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accreditation bodies and the International Organization for Standardization (ISO), regarding any further published or unpublished work.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.
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.
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.
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.
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.
PURPOSE: The purpose of this study was to identify and analyze research into accreditation and accreditation processes.
DATA SOURCES: A multi-method, systematic review of the accreditation literature was conducted from March to May 2007. The search identified articles researching accreditation. Discussion or commentary pieces were excluded.
STUDY SELECTION: From the initial identification of over 3000 abstracts, 66 studies that met the search criteria by empirically examining accreditation were selected. DATA EXTRACTION AND RESULTS OF DATA SYNTHESIS: The 66 studies were retrieved and analyzed. The results, examining the impact or effectiveness of accreditation, were classified into 10 categories: professions' attitudes to accreditation, promote change, organizational impact, financial impact, quality measures, program assessment, consumer views or patient satisfaction, public disclosure, professional development and surveyor issues.
RESULTS: The analysis reveals a complex picture. In two categories consistent findings were recorded: promote change and professional development. Inconsistent findings were identified in five categories: professions' attitudes to accreditation, organizational impact, financial impact, quality measures and program assessment. The remaining three categories-consumer views or patient satisfaction, public disclosure and surveyor issues-did not have sufficient studies to draw any conclusion. The search identified a number of national health care accreditation organizations engaged in research activities.
CONCLUSION: The health care accreditation industry appears to be purposefully moving towards constructing the evidence to ground our understanding of accreditation.
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.
