1. Accreditation: International Perspectives and Evolution of Process Hospital Association Leadership Summit ● International Hospital Federation ● June 1-3, 2010
Karen H. Timmons
President and CEO
Paul vanOstenberg, DDS
Senior Executive Director of International Accreditation and Standards
Joint Commission International
On behalf of Dr. vanOstenberg and myself, we are honored to be here today representing Joint Commission International to speak on how the accreditation process can enhance quality of care. Paul vanOstenberg and myself will be speaking from the perspective of accreditation as a framework for improvement. While we might provide some examples from JCI’s perspective, our intent is to discuss accreditation broadly.
Thank you, Eric and Cedric, and to all who are participating today.
I would like to begin by providing a very brief overview of JCI.

2. Accreditation—Its Evolution
Although accreditation as we now know it is a rather new process, its origins begin thousands of years ago. I’d like to take you on a short journey through the history of the patient safety movement and its evolution into accreditation.

3. The Hippocratic Oath: To Do No Harm
Considered “the Father of Medicine,” Hippocrates developed the Oath of Medical Ethics for physicians. Included in this oath is the mandate, “To Do No Harm.” And although this oath was written in the 4th century BC, its main tenet has endured through the centuries: That physicians should first, do no harm. You could say that this was the beginning of the patient safety movement. Interestingly, though, few medical schools today require students to recite the original Hippocratic oath. Many medical schools require students to recite a modern version of the oath.

4. Florence Nightingale: “The Lady with the Lamp”
Many of you undoubtedly are familiar with the story of Florence Nightingale, an English nurse who, during the Crimean War in the 1800s, discovered that most soldiers died not from battle injuries; rather, they died from infections resulting from their injuries and the unsanitary conditions in the field hospitals. Nightingale’s book, “Notes on Nursing”, is considered the cornerstone of nursing education. Nightingale is also considered to be the founder of the modern nursing profession.

5. Ignaz Semmelweis: “The Savior of Mothers”
Ignaz Semmelweis, a Hungarian physician, is called the “savior of mothers” for discovering that simple handwashing reduced mortality in obstetric clinics. He made this discovery in the 1840s, yet few physicians at that time followed his advice. Today, research has confirmed Semmelweis’s findings, and proper handwashing is one of the key first steps in preventing healthcare-associated infections. Sadly, even today, few health care providers are following Semmelweis’ advice.

6. Ernest A. Codman: End Result Theory
“So I am called eccentric for saying in public that hospitals, if they want to be sure of improvement,
Must find out what their results are.
Must analyze their results, to find their strong and weak points.
Must compare their results with those of other hospitals.
Must welcome publicity not only for their successes, but for their errors.”1
I’d now like to share with you a story about the origins of accreditation. Some of you might have heard this story, but it might be new for many of you. It explains the passion and commitment that so many in this world feel and believe about accreditation.
The origins of accreditation really began with one person–a surgeon educated at Harvard University and who worked at the Massachusetts General Hospital in Boston. His name was Ernest Amory Codman and he was the visionary for what became known as accreditation.
The time was the early 1900’s and Codman had a passion for a construct he believed fervently in--a simple construct--which he called the end result-theory.
The essence of the end results theory was that physicians and hospitals should focus on their end result outcomes – track the treatments they provided to patients – analyze what worked and didn’t work – and then share those results publicly so patients could make informed decisions about which doctor to choose and which hospital to go to (now remember – this was almost 100 years ago!!!).
It turned out that the end result theory had many more complexities and was more radical than he had ever originally envisioned.
Like Ignaz Semmelweis before him, Codman was a man ahead of his time. He was fired from his position for his revolutionary yet courageous viewpoint.

7. The American College of Surgeons described the need for standardization of hospitals through accreditation as the need to:
“Encourage those which are doing the best work, and to stimulate those of inferior standard to do better.”
The American College of Surgeons, however, embraced Codman’s philosophy toward the end result theory and determined to develop guidelines regarding those best practices and standards, so others might follow and improve their performance.
They saw accreditation as a way to standardize best practices. Encourage those who were doing well and stimulate those not doing well to do better.

