Consecutive cycles of hospital accreditation: Persistent low compliance associated with higher mortality and longer length of stay

Accreditation of nutrition support teams: A new initiative by the Turkish Society of Clinical Enteral & Parenteral Nutrition

OBJECTIVES

Accreditation is a process to evaluate compliance of an institution or organization with predetermined performance standards, focusing on achieving continuous improvement strategies and optimal quality standards and motivating the accredited organization to do so. There is no established accreditation program for nutrition support teams (NSTs) at national and international levels. In order to increase the standards of NSTs, developing an accreditation program is being planned by the Turkish Society of Clinical Enteral & Parenteral Nutrition (KEPAN).

METHODS

Accreditation standards were developed by a study group under the organization of KEPAN. Minimum standards for composition, qualifications, physical requirements, workflow charts, medical records, and both patient and health care providers' safety measures in NSTs were specified. These standards were uploaded to a computer program, and the necessary infrastructure for a web-based management of accreditation processes was developed.

RESULTS

An organization applying for accreditation should fill in the application form on KEPAN website electronically. Eligibility criteria for accreditation include number of NST members, physical environment, patient monitoring requirements, research, and training. A total of 22 standards are surveyed under 13 sections. These standards contain 61 criteria. To be accredited, each of 22 standards must score >70 and each of 13 sections must score >80.

CONCLUSIONS

In order to increase the quality of nutritional care and improve patient outcomes, an accreditation program has been developed. This program principally sets the basic standards, organizational scheme, and responsibilities of NSTs.

A Potential Indicator for Assessing Patient Blood Management Standard Implementation

(1) Background: Patient blood management (PBM) program as a multidisciplinary practice and a standard of care for the anemic surgical patient has an increasingly important role in reducing transfusions and optimizing both clinical outcomes and costs. Documented success of PBM implementation is not sufficient for implementation of recommendations and correct use at hospital level. The primary objective of our study was to define a composite patient blood management process safety index-Safety Index in PBM (SIPBM)-that measures the impact of screening and treating anemic patients on the efficiency and effectiveness of the patient care process undergoing elective surgery. (2) Methods: We conducted a retrospective comparative study in a tertiary hospital by collecting data and analyzing the Safety Index in PBM (SIPBM) in patients undergoing major elective surgical procedures. (3) Results: The percentage of patients from the total of 354 patients (178 in 2019 and 176 in 2022) included in the study who benefited from preoperative iron treatment increased in 2022 compared to 2019 from 27.40% to 36.71%. The median value of the SIPBM was 1.00 in both periods analyzed, although there is a significant difference between the two periods (p < 0.005), in favor of 2022. (4) Conclusions: Measuring the effectiveness of PBM implementation and providing ongoing feedback through the Safety Index in PBM (SIPBM) increases the degree to which opportunities to improve the PBM process are identified. The study represents a first step for future actions and baselines to develop tools to measure the safety and impact of the patient blood management process in the surgical field.

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.

Patient-related healthcare disparities in the quality of acute hip fracture care: a 10-year nationwide population-based cohort study

OBJECTIVES

To characterise and quantify possible patient-related disparities in hip fracture care including temporal changes.

DESIGN

Population-based cohort study.

SETTING

All Danish hospitals treating patients with hip fracture.

PARTICIPANTS

60 275 hip fracture patients from 2007 to 2016.

INTERVENTIONS

Quality of care was defined as fulfilment of eligible care process measures for the individual patient recommended by an expert panel. Using yearly logistic regression models, we predicted the individual patient's probability for receiving high-quality care, resulting in a distribution of adjusted probabilities based on age, sex, comorbidity, fracture type, education, family mean income, migration status, cohabitation status, employment status, nursing home residence and type of municipality. Based on the distribution, we identified best-off patients (ie, the 10% of patients with the highest probability) and worst-off patients (ie, the 10% of patients with the lowest probability). We evaluated disparities in quality of care by measuring the distance in fulfilment of outcomes between the best-off and worst-off patients.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome was fulfilment of all-or-none, defined as receiving all relevant process measures. Secondary outcomes were fulfilment of the individual process measures including preoperative optimisation, early surgery, early mobilisation, assessment of pain, basic mobility, nutritional risk and need for antiosteoporotic medication, fall prevention and a postdischarge rehabilitation programme.

