Operational Analysis And Quality Improvement • Nursing Area

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Define accreditation
Explain the difference between accreditation and licensure
Describe the history of accreditation in the United States
Outline the current and future challenges with accreditation
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CHAPTER18Accreditation:AGlobalRegulatoryMechanismtoPromoteQualityandSafety

DavidGreenfield,MarjoriePawsey,andJeffreyBraithwaite

Whathaseludedusthusfar,however,ismaintainingconsistentlyhighlevelsofsafetyandqualityovertimeandacrossallhealthcareservices andsettings.

ChassinandLoeb(2011,p.562)

Theaccreditationofhealthcareorganizationsisaregulatorymechanismusedinmanycountriesaroundtheworld.Accreditationisanimportant strategybywhichimprovementsinqualityandsafetyhavebeenadvocatedandinstitutionalized.Thepurposeofthischapteristoprovidean overviewofaccreditationofhealthorganizations.Thechapterhasfivesections.Thefirstsectionconsidersthepurposeofaccreditation,notingthat ithasbecomeaglobalphenomenonfoundinmanyindustriesandsectorsofhealthcare.Thesecondsectiondiscussestheextentofthe accreditationofhealthorganizations,thematuringofaccreditation513514programphilosophyfromqualityassurancetoqualityimprovement,and theselfgoverningsystemthathasbeendeveloped.Thethirdsectionexploresthecommonalitiesanddifferencesinaccreditationprograms,where increasinglyacommonmodelofaccreditationisenactedbutwithvariationinstandards.Theevidencebaseforaccreditationisexaminedinthe fourthsection.Finally,thefifthsectionconsiderstheissuesandchallengesforaccreditationstakeholders.

ANOVERVIEWOFACCREDITATION WhatIsAccreditation?

Accreditationistheformaldeclarationbyadesignatedauthoritythatanorganization,service,orindividualhasdemonstratedcompetency, authority,orcredibilitytomeetapredeterminedsetofstandards.Accreditationisamechanismthatseekstoreassureexternalstakeholdersthat qualityandsafetystandardsaredemonstrated.Asecondaryandmorerecentgoalinsomeapplications,notablyhealthcare,istoprovideabasisfor qualityimprovementinitiatives(Davisetal.,2009Gibberdetal.,2004Williamsetal.,2005).Theshifttoaccreditation,notablyfromthe1970s onward,isrepresentativeofashiftinphilosophybygovernmentswherebytheyhavesoughttoprovideaframeworkforthegovernanceof servicesratherthantoprovidethoseservicesthemselves.Throughaccreditationandotherregulationstrategies,governmentshavesought abatementorcontrolofriskstosocietybyindirectmeans(Sparrow,2000).

Accreditationhasbecomeaubiquitouspartofourmodernworld.Forexample,itcanapplytoanyofthefollowing:

Industries,includingorganicfood(Gabriel,2007),tourism(AustralianGovernment,2010),andtelecommunicationsservices(Associationof TeleServicesInternational,2010) Institutions,includingeducation(Stimson,2003)andhealth(AustralianCouncilonHealthcareStandards[ACHS],2007a)organizations Products,includingautomobiles(CasperandHancke,1999)andsoftware(JonesandPrice,2002) 514515 Systems,includingmanagementsystems(CasileandDavisBlake,2002)andlaboratoryprocesses(GoughandReynolds,2000) Individuals,includinghealthprofessionals(AustraliasHealthWorkforceOnline,2008),statisticians(StatisticalSocietyofAustralia,2009),and builders(GreenBuildingCertificateInstitute,2010) ACCREDITATIONINTHEHEALTHCAREINDUSTRY

Accreditationisfoundextensivelyinhealthcareindustriesaroundtheworld.Accreditationisanelementinanetworkofactivitiesthatseeksto regulateconductinthehealthsector.Healthorganizations,andindividualprofessionals,arenetworkedtogether,andtheirbehaviorisassessedby independentbodiesthroughaccreditationprograms,standards,andqualityindicators.Regulationviathisnetworkhasbeencallednodal governance(ShearingandWood,2003)thatis,organizations,services,andprofessionalbehaviorinhealthcareareshapedbyanincreasing varietyofgovernmentandnongovernmentbodiesrelatedtobutindependentofeachother.