8. ACS: The Minimum Standard
Organized medical staff
Physicians and surgeons are licensed, competent, and ethical
With the governing body, the medical staff adopts rules, regulations, and policies governing the organization’s professional work
Accurate, complete, and accessible medical records
Competently supervised diagnostic and therapeutic facilities are available
In 1919, the College developed what has become known as the minimum standard, encompassing a requirement for an organized medical staff and requiring hospitals to have
Licensed, competent, and ethical physicians and surgeons
Rules, regulations, and policies governing the medical staff’s professional work
Accurate, complete, and accessible medical records
Competently supervised diagnostic and therapeutic facilities are available, such as laboratories and x-rays
In a first review of compliance against this standard, 692 hospitals from across America were surveyed and only 89 met these minimum requirements.
Afraid of what the media might say about the quality of American hospitals – were the press to find out the results – they were burned in the furnace of the Waldorf Astoria Hotel in NYC during a meeting convened to determine next steps.
It’s hard to believe that almost 100 years later, health care still struggles with transparency, public reporting, and evidence-based medicine.
But thus was born the nucleus of accreditation – and today that nucleus has spread around the globe, facing no borders – as those working in health are – no matter where they live – are united in their commitment to delivering good quality care.

9. Accreditation: A World Trend
U.S., Canada, and Australia have the oldest accreditation systems
Germany, France, Ireland, and Spain have new accreditation systems
Japan, Jordan, Korea, Malaysia, and Thailand have new systems, with a government role
The WHO, World Bank, and development banks recognize the accreditation model
Yet accreditation is not an isolated concept. It is known the world over.
U.S., Canada, and Australia have the oldest accreditation systems
Germany, France, Ireland, and Spain have new accreditation systems.
Japan, Jordan, Korea, Malaysia, and Thailand have new systems, with a government role
The WHO, World Bank, and development banks recognize the accreditation model
Accreditation must be relevant to unique characteristics of each county’s heath care system, financial reimbursement/payment scheme, culture, level of care provided.

10. Accreditation – A Definition
Usually a voluntary process by which a government or non-government agency grants recognition to health care institutions which meet certain standards that require continuous improvement in structures, processes, and outcomes.
What is accreditation? There is no one “right” definition of accreditation. It is typically a methodology that uses standards, onsite evaluation, some form of self assessment, and often decision rules to assess an organization’s performance.
This is a traditional definition of accreditation. Accreditation is:
Voluntary – although in some countries it is mandatory.
It includes recognition given to health care organizations who meet standards. Public recognition comes through a certification/announcement, financial incentive, or a requirement that an organization be accredited. Or, in some cases, accreditation is required to have a nursing or medical school, or insurance discounts.

11. Licensure – A Definition
A process by which a governmental authority grants permission to an individual practitioner or health care organization to operate or to engage in an occupation or profession. Licensure regulations are generally established to ensure that an organization or individual meets minimum standards to protect public health and safety.
In addition to accreditation, licensure and certification play a significant part in health care regulation. Here is a commonly-accepted definition of licensure, although it’s important to note there’s no clarity around these definitions. Is licensure a substitute for accreditation? It’s a minimum requirement.

12. Certification – A Definition
A process by which an authorized body, either a governmental or non-governmental organization, evaluates and recognizes either an individual or an organization as meeting pre-determined requirements or criteria.
And here is a definition of certification.

13. Strengths of Accreditation Methodology
Offers external, objective evaluation
Uses consensus standards
Involves the health professions
Is proactive, not reactive
Is implemented organizationwide
Focuses on systems, not individuals
Stimulates quality culture in the organization
Provides periodic re-evaluation against standards
There are numerous strengths to accreditation, including that it
Offers external, objective evaluation
Uses consensus standards
Involves the health professions
Is proactive, not reactive
Applies organizationwide
Focuses on systems, not individuals
Stimulates quality culture in the organization
Provides periodic re-evaluation against standards

14. Necessary Elements for a Health Care Accreditation System
Standards of Performance
Field Operations
Decision Process
Database
Sources of Funding
Design
Infrastructure
As I’ve stated, there is no one “right” definition of accreditation. Its variable elements are applied differently, such as in the development of standards, the decision process, voluntary versus employed surveyors, and so forth.

15. Commonalities Related to How Accreditation Methodology is Applied
Common goal: to improve the safety and quality of health care
Used to validate compliance with consensus standards
Increasingly using outcomes/indicators to assess compliance
Results are shared publicly, increasing public awareness of—and often demand for—quality
ISQua principles stimulate more commonality
Some key commonalities exist in accreditation. It shares a common goal to improve the safety and quality of health care. It is used to validate compliance with consensus standards. In addition, accreditation increasingly uses outcomes/indicators to assess compliance. Results are shared publicly, increasing public awareness of—and often demand for—quality. And finally, we have noticed that ISQua principles stimulate more commonality across accreditation methodologies.

