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Systematic review

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External inspection of compliance with standards for improved healthcare outcomes

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Journal Cochrane Database of Systematic Reviews
Year 2016
Links Pubmed DOI PubMed Central

This article is included in 2 Broad syntheses 2 Broad syntheses (2 references)

This article includes 2 Primary studies 2 Primary studies (2 references)

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Background: Inspection systems are used in healthcare to promote quality improvements (i.e. to achieve changes in organisational structures or processes, healthcare provider behaviour and patient outcomes). These systems are based on the assumption that externally promoted adherence to evidence-based standards (through inspection/assessment) will result in higher quality of healthcare. However, the benefits of external inspection in terms of organisational-, provider- and patient-level outcomes are not clear. This is the first update of the original Cochrane review, published in 2011. Objectives: To evaluate the effectiveness of external inspection of compliance with standards in improving healthcare organisation behaviour, healthcare professional behaviour and patient outcomes. Search methods: We searched the following electronic databases for studies up to 1 June 2015: the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, Database of Abstracts of Reviews of Effectiveness, HMIC, ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform. There was no language restriction and we included studies regardless of publication status. We also searched the reference lists of included studies and contacted authors of relevant papers, accreditation bodies and the International Organization for Standardization (ISO), regarding any further published or unpublished work. We also searched an online database of systematic reviews (PDQ-evidence.org). Selection criteria: We included randomised controlled trials (RCTs), non-randomised trials (NRCTs), interrupted time series (ITSs) and controlled before-after studies (CBAs) evaluating the effect of external inspection against external standards on healthcare organisation change, healthcare professional behaviour or patient outcomes in hospitals, primary healthcare organisations and other community-based healthcare organisations. Data collection and analysis: Two review authors independently applied eligibility criteria, extracted data and assessed the risk of bias of each included study. Since meta-analysis was not possible, we produced a narrative results summary. We used the GRADE tool to assess the certainty of the evidence. Main results: We did not identify any new eligible studies in this update. One cluster RCT involving 20 South African public hospitals and one ITS involving all acute hospital trusts in England, met the inclusion criteria. A trust is a National Health Service hospital which has opted to withdraw from local authority control and be managed by a trust instead. The cluster RCT reported mixed effects of external inspection on compliance with COHSASA (Council for Health Services Accreditation for South Africa) accreditation standards and eight indicators of hospital quality. Improved total compliance score with COHSASA accreditation standards was reported for 21/28 service elements: mean intervention effect was 30% (95% confidence interval (CI) 23% to 37%) (P < 0.001). The score increased from 48% to 78% in intervention hospitals, while remaining the same in control hospitals (43%). The median intervention effect for the indicators of hospital quality of care was 2.4% (range -1.9% to +11.8%). The ITS study evaluated compliance with policies to address healthcare-acquired infections and reported a mean reduction in MRSA (methicillin-resistant Staphylococcus aureus) infection rates of 100 cases per quarter (95% CI -221.0 to 21.5, P = 0.096) at three months' follow-up and an increase of 70 cases per quarter (95% CI -250.5 to 391.0; P = 0.632) at 24 months' follow-up. Regression analysis showed similar MRSA rates before and after the external inspection (difference in slope 24.27, 95% CI -10.4 to 58.9; P = 0.147). Neither included study reported data on unanticipated/adverse consequences or economic outcomes. The cluster RCT reported mainly outcomes related to healthcare organisation change, and no patient reported outcomes other than patient satisfaction. The certainty of the included evidence from both studies was very low. It is uncertain whether external inspection accreditation programmes lead to improved compliance with accreditation standards. It is also uncertain if external inspection infection programmes lead to improved compliance with standards, and if this in turn influences healthcare-acquired MRSA infection rates. Authors' conclusions: The review highlights the paucity of high-quality controlled evaluations of the effectiveness and the cost-effectiveness of external inspection systems. If policy makers wish to understand the effectiveness of this type of intervention better, there needs to be further studies across a range of settings and contexts and studies reporting outcomes important to patients. © 2016 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

Systematic review

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A systematic review of hospital accreditation: the challenges of measuring complex intervention effects

