The impact of national accreditation reform on survey reliability: a 2-year investigation of survey coordinators' perspectives

The survey visit as a key evaluative event in accreditation-a qualitative study of survey visit experiences among surveyors and general practice professionals

Background

Accreditation is a widely employed quality assurance concept in health care and the survey visit is the central method for assessing participating organisations’ compliance with accreditation standards. Despite this, research on the survey visit as a method for assessing compliance is scarce. In Denmark a mandatory accreditation programme was introduced for general practice clinics in 2016. We performed a qualitative, explorative study of the reflections and actions of surveyors and general practice professionals (GPs and staff) concerning the production of information about compliance with the accreditation standards in relation to the survey visit.

Methods

We conducted qualitative interviews with GPs and staff from general practices in two Danish regions before and after their survey visit. We also interviewed the surveyors. We observed survey visits to qualify the interviews and analysis. All interviews were audio recorded, transcribed, and analysed using an integrative approach.

Results

The surveyors combined documents, questioning of the professionals, and visual impressions of the clinic to assess compliance. They sought to de-dramatise the survey visit and to generate a natural conversation with attention to workflows. Trust in the professionals’ statements was fundamental to the surveyors’ approach, and they were confident in their ability to assess compliance. Their level of scrutiny was influenced by their observations and the quality of documents. The general practice professionals had generally sought to comply with the standards and to give an authentic portrait of the clinic. The few cases of misrepresention concerned standards that the professionals found too excessive.

Conclusion

The validity of the survey visit as a method to assess compliance was highly dependent on the professionals’ willingness to convey a realistic picture of their practice. Since they were generally willing to do so, the trust-based approach seemed suitable for identifying cases of non-compliance caused by insufficient understanding of the standards. However, it can be difficult for the surveyors to detect when the professionals engage in misrepresentation due to disagreements with the standards. Thus, when adopting a trust-based approach to the survey visit, it seems particularly important to ensure that the professionals view the standards as meaningful and manageable.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12875-021-01497-7.

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.

Mediators of change in healthcare organisations subject to external assessment: a systematic review with narrative synthesis

OBJECTIVES

External inspections are widely used to improve the quality of care. The effects of inspections remain unclear and little is known about how they may work. We conducted a narrative synthesis of research literature to identify mediators of change in healthcare organisations subject to external inspections.

METHODS

We performed a literature search (1980-January 2020) to identify empirical studies addressing change in healthcare organisations subject to external inspection. Guided by the Consolidated Framework for Implementation Research, we performed a narrative synthesis to identify mediators of change.

RESULTS

We included 95 studies. Accreditation was the most frequent type of inspection (n=68), followed by statutory inspections (n=19), and external peer review (n=9). Our findings suggest that the regulatory context in which the inspections take place affect how they are acted on by those being inspected. The way inspections are conducted seem to be critical for how the inspection findings are perceived and followed up. Inspections can engage and involve staff, facilitate leader engagement, improve communication and enable the creation of new networks for reflection on clinical practice. Inspections can contribute to creating an awareness of the inspected organisation's current practice and performance gaps, and a commitment to change. Moreover, they can contribute to facilitating the planning and implementation of change, as well as self-evaluation and the use of data to evaluate performance.

CONCLUSIONS

External inspections can affect different mediators of organisational change. The way and to what extent they do depend on a range of factors related to the outer setting, the way inspections are conducted and how they are perceived and acted on by the inspected organisation. To improve the quality of care, the organisational change processes need to involve and impact the way care is delivered to the patients.

Options to enhance the veracity of Australian health service accreditation assessments

Background:

Assessment processes applied within some health service accreditation programs have been criticised at times for being inaccurate, inconsistent or inefficient. Such criticism has inspired the development of innovative assessment methods.

Objective:

The Australian Commission on Safety and Quality in Health Care considered the use of three such methods: short-notice or unannounced methods; patient journey or tracer methods; and attestation by governing bodies.

Method:

A systematic search and synthesis of published peer-reviewed and grey literature associated with these methods.

Results and Conclusion:

The published literature demonstrates that the likely benefits of these three assessment methods warrant further evaluation, real-world trials and stakeholder consultation to determine the most appropriate models to introduce into national accreditation programs.