16. Differences In How Accreditation Methodology is Applied
Some use accreditation to validate continuous quality improvement, others to effect organizational change
Some approaches involve providers and other key stakeholders in developing standards and other requirements; others do not
In some countries, accreditation is a government mandate; in others, it is not—“inspection” versus accreditation
In many cases, standards set country-specific norms
Yet there are differences as well. Some use accreditation to validate continuous quality improvement, others to effect organizational change. Some approaches involve providers and other key stakeholders in developing standards and other requirements; others do not. And in some countries, accreditation is a government mandate; in others, it is not—“inspection” versus accreditation. In addition, in many cases standards set country-specific norms.

17. Differences (cont.)
Some approaches involve a self-assessment component that is validated in a shorter onsite visit
Some approaches require use of quality/safety measures, others do not
Some use volunteers in onsite evaluation process
Voluntary vs. mandatory
In many cases, standards are country-specific. Some approaches involve a self-assessment that is validated onsite, while others do not. Some approaches require use of quality and safety measures, others do not. Some use volunteers in the onsite evaluation process. And in some cases, accreditation is voluntary rather than mandatory.

18. Other Methodologies EFQM Baldrige ISO Lean/Six Sigma
“Best Practices”—IHI, Premier, etc
Others
We know that accreditation isn’t the only methodology for evaluating systems and processes to ensure quality improvement. Health care organizations use various other methodologies such as
EFQM--European Foundation for Quality Management
Baldrige Criteria
ISO
Lean/Six Sigma
In addition, many organizations, such as the Institute for Healthcare Improvement--IHI—and Premier offer learning collaboratives and other methods for health care organizations to share best practices and learn from each other about quality improvement and patient safety. However, there is no external evaluation of these efforts.

19. Accreditation— What Is the JCI Model?
Now I would like provide a brief look into JCI accreditation.

20. Mission of Joint Commission International
To improve the safety and quality of care in the international community through the provision of education, publications, consultation, evaluation, and accreditation services
For those of you who might not be familiar with JCI, I would like to provide a few highlights. JCI’s mission undoubtedly complements the mission of many in this room—to improve the quality and safety of health care. I am always struck when I travel that no matter which country we live in, which language we speak, what type of health care system we are involved in, those who seek to work in health care share similar motivations to provide safe and quality care to their patients. 20

21. Joint Commission International
Global knowledge disseminator of quality improvement and patient safety
346 accredited organizations in 41 countries
ISQua-accredited
WHO Collaborating Centre for Patient Safety Solutions
Today, The Joint Commission accredits over 17,000 health care organizations across the mainstream of delivery. JCI is the international affiliate serving as a global knowledge disseminator for quality and safety. We are accredited by the International Society for Quality in Health Care, which accredits accrediting bodies. This is an excellent opportunity for JCI to walk in its clients’ shoes! We also serve as the WHO Collaborating Centre for Patient Safety Solutions, providing solutions to help mitigate the risk of harm to patients across the globe.

22. Mission Work at Three Levels
Individual organizations
Country-level efforts to assist Ministries of Health and Governmental Agencies to strengthen the role of quality oversight at the country level
International level as a consensus builder and vehicle for sharing new knowledge on quality and safety in health care
JCI meets its mission in three ways:
Individual organization accreditation
Country-level efforts to assist Ministries of Health and Governmental Agencies to strengthen the role of quality oversight at the country level
International level as a consensus builder and vehicle for sharing new knowledge on quality and safety in health care

23. WHO Collaborating Centre for Patient Safety Solutions
Developed Nine Patient Safety Solutions
High 5s Project Collaboration between the Centre and WHO Patient Safety Programme
Offers proactive solutions for patient safety based on empirical evidence, hard research and best practice
Advances the entire continuum of patient safety
System design and redesign
Product safety
Safety of services
Environment of care
Facts about the Centre
JCI and the Joint Commission were recently re-designated as the Collaborating Centre for Patient Safety Solutions, as part of the WHO Patient Safety Programme (previously the World Alliance for Patient Safety), created by WHO to promote safer care.
The Collaborating Centre launched the first set of solutions in The next Solution, on Central Line-Associated Blood Stream Infections, is currently in development. The Collaborating Centre will also be conducting a credible, systematic, and formative evaluation study regarding the concept, value, quality, and impact of the Solutions, as well as what improvements might be beneficial to the concept, product, and process of the Solution’s development and dissemination. 23 23

24. Joint Commission International Accreditation
International Accreditation Philosophy
Maximum achievable standards
Patient-centered
Culturally adaptable
Process stimulates continuous improvement
I’d now like to talk briefly about JCI’s accreditation approach.
JCI’s entire philosophical framework is based on CQI. First, standards are optimally achievable, setting the bar high, but are professionally driven and developed through a consensus process that strives to assure they are also achievable and realistic.
Our process focuses on the patient and we have noted already the commitment that the standards be culturally sensitive and stimulate continuous improvement. Hospitals being surveyed for the first time must demonstrate a track record of at least 4 months to show trends of improvement.
After its first accreditation, an organization’s onsite survey is conducted every three years and the trend data from that period is reviewed.
Thus, hospitals seeking JCI accreditation are demonstrating to the international community their commitment to quality improvement and safety as they voluntarily seek an objective, independent review of how well they comply with professionally driven standards that contribute and foster good outcomes.

