The number of countries implementing accreditation programs in their healthcare systems has grown in the past decade, but accreditation's impact has not been tested rigorously using a randomized control trial. The purpose of this study was to conduct such a trial in a developing country setting and to air its implications. The KwaZulu-Natal (KZN) province of South Africa was chosen because it had just contracted with the Council for Health Services Accreditation of Southern Africa (COHSASA) to introduce hospital accreditation into KZN public hospitals. Following discussions between COHSASA and the Joint Commission International (JCI), a joint research team representing the Medical Research Council (MRC) of South Africa and JCI, under the sponsorship of the USAID Quality Assurance Project, was engaged to study the impact of the COHSASA accreditation program on KZN hospitals. The KZN province agreed that 20 randomly selected public hospitals, stratified by size, could be part of the study. Ten of these hospitals entered the accreditation program in 1998; the other ten, which served as a control, entered about two years later. The study prospectively measured the effects of the COHSASA hospital accreditation program on various indicators of hospital care. The study used survey data from the COHSASA accreditation program measuring hospital structures and processes, along with eight indicators of hospital quality of care collected by an independent research team. The indicators of hospital quality had been developed by consensus of an advisory committee in South Africa. The indicators were: nurse perceptions of quality, client satisfaction, client medication education, accessibility and completeness of medical records, quality of peri-operative notes, hospital sanitation, and labeling of ward stocks. Indicators of mortality and morbidity were dropped because of difficulty in achieving comparability across the hospitals. The investigators compared the performance of the ten hospitals participating in the accreditation program (intervention hospitals) with the ten not yet participating (control hospitals). About two years after accreditation began, the study found that intervention hospitals significantly improved their average compliance with COHSASA accreditation standards from 38 percent to 76 percent, while no appreciable increase was observed in the control hospitals (from 37 percent to 38 percent). This improvement of the intervention hospitals relative to the controls was statistically significant and seems likely to have been due to the accreditation program. However, with the exception of nurse perceptions of clinical quality, the independent research team observed little or no effect of the intervention on the eight quality indicators. Limitations of the study design may have influenced these results. Several intervention hospitals were still trying to achieve accredited status at the time of the second COHSASA survey, and in general the full impact of the program may take longer than the interval measured in this study. The practical implications of the results of this study are: (1) the COHSASA-facilitated accreditation program was successful in increasing public hospitals' compliance with COHSASA standards, and (2) additional work is needed to determine if improvements in COHSASA structure and process standards result in improved outcomes. (author's)
