Accreditation as a driver of improvement

and knowledge transfer

Carsten Engel, Denmark

Overview of webinar
 Introduction – accreditation and IAP

 Managing quality in a complex system

 How can we harness the power of accreditation?

 Impact and evidence

 Current trends in accreditation

 Some take-home messages

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Terminology Principles

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Formal definition of accreditation
 External, independent third-party evaluation of an
organisation, system or programme
 Against predetermined requirements, generally set out in
standards developed specifically for this purpose
 Service wide approach
 May address more than legal requirements
 Aims to promote continuous quality improvement
 Results in a report and an award (if successful)

(source: ISQua Terminology Principles, 2018)

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International Accreditation
Programme (IAP)

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IAP Global Presence

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IAP Presence 6
 Managing quality in a complex
system

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Healthcare delivery is a complex
system
 We can’t understand the system just by understanding
all parts of it
 Health care is not entirely deterministic, neither on the
patient level nor or the system level
 We can’t always predict the consequences of our actions

– we can’t even expect that the same action will always

lead to the same outcome

Braithwaite J, Churruca K, Ellis LA et al. Complexity Science in Healthcare –

Aspirations, Approaches, Applications and Accomplishments: A White Paper.
2017, Australian Institute of Health Innovation, Macquarie University: Sydney,
Australia.
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What is the significance of this?
 Complexity renders the system the ability to develop and
learn – improve – but also to drift into failure

 Complex healthcare systems have no ”natural”

boundaries – boundaries are chosen for a purpose
◼ Organizational performance vs patient
pathways/population care

Sidney Dekker. Drift into failure. Ashgate, 2011

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What is it like working in a complex
system?
 Knowledge is limited and local
 Couplings are important
 Variability of conditions is important

 Trade off’s are necessary, ie efficiency vs safety

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Work-as-imagined vs. Work-as-
done
 Work-as-imagined:
◼ Design
◼ Procedures and protocols
◼ Plans
◼ What managers think

 Work-as-done

Resilient Health Care, Volume 3: Reconciling Work-as-Imagined and Work-as-

Done. Braithwaite J, Wears RL, Hollnagel E (Editors). 2016, CRC Press.

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Why then standardize?
 Introduce ”traffic rules” and clarify role expectations

 Support evidence based best practice

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Can standization improve patient-
centredness?
 Yes, maybe – but

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Can standarization improve quality
and risk management?
 Yes, but

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 The most important difference between ”good” and
”excellent” may not ”more or better Work-as-imagined”.
◼ Potential to anticipate
◼ Potential to monitor
◼ Potential to respond in a flexible way
◼ Potential to learn
(individually and as a collective).

Erik Hollnagel’s work on Safety I and II.

Liberati EG et al. How to be a very safe maternity unit: An ethnographic study.
Social Science & Medicine 223 (2019) 64–72.
Weick, K.E., Sutcliffe, K.M., 2001. Managing the Unexpected: Assuring High
Performance in an Age of Uncertainty.

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Conclusion
 Standardization is helpful

 Linear processes imbedded in the complex system

 Patient safety

 But …….

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 How can we harness the power of
accreditation?

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Outcome data Aim Primary Drivers Secondary
Care Drivers
processes for
Clinical outcome A healthcare specific
conditions
measures
PREM’s
system with Governance
Generic care Management
PROM’s excellent processes Clinical governance
Access indicators
performance (safety Quality and risk
critical) management
Safety indicators over a broad Including use of
Equity indicators
range of Support outcome data
HR management
processes
Cost-efficiency outcomes IT management
Value Etc.etc.
Culture,
attitudes

What you
are
accountable Facilitators
for

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Facilitators
 Coherence (alignment between accreditation and the
organisation’s beliefs, context and model of service
delivery)

 Organisational buy-in

 Organisational action in response to observations,

feedback or self-reflection resulting from the accreditation
process

Desvaux L et al: Understanding the impact of accreditation on quality in

healthcare: A grounded theory approach. Int J Qual Health Care 2017, 29, 941-7
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Accreditation should be integrated
 Accreditation needs to be a part of the strategy of the
organisation – not an externally imposed add-on.

