How can healthcare standards be standardised?

International travel, medical tourism and trade have created a demand for reliable assessment of healthcare provision across borders, and for information which is accessible to patients, insurers and referring institutions. External assessment schemes for healthcare providers may be clustered into three types: statutory regulation and institutional licensing, International Standardization Organisation certification, and voluntary systems such as peer review and healthcare accreditation. Increasing complexity of healthcare provision, pressures for public accountability and expectations of professional self-governance place a burden on the inspectors and the inspected. If only to contain costs of external assessment and to increase access to reliable information for patients and insurers, the three approaches must work together rather than compete. This paper summarises the origins, aims, authority and methods of the three general models, describing current pressures and opportunities for convergence (between systems and across borders) in the UK and in Europe.

The effect of certification and accreditation on quality management in 4 clinical services in 73 European hospitals.

OBJECTIVE: To investigate the relationship between ISO 9001 certification, healthcare accreditation and quality management in European hospitals. DESIGN: A mixed method multi-level cross-sectional design in seven countries. External teams assessed clinical services on the use of quality management systems, illustrated by four clinical pathways. SETTING AND PARTICIPANTS: Seventy-three acute care hospitals with a total of 291 services managing acute myocardial infarction (AMI), hip fracture, stroke and obstetric deliveries, in Czech Republic, France, Germany, Poland, Portugal, Spain and Turkey. MAIN OUTCOME MEASURE: Four composite measures of quality and safety [specialized expertise and responsibility (SER), evidence-based organization of pathways (EBOP), patient safety strategies (PSS) and clinical review (CR)] applied to four pathways. RESULTS: Accreditation in isolation showed benefits in AMI and stroke more than in deliveries and hip fracture; the greatest significant association was with CR in stroke. Certification in isolation showed little benefit in AMI but had more positive association with the other conditions; greatest significant association was in PSS with stroke. The combination of accreditation and certification showed least benefit in EBOP, but significant benefits in SER (AMI), in PSS (AMI, hip fracture and stroke) and in CR (AMI and stroke). CONCLUSIONS: Accreditation and certification are positively associated with clinical leadership, systems for patient safety and clinical review, but not with clinical practice. Both systems promote structures and processes, which support patient safety and clinical organization but have limited effect on the delivery of evidence-based patient care. Further analysis of DUQuE data will explore the association of certification and accreditation with clinical outcomes.

Evidence-based organization and patient safety strategies in European hospitals.

OBJECTIVE: To explore how European hospitals have implemented patient safety strategies (PSS) and evidence-based organization of care pathway (EBOP) recommendations and examine the extent to which implementation varies between countries and hospitals. DESIGN: Mixed-method multilevel cross-sectional design in seven countries as part of the European Union-funded project 'Deepening our Understanding of Quality improvement in Europe' (DUQuE). SETTING AND PARTICIPANTS: Seventy-four acute care hospitals with 292 departments managing acute myocardial infarction (AMI), hip fracture, stroke, and obstetric deliveries. Main outcome measure Five multi-item composite measures-one generic measure for PSS and four pathway-specific measures for EBOP. RESULTS: Potassium chloride had only been removed from general medication stocks in 9.4-30.5% of different pathways wards and patients were adequately identified with wristband in 43.0-59.7%. Although 86.3% of areas treating AMI patients had immediate access to a specialist physician, only 56.0% had arrangements for patients to receive thrombolysis within 30 min of arrival at the hospital. A substantial amount of the total variance observed was due to between-hospital differences in the same country for PSS (65.9%). In EBOP, between-country differences play also an important role (10.1% in AMI to 57.1% in hip fracture). CONCLUSIONS: There were substantial gaps between evidence and practice of PSS and EBOP in a sample of European hospitals and variations due to country differences are more important in EBOP than in PSS, but less important than within-country variations. Agencies supporting the implementation of PSS and EBOP should closely re-examine the effectiveness of their current strategies.

Profiling health-care accreditation organizations: an international survey.

OBJECTIVE: To describe global patterns among health-care accreditation organizations (AOs) and to identify determinants of sustainability and opportunities for improvement. DESIGN: Web-based questionnaire survey. PARTICIPANTS: Organizations offering accreditation services nationally or internationally to health-care provider institutions or networks at primary, secondary or tertiary level in 2010. MAIN OUTCOME MEASURE: s) External relationships, scope and activity public information. RESULTS: Forty-four AOs submitted data, compared with 33 in a survey 10 years earlier. Of the 30 AOs that reported survey activity in 2000 and 2010, 16 are still active and stable or growing. New and old programmes are increasingly linked to public funding and regulation. CONCLUSIONS: While the number of health-care AOs continues to grow, many fail to thrive. Successful organizations tend to complement mechanisms of regulation, health-care funding or governmental commitment to quality and health-care improvement that offer a supportive environment. Principal challenges include unstable business (e.g. limited market, low uptake) and unstable politics. Many organizations make only limited information available to patients and the public about standards, procedures or results.

Comparison of health service accreditation programs in low- and middle-income countries with those in higher income countries: a cross-sectional study.