Implications:

The subsequent introduction of models of short-notice assessments and attestation by governing bodies into the Australian Health Service Safety and Quality Accreditation Scheme in January 2019 demonstrates how the findings presented in this article influenced the national change in assessment practice, providing an example of evidence-informed accreditation development.

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

Objective

To examine the association between compliance with consecutive cycles of accreditation and patient-related outcomes.

Design

A Danish nationwide population-based study from 2012 to 2015.

Setting

In-patients admitted with one of the 80 diagnoses at public, non-psychiatric hospitals.

Participants

In-patients admitted with one of 80 primary diagnoses which accounted for 80% of all deaths occuring within 30 dyas after admission.

Intervention

Admission to a hospital with high (n = 125 485 in-patients) or low compliance (n = 152 074 in-patients) in both cycles of accreditation by the Danish Healthcare Quality Programme.

Main outcome measures

A 30-day mortality, length of stay (LOS) and all-cause acute readmission. We computed adjusted odds ratios (OR) and hazard ratios (HR) using logistic and Cox Proportional Hazard regression including adjustment for six potential patient-related confounders.

Results

The 30-day mortality risk for in-patients admitted at high compliant hospitals was 3.95% (95% confidence interval (CI): 3.84-4.06) and 4.39% (95% CI: 4.29-4.49) at low compliant hospitals. In-patients admitted at low compliant hospitals had a substantially higher risk of dying within 30-day after admission (adjusted OR: 1.26 (95% CI: 1.11-1.43) and a longer LOS (adjusted HR of discharge: 0.89 (95% CI: 0.82-0.95) than in-patients at high compliant hospitals. No difference was seen for acute readmission (adjusted HR: 0.98 (95% CI: 0.90-1.06)). Focusing on the second cycle alone, in-patients at partially accredited hospitals had a higher 30-day mortality risk and longer LOS than admissions at fully accredited hospitals (30-day: adjusted OR: 1.12 (95% CI: 1.02-1.24) and LOS: adjusted HR: 0.91 (95% CI: 0.84-0.98)).

Conclusion

Persistent low compliance with the DDKM (in Danish: Den Danske Kvalitetsmodel) accreditation was associated with higher 30-day mortality and longer LOS.

Comparing the old to the new: A comparison of similarities and differences of the accreditation standards of the chiropractic council on education-international from 2010 to 2016

Background

Chiropractic programs are accredited and monitored by regional Councils on Chiropractic Education (CCE). The CCE-International has historically been a federation of regional CCEs charged with harmonising world standards to produce quality chiropractic educational programs. The standards for accreditation periodically undergo revision. We conducted a comparison of the CCE-International 2016 Accreditation Standards with the previous version, looking for similarities and differences, expecting to see some improvements.

Method

The CCE-International current (2016) and previous versions (2010) were located and downloaded. Word counts were conducted for words thought to reflect content and differences between standards. These were tabulated to identify similarities and differences. Interpretation was made independently followed by discussion between two researchers.

Results

The 2016 standards were nearly 3 times larger than the previous standards. The 2016 standards were created by mapping and selection of common themes from member CCEs' accreditation standards and not through an evidence-based approach to the development and trialling of accreditation standards before implementation. In 2010 chiropractors were expected to provide attention to the relationship between the structural and neurological aspects of the body in health and disease. In 2016 they should manage mechanical disorders of the musculoskeletal system. Many similarities between the old and the new standards were found. Additions in 2016 included a hybrid model of accreditation founded on outcomes-based assessment of education and quality improvement. Both include comprehensive competencies for a broader role in public health. Omissions included minimal faculty qualifications and the requirement that students should be able to critically appraise scientific and clinical knowledge. Another omission was the requirement for chiropractic programs to be part of a not-for-profit educational entity. There was no mention of evidence-based practice in either standards but the word 'evidence-informed' appeared once in the 2016 standards.

Conclusions

Some positive changes have taken place, such as having bravely moved towards the musculoskeletal model, but on the negative side, the requirement to produce graduates skilled at dealing with scientific texts has been removed. A more robust development approach including better transparency is needed before implementation of CCE standards and evidence-based concepts should be integrated in the programs. The CCE-International should consider the creation of a recognition of excellence in educational programs and not merely propose minimal standards.