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The standards should not be
interpreted as rigid prescriptions
We subscribe to the excellent way this was expressed by
the Royal Australian College of General Practitioners:

“The RACGP envisages that formal accreditation against

the RACGP Standards will be based on common sense
and will not seek to penalise or exclude practices on the
basis of technicalities.”

(From the introduction to the RACGP standards for general practice)

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"If the bureaucratic approach is prevailing, much energy will
be used to demonstrate formal compliance with standards,
but there will be no real willingness to change and improve
patient safety“

(Carlo Ramponi, 2008, at the time Managing Director Europe, Joint

Commission International – in the Danish Political Weekly Magazine “Mandag
Morgen”)

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Sometimes more – or less – is
needed

Command and control

Mandated
accreditation

Self-regulation e.g.
voluntary accreditation

Market mechanisms
Integration in culture

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 Impact and evidence

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 How did you experienced the on-site survey?
(N=59)

15 The overall experience

Number of respondents

10

0
1 Really 2 3 4 5 6 7 8 9 10 Really
bad good
experience Public hospitals (n=30) Private hospitals (n=29) experience

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 Did the survey reveal relevant quality issues?
(N=59)

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 Has the participation in the DDKM helped
you improve quality? (N=59)
20 Quality of patient experience

Number of respondents
15

10

0
To a great extent To some extent To a lesser extent Not at all Don't know

20 Clinical quality
Number of respondents

15
10
5
0
To a great extent To some extent To a lesser extent Not at all Don't know

20 Organisational quality
Number of respondents

15
10
5
0
To a great extent To some extent To a lesser extent Not at all Don't know
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Public hospitals (n=30) Private hospitals (n=29) 27
What is accreditation good for?
”Managers perceived that accreditation ‘was good for’
improving the overall quality of care, promoting
systematization, increasing standards for professionalism
and a common language for understanding and enshrining
patient safety. However there were major concerns with
cumbersome paperwork. Participants suggested that
extensive documentation and bureaucracy sometimes
destract form patient care activities.”

Nicolaisen et al. Poster at ISQua conference, London 2017

Based on survey of senior and middle level managers. Response rate 49%,
N=533.
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Attitudes vary between hospital staff
 Survey with 5055 respondents (2014):

 Overall attitude towards accreditation supportive

◼ Managers > nurses > physicians
◼ Organizational quality > clinical quality > patient-experienced
quality

 A small group of physicians (5%) extremely negative

◼ Average of 1.0 on all quality dimensions (Likert scale 1-7).

LH Ehlers et al: Attitudes towards accreditation among hospital employees

in Denmark: a cross-sectional survey. Int J Qual Health Care 2017, 29,
693-698.
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Does accreditation close the gap?
Follow up needed after initial survey visit in:
 26/39 public hospitals
 29/37 private hospitals
After having an opportunity for follow up everything resolved
in:
 39/39 public hospitals
 34/37 private hospitals
”Not accredited” after an opportunity for follow up:
 None

First hospital accreditation cycle in Denmark, 2010-2012

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Does accreditation close the gap?
Follow up needed after initial survey visit in:
 33% of GP clinics
 22% of specialist physician clinics
After having an opportunity for follow up everything
resolved in:
 96.8% of GP clinics
 98.5% of specialist physician clinics
”Not accredited” after an opportunity for follow up:
 18/1602 GP clinics
 4/885 specialist physician clinics

Results after completed accreditation cycle, Denmark 2015-2018

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What is the impact, we are looking
for – (1)?
 Do organisations who perform well within a given
accreditation programme also perform well in terms of
◼ Delivering evidence-based healthcare?
◼ Outcomes relevant to patients?