OBJECTIVE: The study aim was twofold: to investigate and describe the organizational attributes of accreditation programmes in low- and middle-income countries (LMICs) to determine how or to what extent these differ from those in higher-income countries (HICs) and to identify contextual factors that sustain or are barriers to their survival. DESIGN: Web-based questionnaire survey. PARTICIPANTS: National healthcare accreditation providers and those offering international services. In total, 44 accreditation agencies completed the survey. MAIN OUTCOME MEASURE(S): Income distinctions, accreditation programme features, organizational attributes and cross-national divergence. RESULTS: Accreditation programmes of LMICs exhibit similar characteristics to those of HICs. The consistent model of accreditation worldwide, centres on promoting improvements, applying standards and providing feedback. Where they do differ, the divergence is over specialized features rather than the general logic. LMICs were less likely than HICs to include an evaluation component to programmes, more likely to have certification processes for trainee surveyors and more likely to make decisions on the accreditation status based on a formulaic, mathematically oriented approach. Accreditation programme sustainability, irrespective of country characteristics, is influenced by ongoing policy support from government, a sufficient large healthcare market size, stable programme funding, diverse incentives to encourage participation in accreditation by Health Care Organizations as well as the continual refinement and improvement in accreditation agency operations and programme delivery. CONCLUSIONS: Understanding the similarities, differences and factors that sustain accreditation programmes in LMICs, and HICs, can be applied to benefit programmes around the world. A flourishing accreditation programme is one element of the institutional basis for high-quality health care.

Sustainable healthcare accreditation: messages from Europe in 2009.

BACKGROUND: Healthcare accreditation has grown rapidly since the 1980s but critics question the value of accreditation rather than certification or inspection. Research has focused more on evidence of impact on provider institutions than on health systems; little has been published on the determinants of growth or decline of accreditation organizations and programmes. OBJECTIVE: To describe the development of national accreditation organizations in Europe in relation to incentives, funding and market position in 2009; to identify trends over time using data from previous surveys. METHODS: Contacts in 24 countries, identified by previous surveys, were invited to complete a web-based questionnaire comprising 183 items seeking numerical data or posing multiple choice options. Preliminary results were verified with respondents and agreed for publication. MAIN OUTCOME MEASURES: National healthcare environment, incentives, government policy, legislation, regulation; programme governance, development, funding. RESULTS: The survey identified 18 active national accreditation organizations in Europe. Older ones tend to be independent, profession-dominated and self-financing; they have shown little growth in activity and coverage of the potential market. Newer ones have broad stakeholder governance, support from government policy and growth sustained by legal or financial incentives-giving wide coverage across the healthcare system. The traditional collegial model of accreditation is moving towards a semi-regulatory model of external assessment which could integrate minimal standards of licensing, public safety and accountability with aspirational standards for organizational development and improvement. CONCLUSIONS: The principal challenges to sustainable accreditation appear to be market size, consistency of policy support, programme funding and financial incentives for participation.

Accreditation in European health care.

BACKGROUND: In the past 15 years many countries, with widely differing health systems, have established national accreditation programs. A European survey report on accreditation, which includes data and updates from 2003 that were submitted between January and October 2004, is summarized. METHODS: A one-page questionnaire was circulated, with the summary of the 2002 survey, in February 2004 to known contacts in 44 of the larger states in the European Region of the World Health Organization. Combining the surveys of 2000, 2002, and 2004, responses were received from 36 of the 44 larger countries of the European Region from which information was sought. FINDINGS: The number of national accreditation programs for health services has continued to grow since the mid-1990s. By 2004, 26 programs were active or in development in 18 countries. The "English-speaking" model of North America remains the leading influence; however, newer programs are increasingly influenced by other models. Governmental programs are more likely to publish findings of accreditation assessments, and more recent programs are more likely to make results public. DISCUSSION: Accreditation programs are being set up more frequently in Europe than anywhere else; the trend is from voluntary, confidential, and self-financed organizational development toward benign but transparent regulation of stakeholders, governmental support, and public funding. Programs vary widely, yet patient and staff mobility, cross-border purchasing, freedom of trade, and protection of public safety and patients' rights imply the need for a common approach to definition, assessment, and improvement of standards in health care.

Developing hospital accreditation in Europe / prepared by Charles D. Shaw

This brief guide is addressed to governments of Member States in the WHO/European Region, which are considering or implementing a programme of accreditation, particularly for hospitals. It is also addressed to funding agencies in order to assist in the specification, monitoring and evaluation of contracts for health care development funding. It is not intended to be a comprehensive document but it includes references to more detailed guidance

Measuring against clinical standards.

Systematic improvement of health services requires the objective measurement of people, practices and organisations against valid and explicit standards in order to identify and implement appropriate change. Effective quality systems must embrace a wide range of definitions of quality, and a similar variety of approaches to defining, measuring and improving. Clinical performance may be examined from three professional viewpoints--clinical competence: assessment of individual practitioners against explicit criteria to recognise achievement and to promote continuing development. Traditional mechanisms of training, registration and accreditation enable clinicians to reach career grades but responsibility for subsequent support is often unclear between employers, professions and registering bodies. Clinical practice: assessment of actual clinical process and outcomes against research-based "best practice" to identify and reduce variation. Peer review, clinical audit and confidential enquiries are examples of this approach, which may involve single or multiple professional groups and their interface with management. Service accreditation: systems to assess health care organisations against published standards in order to encourage best management practice. These are usually run on a regional or national basis and, though sensitive to expectations of patients, managers, clinicians, paying agencies and government, they are usually managed by an impartial but authoritative organisation.

A background for national quality policies in health systems / by Charles D. Shaw and Isuf Kalo

The improvement of quality is, for most countries, central to the reform of health systems and service delivery. All countries face challenges to ensure access, equity, safety and participation of patients, and to develop skills, technology and evidence-based medicine within available resources. The first part of this document outlines some of the values, forms and concepts which affect national approaches, together with the international influences of the Council of Europe, European Union and the WHO Regional Office. The second part offers a framework and principles for a national quality strategy. This gives examples of policy, organization, methods and resources which have been applied to the institutionalisation of quality by Member States. The appendices include a summary of recommendations from expert advisers on behalf of the Council of Europe and of WHO Europe. There is also a self-assessment tool to help identify existing mechanisms and future opportunities for quality improvements, as well as references to relevant publications and websites