Healthcareorganizationsareaccreditedforthemanagementandprovisionoftheirservices,includinghospitals,generalpractices,geriatriccare facilities,andpublichealth(ACHS,2007aTheJointCommission[TJC],2010SimoneandEpstein,2009).Withinhealthorganizations, specializedhealthservicescanbeaccredited,suchastissuebanks(AmericanAssociationofTissueBanks,2009),pharmacies(AmericanCollege ofHealthSystemPharmacists,2006),andaeromedicaltransportationservices(AssociationofAirMedicalServices,2010).Additionally, individualprofessionalsfrommedical(AmericanAcademyofNeurology,2010),nursing(AmericanAcademyofNursePractitioners,2010),and alliedhealth(AmericanPhysicalTherapyAssociation,2009CouncilonPodiatricMedicalEducation,2010)fields,andadministrators,including medicaladministrators(AmericanAcademyofMedicalAdministrators,2010),areincreasinglyrequiredtobecertified.Giventhebreadthand complexityoftheaccreditationmeasuresinthehealthcareindustry,thischaptertakesasitsfocustheaccreditationofhealthorganizations.

515516 TheSelfGoverningSystemofAccreditationofHealthOrganizations

AccreditationinhealthwasfirstinitiatedintheUnitedStatesthroughtheworkoftheAmericanCollegeofSurgeons,whichin1917developedthe MinimumStandardsforHospitals.ThisorganizationsubsequentlycollaboratedwithcollegesandassociationsfromtheUnitedStatesand Canadatocreate,in1951,theJointCommissiononAccreditationofHospitals(ViswanathanandSalmon,2000),whichisnowreferredtoasThe JointCommission(TJC).Fromthisbeginning,accreditationhasspreadtobepracticedacrosstheworld.Afewfigureshighlighttheglobalextent andreachofaccreditation.Accreditationisnowpracticedinmorethan70countries.Thereare22nationalbodiesandaninternationalagency,the InternationalSocietyforQualityinHealthCare(ISQua),thatarefocusedontheissue(GreenfieldandBraithwaite,2008).IntheUnitedStates, TJCaccreditsmorethan4,000organizations,or82%ofthehospitalsinthecountry(2010).TheHauteAutoritdeSant(HAS)accreditsallacute healthcareorganizationsinFrance,whichtotalmorethan700hospitals(TouatiandPomey,2009).AccreditationCanada(2008)andtheACHS (2007a)eachaccreditmorethan1,000organizationsintheirrespectivecountries.These,andmanyothermajorinternationalhealthcare accreditationagencies,areindependent,notforprofit,nongovernmentagencies.

Accreditationagenciesassessorganizationsandservicesagainststandards,anddevelopandsupervisepeerreviewerstomaintainasurveyor workforce.Additionally,someaccreditationagenciessetandrevisetheirownstandards.Accreditationinvolvesassessmentagainstminimum standardsandmorerecentlyhasevolved,asaresultofhigherqualityandsafetyexpectations,tobeadevelopmentalprocesspromotingcontinuous qualityimprovement(CudneyandReinbold,2002ParsonsandRiley,2009).ThiscurrenttrendisespeciallynotableinpublichealthintheUnited

States(ParsonsandRiley,2009).Thismodelofaccreditationisreflectiveofpracticeinmanycountries,including,forexample,intheUnited

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States(ParsonsandRiley,2009).Thismodelofaccreditationisreflectiveofpracticeinmanycountries,including,forexample,intheUnited States(ViswanathanandSalmon,2000),Australia(Greenfield,Braithwaite,etal.,2008),Canada(TouatiandPomey,2009),France(Pomeyetal., 2004),andLebanon(ElJardalietal.,2008).

Accreditationprogramsintheirinitialphasetypicallyfocusedonstandardsaimedatthestructuresandprocessesoforganizations.Asprograms 516517havematured,andnewoneshaveemerged,attentionhasshiftedsothatorganizationshavebeenincreasinglyrequiredtodemonstratethat inadditiontohavingstructuresandprocessesinplacetheyarefunctioningeffectively.Thatis,therehasbeenaphilosophicalshiftfromquality assurancetoqualityimprovement.Theformerisregardedasaprogramthatstrivestoimprovequalitythroughdefiningandmeasuringit (Silimperietal.,2002).Thelatterincorporatesbothretrospectiveandprospectiveassessmentsandisaimedatdevelopingstrategiestomakethings betterandtocreatesystemstopreventerrors(McLaughlinandKaluzny,2006ParsonsandRiley,2009).Insimpleterms,qualityimprovement involveshealthprofessionalsconstantlyaskingthemselvesDespitehavingtherightthingsinplacetodotherightthings,whatarewedoing nowthatwecandobetter?Furthermore,accreditationisaboutansweringthequestionposedbyexternalassessors:Whatsystemshaveyou implemented,howdotheywork,andcanyoushowmehowyouareplanningtodothingsbetter?

