Session Brief:
Quality Assurance and Hospital Accreditation
Speaker: Jiruth Sriratanaban
Objectives of Session:
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To review the reasons why external quality assurance of hospitals is needed
To summarize the different external quality assurance methods
To clarify the differences between registration, certification, process-focused
EQA, and participatory EQA
To introduce Hospital Accreditation concepts
To summarize three popular models of hospital accreditation in OECD countries
To stimulate discussion among participants about the potential relevance of
accreditation and other EQA methods in their own countries
Outline of Session:
I. Hospital Quality
a. The difference between a high-quality hospital and a low-quality hospital
b. Information differential: why the market by itself will not punish poor
quality hospitals
c. Dimensions of hospital quality
i. Inputs
1. Staff, doctors, specialists
2. Medicines
ii. Facilities
1. Utilities
2. Equipment
iii. Processes
1. Management
2. Checklists
3. MIS systems – identifying, learning from, correcting errors
iv. Perceptions
1. Waiting times
2. Information to patients
3. Responsiveness
d. Not a dimension of quality: cost
e. Results of quality
i. Probably health outcomes
ii. But not always (eg: problem with hospital scorecards, where best
facilities attract most difficult cases)
1. Evidence from public-private systematic review
II. Ways to assure Hospital Quality
a. Licensure
i. Norm in all countries
ii. Usually denotes that minimum standards are met:
1. Staff levels/ratios
2. Equipment/facility standards (eg: operating theater,
inpatient beds, medical gasses, sterilization equipment)
3. Sometimes geographic (to prevent competition /
cannibalization of government facilities)
iii. Sometimes periodic (eg: every 3 or 5 yrs)
iv. Inspection based
b. Certification
i. Similar to licensure: minimum standards
ii. Difference is that onus is put on hospitals to collect and submit
information demonstrating that they meeting standards
iii. More likely than licensure to also include process measurement
1. Eg: periodicity of testing the efficacy of autoclaves
c. External Quality Assurance
i. Objective
ii. Published standards
iii. Comparison of hospitals against ‘ideal’ measure rather than
‘minimum’
iv. Focus on processes
1. Accreditation systems evolved from manufacturing
experiences
III. External Quality Assurance
a. ISO
i. Process-focused
ii. Public standards
iii. High level of credibility
iv. Professional evaluators
b. Accreditation
i. Process-focused
ii. Public standards
iii. Often not known outside of purchaser/provider
iv. Both professional and participatory evaluators
c. Pros/cons
i. Cost
ii. Learning-from-others
iii. Public appreciation
iv. Evolving standards over time
1. Constantly improving benchmark
IV. Accreditation experience
a. Three common models
i. Canada
ii. Australia
iii. USA
b. Voluntary vs. Mandatory Accreditation
i. Historically all accreditation was voluntary
1. Accredited hospitals pay to join
a. Major attraction for gvt
2. Blurring of the lines
3. US state of CA requires JHACO accreditation for licensure
ii. Mandatory participation in some EU countries
1. Notably France
2. Raising question of whether accreditation in these countries
is simply 3rd party certification. Not necessarily a bad thing
c. Accreditation in middle-income countries
i. International
1. ISO
2. JCI
ii. National
1. Grown during 1990s and early 2000s
a. Thailand
b. Malaysia
c. South Africa
2. Both
V.
VI.
VII.
VIII.
a. Thailand
Where international EQA has grown
a. India, Thailand, Singapore, etc
i. Medical tourism
ii. High-end local market
Where National Accreditation has failed
a. Stagnation since early 2000s
b. Difficult to create
i. Expensive
ii. Multi-year process to develop
iii. Limited membership will limit value/importance
iv. Requires political will
v. Requires single large purchaser – gvt – to assure that benefits of
accreditation outweigh the costs
Costs to Hospitals
a. JCI - $60,000 per review
b. Brazil – ONA accreditation $100,000 per review
c. S. Africa
d. India
e. Thailand
f. …
What about accreditation of other providers/facilities?
a. Blood banks and Laboratories
i. Lower variability may make participatory accreditation less
important than certification or ISO-style EQA
b. Individual doctors
i. Prohibitively expensive
ii. Difficult to measure
iii. Tried in India, New Jersey USA, etc. Failed
IX. For participants: could accreditation be useful, be undertaken, in your country?
Main Messages:
EQA is necessary for private hospitals.
EQA systems should be broadly applied to as many private facilities as possible, and
ideally to both public and private hospitals equally.
International accreditation schemes are useful but too expensive to serve a role in the
overall health market.
National accreditation programs are extremely useful, but difficult to create.
A lead-institution with long-term commitment and political approval or backing is
required for effective EQA.
If the government is not a large purchaser of health services, accreditation is unlikely to
work well.
Mandatory accreditation cannot reasonably take the place of certification systems in
middle-income countries.
Discussion/Study Questions:
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Is process quality an appropriate measure for hospitals or are output and input
measures sufficient?
What are the alternatives to accreditation that are currently in place in your
country? What other alternatives might be implemented?
Where government does not purchase from private hospitals, does it make sense
for the government to subsidize creation /operation of an accreditation program?
Background Reading:
Shaw, C. (2001). External assessment of health care. BMJ 322:851-4.