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Journal BMC health services research
Year 2015
Links Pubmed DOI PubMed Central

This article is included in 1 Broad synthesis 1 Broad syntheses (1 reference)

This article includes 1 Primary study 1 Primary studies (1 reference)

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BACKGROUND: The increased international focus on improving patient outcomes, safety and quality of care has led stakeholders, policy makers and healthcare provider organizations to adopt standardized processes for evaluating healthcare organizations. Accreditation and certification have been proposed as interventions to support patient safety and high quality healthcare. Guidelines recommend accreditation but are cautious about the evidence, judged as inconclusive. The push for accreditation continues despite sparse evidence to support its efficiency or effectiveness. METHODS: We searched MEDLINE, EMBASE and The Cochrane Library using Medical Subject Headings (MeSH) indexes and keyword searches in any language. Studies were assessed using the Cochrane Risk of Bias Tool and AMSTAR framework. 915 abstracts were screened and 20 papers were reviewed in full in January 2013. Inclusion criteria included studies addressing the effect of hospital accreditation and certification using systematic reviews, randomized controlled trials, observational studies with a control group, or interrupted time series. Outcomes included both clinical outcomes and process measures. An updated literature search in July 2014 identified no new studies. RESULTS: The literature review uncovered three systematic reviews and one randomized controlled trial. The lone study assessed the effects of accreditation on hospital outcomes and reported inconsistent results. Excluded studies were reviewed and their findings summarized. CONCLUSION: Accreditation continues to grow internationally but due to scant evidence, no conclusions could be reached to support its effectiveness. Our review did not find evidence to support accreditation and certification of hospitals being linked to measurable changes in quality of care as measured by quality metrics and standards. Most studies did not report intervention context, implementation, or cost. This might reflect the challenges in assessing complex, heterogeneous interventions such as accreditation and certification. It is also may be magnified by the impact of how accreditation is managed and executed, and the varied financial and organizational healthcare constraints. The strategies hospitals should impelment to improve patient safety and organizational outcomes related to accreditation and certification components remains unclear.

Systematic review

Unclassified

Factors affecting implementation of accreditation programmes and the impact of the accreditation process on quality improvement in hospitals: a SWOT analysis.

Journal Hong Kong medical journal = Xianggang yi xue za zhi / Hong Kong Academy of Medicine
Year 2013
Links Pubmed DOI

This article is included in 1 Broad synthesis 24 Broad syntheses (1 reference)

This article includes 24 Primary studies 24 Primary studies (24 references)

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OBJECTIVES: The objectives of this review were to identify factors that influence implementation of hospital accreditation programmes and to assess the impact of the accreditation process on quality improvement in public hospitals. DATA SOURCES: Two electronic databases, Medline (OvidSP) and PubMed, were systematically searched. STUDY SELECTION: "Public hospital", "hospital accreditation", and "quality improvement" were used as the search terms. A total of 348 citations were initially identified. After critical appraisal and study selection, 26 articles were included in the review. DATA EXTRACTION: The data were extracted and analysed using a SWOT (strengths, weaknesses, opportunities, threats) analysis. DATA SYNTHESIS: Increased staff engagement and communication, multidisciplinary team building, positive changes in organisational culture, and enhanced leadership and staff awareness of continuous quality improvement were identified as strengths. Weaknesses included organisational resistance to change, increased staff workload, lack of awareness about continuous quality improvement, insufficient staff training and support for continuous quality improvement, lack of applicable accreditation standards for local use, and lack of performance outcome measures. Opportunities included identification of improvement areas, enhanced patient safety, additional funding, public recognition, and market advantage. Threats included opportunistic behaviours, funding cuts, lack of incentives for participation, and a regulatory approach to mandatory participation. CONCLUSIONS: By relating the findings to the operational issues of accreditation, this review discussed the implications for successful implementation and how accreditation may drive quality improvement. These findings have implications for various stakeholders (government, the public, patients and health care providers), when it comes to embarking on accreditation exercises.

Systematic review

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Prevalence and nature of medication administration errors in health care settings: a systematic review of direct observational evidence.