Theshiftcanbeillustratedbyanexampleconcerningpatientsatisfactionsurveys.Anaccreditationprogrampromotingaqualityassurance approachwouldfocusonapatientsatisfactionsurveyandhowitisdevelopedandadministered.Incontrast,anaccreditationprogramwitha qualityimprovementphilosophywouldfocusontheresponserateofthesurveys,theissuesidentifiedbythepatients,theorganizationsactions, andconfirmationofimprovementinsubsequentsurveys.

Whilethecontinuousqualityimprovementmodelisthedominantaccreditationmodelforhealthcareorganizations,thereisanalternative,more genericmodelthatcanbedescribedasanauditmodel.Inthismodel,anexternalreviewer,withorwithouthealthcareexperience,usesageneric setofqualitystandardstoassessthepresenceorabsenceoforganizationalqualityactivities.ThismodelisendorsedbytheInternational OrganizationforStandardization,whichaccreditsorganizationsinmanydiverseindustries,includinghealth(seehttp://www.iso.org).

Thereareexternalandinternalmotivationsthatdrivehealthcareorganizationstoseekaccreditation(GreenfieldandBraithwaite,2007).External motivationcomesfromgovernments,insurers,andconsumersrequiringthatorganizationsundertakeeffortsthatdemonstrateoutcomesthat advancehighqualityandsaferhealthcare(AccreditationCanada,2009ACHS,2007bElJardalietal.,2008HAS,2008bTJC,2010). 517518Theinternalimpetuscomesfromstaffwhomakeupthehealthorganizations.Theyreportadesiretoimprovetheirservicesandthecare theyprovide(GreenfieldandBraithwaite,2007).Togetherthesetwomotivations,whicharemutuallyreinforcing,havecombinedtodrawmany healthcareorganizationsundertheumbrellaofaccreditation.

Accreditationagencies,involvingmanyoftheirstakeholders,haveconstructedaselfgoverningsystem(Greenfield,Pawsey,Naylor,etal., 2009a).Itisasystemresponsivetotheconductandcultureofthosebeingregulatedthisapproachhasbeenlabeledresponsiveregulation (Braithwaiteetal.,2005).Thesystemseekstoinfluencetheattitudesandpracticesofthoseinvolved,whethertheyareintheroleofaccreditation agencypersonnel,surveyors,orhealthstaff,inanorganizationbeingaccredited.Throughparticipationinthedevelopmentofaccreditation programsortheaccreditingofhealthcareorganizations,acommonunderstandingofstandardsandsharedexpectationsisconstructed. Additionally,participantsregulatetheirownandothercolleaguesbehaviorstocomplywiththestandardsandexpectations.Thesystemcombines internalassessment,orselfregulation,withselfdirectedimprovementstrategiesoverseenbyexternalpeerreview.Itisaculturalcontrolstrategy whoseinfluenceissignificantonthosedirectlyinvolved(Greenfield,Pawsey,Naylor,etal.,2009a).Thosehealthprofessionalswhoparticipatein theirorganizationsaccreditationactivitiesgenerallyreportimprovementstoqualityandsafety.However,asrecentresearchhasshown,the influenceofaccreditationcanwaneasparticipationintheprogramdeclines(Paccionietal.,2008).Healthprofessionalsnotdirectlyinvolvedin theirorganizationsaccreditationactivitiesareknowntoremainskepticalaboutthepurpose,value,andbenefitsoftheprogram.Theyquestionthe bureaucraticandtimeconsumingactivitiesassociatedwithanaccreditationprogram.