25. JCI’s Accreditation Tools
Standards
Evaluation Methodology
Patient Safety Goals and Tools
Data on Performance and Benchmarks
Education
Most accrediting bodies have distinct tools and methodologies designed to help organizations improve and that complement each other. I will highlight 5 that JCI uses:
Standards
Evaluation Methodology
Patient Safety Goals
Data on Performance and Benchmarks
Education

26. JCI Standards A system framework
Address all the important managerial and clinical functions of a health care organization
Focus on patients in context of their family
A balance of structure, process, and outcomes standards
Set optimal, achievable expectations
Set measurable expectations
Standards are the heart of any accreditation program and the critical organ the other components rely upon. They are common to all accrediting bodies. They must be designed well and be professionally driven. The art and science of developing standards needs to be based on what is known to work, based on best available evidence, scientific literature, and past experience. It is necessary for expert groups with expertise to be involved in their development. With the proper development of standards, accreditation can help facilitate the appropriate design of systems and processes within an organization.
In developing standards, we look at health care organizations as a system and examine the inputs, outputs, and interdependencies of the various processes. We ensure significant management and clinical activities are reviewed.
Standards also need to be continually reviewed for their appropriateness, relevance, and surveyability—and must be revised periodically to reflect evidence-based changes in practice. Thus, setting the bar high is an important component of standards development. 26

27. JCI Evidence Gathering Onsite
Standards have multiple dimensions and thus have multiple sources of evidence
Policy – document review
Knowledge – staff training logs, interviews with staff
Practice – clinical observation, patient interviews
Documentation of practice – open and closed record review
A good standard permits a convergent validity scoring process – all surveyors evaluating all types of evidence and reaching one score
JCI also reviews how standards will be evaluated and measured. It is readily understood how compliance with the standard is achieved. A good standard will permit convergent validity or multiple ways for different surveyors to assess compliance. Inter-rater reliability between and amongst the surveyors is critical and depends on careful selection, training, support, and management of the surveyors. JCI surveyors undergo rigorous initial training (preceptorship) and are mandated to undergo annual training. Additionally, JCI has indigenous surveyors located around the world who understand local health care delivery systems.
This process also promotes transparency because organizations will understand what evidence of compliance is necessary for them to achieve accreditation. It also requires organizations to follow up on noncompliant issues. There should be no “black box” in accreditation.
I would now like to turn this over to Dr. Paul vanOstenberg, who will speak about accreditation and the link to quality.

28. Accreditation: What Do We Know About the Link to Quality?
One of the key questions related to accreditation is the value equation—how do we know that accreditation brings value? Where is the evidence that:
Accreditation improves quality and safety of care?
High quality lowers cost of health care?
The cost of implementing accreditation standards is worth the achievable benefit?
We know that many organizations around the world have pursued or are pursuing accreditation—even with little evidence that this is the best use of resources for improving quality.1 Many studies evaluating accreditation’s impact on quality have been conducted, but there is little empirical evidence showing that accreditation does improve quality. In addition, many researchers acknowledge that it is difficult to define a methodology for evaluating the impact. I will highlight some of these studies.
1. Ovretveit J., Gustafson D.: Improving the quality of health care: Using research to inform quality programmes. BMJ 326: , 2003.

29. Summary of Studies on the Impact of Accreditation
Braithwaite et al: Accreditation performance significantly positively correlated with organizational culture and leadership but unrelated to organizational climate and consumer involvement
El Jardali et al: Lebanese study showed hospital accreditation is a good tool for improving quality of care from nurses’ perspective but there is a need to assess quality based on patient outcome indicators
Greenfield et al: Unannounced surveys and tracer methodology are effective but there is no empirical evidence in the literature to support their benefit in health care
Braithwaite J, et al.: Health service accreditation as a predictor of clinical and organizational performance: a blinded, random, stratified study. Qual Saf Health Care 2010; 19: Study showed that accreditation performance was significantly positively correlated with organizational culture and leadership. There was a trend between accreditation and clinical performance, but accreditation was unrelated to organizational climate and consumer involvement. The authors suggest that unannounced surveys and tracer methodology should be used to improve the accreditation process, but note that these approaches are untested.
El-Jardali F., et al: The impact of hospital accreditation on quality of care: perception of Lebanese nurses. Int J Qual Health Care 2008 Oct; 20(5): The study, a cross-sectional survey design in which all hospitals that successfully passed both national accreditation surveys were included, assessed the perceived impact of accreditation on quality of care from the perspective of nurses. The authors conclude that at least from the perspective of Lebanese nurses, hospital accreditation is a good tool for improving quality of care, but to ensure that accreditation brings effective quality improvement practices, there is a need to assess quality based on patient outcome indicators.
Greenfield D, et al.: Unannounced surveys and tracer methodology: literature review. Sydney: Centre for Clinical Governance Research, 2007.