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Journal The Annals of pharmacotherapy
Year 2013
Links Pubmed DOI

This article includes 62 Primary studies 62 Primary studies (62 references)

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OBJECTIVE: To systematically review empirical evidence on the prevalence and nature of medication administration errors (MAEs) in health care settings. DATA SOURCES: Ten electronic databases (MEDLINE, EMBASE, International Pharmaceutical Abstracts, Scopus, Applied Social Sciences Index and Abstracts, PsycINFO, Cochrane Reviews and Trials, British Nursing Index, Cumulative Index to Nursing and Allied Health Literature, and Health Management Information Consortium) were searched (1985-May 2012). STUDY SELECTION AND DATA EXTRACTION: English-language publications reporting MAE data using the direct observation method were included, providing an error rate could be determined. Reference lists of all included articles were screened for additional studies. DATA SYNTHESIS: In all, 91 unique studies were included. The median error rate (interquartile range) was 19.6% (8.6-28.3%) of total opportunities for error including wrong-time errors and 8.0% (5.1-10.9%) without timing errors, when each dose could be considered only correct or incorrect. The median rate of error when more than 1 error could be counted per dose was 25.6% (20.8-41.7%) and 20.7% (9.7-30.3%), excluding wrong-time errors. A higher median MAE rate was observed for the intravenous route (53.3% excluding timing errors (IQR 26.6-57.9%)) compared to when all administration routes were studied (20.1%; 9.0-24.6%), where each dose could accumulate more than one error. Studies consistently reported wrong time, omission, and wrong dosage among the 3 most common MAE subtypes. Common medication groups associated with MAEs were those affecting nutrition and blood, gastrointestinal system, cardiovascular system, central nervous system, and antiinfectives. Medication administration error rates varied greatly as a product of differing medication error definitions, data collection methods, and settings of included studies. Although MAEs remained a common occurrence in health care settings throughout the time covered by this review, potential targets for intervention to minimize MAEs were identified. CONCLUSIONS: Future research should attend to the wide methodological inconsistencies between studies to gain a greater measure of comparability to help guide any forthcoming interventions.

Systematic review

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The attitude of health care professionals towards accreditation: A systematic review of the literature.

Authors Alkhenizan A , Shaw C
Journal Journal of family & community medicine
Year 2012
Links Pubmed DOI PubMed Central

This article is included in 1 Broad synthesis 14 Broad syntheses (1 reference)

This article includes 14 Primary studies 14 Primary studies (14 references)

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Accreditation is usually a voluntary program, in which authorized external peer reviewers evaluate the compliance of a health care organization with pre-established performance standards. The aim of this study was to systematically review the literature of the attitude of health care professionals towards professional accreditation. A systematic search of four databases including Medline, Embase, Healthstar, and Cinhal presented seventeen studies that had evaluated the attitudes of health care professionals towards accreditation. Health care professionals had a skeptical attitude towards accreditation. Owners of hospitals indicated that accreditation had the potential of being used as a marketing tool. Health care professionals viewed accreditation programs as bureaucratic and demanding. There was consistent concern, especially in developing countries, about the cost of accreditation programs and their impact on the quality of health care services.

Systematic review

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The standard of healthcare accreditation standards: a review of empirical research underpinning their development and impact.

Journal BMC health services research
Year 2012
Links Pubmed DOI PubMed Central

This article includes 13 Primary studies 13 Primary studies (13 references)