ISQuapromotesselfgovernancethroughtheiraccreditingofaccreditationagencies.Thatis,ISQuaprovidesguidelines,support,andassessment ofaccreditationandsurveyortrainingprograms(seehttp://www.isqua.org).Furthermore,theselfgovernancemodalityisreinforcedthrough ISQuasencouragementofparticipationinitsorganizationandtheinternationalhealthqualityandsafetyconferencesitconvenes.Consequently, theworkofISQuahasevokedaninternationalconvergenceofunderstandingabout,andsimilarityintheenactmentof,healthaccreditation programs.

518519 COMMONALITIESANDDIFFERENCESINTHEACCREDITATIONMODEL TheAccreditationModel

Acommonmodelofaccreditationisenactedbymanyhealthaccreditationagencies(AccreditationCanada,2009ACHS,2007bTJC,2010).A breakdownoftheprocesstypicallyinvolvedinthismodelisasfollows.Anorganizationseekingtobeaccrediteddevelops,implements,and continuouslyreviewsitsqualityimprovementplanandselfassessesprogressagainstthestandardsoftheaccreditationprogram.Itconcludesthis taskbyprovidingawrittenselfassessmentreporttotheaccreditingagency.Theaccreditingagencyassessestheorganizationsreportand dispatchesanaccreditationsurveyteam,comprisedofpeerreviewers,tovisitandassesstheorganizationonsite.Thevisitcomprisesobservations offacilities,interviewswithstaff,andareviewofdocumentation.Thesurveyteamduringandattheconclusionofthesurveyprovidesverbal feedbacktotheorganization.Theaccreditingagencyreceivesawrittenreportfromthesurveyteamashorttimeafterthevisit.Thereport summarizesthesurveyteamsassessmentoftheorganizationsprogressinachievingthestandardsandmakesrecommendationsor commendationsasappropriate.Followingthecorrectionofanyerrorsoffactbytheorganization,thereportisthenconsideredbytheaccrediting agency.Theagencyassessesthereportanddecideswhethertoawardaccreditationstatusornot.Accreditationisforadefinedperiod,depending ontheprogram,andtypicallyfor3to5years.Itiscommonforaccreditingagenciestosendsurveyteamstoreassessanorganizationduringthe accreditationperiod.Thesurveyteamreviewstheorganizationscontinualprogressagainsttheupdatedqualityplanandaccreditationstandards. Thesurveyorsprovideverbalfeedback,and,afterendorsementbytheaccreditingagency,awrittenreportisprovidedtotheorganization.The improvementcyclecontinues,withtheorganizationusingthereporttoinitiatefurtherreflectionandexaminationofitsstructures,processes,and practicestoidentifyanddriveareasforongoingimprovement.

AccreditationStandards

Accreditingagenciesareresponsibleforthedevelopmentandrevisionofstandards.Itiscommonforagenciestodevelopstandardsusing 519520representativesdrawnfromthehealthindustry.Forexample,intheUnitedStates(TJC,2010),Canada(AccreditationCanada,2009), France(HAS,2008a),andAustralia(ACHS,2007b),standardsaredevelopedthroughconsultationwithawiderangeofstakeholders,including combinationsofhealthcareexperts,researchers,representativesfromindustrygroups,consumers,andgovernmentalagencies.Thenumberand statusofstandardsvaryfromaccreditationprogramtoprogram.Forexample,theU.S.PublicHealthAccreditationBoardprogramhas32 standards(ParsonsandRiley,2009).Fortheaccreditationofhospitals,AccreditationCanadauses30standards(AccreditationCanada,2009),and

HAS,theFrenchaccreditationagency,hasonly13standards,orprioritypractices,astheyarecalled(HAS,2008a).ACHS,fromAustralia,has

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HAS,theFrenchaccreditationagency,hasonly13standards,orprioritypractices,astheyarecalled(HAS,2008a).ACHS,fromAustralia,has 43standardsinitsprogram,ofwhich19aremandatoryand24arenonmandatory(ACHS,2007b).IntheACHSprogram,failuretomeetthe requirementsofamandatorystandardwillresultinanorganizationnotbeingaccredited.However,anorganizationmaybeassessedasmeeting mandatorystandardsbutnotmeetinganonmandatorystandardandstillbeconferredaccreditationstatus.