RESULTS

The proportion of patients receiving high-quality care varied over time for both best-off and worst-off patients. The absolute difference in percentage points between the best-off and worst-off patients for receiving all-or-none of the eligible process measures was 12 (95% CI 6 to 18) in 2007 and 23 (95% CI 19 to 28) in 2016. Disparities were consistent for a range of care processes, including assessment of pain, mobilisation within 24 hours, assessment of need for antiosteoporotic medication and nutritional risk assessment.

CONCLUSIONS

Disparity of care between best-off and worst-off patients remained substantial over time.

An appraisal of healthcare accreditation agencies and programs: similarities, differences, challenges and opportunities

BACKGROUND

The study, following similar reviews in 2000 and 2010, presents an update of knowledge about external evaluation agencies and accreditation programs.

OBJECTIVE

The study aim was to investigate the current profile of external evaluation agencies identifying their program features, and significant changes and challenges.

The impact of hospital accreditation on the quality of healthcare: a systematic literature review

BACKGROUND

Accreditation is viewed as a reputable tool to evaluate and enhance the quality of health care. However, its effect on performance and outcomes remains unclear. This review aimed to identify and analyze the evidence on the impact of hospital accreditation.

METHODS

We systematically searched electronic databases (PubMed, CINAHL, PsycINFO, EMBASE, MEDLINE (OvidSP), CDSR, CENTRAL, ScienceDirect, SSCI, RSCI, SciELO, and KCI) and other sources using relevant subject headings. We included peer-reviewed quantitative studies published over the last two decades, irrespective of its design or language. Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, two reviewers independently screened initially identified articles, reviewed the full-text of potentially relevant studies, extracted necessary data, and assessed the methodological quality of the included studies using a validated tool. The accreditation effects were synthesized and categorized thematically into six impact themes.

RESULTS

We screened a total of 17,830 studies, of which 76 empirical studies that examined the impact of accreditation met our inclusion criteria. These studies were methodologically heterogeneous. Apart from the effect of accreditation on healthcare workers and particularly on job stress, our results indicate a consistent positive effect of hospital accreditation on safety culture, process-related performance measures, efficiency, and the patient length of stay, whereas employee satisfaction, patient satisfaction and experience, and 30-day hospital readmission rate were found to be unrelated to accreditation. Paradoxical results regarding the impact of accreditation on mortality rate and healthcare-associated infections hampered drawing firm conclusions on these outcome measures.

CONCLUSION

There is reasonable evidence to support the notion that compliance with accreditation standards has multiple plausible benefits in improving the performance in the hospital setting. Despite inconclusive evidence on causality, introducing hospital accreditation schemes stimulates performance improvement and patient safety. Efforts to incentivize and modernize accreditation are recommended to move towards institutionalization and sustaining the performance gains. PROSPERO registration number CRD42020167863.

Consecutive cycles of accreditation and quality of in-hospital care: a Danish population-based study

BACKGROUND

Little is known about whether repeated cycles of hospital accreditation are a robust method to improve quality of care continuously.

OBJECTIVE

We aimed to examine the association between compliance with consecutive cycles of accreditation and quality of in-hospital care.

METHODS

We conducted a Danish nationwide population-based study including patients aged 18 years treated for acute stroke, chronic obstructive pulmonary disease, diabetes, heart failure or hip fracture at public, non-psychiatric hospitals. From 2012 to 2015, two cycles of national hospital accreditation were completed, resulting in 12 high and 14 low compliant hospitals (Low = partially accredited in both cycles). Our outcome measure was quality of in-hospital care measured by 39 process performance measures (PPMs), reflecting recommendations from the national clinical guidelines by adherence to (i) individual PPMs and (ii) the full bundle of PPMs (all-or-none). We computed adjusted odds ratios (ORs) using logistic regression based on robust standard error estimation for cluster sampling of data at hospital level.