Montagu, D., (2003). Accreditation and other external quality assessment systems
for healthcare. DFID Health Systems Resource Center. Retrieved from:
pakqualitycare.net/hospital/hospital/files/Accreditation.
Notes on the Readings:
Shaw, C. (2001). External assessment of health care. BMJ 322:851-4.
Abstract:
External assessment is increasingly used worldwide to regulate, improve and market
health care providers, especially hospitals. The commonest models are peer review,
accreditation, statutory inspection, ISO certification and evaluation (usually internal)
against the 'business excellence' framework. Each of these is progressively adapting to
meet the changing demands of public accountability, clinical effectiveness and
improvement of quality and safety, but the most rapid development is in accreditation.
Montagu, D., (2003). Accreditation and other external quality assessment systems
for healthcare. DFID Health Systems Resource Center. Retrieved from:
pakqualitycare.net/hospital/hospital/files/Accreditation.
Summary:
Accreditation schemes can help to improve standards at health facilities in developing
countries, but only with careful implementation and substantial support. A review from
DFID’s Health Systems Resource Centre summarises worldwide experience in
accreditation and external quality assessment (EQA) systems. Success in different
settings has been mixed but the review concludes that these methods have the potential to
make a big difference to the quality of healthcare delivery.
The review builds on current theories of EQA and healthcare management. It then
summarises experience in international accreditation, both in OECD and developing
countries. It examines the implications of EQA’s position at the intersection of private
and public interests in healthcare. Finally, it focuses on past and potential applications of
accreditation in developing countries.
Accreditation is an external review of quality which is (1) based on written and published
standards, (2) carried out by professional peers, (3) run by an independent body, and (4)
designed to encourage organisational change. Evidence in the review shows that
accreditation and other EQA programmes can help facilities to improve the quality of
their operations by providing achievable quality standards, supportive counselling and
benchmarking scores. The review also finds that:
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there is a growing availability of well-tested standards for a wide range of
healthcare facility types, which can be adapted to local conditions quite easily and
quickly
they provide information on quality that is almost impossible to find out otherwise
accreditation programmes can increase equity, but only if smaller facilities that
serve marginalised populations receive financial support from funders to join in
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they can improve the quality of services in health facilities in many developing
countries if they have careful planning, strong government support and
organisational commitment
small facilities will find the costs of surveys and compliance a greater burden than
larger ones, in the absence of direct funding or subsidy
accreditation of individual providers tends to be ineffective and there is no good
model for this.
The review raises the following issues for governments interested in promoting
accreditation as a means of improving quality:
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An effective accreditation organisation must be independent but have the support
of government licensing and health service bodies.
Without intervention by governments or donors, accreditation will probably only
be attractive to high-end facilities and will not improve healthcare quality at the
national level.
A new accreditation programme will need a minimum of three years financial
support, or more in poorer countries.
The most effective way to provide long-term support for an accreditation
programme is indirectly, by offering financial incentives for participation.
Programmes are most likely to succeed if they are voluntary and exist in parallel
with enforced governmental licensing that assures minimum standards. They
cannot be low cost substitutes for regulation.
Local schemes can serve a broader range of organisations than international
programmes and can develop standards that suit local conditions.
Shaw, C. (2005). Toolkit for Accreditation Programs: Some issues in the design and
redesign of external health care assessment and improvement systems. International
Society for Quality Assurance. Retrieved from http://www.proqaly.hu/files/userfiles/File/letoltes/Dokumentumok/ISQuaAccreditationToolkit.pdf.
Introduction:
During the past ten years there has been rapid growth, worldwide, in the establishment of
national and regional accreditation programs for health services. These programs have
tended increasingly to be initiated by government, rather than the medical profession.
A clear need has been felt for a straightforward tool for implementing health service
accreditation within a nation state or health care organisation: an aid for accreditation
providers which would also meet the requirements of funding agencies such as the World
Bank, intergovernmental organisations such as WHO, and individual countries
considering the development of a national program. The experience of the last decade
shows that accreditation has been a valuable technology for quality improvement in many
settings. But the effectiveness of an accreditation program, as well as its affordability and
whether it will be sustainable, depends ultimately on many variable factors in the
particular healthcare environment of the country or organisation involved. It also depends
on the kind of program concerned, and how it is implemented. In this toolkit, these
variables are addressed under four principal headings: policy, organisation, methods and
resources…
Shaw, C. (2003). Quality and accreditation in health care services: a global review.
Geneva: World Health Organization.
Overview:
Quality and accreditation in health care services: a global review resulted from a study
conducted by the International Society for Quality in Health Care (ISQua) under contract
to the World Health Organization. The first of this report’s three parts describes
structures and activities at national and international levels around the world to promote
quality in health care. The second part catalogues quality concepts and tools in local use
in various countries. The third part outlines initiatives in health service accreditation and
analyses the operation of functioning national programmes around the world. The
appendices include recommendations of major international bodies and meetings on
quality assurance.
Sriratanaban, J. & Wanavanichkul, Y. Implementing hospital-wide quality
improvement in Thailand: A Case study of King Chulalongkorn Memorial Hospital.
The Joint Commission Journal on Quality and Safety, 30(5): 246- 256.
No summary