30. Summary of Studies on the Impact of Accreditation, cont’d
Greenfield, Braithwaite: Summary of studies of effectiveness of accreditation on clinical outcomes, with consistent findings showing accreditation positively impacted promoting change and professional development but inconsistent findings related to professions’ attitudes toward accreditation, organizational impact, financial impact, quality measures, and program assessment
Pomey et al: Accreditation process is effective for introducing change but is subject to a learning cycle and learning curve
Greenfield D, Braithwaite J: Health sector accreditation research: a systematic review. Int J Qual Health Care 2008; 20:3, pp Article summarizes studies of the effectiveness of accreditation on clinical outcomes. Results reveal a complex picture, with mixed views and inconsistent findings. Only two categories had consistent findings: accreditation positively impacted promoting change and professional development. Inconsistent findings related to professions’ attitudes toward accreditation, organizational impact, financial impact, quality measures, and program assessment.
Pomey M.P., et al: Does accreditation stimulate change? A study of the context and the impact of the accreditation process on Canadian healthcare organizations. Implement Sci 2010 Apr 26;5(1):31. This study evaluated how the accreditation process helps introduce organizational changes that enhance the quality and safety of care. The authors concluded that the accreditation process is effective for introducing change, but is subject to a learning cycle and a learning curve. Institutions invest greatly to conform to the first accreditation visit and reap the greatest benefits in the next three accreditation cycles (3 to 10 years after initial accreditation). After 10 years, institutions begin to find accreditation less challenging. Interesting note about this study: The study found that accreditation was used successfully as a management tool in organizations that are merging, spurring them to integrate common clinical practices. JCI’s experience with the Copenhagen Hospital Association bears this out as well. The structures and processes put in place during the accreditation process helped ensure an efficient merger of 6 hospitals, with integrated clinical processes and stronger social links among staff.

31. Summary of Studies on the Impact of Accreditation, cont’d
Salmon et al: Accredited hospitals significantly improved their average with accreditation standards while no appreciable increase was observed in non-accredited hospitals
Shaw: Too many variables to prove that inspection causes better clinical outcomes
Touati, Pomey: Accreditation has positive impacts in France and Canada but current trends in evolution of accreditation threaten purpose of the accreditation process
Salmon JW et al: The impact of accreditation on the quality of hospital care: KwaZulu-Natal Province, Republic of South Africa. Randomized controlled trial compared performance on various indicators in 10 COHSASA-accredited hospitals with 10 non-accredited hospitals in South Africa. The study found that accredited hospitals significantly improved their average with COHSASA accreditation standards from 38% to 76%, while no appreciable increase was observed in the control (non-accredited hospitals.) Limitations: Although the accredited hospitals showed improvement in complying with accreditation standards, additional work is needed to determine if improvements in COHSASA structure and process standards result in improved outcomes.
Shaw C.: External assessment of health care. BMJ 2001;322: There are too many variables to prove that inspection causes better clinical outcomes.
Touati N, Pomey MP.: Accreditation at a crossroads: are we on the right track? Health Policy 2009 May;90(2-3): Qualitative meta-analysis of studies of French and Canadian accreditation experiences to assess whether accreditation is used as a learning tool or a bureaucratic tool of coercion. Results show that accreditation has positive impacts in the two countries but is more coercion-oriented in France than in Canada; comparison of the two cases shows that current trends in the evolution of accreditation threaten the very purpose of the accreditation process.

