quality indicators, could shape the way organisations think about quality care.
  • Varying conceptualisations of quality creates confusion and competing priorities for healthcare organisations when identifying relevant metrics to fuel quality improvement.
Internal factors:

  • Reflected the influence of the unique characteristics of individuals, including communication processes and organisational strategies.
  • Strong relationships facilitate organisational buy-in, through amplifying the influence of the conceptual champion(s) and enabling the operational champion to engage staff, further contributing to cultural cohesion.
  • Strong relationships with accreditation staff and surveyors play a critical role in providing the support required to create a consistent approach across the organisation, especially when a full-time operational champion available.
Collective quality improvement action When organisations take purposeful action in response to observations, feedback or self- reflection resulting from the accreditation process. Outputs of the accreditation process that may act as a mechanism to stimulate quality improvement actions. The provision of knowledge through the accreditation process may draw attention to best practices. Macro-level feedback draws attention to opportunities for improvement across the organisation, including greater service integration and strengthened processes.

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