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22 Hospital Accreditation KCE reports 70 Table 5 : Example research questions Source: 22 4.3 INTERNATIONAL SURVEY: LACK OF EVIDENCE The International Survey carried out in the context of this project did address the question on the measurement of outcomes. More precisely, the following question was included in the survey: Do you have data to quantify beneficial impacts of accreditation on hospitals, staff, patients? Whenever the answer was positive the country was asked to identify. However, as pointed out in Chapter 5.1.3 ‘Synthesis of the literature study results and the survey answers’ only 1 country, namely Ireland claims to have outcomes related data based on performance statistical indicators. Yet, Ireland did not provide any details. The NHS QIS in Scotland and the UK Healthcare Commission, both accreditation agencies linked to the respective governments, indicated that currently research/audits on their effectiveness are carried out and will/should be delivered in 2007. Meanwhile the Scottish study has been released and seeks to evaluate the impact of NHS QIS both as a whole and in representative areas of its activity 25 . The evaluation was carried out between September and December 2006 and was conducted using semi-structured interviews at 3 levels of NHS Scotland personnel:
KCE Reports 70 Hospital Accreditation 23 senior management in NHS Scotland Boards, practising clinicians and closely associated managers (“practitioners”), and senior members of the Academy of the Royal Colleges and faculties in Scotland. The views and experiences of patients and the general public were seen as significant, though it was recognised that a different approach would be needed to reliably identify and assess these views. At this stage, therefore, research with patients and public has been deferred. So, the study does focus on reported views (perceptions) on outcomes rather than measurement of direct outcomes. The main findings of the report can be summarised as follows: • 60% of senior managers and 55% of practitioners reported an increase in professional knowledge as a results of NHS QIS initiatives • 72% of senior managers and 65% of practitioners reported a change in policy or practice as a result of NHS QIS initiatives • 62% of senior managers and 65% of practitioners reported a belief in improved patient outcomes as a result of NHS QIS initiatives It will be interesting to see what conclusions are drawn from the UK Healthcare Commission report and whether measurement of (direct) outcomes is included. 4.4 POSSIBLE REASONS FOR THE LACK OF EVIDENCE Given the above, it turns out, both from the literature study and the International survey which was conducted amongst the 26 other Member States of the European Union (cfr Chapter 2 ‘Global methodology’), that there is surprisingly no unambiguous outcome related evidence to be found: • The research conducted does not prove that healthcare quality delivered by accredited healthcare institutions does improve (apart from individual cases) • In case that positive outcomes or quality improvements are reported there is no model to establish a causal relationship between the quality concept in place (accreditation, certification or licensing) and the results, or the association is not statistically significant • There are some biases hampering the sound proof of an existing causal link: o In some cases accreditation leads to paradox results as the improved registration of quality or process related data (initially) leads to increased incidents or cases having a negative impact on the results o In voluntary systems, the hospitals participating in accreditation are often those already interested in quality improvement and are already of higher quality (selection bias) 8 o A program effect may occur. Organizations that participate in an accreditation program may improve their service in advance to achieve program standards than because of the accreditation 23 Based on the research there are multiple possible reasons why outcome indicators have not been integrated in the accreditation programmes and why evidence on the outcome effects of accreditation is not present. For a start, the standards applied in most accreditation programmes do not concern outcome related performance indicators. As a matter of fact the pattern in the different programmes is to focus mainly on ‘process indicators’ which as such should guarantee optimised exchange of information, communication and rigour of actions.
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