Accreditation: International
Perspectives and Evolution of Process
Hospital Association Leadership Summit
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International Hospital Federation ● June 1-3, 2010
Paul vanOstenberg, DDS
Senior Executive Director of International Accreditation
and Standards
Joint Commission International
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Karen H. Timmons
President and CEO
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Accreditation—Its Evolution
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The Hippocratic Oath:
To Do No Harm
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Florence Nightingale:
“The Lady with the Lamp”
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Ignaz Semmelweis:
“The Savior of Mothers”
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“So I am called eccentric for saying in
public that hospitals, if they want to be sure
of improvement,
– Must find out what their results are.
– Must analyze their results, to find their
strong and weak points.
– Must compare their results with those of
other hospitals.
– Must welcome publicity not only for their
successes, but for their errors.”1
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Ernest A. Codman:
End Result Theory
“Encourage those which are
doing the best work, and to
stimulate those of inferior
standard to do better.”
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The American College of Surgeons
described the need for
standardization of hospitals through
accreditation as the need to:
1. Organized medical staff
2. Physicians and surgeons are licensed,
competent, and ethical
3. With the governing body, the medical staff
adopts rules, regulations, and policies
governing the organization’s professional
work
4. Accurate, complete, and accessible medical
records
5. Competently supervised diagnostic and
therapeutic facilities are available
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ACS: The Minimum Standard
Accreditation: A World Trend
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 U.S., Canada, and Australia have the oldest
accreditation systems
 Germany, France, Ireland, and Spain have new
accreditation systems
 Japan, Jordan, Korea, Malaysia, and Thailand
have new systems, with a government role
 The WHO, World Bank, and development banks
recognize the accreditation model
Accreditation – A Definition
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Usually a voluntary process by which a
government or non-government agency grants
recognition to health care institutions which
meet certain standards that require continuous
improvement in structures, processes, and
outcomes.
Licensure – A Definition
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A process by which a governmental authority
grants permission to an individual practitioner or
health care organization to operate or to engage
in an occupation or profession. Licensure
regulations are generally established to ensure
that an organization or individual meets minimum
standards to protect public health and safety.
Certification – A Definition
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A process by which an authorized body, either a
governmental or non-governmental organization,
evaluates and recognizes either an individual or
an organization as meeting pre-determined
requirements or criteria.
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Offers external, objective evaluation
Uses consensus standards
Involves the health professions
Is proactive, not reactive
Is implemented organizationwide
Focuses on systems, not individuals
Stimulates quality culture in the organization
Provides periodic re-evaluation against
standards
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Strengths of Accreditation
Methodology
Necessary Elements for a Health
Care Accreditation System
Standards of
Performance
Field
Operations
Infrastructure
Accreditation
System
Sources of
Funding
Database
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Decision
Process
Design
 Common goal: to improve the safety and
quality of health care
 Used to validate compliance with consensus
standards
 Increasingly using outcomes/indicators to
assess compliance
 Results are shared publicly, increasing public
awareness of—and often demand for—quality
 ISQua principles stimulate more commonality
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Commonalities Related to How
Accreditation Methodology is Applied
Differences In How Accreditation
Methodology is Applied
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 Some use accreditation to validate continuous quality
improvement, others to effect organizational change
 Some approaches involve providers and other key
stakeholders in developing standards and other
requirements; others do not
 In some countries, accreditation is a government
mandate; in others, it is not—“inspection” versus
accreditation
 In many cases, standards set country-specific norms
Differences (cont.)
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 Some approaches involve a self-assessment
component that is validated in a shorter onsite
visit
 Some approaches require use of quality/safety
measures, others do not
 Some use volunteers in onsite evaluation
process
 Voluntary vs. mandatory
Other Methodologies
EFQM
Baldrige
ISO
Lean/Six Sigma
“Best Practices”—IHI, Premier, etc
Others
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Accreditation—
What Is the JCI Model?