32. Summary of Studies on the Impact of Accreditation, cont’d
Wachter: Joint Commission’s NPSGs and use of tracer methodology are effective but ill-suited to drive progress in culture and communication
Walshe et al: Although external review systems are widely used to promote quality improvement, their effectiveness is little researched
Walshe, Shortell: Study results show consensus that health care regulation does have a significant impact by causing organizations to change their behavior, but less consensus about how beneficial impact was and whether it led to quality and PI
Wachter RM: Patient safety at ten: unmistakable progress, troubling gaps. Health Aff Jan-Feb; 29(1): The author evaluates the progress in patient safety 10 years after the release of the IOM’s report, To Err is Human. The author grades The Joint Commission’s efforts to improve patient safety as a B+, down from an A in The author cites that although the Joint Commission’s National Patient Safety Goals and use of tracer methodology are effective, they are ill-suited to drive progress in complex, nuanced areas such as culture and communication.
Walshe K et al: The external review of quality improvement in health care organizations: a qualitative study. Int J Qual Health Care 2001 Oct;13(5): The results show that the prospect of external review produced mixed reactions in health care provider organizations, and preparing for such a review was a substantial and time-consuming task. External reviews rarely generated wholly new knowledge, were more confirmatory than revelatory, and did not usually lead to major changes in policy, strategy or practice. The authors conclude that external review systems are widely used in health care to promote quality improvement in health care provider organizations, but their effectiveness is little researched and the optimal design of systems of external review is not well understood.
Walshe K, Shortell S: Social regulation of healthcare organizations in the United States: developing a framework for evaluation. Health Services Management Research 17, 79-99, Includes Joint Commission accreditation under the “regulation” umbrella. Study results show consensus that health care regulation does have a significant impact in that it causes organizations to change their behavior. However, there was less consensus about how beneficial the impact was and whether it led to quality and performance improvement.

33. Sentinel Event Experience to Date
Sentinel events reviewed by The Joint Commission: 1995 – 2010
908 Events of wrong site surgery
804 Inpatient suicides
734 Operative/post op complications
580 Deaths related to delay in treatment
547 Events relating to medication errors
436 Patient falls
360 Retained foreign objects
256 Assault/rape/homicide
209 Perinatal death/injury
201 Deaths of patients in restraints
146 Transfusion-related events
145 Infection-related events
102 Fires
100 Anesthesia-related events
1254 “Other”
= 6782 RCAs
And we also know that even in accredited organizations, sometimes bad things do still happen. The Joint Commission has been collecting data on sentinel events since its policy first went into effect in This slide show the types of errors and their frequency since health care organizations began reporting sentinel events, in 1995, through March As you can see, there have been many sentinel events reported, but it is important to point out that this represents only a fraction of the actual number of events. 33

34. Sentinel Event Alert
From this data we have developed Sentinel Event Alerts, which address a significant error and provide advice on how to prevent the error. Here is a sample of the most recent Sentinel Event Alert, which addresses maternal death.

35. Impact of Accreditation: Some Examples
Medical Records
First required in 1917, many considered the medical record unnecessary
Today the medical record is the central point of information gathering for treatment decisions, research, patient monitoring, outcomes measurement, and even billing
We do know that accreditation does have an impact. For example, the process of JCI accreditation has set many of the fundamental principles that guide health care organizations today. Many of these principles are routine in health care today but were revolutionary in their time. I’d like to provide a few examples.
First required in 1917, many considered medical records to be unnecessary. Today the medical record is inarguably the central point of information gathering for treatment decisions, research, patient monitoring, outcomes measurement, and even billing.

36. Impact of Accreditation: Some Examples
Infection Control Programs
In the mid-1950s, patients, especially surgery patients and newborns, acquired infections in epidemic proportions
In the 1950s, hospitals were required to appoint infection control committees to direct activities aimed at curbing epidemics of infections
Infection control programs were created that reduced the spread of devastating infectious agents
Infection Control Programs
In the mid-1950s, patients, especially surgery patients and newborns, acquired infections in epidemic proportions. At the time, hospitals were required to appoint infection control committees to direct activities aimed at curbing epidemics of infections, and so infection control programs were created that reduced the spread of devastating infectious agents. We know, though, that infections still occur in alarming numbers, so the Joint Commission and JCI continue to focus on helping organizations reduce hospital-acquired infections.

37. Impact of Accreditation: Some Examples
Fire Safety
Non-smoking standards for hospitals were developed due to the adverse effects of passive non-smokers and significant fire hazards
Advance Directives
Protects patients from a life or death they would not have wished
Requires organizations to establish Do-Not-Resuscitate (DNR) standards and request an advance directive from each patient so the individual’s wishes can be documented in the patient chart
In the 1980s only 20% of hospitals addressed this issue; since the implementation of the standard, nearly 100% of accredited organizations are in compliance with the standard
Using fire safety as another example, I’d like to point out that non-smoking standards for hospitals were developed due to the adverse effects of passive non-smokers and significant fire hazards.
And finally, advance directives
Protect patients from a life or death they would not have wished
Require organizations to establish Do-Not-Resuscitate (DNR) standards and request an advance directive from each patient so the individual’s wishes can be documented in the patient chart
In the 1980s, only 20% of hospitals addressed this issue; since the implementation of the standard, nearly 100% of accredited organizations are in compliance with the standard

