Vergelijkende studie van ... - KCE

30 Hospital Accreditation KCE reports 70
During the assessment the majority (68% and above - at least 16 out of 19) require
documented evidence on:
• Either, adoption of clinical practice guidelines,
• Or routinely availability of clinical governance indicators
• Or clinical practice being subject to formal review
Only for 2 programmes for whom information was available there is no requirement
related to clinical practice at all, namely for Latvia and Poland.
In all the 17 programmes, except for Spain - Andalusia, the survey team does report
back key findings of the survey to senior management of the hospital at the end of the
visit. In addition, in 72% of the cases (13 out of 18), the draft survey is referred back to
the hospital prior to submission for accreditation award. Spain - FADA-JCI and Spain –
Valencia do not ‘communicate’ with the hospital in terms of draft reference, as is also
the case for Czech Republic, Latvia and the UK - Healthcare Commission.
SURVEYORS RECRUITMENT AND TRAINING
As far as the selection, recruitment and training of surveyors is concerned there is a
wide variety on the number of surveyors available by the accreditation organisation and
the duration of the induction training they attend, although for 70% (12 out of 17) this is
between 1-4 days.
CHANGE MANAGEMENT
In terms of services provided by the accreditation organisation, as a mean to assist the
hospitals in getting acquainted with, and preparing for, the accreditation programme,
there is very limited information available (7 out of 19 did not provide information). The
other respondents provide tools, training or consultancy. Denmark, Portugal, Spain and
the UK -HAQU offer all these 3 services.
DECISION AND APPEAL
In the accreditation decisions (the awarding) there are distinct differences:
• 5 out of 11 (45%) apply a binary system i.e. ‘accredited’ versus ‘nonaccredited’,
namely Bulgaria, Latvia, The Netherlands, Spain – FADA-
JCI and UK - HAQU
• 6 out of 11 (55%) apply different levels, namely France, Ireland, Spain
(Andalusia & Valencia), UK - Healthcare Commission and Scotland
As far as the validity period of accreditation is concerned there is also large variety
amongst the different countries, yet the minimum duration is 1 year and maximum 5
years. 53% (9 out of 17) have 3 years cycles whilst for the remaining countries there is a
split between 1 (Luxemburg – Incitants qualité), 4 (18% - 3 out of 17) and 5 years (24% -
4 out of 17) respectively. France has recently changed the duration from 5 to 4 years.
The turnaround time between the on-site survey and the delivery of the final report
varies widely between the different programmes, yet 44% (7 out of 16) report a
duration between 1-4 weeks, while here is the same significant minority where the
duration takes between 5-8 weeks. Only in the case of France and Luxemburg -
Incitants qualité the turnaround exceeds 8 weeks.
Independent of the mandatory or voluntary character of the accreditation programme
in 18 out of 19 programmes (95%) there is a defined mechanism for hospitals to appeal
the accreditation decision. Only in Bulgaria an appeal mechanism does not exist.