Mission of
Joint Commission International
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To improve the safety and quality of care
in the international community through the
provision of education, publications,
consultation, evaluation, and accreditation
services
Joint Commission International
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 Global knowledge disseminator of quality
improvement and patient safety
 346 accredited organizations in 41 countries
 ISQua-accredited
 WHO Collaborating Centre for Patient Safety
Solutions
Mission Work at Three Levels
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 Individual organizations
 Country-level efforts to assist
Ministries of Health and
Governmental Agencies to
strengthen the role of quality
oversight at the country level
 International level as a
consensus builder and vehicle
for sharing new knowledge on
quality and safety in health care
 Developed Nine Patient Safety Solutions
about
the Centrebetween
 High 5sFacts
Project
Collaboration
the Centre and WHO Patient Safety
Programme
 Offers proactive solutions for patient
safety based on empirical evidence,
hard research and best practice
 Advances the entire continuum of
patient safety
 System design and redesign
 Product safety
 Safety of services
 Environment of care
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WHO Collaborating Centre for
Patient Safety Solutions
Joint Commission International
Accreditation
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International Accreditation Philosophy
 Maximum achievable standards
 Patient-centered
 Culturally adaptable
 Process stimulates continuous improvement
JCI’s Accreditation Tools
Standards
Evaluation Methodology
Patient Safety Goals and Tools
Data on Performance and Benchmarks
Education
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 A system framework
 Address all the important managerial and
clinical functions of a health care organization
 Focus on patients in context of their family
 A balance of structure, process, and
outcomes standards
 Set optimal, achievable expectations
 Set measurable expectations
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JCI Standards
 Standards have multiple dimensions and thus have
multiple sources of evidence
– Policy – document review
– Knowledge – staff training logs, interviews with staff
– Practice – clinical observation, patient interviews
– Documentation of practice – open and closed
record review
 A good standard permits a convergent validity scoring
process – all surveyors evaluating all types of
evidence and reaching one score
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JCI Evidence Gathering Onsite
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Accreditation:
What Do We Know About
the Link to Quality?
 Braithwaite et al: Accreditation performance significantly
positively correlated with organizational culture and
leadership but unrelated to organizational climate and
consumer involvement
 El Jardali et al: Lebanese study showed hospital
accreditation is a good tool for improving quality of care
from nurses’ perspective but there is a need to assess
quality based on patient outcome indicators
 Greenfield et al: Unannounced surveys and tracer
methodology are effective but there is no empirical
evidence in the literature to support their benefit in health
care
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Summary of Studies on
the Impact of Accreditation
 Greenfield, Braithwaite: Summary of studies of
effectiveness of accreditation on clinical outcomes, with
consistent findings showing accreditation positively
impacted promoting change and professional development
but inconsistent findings related to professions’ attitudes
toward accreditation, organizational impact, financial
impact, quality measures, and program assessment
 Pomey et al: Accreditation process is effective for
introducing change but is subject to a learning cycle and
learning curve
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Summary of Studies on
the Impact of Accreditation, cont’d
Summary of Studies on
the Impact of Accreditation, cont’d
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 Salmon et al: Accredited hospitals significantly improved
their average with accreditation standards while no
appreciable increase was observed in non-accredited
hospitals
 Shaw: Too many variables to prove that inspection causes
better clinical outcomes
 Touati, Pomey: Accreditation has positive impacts in France
and Canada but current trends in evolution of accreditation
threaten purpose of the accreditation process
 Wachter: Joint Commission’s NPSGs and use of tracer
methodology are effective but ill-suited to drive progress
in culture and communication
 Walshe et al: Although external review systems are
widely used to promote quality improvement, their
effectiveness is little researched
 Walshe, Shortell: Study results show consensus that
health care regulation does have a significant impact by
causing organizations to change their behavior, but less
consensus about how beneficial impact was and whether
it led to quality and PI
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Summary of Studies on
the Impact of Accreditation, cont’d
Sentinel Event Experience to Date
Sentinel events reviewed by The Joint Commission: 1995 – 2010
908 Events of wrong site surgery
= 6782 RCAs
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804 Inpatient suicides
734 Operative/post op complications
580 Deaths related to delay in treatment
547 Events relating to medication errors
436 Patient falls
360 Retained foreign objects
256 Assault/rape/homicide
209 Perinatal death/injury
201 Deaths of patients in restraints
146 Transfusion-related events
145 Infection-related events
102 Fires
100 Anesthesia-related events
1254 “Other”
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Sentinel Event Alert
Medical Records
 First required in 1917, many
considered the medical
record unnecessary
 Today the medical record is
the central point of
information gathering for
treatment decisions,
research, patient monitoring,
outcomes measurement,
and even billing
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Impact of Accreditation:
Some Examples
Infection Control Programs
 In the mid-1950s, patients,
especially surgery patients and
