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Accreditation: International Perspectives and Evolution of ProcessHospital Association Leadership Summit ● International Hospital Federation ● June 1-3, 2010
Karen H. Timmons
President and CEO
Paul vanOstenberg, DDS
Senior Executive Director of International Accreditation and Standards
Joint Commission International
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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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Ernest A. Codman: End Result Theory
“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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The American College of Surgeons described the need for
standardization of hospitals through accreditation as the need to:
“Encourage those which are doing the best work, and to stimulate those of inferior
standard to do better.”
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ACS: The Minimum Standard
1. Organized medical staff2. Physicians and surgeons are licensed,
competent, and ethical3. 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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Accreditation: A World Trend
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
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Accreditation – A Definition
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.
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Licensure – A Definition
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.
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Certification – A Definition
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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Strengths of Accreditation Methodology
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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Accreditation System
Standards of Performance
Field Operations
Decision Process
DatabaseSources of Funding
Design
Infrastructure
Necessary Elements for a Health Care Accreditation System
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Commonalities Related to How Accreditation Methodology is Applied
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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Differences In How Accreditation Methodology is Applied
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
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Differences (cont.)
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
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Other Methodologies
EFQM Baldrige ISO Lean/Six Sigma “Best Practices”—IHI, Premier, etc Others
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Accreditation—What Is the JCI Model?
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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
Mission of Joint Commission International
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Joint Commission International
Global knowledge disseminator of quality improvement and patient safety
346 accredited organizations in 41 countries ISQua-accredited WHO Collaborating Centre for Patient Safety
Solutions
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Mission Work at Three Levels
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
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WHO Collaborating Centre for Patient Safety Solutions
Facts about the Centre Developed Nine Patient Safety Solutions High 5s Project Collaboration between
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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Joint Commission International Accreditation
International Accreditation Philosophy Maximum achievable standards Patient-centered Culturally adaptable Process stimulates continuous improvement
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JCI’s Accreditation Tools
Standards Evaluation Methodology Patient Safety Goals and Tools Data on Performance and Benchmarks Education
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JCI Standards
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 Evidence Gathering Onsite
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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Accreditation: What Do We Know About
the Link to Quality?
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Summary of Studies on the Impact of Accreditation
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, cont’d
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
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
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Summary of Studies on the Impact of Accreditation, cont’d
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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Sentinel Event Experience to Date
908 Events of wrong site surgery 804 Inpatient suicides734 Operative/post op complications580 Deaths related to delay in treatment547 Events relating to medication errors436 Patient falls360 Retained foreign objects256 Assault/rape/homicide 209 Perinatal death/injury201 Deaths of patients in restraints146 Transfusion-related events145 Infection-related events102 Fires100 Anesthesia-related events1254 “Other”
Sentinel events reviewed by The Joint Commission: 1995 – 2010
= 6782 RCAs
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Sentinel Event Alert
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Impact of Accreditation: Some Examples
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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Studies Supporting the Value of Joint Commission Accreditation
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
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Value and Impact of Accreditation Study
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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Completed Assessment of Inpatient Transfers
“Qualified Rate”= “Actual Rate”
Actual rate of recording of patient’s condition at assessment
Clifford Hospital, Panyü, P.R. China
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Ventilator Associated Pneumonia (VAP)
0
10
20
30
40
50
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
VA
P p
er 1
000
dev
ice
day
s
Hosp 1 Hosp 2 Hosp 3 NNIS Benchmark
Three JCI-accredited hospitals in India
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Unscheduled Acute Care Readmissions
0.00
2.00
4.00
6.00
8.00
10.00
12.00
14.00
Jul-07 Aug-07 Sep-07 Oct-07 Nov-07 Dec-07 Jan-08 Feb-08 Mar-08
Facility
Europe Weighted Mean
% of unscheduled readmissions within 31 days for patients with primary Dx of heart failure or related condition
Perc
en
tag
e
Santa Chiara Hospital, Trento, Italy 42
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So Far So Good
These are individual reports, dealing with segments of hospital operations – Anecdotal accounts
To study it systematically, – One Middle East hospital embarked on a study of
the effect of the process, not of the outcome, before and after JCI accreditation
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Study Details
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
Hassan, DK & Kanji, GK: Measuring Quality Performance in Healthcare 2007.
Kingsham Press, Chichester, UK
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Findings of Study
All stakeholder groups reported improvement in every dimension measured
Overall improvement: 49% over baseline
Main Areas of ImprovementLeadership & managementQuality improvementPatient safetyPt satisfaction & “delight”Ethical performanceDocumentationOrganizational learningOrganizational excellence
Areas of Lesser ImprovementCorporate structureHuman resources managementStaff satisfaction
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Accreditation: What Should The Future Look Like?
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A Revolution in Health Care Delivery
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What Should The Future of Accreditation Look Like?
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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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
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
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Questions to Answer
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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Moving Forward with Accreditation
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