Accreditation and the Development of Process Performance Measures

Accreditation is an external review process used to assess how well an organisation performs relative to established standards. Accreditation provides a framework for continuous quality improvement, and health services worldwide embrace accreditation and use it as a strategy to improve quality in organisations. The scientific literature is sparse and consists of inconsistent
results. Therefore, it is not possible to draw a clear conclusion regarding whether accreditation serves as a framework for improvement. In Denmark, hospital accreditation was first adopted in 2002 by hospitals in the capital, which were voluntarily accredited. These hospitals were followed two years later by hospitals from the Southern Jutland County, which were also voluntarily accredited. In 2009, a mandatory accreditation programme was launched for all
public hospitals.
This thesis examined the effect of hospital accreditation on quality of care using nationwide quantitative designs aimed at detecting changes over time in hospital performance in relation to both voluntary (Study 1) and mandatory accreditation (Study 2). Further, a qualitative study (Study 3) was conducted to complement the findings in Study 2.
To examine the voluntary accreditation programme, we used a controlled pre- and post-design with difference-in-differences analysis based on process data from patients admitted for acute stroke, heart failure or ulcer. The primary outcome was a change in the opportunity-based composite score, and the secondary outcome was a change in all-or-none scores. The opportunity-based composite score improved significantly more for non-accredited hospitals.
The absolute difference between improvements in the all-or-none score for non-accredited and accredited hospitals was not significant. A mixed-method sequential explanatory design was used to examine the mandatory accreditation programme. The quantitative study was a multilevel, longitudinal, stepped-wedge, nationwide study of process performance measures based on data from patients admitted for acute stroke, heart failure, ulcer, diabetes, breast cancer and lung cancer. The qualitative study was based on eight semi-structured interviews conducted at a Danish hospital. Overall, mandatory accreditation did not contribute to improvement process measures, but development began to plateau when the external survey was conducted. Staff argued that these processes were already well implemented before the mandatory accreditation and were not considered to have contributed to anything new in that respect. The quantitative analyses showed that heart failure and breast cancer were overall negatively affected by DDKM, but for processes below target values, diabetes and diagnostics were positively affected. Staff reported that accreditation affected management’s priorities. In favour of DDKM, other improvement initiatives were neglected, and staff spent less time with patients, which might explain why performance measures in some cases were negatively affected. The quantitative analysis showed that mandatory accreditation affected quality development to a similar extent across all types of 6 hospitals. Finally, process measures below best-practice target values were positively affected
by accreditation to a greater extent than processes above the target values. Mandatory accreditation was perceived by staff to have created a foundation for how hospital staff work with quality improvement in the future.