newborns, acquired infections in
epidemic proportions
 In the 1950s, hospitals were
required to appoint infection control
committees to direct activities
aimed at curbing epidemics of
infections
 Infection control programs were
created that reduced the spread of
devastating infectious agents
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Impact of Accreditation:
Some Examples
 Fire Safety
 Non-smoking standards for hospitals were developed due to the
adverse effects of passive non-smokers and significant fire
hazards
 Advance Directives
 Protects patients from a life or death they would not have wished
 Requires organizations to establish Do-Not-Resuscitate (DNR)
standards and request an advance directive from each patient so
the individual’s wishes can be documented in the patient chart
 In the 1980s only 20% of hospitals addressed this issue; since
the implementation of the standard, nearly 100% of accredited
organizations are in compliance with the standard
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Impact of Accreditation:
Some Examples
Studies Supporting the Value of Joint
Commission Accreditation
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 Devers, Pham, Liu: Accreditation requirements
influenced hospitals’ efforts toward implementing patient
safety initiatives, and hospital leaders ranked Joint
Commission as most important driver of patient safety
 Hosford: Accreditation is effective in driving efforts to
reduce errors
 Longo et al: Accreditation Improves Patient Safety
 Conducted with JCI-accredited and non-accredited
hospitals in Jordan
 Pilot collected and analyzed data related to 6
managerial and economic quality indicators
 Results show statistically-significant improvements in
the JCI-accredited hospitals on 3 indicators:
– Return to ICU within 24 hours of discharge
– Staff turnover per year
– Completeness of medical records
Total annual savings per accredited hospital = $87,600
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Value and Impact of Accreditation
Study
Completed Assessment of
Inpatient Transfers
“Qualified Rate”= “Actual Rate”
Clifford Hospital, Panyü, P.R. China
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Actual rate of recording of patient’s condition
at assessment
Ventilator Associated Pneumonia
(VAP)
Hosp 2
Hosp 3
NNIS Benchm ark
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40
30
20
10
0
M-(6-1)
M0
M+1
M+2
M+3
M+4
M+5
M+6
M+7
M+8
M1-12
M 13-18
Months before & after intervention
Three JCI-accredited hospitals in India
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VAP per 1000 device days
Hosp 1
Unscheduled Acute Care
Readmissions
% of unscheduled readmissions within 31 days
for patients with primary Dx of heart failure or related condition
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Facility
Europe Weighted Mean
12.00
8.00
6.00
4.00
2.00
0.00
Jul-07
Aug-07 Sep-07 Oct-07 Nov-07 Dec-07 Jan-08 Feb-08 Mar-08
Santa Chiara Hospital, Trento, Italy
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Percentage
10.00
So Far So Good
 These are individual reports, dealing with
segments of hospital operations – Anecdotal
accounts
 To study it systematically,
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– One Middle East hospital embarked on a study of
the effect of the process, not of the outcome, before
and after JCI accreditation
Study Details
Hassan, DK & Kanji, GK:
Measuring Quality Performance in Healthcare 2007.
Kingsham Press, Chichester, UK
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 400-bed Government Hospital
 Accredited in 2007
 Studied before start of project to comply with
JCI standards
 Repeat study 15 months later (before survey)
 Perceptions of stakeholders studied by
questionnaires
 100-point indices
Findings of Study
 All stakeholder groups reported improvement
in every dimension measured
 Overall improvement: 49% over baseline
Areas of Lesser Improvement
Corporate structure
Human resources management
Staff satisfaction
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Main Areas of Improvement
Leadership & management
Quality improvement
Patient safety
Pt satisfaction & “delight”
Ethical performance
Documentation
Organizational learning
Organizational excellence
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Accreditation:
What Should The Future Look Like?
A Revolution in Health Care
Delivery
Standardized Care
Performance
Measurement
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Transparent
Reporting
Should it be . . .
 Flexible and performance-based?
 Able to address issues related to coordination
of care from one country to another?
 Extended beyond organizations to focus on
individual providers?
 Able to provide reliable quality data?
 Adaptable to improved technologies?
 Sustainable?
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What Should The Future of
Accreditation Look Like?
Suggested Principles for
Effective Regulation
Improvement focus
Responsiveness
Proportionality and targeting
Rigour and robustness
Flexibility and consistency
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Suggested Principles for
Effective Regulation, cont’d
Cost consciousness
Openness and transparency
Enforceability
Accountability and independence
Formative evaluation and review
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Developing the Evidence Base for
Accreditation
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 New accreditation initiatives being introduced
without high levels of transparency
 Introduce new initiatives as pilot projects that
are moved into full-scale implementation with
rigorous evaluation
 Publish findings—positive and negative—in
peer-reviewed journals
 How do we identify the most effective and efficient
framework for delivering quality care and services?
 How do we use accreditation to enhance the quality
and safety of health care?
 How do we sustain accreditation, embedding QI into
daily activities?
 How do we motivate all staff, particularly physicians?
 How do we ensure ROI?
 How do we develop health care organizations into
high-reliability organizations?
 How do we involve patients?
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Questions to Answer
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Moving Forward with Accreditation