RESULTS

In total, 78 387 patient pathways covering 508 816 processes were included, of which 47% had been delivered at high compliant hospitals and 53% at low compliant hospitals, respectively. Compliance with consecutive cycles was not associated with improved quality of in-hospital care (individual: OR = 0.92, 95% confidence interval (CI): 0.77-1.10; All-or-none: OR = 0.87, 95% CI: 0.66-1.15). However, in the second cycle alone, patients treated at partially accredited hospitals had a lower adherence than patients treated at fully accredited hospitals (Individual: OR = 0.84, 95% CI: 0.71-0.99; All-or-none: OR = 0.78, 95% CI: 0.59-1.03). The association was particularly strong among patients treated at partially accredited hospitals required to submit additional documentation.

CONCLUSION

Compliance with consecutive cycles of hospital accreditation in Denmark was not associated with improved quality of in-hospital care. However, compliance with the second cycle alone was associated with improved quality of in-hospital care.

Comparison of Major Clinical Outcomes between Accredited and Nonaccredited Hospitals for Inpatient Care of Acute Myocardial Infarction

Hospital accreditation programs are used worldwide to improve the quality of care and improve patient safety. It is of great help in improving the structure of hospitals, but there are mixed research results on improving the clinical outcome of patients. The purpose of this study was to compare the levels of core clinical outcome indicators after receiving inpatient services from accredited and nonaccredited hospitals in patients with acute myocardial infarction (AMI). For all patients with AMI admitted to general hospitals in Korea from 2010 to 2017, their 30-day mortality and readmissions and length of stay were compared according to accreditation status. In addition, through a multivariate model that controls various patients’ and hospitals’ factors, the differences in those indicators were analyzed more accurately. The 30-day mortality of patients admitted to accredited hospitals was statistically significantly lower than that of patients admitted to nonaccredited hospitals. However, for 30-day readmission and length of stay, accreditation did not appear to yield more desirable results. This study shows that when evaluating the clinical impact of hospital accreditation programs, not only the mortality but also various clinical indicators need to be included, and a more comprehensive review is needed.

Accreditation as a quality-improving policy tool: family planning, maternal health, and child health in Egypt

Accreditation of healthcare providers has been established in many high-income countries and some low- and middle-income countries as a tool to improve the quality of health care. However, the available evidence on the effectiveness of this approach is limited and of questionable quality, especially in low- and middle-income countries. We exploit the interventions introduced under Egypt's health sector reform program between 2000 and 2014 to estimate the effect of health facility accreditation on family planning, maternal health, and child health outcomes. We use difference-in-differences fixed-effects and propensity score matching difference-in-differences models. To do so, we spatially link women to their nearest mapped health facilities using their global positioning system coordinates. We find that accreditation had multiple positive effects, especially on delivery care and child morbidity prevalence. The effects appear to weaken over time though. Our findings suggest that facility accreditation can be effective in improving family planning, antenatal care, delivery care, and child health, but stress the need to study how the effects can be sustained.

Promoting patients' rights through hospital accreditation

BACKGROUND

Over the past decade, hospitals in many countries, including Israel, have undergone an accreditation process aimed at improving the quality of services provided. This process also refers to the protection and promotion of patients' rights. However, reviewing the criteria and content included in this category in the Israeli context reveals definitions and implications that differ from those presented by the law - specifically the Patient's Rights Act 1995. Moreover, the rights included in it are not necessarily equally represented in other legislation.

METHODS

This study seeks to examine the question of whether and to what extent the scope, contents, and definitions of patients' rights in the JCI Standards are similar to or different from patients' rights as they are addressed and protected in national legislation. The article provides a comparison and examination of the different regulatory frameworks of patients' rights, especially those in the accreditation of healthcare institution and legislation, analyzes the gaps between such frameworks, and suggests possible implications on our understanding of the concept of patients' rights.

RESULTS

The patients' right chapter in the accreditation process introduces and promotes the concepts of patient and family rights, increases the awareness and compliance of such concepts, and may create greater consistency in their introduction and application.

CONCLUSIONS

Discussion of the Israeli case not only demonstrates how regulatory frameworks are instrumental - for broader policy purposes, especially in the area of patients' rights and the rights of patients' families - but also calls for a more general examination of the concept of patients' rights in health policies and its contribution to the quality of health services. Reference to patients' rights in accreditation of healthcare institutions may promote and enhance this concept and contribute to the delivery of care, thereby complementing a lacuna in the law.

