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18 Hospital Accreditation KCE reports 70
Also outside the USA, and within the country scope of our International comparison of
hospital accreditation programmes, it is interesting to refer to a lengthy (5 year)
research initiative, known as Quest for Quality and Improved Performance (QQIP),
which was conducted by The Health Foundation in 2006 with a focus on the quality of
healthcare in the UK 17 . The study focused on the impact of regulatory interventions on
quality of healthcare. Institutional regulation is divided into 2 categories:
• those concerned with direction, that is defining and communicating
expected levels of performance
• those concerned with surveillance and enforcement, often referred to
as external oversight
Target and standard setting are considered to fall within the 1 st category whereas the
researchers include accreditation and inspection into the 2 nd category. The report states
that within systems that rely heavily on accreditation, accredited organisations generally
provide higher quality care. Yet it continues to conclude that there is no evidence to
suggest that accreditation has secured improved quality. External oversight models are
often used in tandem with directive approaches such as target and standard setting, as
well as enforcement processes via the insurance of informal advice and formal reports,
and in extreme cases delicensing or takeover. When discussing the link between
accreditation as an institutional intervention the authors refer once again to the
accreditation programme of the JCAHO. Historically this programme focused on
structural standards but in recent years there has been greater emphasis on process and
quality improvement. As of 2004, surveys included a methodology for evaluating actual
care processes. On evidence of accreditation the authors state despite the huge level of
resources spent on accreditation, there have been few evaluations that assess the
effectiveness of accreditation as a lever to improve quality in healthcare.
And for the US they conclude in summary:
• Although there is some evidence of an association between quality of
care and accreditation status, there is no evidence of causality. That is,
the accreditation performance association could be explained by high
performing organisations choosing to participate in accreditation,
rather than accreditation processes leading to better performance or
higher quality healthcare
• No correlation between JCAHO scores and alternative, evidencebased,
measures of healthcare quality and safety
• No difference in the medical error rates between accredited and nonaccredited
hospitals
• No correlation between patient satisfaction scores and JCAHO survey
scores
• Disjunction between outcomes measures and JCAHO evaluations
• JCAHO has acted as a key driver in the development of hospitals’
patient-safety initiatives although no evidence of patient impact
Within the literature study on individual country level, there was only 1 pertinent result
for France. In the International Journal for Quality in Health Care of 2003 18 , discussing
the results of the first 100 accreditation procedures in France there is no outcome
related evidence. The French accreditation procedure investigates (macro) processes
and not outcomes. It is stated that ‘until links between clinical processes and outcomes
are studied further, we lack information about the relationship between these macroprocesses
and outcomes. Herein lies an area of research that might even question the
overall effectiveness and efficiency of the accreditation process’.
In a study on ‘Hospital Accreditation Policy in Lebanon: its potential for quality
improvement’ there is another reference to the French experience 19 .