Many thanks to Dr Anne-marie Boxall, Deeble Institute for Health Policy Research and Drs Reece Hinchcliff and David Greenfield from the Australian Institute of Health Innovation for providing the following insights into the evidence behind accreditation programs:
Accreditation programs are deployed widely to monitor and promote safety and quality in healthcare. Governments, health service organisations and accreditation agencies have invested considerable resources into programs, but to date, evidence of their effectiveness is limited and varied in some areas prompting the question: is it money and time well spent?
A recently published Evidence Brief examines this question (see here for full details). It synthesises findings from a recent literature review of 122 published empirical studies regarding health service accreditation programs. Overall, these studies investigate varied aspects of accreditation, including the impacts on:
- measures of quality (for example, indicators of organisational performance or patient outcomes);
- health service processes, policies and operating environments;
- organisational change mechanisms; and
- professionals’ attitudes.
Improving the quality of healthcare is undoubtedly a key aim of accreditation, and over 60 studies have evaluated program impacts on different quality measures. Unfortunately, the majority do not use non-accredited health services as control sites in comparative study designs, decreasing the strength of evidence produced. Also, findings from individual investigations are shaped by contextual issues limiting the generalisability and comparability of studies, with examples of both positive and negative impacts identified.
Advocates of accreditation argue that a key benefit is that it stimulates improvements in health service processes, policies and operating environments. Some research supports these claims, with one study demonstrating that staff in accredited organisations are more compliant with best-practice guidelines and open to implementing changes that improve quality and safety. However, few high-quality studies have examined whether programs actually deliver such tangible benefits.
Fortunately, there is stronger evidence on how preparing for and undergoing accreditation establishes mechanisms for change within health service organisations. The research suggests that accreditation causes organisations to change because:
- staff become more engaged in quality improvement activities, such as self-assessment;
- systems for delivering quality care are promoted within the organisation;
- data is collected, collated and used for internal and external benchmarking more often; and
- staff begin to implement best-practice guidelines.
One particularly perplexing aspect of the evidence concerns health professionals’ views of accreditation programs. Overall, the research shows that professionals see accreditation as an effective method of promoting quality and safety in healthcare, and they are more likely to remain satisfied and employed in accredited organisations.
However other studies have found that professionals have concerns about the human and financial resources needed for organisations to participate successfully in programs, and that participation might divert attention and resources away from more (unspecified) critical organisational and system-level problems. How quality would be systematically managed and assessed remains unclear without an accreditation program. As engaging health professionals in the accreditation process is critical to its success, it would be valuable to further explore the reasons for this issue.
When taken as a whole, the published research evidence provides credible support for health service accreditation programs, but there are limitations that make it difficult for policymakers to forge ahead with confidence. The evidence base is considered to be of only moderate quality, and findings from individual studies regarding the same topics are highly contextual in many cases.
There remain major knowledge-gaps that need to be addressed to understand what aspects of accreditation programs work, in what contexts and why. These questions may be in part answered by ‘ACCREDIT’, a five-year Australian Research Council Project administered by Professors Braithwaite and Westbrook at the Australian Institute of Health Innovation, University of New South Wales. Without the robust evidence that such large-scale and long-term studies can produce, policymakers will need to continue drawing on expert opinion, small-scale program evaluations and cautious comparative assessments of the literature when reviewing, revising or implementing accreditation programs.