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BACKGROUND: Healthcare accreditation standards are advocated as an important means of improving clinical practice and organisational performance. Standard development agencies have documented methodologies to promote open, transparent, inclusive development processes where standards are developed by members. They assert that their methodologies are effective and efficient at producing standards appropriate for the health industry. However, the evidence to support these claims requires scrutiny. The study's purpose was to examine the empirical research that grounds the development methods and application of healthcare accreditation standards. METHODS: A multi-method strategy was employed over the period March 2010 to August 2011. Five academic health research databases (Medline, Psych INFO, Embase, Social work abstracts, and CINAHL) were interrogated, the websites of 36 agencies associated with the study topic were investigated, and a snowball search was undertaken. Search criteria included accreditation research studies, in English, addressing standards and their impact. Searching in stage 1 initially selected 9386 abstracts. In stage 2, this selection was refined against the inclusion criteria; empirical studies (n = 2111) were identified and refined to a selection of 140 papers with the exclusion of clinical or biomedical and commentary pieces. These were independently reviewed by two researchers and reduced to 13 articles that met the study criteria. RESULTS: The 13 articles were analysed according to four categories: overall findings; standards development; implementation issues; and impact of standards. Studies have only occurred in the acute care setting, predominately in 2003 (n = 5) and 2009 (n = 4), and in the United States (n = 8). A multidisciplinary focus (n = 9) and mixed method approach (n = 11) are common characteristics. Three interventional studies were identified, with the remaining 10 studies having research designs to investigate clinical or organisational impacts. No study directly examined standards development or other issues associated with their progression. Only one study noted implementation issues, identifying several enablers and barriers. Standards were reported to improve organisational efficiency and staff circumstances. However, the impact on clinical quality was mixed, with both improvements and a lack of measurable effects recorded. CONCLUSION: Standards are ubiquitous within healthcare and are generally considered to be an important means by which to improve clinical practice and organisational performance. However, there is a lack of robust empirical evidence examining the development, writing, implementation and impacts of healthcare accreditation standards.

Systematic review

Unclassified

Impact of accreditation on the quality of healthcare services: a systematic review of the literature.

Authors Alkhenizan A , Shaw C
Journal Annals of Saudi medicine
Year 2011
Links Pubmed DOI PubMed Central

This article is included in 1 Broad synthesis 20 Broad syntheses (1 reference)

This article includes 20 Primary studies 20 Primary studies (20 references)

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Background and Objective: Accreditation is usually a voluntary program in which trained external peer reviewers evaluate a healthcare organization's compliance and compare it with pre-established performance standards. The aim of this study was to evaluate the impact of accreditation programs on the quality of healthcare services Methods : We did a systematic review of the literature to evaluate the impact of accreditation programs on the quality of healthcare services. Several databases were systematically searched, including Medline, Embase, Healthstar, and Cinhal. Results: Twenty-six studies evaluating the impact of accreditation were identified. The majority of the studies showed general accreditation for acute myocardial infarction (AMI), trauma, ambulatory surgical care, infection control and pain management; and subspecialty accreditation programs to significantly improve the process of care provided by healthcare services by improving the structure and organization of healthcare facilities. Several studies showed that general accreditation programs significantly improve clinical outcomes and the quality of care of these clinical conditions and showed a significant positive impact of subspecialty accreditation programs in improving clinical outcomes in different subspecialties, including sleep medicine, chest pain management and trauma management. Conclusions: There is consistent evidence that shows that accreditation programs improve the process of care provided by healthcare services. There is considerable evidence to show that accreditation programs improve clinical outcomes of a wide spectrum of clinical conditions. Accreditation programs should be supported as a tool to improve the quality of healthcare services.

Systematic review

Unclassified

Advantages and Disadvantages of Health Care Accreditation Mod-els.

Authors Tabrizi JS , Gharibi F , Wilson AJ
Journal Health promotion perspectives
Year 2011
Links Pubmed DOI PubMed Central

This article is included in 1 Broad synthesis 60 Broad syntheses (1 reference)

This article includes 60 Primary studies 60 Primary studies (60 references)

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BACKGROUND: This systematic review seeks to define the general advantages and disadvan-tages of accreditation programs to assist in choosing the most appropriate approach. METHOD: Systematic search of SID, Ovid Medline & PubMed databases was conducted by the keywords of accreditation, hospital, medical practice, clinic, accreditation models, health care and Persian meanings. From 2379 initial articles, 83 articles met the full inclusion criteria. From initial analysis, 23 attributes were identified which appeared to define advantages and disadvantages of different accreditation approaches and the available systems were compared on these. RESULTS: Six systems were identified in the international literature including the JCAHO from USA, the Canadian program of CCHSA, and the accreditation programs of UK, Australia, New Zealand and France. The main distinguishing attributes among them were: quality improve-ment, patient and staff safety, improving health services integration, public's confi-dence, effectiveness and efficiency of health services, innovation, influence global standards, information management, breadth of activity, history, effective relationship with stakeholders, agreement with AGIL attributes and independence from government. CONCLUSION: Based on 23 attributes of comprehensive accreditation systems we have defined from a systematic review, the JCAHO accreditation program of USA and then CCHSA of Can-ada offered the most comprehensive systems with the least disadvantages. Other programs such as the ACHS of Australia, ANAES of France, QHNZ of New Zealand and UK accredita-tion programs were fairly comparable according to these criteria. However the decision for any country or health system should be based on an assessment weighing up their specific objec-tives and needs.