38. Studies Supporting the Value of Joint Commission Accreditation
Devers, Pham, Liu: Accreditation requirements influenced hospitals’ efforts toward implementing patient safety initiatives, and hospital leaders ranked Joint Commission as most important driver of patient safety
Hosford: Accreditation is effective in driving efforts to reduce errors
Longo et al: Accreditation Improves Patient Safety
We also know of studies that have shown accreditation does have value. For example,
Devers K.J., Pham H.H., Liu G: What is driving hospitals’ patient-safety efforts? Health Affairs 23(2): , 2004.
Hosford S.B.: Hospital progress in reducing error: The impact of external interventions. Hospital Topics 86(1):9-19, 2008.
Longo D.R., Hewett J.E., Ge B., Schubert S.: Hospital Patient Safety: Characteristics of Best-Performing Hospitals. J Healthc Manag. 52(3): , May-June 2007.

39. Value and Impact of Accreditation Study
Conducted with JCI-accredited and non-accredited hospitals in Jordan
Pilot collected and analyzed data related to 6 managerial and economic quality indicators
Results show statistically-significant improvements in the JCI-accredited hospitals on 3 indicators:
Return to ICU within 24 hours of discharge
Staff turnover per year
Completeness of medical records
Total annual savings per accredited hospital = $87,600
In addition, JCI has undertaken a research study with a sample of accredited hospitals to find out how valuable accreditation is. The purpose of this study, conducted with the support of Brandeis University, is to examine the impact of JCI hospital accreditation on selected measures of the value (quality) and economic cost of hospital services. The pilot study was conducted with JCI-accredited and non-accredited hospitals in Jordan. The study collected and analyzed data related to 6 managerial and economic quality indicators.
Results from the pilot study show statistically-significant improvements in the JCI-accredited hospitals (p<0.05) related to 3 indicators:
Return to ICU within 24 hours of discharge—The JCI-accredited hospitals showed a -0.1% decrease in re-admissions, while the control hospitals showed an increase of 0.9% over the study period. The monetary savings per hospital per year were US$34,400.
Staff turnover per year—The JCI-accredited hospitals had a -3.0% staff turnover rate, while the control hospitals had a 13.0% rate. The monetary savings per hospital per year were US$53,200.
Completeness of medical records—The rate of complete medical records in accredited hospitals was 27.6%, while in the control hospitals it was -2.5%.
The total savings per accredited hospital were $87,600 per year.

40. Completed Assessment of Inpatient Transfers
Actual rate of recording of patient’s condition
at assessment
The value of accreditation isn’t proven just in the literature. JCI sees it in the improvements accredited organizations have made. I’d like to share with you some examples from JCI-accredited organizations that have demonstrated improvement in their care.
Clifford Hospital in Panyu has shown improvement in completed assessment of inpatient transfers.
“Qualified Rate”= “Actual Rate”
Clifford Hospital, Panyü, P.R. China

41. Ventilator Associated Pneumonia (VAP)
Three JCI-accredited hospitals in India

42. Unscheduled Acute Care Readmissions
% of unscheduled readmissions within 31 days
for patients with primary Dx of heart failure or related condition
Percentage
This example from a hospital in Italy shows a decrease in unscheduled acute care readmissions.
Santa Chiara Hospital, Trento, Italy

43. So Far So Good
These are individual reports, dealing with segments of hospital operations – Anecdotal accounts
To study it systematically,
One Middle East hospital embarked on a study of the effect of the process, not of the outcome, before and after JCI accreditation
We also have this report from one of our accredited hospitals in the Middle East.

44. Study Details 400-bed Government Hospital Accredited in 2007
Studied before start of project to comply with JCI standards
Repeat study 15 months later (before survey)
Perceptions of stakeholders studied by questionnaires
100-point indices
Hassan, DK & Kanji, GK:
Measuring Quality Performance in Healthcare
Kingsham Press, Chichester, UK

45. Findings of Study
All stakeholder groups reported improvement in every dimension measured
Overall improvement: 49% over baseline
Main Areas of Improvement
Leadership & management
Quality improvement
Patient safety
Pt satisfaction & “delight”
Ethical performance
Documentation
Organizational learning
Organizational excellence
Areas of Lesser Improvement
Corporate structure
Human resources management
Staff satisfaction

46. Accreditation: What Should The Future Look Like?
Considering the studies and evidence that accreditation does have an impact on quality and safety, yet acknowledging the need for additional studies, where should accreditation evolve from here? How should accreditation evolve to truly make an impact on quality and safety?