Accreditationstandardscoverinfrastructure,organizational,service,andcontinuumofpatientcareissues(GreenfieldandBraithwaite,2007HAS, 2008a).Standardsarefocusedonorganizationalprocessesandsystemsandtheavailabilityofappropriateresourcesfortheorganizationtodeliver thedefinedservices.Accreditingagenciesareincreasinglyexaminingstrategiestoexpandstandardstoincorporateorganizationalperformanceand clinicalmeasures(AccreditationCanada,2009ACHS,2007aHAS,2008bTJC,2009).AccreditationCanada,withtheintroductionofitsnew accreditationprogramQmentum,hasintroducedperformancemeasurestostrengthentherigorandobjectivityoftheaccreditationprocess (AccreditationCanada,2009).Themeasuresareusedtodirectsurveyorstoexamineparticularpartsofanorganizationrequiringcloseassessment.

Alternatively,outcomemeasuresarebeingreporteduponseparatelytoaccreditationsurveys.Accreditationagenciesareproducingreportsof organizationalandclinicalcompliancewithexpectedguidelinestoraiseawarenessacrosstheindustry.Forexample,intheUnitedStates,since 2006,theTJChastrackedandreporteduponqualityofcaremeasures(TJC,2009).Theseitemsareevidencebased,standardized,national measuresthatallowcomparisonsacrossorganizations.Currently,TJCis520521reportingon31measures,withdatadrawnfrommorethan3,000 accreditedhospitals.Inparticular,thereportdocuments,overthelast7years,increasedqualityperformanceresultsforheartattack,heartfailure, andpneumoniacare.Overshortertimeperiods,therehavebeenimprovementsonindividualsurgicalcareperformancemeasures(last2years), individualheartattack(last3years),andpneumoniacare(last4years)measures.Similarly,1yearofmeasurementshowsveryhighcompliance, morethan99%,ontwoindividualmeasuresofqualityrelatingtoinpatientcareforchildhoodasthma.Twomeasureswereidentifiedasproblematic formanyorganizations:Providingfibrinolytictherapytoheartattackpatientswithin30minutesofarrivalwasachievedbyjustover50%of hospitals,andonly60%providedantibioticstointensivecareunitpneumoniapatientswithin24hoursofarrival.Consequently,thereportnotes thatimprovementisstillneeded,andthereremainsunacceptablevariationbetweenorganizations.

Astheseexamplesdemonstrate,theuseofqualityofcaremeasuresinaccreditationsurveysandthepublicationofcompliancereportsarestrategies bywhichaccreditationagenciesareworkingwithhealthorganizationstoassess,measure,andimprovetheircare.Theiruseformspartofthe systemofselfgovernancewithinandacrosshealthorganizations.

THEEVIDENCEBASEFORTHEACCREDITATIONOFHEALTHORGANIZATIONS

Whiletheaccreditationofhealthserviceshasexpandedacrosstheworld,totheextentthatitisnowundertakeninmorecountriesandcoversmore healthsettingsthaneverbefore,theevidencebaseremainsunderdeveloped.Thereisapressingneedforincreasedresearch,transparency,and innovationintoaccreditation(GreenfieldandBraithwaite,2009).Thisisnotanewdevelopment,withcallshavingbeenmadeoveranumberof yearsforincreasedresearchintoaccreditation(Fernandopulleetal.,2003vretveitandGustafson,2003Shaw,2001).Whatisnewisthat accreditationagenciesarereportedlyundertakingresearchstudiesandprograms.Forexample,inthelastfewyears,substantialresearchefforts havebeencommencedbytheHAS,TJC,AccreditationCanada,theACHS,theItalianSocietyforQualityofHealthCare,theIrish521522Health ServicesAccreditationBoard,andtheSpanishaccreditingagencyFundacinAvedisDonabedian.Whatremainsunclearishowtransparentthe accreditationagencieswillbewiththeirresults(GreenfieldandBraithwaite,2009).

SystematicReviewoftheAccreditationResearchLiterature

Asystematicreviewoftheaccreditationresearchliteraturewaspublishedin2008(GreenfieldandBraithwaite,2008).Thereviewinitially identifiednearly34,000itemsofliteratureassociatedwithaccreditationandaccreditingagencies.Byfocusingonsubstantivework,thesamplewas reducedtojustover3,000,lessthan11%oftheoriginalsearch.Subsequentanalysisoftheabstractsidentifiedthatthevastmajoritywere discussionorcommentarypapers.Therewere66empiricalresearcharticlesidentifiedforthereview.Thestudieswereanalyzedandgrouped under10headings.TheassessmentoftheaccumulativefindingsforeachcategoryispresentedinTable181.

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