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Findings from a series of Danish
studies (Falstie-Jensen et al.)
Accreditation of all Danish public hospitals
Associations between accreditation outcome and outcomes
collected through nation-wide registers of healthcare
provision and outcome
 Lower 30 day mortality at fully compared to partially
accredited hospitals (adjusted mortality, OR 0.83 (0.72-0.96))
and at hospitals compliant vs non-compliant with four
previously selected standards

 Shorter LOS at fully compared to partially accredited hospitals

(moderate effect only)

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Findings from a series of Danish
studies (Falstie-Jensen et al.)
Accreditation of all Danish public hospitals
Associations between accreditation outcome and outcomes
collected through nation-wide registers of healthcare
provision and outcome
 No difference in acute readmissions

 High compliance with accreditation standards associated with

more evidence-based hospital care

 Effect on mortality and LOS persists over two succesive

accreditation cycles

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Findings from a series of Danish
studies (Falstie-Jensen et al.)

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Discussion
 Cause-effect relationship?

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What is the impact, we are looking
for – (2)?
 Does performance of an organisation improve, while it
implements accreditation standards in preparation for
accreditation survey?

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Improvement in delivery of
evidence-based care

From Bogh et al: Int J Qual Health Care 2016; 28: 715-720
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Discussion
 To demonstrate improvement, there must be something
to improve

 Ceiling effect

 Differentiate between
◼ Improving everyone
◼ Helping those who lag behind

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What is the impact, we are looking
for – (3)?
 Do organisations that participate in an accreditation
programme perform better than organisations, who
don’t?

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Improvement in delivery of
evidence-based care???

From Bogh et al: Int J Qual Health Care 2015; 27: 336-343.
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Discussion
 What are we comparing?

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Bibliography – peer reviewed
research on accreditation in Denmark
 SB Bogh et al: Accreditation and improvement in process quality of care: a nationwide study. Int J
Qual Health Care 2015, 27, 336-343
 AM Falstie-Jensen et al: Compliance with hospital accreditation and patient mortality: A Danish
nationwide population-based study. Int J Qual Health Care 2015, 27, 165-174
 AM Falstie-Jensen et al: Is compliance with hospital accreditation associated with length of stay
and acute readmission: A Danish nationwide population-based study. Int J Qual Health Care
2015, 27, 451-458
 SB Bogh et al: Improvement in quality of hospital care during accreditation: A nationwide stepped-
wedge study. Int J Qual Health Care 2016, 28, 715-720
 LH Ehlers et al: Unannounced versus announced hospital surveys: a nationwide cluster-
randomized controlled trial. Int J Qual Health Care 2017, 29, 406-411
 AM Falstie-Jensen et al: Compliance with accreditation and recommeded hospital care - a Danish
nationwide population-based study. Int J Qual Health Care 2017, 29, 625-633
 SB Bogh et al: Predictors of the effectiveness of accreditation on hospital performance: A
nationweide stepped-wedge study. Int J Qual Health Care 2017, 29, 477-483
 LH Ehlers et al: Attitudes towards accreditation among hospital employees in Denmark: a cross-
sectional survey. Int J Qual Health Care 2017, 29, 693-698
 MK Andersen et al: Accreditation in general practice in Denmark: study protocol for a cluster-
randomized controlled trial. Trials 2017, 18, 69

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Bibliography – peer reviewed
research on accreditation in Denmark
 LB Pedersen et al: Can external interventions crowd in intrinsic motivation? A cluster randomised
field experiment on mandatory accreditation of general practice in Denmark. Social Science &
Medicine 2018, 211, 224-233
 AM Falstie-Jensen et al: Consecutive cycles of hospital accreditation: Persistent low compliance
associated with higher mortality and longer lenght of stay. Int J Qual Health Care 2018, 30, 382-
389
 A Nicolaisen et al: Managers’ perceptions of the effects of a national mandatory accreditation
program in Danish hospitals. A cross-sectional survey. Int J Qual Health Care 2019, 31, 331-337
 Andersen MK et al: Retirement, job satisfaction and attitudes towards mandatory accreditation: a
Danish survey study in general practice. BMJ Open 2018;8:e020419. doi: 10.1136/bmjopen-2017-
020419
 TD Due et al: Understanding accreditation standards in general practice - a qualitative study. BMC
Family Practice 2019, 20, 23.
 MB Kousgaard et al: Experience of accreditation impact in general practice - a qualitative study
among general practitioners and their staff. BMC Family Practice 2019, 20, 146.