Association between Accreditation and In-Hospital Mortality in Patients with Major Cardiovascular Diseases in South Korean Hospitals: Pre-Post Accreditation Comparison

The direct impact of hospital accreditation on patients' clinical outcomes is unclear. The purpose of this study was to evaluate whether mortality within 30 days of hospitalization for acute myocardial infarction (AMI), ischemic stroke (IS), and hemorrhagic stroke (HS) differed before and after hospital accreditation. This study targeted patients who had been hospitalized for the three diseases at the general hospitals newly accredited by the government in 2014. Thirty-day mortality rates of three years before and after accreditation were compared. Mortality within 30 days of hospitalization for the three diseases was lower after accreditation than before (7.34% vs. 6.15% for AMI; 4.64% vs. 3.80% for IS; and 18.52% vs. 15.81% for HS). In addition, hospitals that meet the criteria of the patient care process domain have a statistically lower mortality rate than hospitals that do not. In the newly accredited Korean general hospital, it was confirmed that in-hospital mortality rates of major cardiovascular diseases were lower than before the accreditation.

Accreditation as a management tool: a national survey of hospital managers' perceptions and use of a mandatory accreditation program in Denmark

BACKGROUND

This study aimed to examine managers' attitudes towards and use of a mandatory accreditation program in Denmark, the Danish Healthcare Quality Program (Den Danske Kvalitetsmodel [DDKM]) after it was terminated in 2015.

METHODS

We designed a nationwide cross-sectional online survey of all senior and middle managers in the 31 somatic and psychiatric public hospitals in Denmark. We elicited managers' attitudes towards and use of DDKM as a management using 5-point Likert scales. Regression analysis examined differences in responses by age, years in current position, and management level.

RESULTS

The response rate was 49% with 533 of 1095 managers participating. Overall, managers' perceptions of accreditation were favorable, highlighting key findings about some of the strengths of accreditation. DDKM was found most useful for standardizing processes, improving patient safety, and clarifying responsibility in the organization. Managers were most negative about DDKM's ability to improve their hospitals' financial performance, reshape the work environment, and support the function of clinical teams. Results were generally consistent across age and management level; however, managers with greater years of experience in their position had more favorable attitudes, and there was some variation in attitudes towards and use of DDKM between regions.

CONCLUSION

Future attention should be paid to attitudes towards accreditation. Positive attitudes and the effective use of accreditation as a management tool can support the implementation of accreditation, the development of standards, overcoming disagreements and boundaries and improving future quality programs.

Hospital accreditation: Driving best outcomes through continuity of midwifery care? A scoping review

PROBLEM

Continuity of midwifery care models are the gold standard of maternity care. Despite being recommended by the Australian Health Ministers' Advisory Council, few women in Australia have access to such models.

BACKGROUND

Extensive research shows that if all women had access to continuity of midwifery care, maternal and neonatal outcomes would improve. Hospital accreditation, the main national safety and quality system in Australia, aims to encourage and enable the translation of healthcare quality and safety standards into practice.

AIM

This paper explored the realities and possibilities of a health care accreditation system driving health service re-organisation towards the provision of continuity of midwifery care for childbearing women.

METHODS

A scoping review sought literature at the macro (policy) level. From 3036 records identified, the final number of sources included was 100:73 research articles and eight expert opinion pieces/editorials from journals, 15 government/accreditation documents, three government/accreditation websites, and one thesis.

FINDINGS

Two narrative themes emerged: (1) Hospital accreditation: 'Here to stay' but no clear evidence and calls for change. (2) Measuring and implementing quality and safety in maternity care.

DISCUSSION

Regulatory frameworks drive hospitals' priorities, potentially creating conditions for change. The case for reform in the hospital accreditation system is persuasive and, in maternity services, clear. Mechanisms to actualise the required changes in maternity care are less apparent, but clearly possible.

CONCLUSIONS

Structural changes to Australia's health accreditation system are needed to prioritise, and mandate, continuity of midwifery care.