47. A Revolution in Health Care Delivery
In a recent article in the New England Journal of Medicine, a group of key health care stakeholders in the U.S. representing a variety of organizations, including the Joint Commission, call for a paradigm shift in the current methodology of health care delivery in the U.S. to one involving three key elements:
Standardized Care
Performance Measurement
Transparent Reporting
This shift will require the increased use of evidence-based medicine, rewarding better patient outcomes while encouraging innovation, and closing the gap between established science and current practice.

48. What Should The Future of Accreditation Look Like?
Should it be . . .
Flexible and performance-based?
Able to address issues related to coordination of care from one country to another?
Extended beyond organizations to focus on individual providers?
Able to provide reliable quality data?
Adaptable to improved technologies?
Sustainable?
How do we design the future of accreditation?
Should it be . . .
Flexible and performance-based?
Able to address issues related to coordination of care from one country to another?
Extended beyond organizations to focus on individual providers?
Able to provide reliable quality data?
Adaptable to improved technologies?
Sustainable?
Suggested by an analysis of accountability by Pawlson and Kane in Health Affairs journal.
There have been almost as many suggestions as there have been studies on the effectiveness of accreditation.
The Pomey et al study (Implementation Science 2010) suggests that institutions invest greatly to conform to the first accreditation visit and reap the greatest benefits in the next three accreditation cycles (3 to 10 years after initial accreditation). After 10 years, institutions begin to find accreditation less challenging. To maximize the benefits of the accreditation process, HCOs and accrediting bodies must find ways to take full advantage of each stage of the accreditation process over time.

49. Suggested Principles for Effective Regulation
Improvement focus
Responsiveness
Proportionality and targeting
Rigour and robustness
Flexibility and consistency
In addition, in their article in Health Services Management Research, Walshe and Shortell suggest the following principles for effective regulation:
Improvement focus
Responsiveness
Proportionality and targeting
Rigour and robustness
Flexibility and consistency

50. Suggested Principles for Effective Regulation, cont’d
Cost consciousness
Openness and transparency
Enforceability
Accountability and independence
Formative evaluation and review
Cost consciousness
Openness and transparency
Enforceability
Accountability and independence
Formative evaluation and review
While the authors acknowledge that these principles are merely a first step toward more rigorous evaluation, they do admit further empirical work is needed.

51. Developing the Evidence Base for Accreditation
New accreditation initiatives being introduced without high levels of transparency
Introduce new initiatives as pilot projects that are moved into full-scale implementation with rigorous evaluation
Publish findings—positive and negative—in peer-reviewed journals
Researchers Greenfield and Braithwaite have studied the effectiveness of accreditation for many years, and they continue to stress the need for more empirical evidence, stating in their June 2009 editorial in Quality and Safety in Health Care that a “rigorous, transparent examination of different aspects of accreditation, and publication of the subsequent results, has not become the norm.” They offer suggestions for developing the evidence base for accreditation:
New accreditation initiatives being introduced without high levels of transparency
Introduce new initiatives as publicly-evaluated pilot projects that are moved into full-scale implementation with rigorous evaluation
Publish findings--positive and negative--in peer-reviewed journals

52. Questions to Answer
How do we identify the most effective and efficient framework for delivering quality care and services?
How do we use accreditation to enhance the quality and safety of health care?
How do we sustain accreditation, embedding QI into daily activities?
How do we motivate all staff, particularly physicians?
How do we ensure ROI?
How do we develop health care organizations into high-reliability organizations?
How do we involve patients?
But again, how do we
Identify the most effective and efficient framework for delivering quality care and services?
Use accreditation to enhance the quality and safety of health care?
Sustain accreditation and embed QI into daily activities?
Motivate all staff, particularly physicians?
Ensure our return on investment?
Develop health care organizations into high-reliability organizations?
Involve patients?
Accreditation Canada conducted a study on public awareness of and attitudes toward health care accreditation. 44% of the 1509 respondents indicated familiarity with accreditation, and 68% of these endorsed the value of accreditation, considering it an important assurance of quality service. But the study also highlights the need for accrediting bodies to raise their public profile, as only 20% of the respondents could name organizations involved with accreditation.

53. Moving Forward with Accreditation
What you see here are four different modes of transportation—a wheel, a bicycle, an automobile, and an airplane. What this slide is intended to represent is that all these modes serve the same purpose—to transport—but each mode works differently. Some are more efficient and safer than others. As with accreditation, the essential building blocks are important, but they vary widely, making it difficult to evaluate the methodology.
Just as transportation has evolved into more efficient and safer modalities, so too, must accreditation. We know that accreditation can make a difference in health care quality. Let’s discuss how to evolve it into something even stronger.