Oral presentations and posters at ISQua and other conferences

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 Current trends in accreditation

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International Landscape and Trends
 Survey of the members of the ISQua Accreditation
Council (April/May, 2018) – 15 of 22 responded
 Questions posed:
◼ What are the trends on the accreditation landscape?
◼ What healthcare trends are impacting on how accreditation
is conducted?
◼ What are the risks faced by accreditation now and in the
future?
◼ What innovations are being utilized within existing
accreditation programs?

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Some identified trends on the
accreditation landscape
 Focusing on person-centred care (incl. providers)
 Focusing on patient safety (while balancing quality)
 Increasing public awareness & pressure about quality of
care
 Increasing recognition of the value of accreditation
 Decreasing the complexity of accreditation (decrease the
work)

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More identified trends
 Increasing customization and focus on specialized areas
 Moving from
◼ organization to system accreditation
◼ announced to unnannounced visits
◼ voluntary to mandatory

 Must move beyond structure and process as the primary

focus – increase focus on outcomes

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Responding to the trends and
impacts
 Patient involvement

 Risk-based and proportionate auditing

 Reflect/integrate care experiences of care recipients in

each service

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External evaluation of the future? As opposed to

Setting an agenda to achieve a defined aim
Facilitation by indicating ways in which aim
may be achieved
Examine processes to understand why
outcomes are as they are
Exploratory survey
Listing criteria for a well performing
organization
Facilitation by expressing criteria as
requirements for structures and processes
Examine processes for compliance with
requirements
Examinatory survey

Judge on outcomes, but report on Judge on process compliance

mechanisms
More data sources contribute to assessment Assessment based on survey methodology

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 Some take home messages

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Where is the place for accreditation
 Quality planning
◼ Preparing to meet quality goals

 Quality control
◼ Meeting quality goals Q.P
during operations

 Quality improvement
◼ Reaching unprecedented
levels of performance
Q.C. Q.I.

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Accreditation operates in all corners
of the triangle
 Quality planning, including planning of Quality control

 Quality assurance
◼ Detect in time
◼ Catch up with holes (within/among organisations)

 Quality improvement
◼ But you need to know, what you want to improve and how
you will facilitate by accreditation

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Accreditation can support ”closing
the gap”
 The merit of this depends on, whether you have selected
the right gaps to close

 Hard to compare to other strategies with same aim

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A number of don’ts
 Don’t overstandardize
 Don’t demand overdocumentation
 Don’t overmonitor

 Don’t confuse quality assurance with one or several

extra layers of quality control

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Remember these important
facilitators
 Coherence (alignment between accreditation and the
organisation’s beliefs, context and model of service
delivery)

 Organisational buy-in

 Organisational action in response to observations,

feedback or self-reflection resulting from the accreditation
process

Desvaux L et al: Understanding the impact of accreditation on quality in

healthcare: A grounded theory approach. Int J Qual Health Care 2017, 29, 941-7
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"If the bureaucratic approach is prevailing, much energy will
be used to demonstrate formal compliance with standards,
but there will be no real willingness to change and improve
patient safety“

(Carlo Ramponi, 2008, at the time Managing Director Europe, Joint

Commission International – in the Danish Political Weekly Magazine “Mandag
Morgen”)

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Beware of the drift towards
bureaucratization
 The Evaluation Machine:

“mandatory procedures for automated and detailed

surveillance that give an overview of organizational
activities by means of documentation and intense data
concentration”

P Dahler-Larsen: The Evaluation Society, Stanford University Press, 2012

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Some last important points
 Accreditation standards are not a set of prescriptions for
action, but a tool for investigation of your organisation

 Accreditation is a mindset, not a task that can be

delegated to an accreditation manager

 Go for the learning value, not for the award

 Beware of ”overimplementation” – healthcare is a

complex system – you can standardize (many)
procedures, but not the system as a whole
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