Systematic review

Unclassified

Increasing smoking cessation care provision in hospitals: a meta-analysis of intervention effect.

Journal Nicotine & tobacco research : official journal of the Society for Research on Nicotine and Tobacco
Year 2009
Links Pubmed DOI RxForChange

This article is included in 1 Structured summary of systematic reviews 25 Structured summaries of systematic reviews (1 reference)

This article includes 27 Primary studies 25 Primary studies (27 references)

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INTRODUCTION: Levels of hospital smoking cessation care are less than optimal. This study aimed to synthesize the evidence regarding the effectiveness of interventions in increasing smoking cessation care provision in hospitals. METHODS: A review identified relevant studies published between 1994 and 2006. A description of studies, including methodological quality, was undertaken. Intervention effectiveness in increasing smoking cessation care practices was examined for controlled studies using meta-analysis. Care practices examined were assessment of smoking status; advice to quit; counseling or assistance to quit; advising, offering, or providing nicotine replacement therapy (NRT); and follow-up or referral. RESULTS: Of the 25 identified studies, 18 were U.S. based and in inpatient settings. Of the 10 controlled trials, 4 addressed cardiac patients, 5 measured one smoking cessation care practice, and 9 implemented multistrategic interventions (e.g., combining educational meetings with reminders and written resources). The methodology described in these studies was generally of poor quality. Meta-analysis of controlled trials demonstrated a significant intervention effect for provision of assistance and counseling to quit (pooled risk difference = 16.6, CI = 4.9-28.3) but not for assessment of smoking status, advice to quit, or the provision or discussion of NRT. Statistical heterogeneity was indicated for all smoking cessation care practices. An insufficient number of studies precluded the use of meta-analysis for follow-up or referral for further assistance. DISCUSSION: Interventions can be effective in increasing the routine provision of hospital smoking cessation care. Future research should use more rigorous study design, examine a broader range of smoking cessation care practices, and focus on hospital-wide intervention implementation.

Systematic review

Unclassified

Using quality indicators to improve hospital care: a review of the literature.

Journal International journal for quality in health care : journal of the International Society for Quality in Health Care / ISQua
Year 2009
Links Pubmed DOI

This article is included in 1 Structured summary of systematic reviews 21 Structured summaries of systematic reviews (1 reference)

This article includes 21 Primary studies 21 Primary studies (21 references)

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PURPOSE: To review the literature concerning strategies for implementing quality indicators in hospital care, and their effectiveness in improving the quality of care. DATA SOURCES: A systematic literature study was carried out using MEDLINE and the Cochrane Library (January 1994 to January 2008). STUDY SELECTION: Hospital-based trials studying the effects of using quality indicators as a tool to improve quality of care. DATA EXTRACTION: Two reviewers independently assessed studies for inclusion, and extracted information from the studies included regarding the health care setting, type of implementation strategy and their effectiveness as a tool to improve quality of hospital care. RESULTS: A total of 21 studies were included. The most frequently used implementation strategies were audit and feedback. The majority of these studies focused on care processes rather than patient outcomes. Six studies evaluated the effects of the implementation of quality indicators on patient outcomes. In four studies, quality indicator implementation was found to be ineffective, in one partially effective and in one it was found to be effective. Twenty studies focused on care processes, and most reported significant improvement with respect to part of the measured process indicators. The implementation of quality indicators in hospitals is most effective if feedback reports are given in combination with an educational implementation strategy and/or the development of a quality improvement plan. CONCLUSION: Effective strategies to implement quality indicators in daily practice in order to improve hospital care do exist, but there is considerable variation in the methods used and the level of change achieved. Feedback reports combined with another implementation strategy seem to be most effective.