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- Introduction
- Defining Accreditation
- International Developments
- Key International Principles for Standards
- Accreditation for Accreditors
- Getting Started with Accreditation
- The ALPHA Council
- Accreditation as a Global Movement
- Notes
- Terminology
- References
Introduction
Across the world, quality has rapidly emerged as a central concern of health care policy makers and service providers. A range of methodologies is being implemented to assure quality in health care delivery and, with increasing frequency, to meet the health service accountability requirements of funding providers.
Different countries and groups have adopted diverse approaches in their commitment to high quality in health care. Some approaches have been very formal and have been linked to funding provisions. For example, several countries have made accreditation by external bodies mandatory in order for health care facilities to qualify for public health funds.
There are growing consumer expectations too and increased focus on reducing error and improving the safety of health care. Many countries or regions are now involved in setting standards for different types of health care organisations and services. Such activities appear to be growing rapidly and continuously.
In addition to setting standards, various approaches to determining compliance with standards are also being examined and implemented. Accreditation, as one of these approaches, is a method that is receiving considerable attention.
This paper covers some of the evolution of accreditation of health care services into the international arena through the work of The International Society for Quality in Health Care (ISQua).
These developments have happened over the past four years through careful consultation with the leading national healthcare standards and accreditation organisations in all regions of the world.
Defining Accreditation
Accreditation is a self-assessment and external peer review process used by healthcare organisations to accurately assess their level of performance in relation to established standards and to implement ways to continuously improve the healthcare system.
ISQua definition: Federation Operating Rules 1998
In the health care accreditation process, compliance with pre-determined, acceptable standards is verified by a team of external reviewers, generally called surveyors. Self-assessment (the process of measuring one’s own performance against standards) may or may not occur in addition to assessment by external reviewers.
Generally, however, self-assessment is regarded within the discipline of accreditation as a critical first step. It gives an organisation the opportunity to undertake a structured and comprehensive assessment of its performance, improve the efficiency of its operations, enhance staff morale and teamwork and demonstrate to the facility’s peers and the public a conscious and active effort to maintain high professional standards of care.
Accreditation is an on-going process and accreditation visits are made to health care organisations at regularly scheduled intervals. While it is most often characterised as voluntary, there are increasing expectations of the accreditation process by governments.
The process of making the evaluation of health organisations more consistent and accurate is being regularly reviewed. While there is some evidence of part-convergence between some methods by which services are formally evaluated, accreditation remains one of the few and most effective ways for health organisations to examine the quality of their services and, through reports and recommendations, to subsequently continue to improve their performance.
Accreditation first emerged in the United States in 1917. Initiated and driven over many years by the American College of Surgeons, it reflected the interests of professionals in improving the quality of health care and the health care system in which they worked. Links with the American College of Physicians led to a more free-standing national accreditation organisation in the early 1950s. Strong Canadian and Australian accreditation systems also emerged in these years.
Over time, the emphasis of the accreditation process has significantly shifted. In more recent years, with the increasing privatisation of health services across the world, many countries have increasingly demanded assessment of the performance of services. The new users of the accreditation process are now governments and health care purchasers, ie, mainly insurance groups and individual consumers themselves, in the non-government sector. These groups depend on accreditation to demonstrate compliance with national standards.
International Developments
In various forums, the question of "who assesses" or "who certifies the accreditors?" has often been raised. National health care accrediting bodies themselves have expressed interest in having access to external, independent, peer assessment mechanisms which could certify that their activities comply with agreed international standards and criteria for the accreditation process.
The feasibility of aligning health care standards and accreditation processes internationally, and how this might be managed, was addressed by a Sub-Committee of (ISQua). This special task group was established in March 1997 when ISQua confirmed it wished to lead efforts in establishing an international accreditation council.
The Sub-Committee then:
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In its consultations about the international alignment of health care standards and accreditation processes, the Sub-Committee also considered whether, if such alignment was desirable, ISQua could be the umbrella organisation under which this might occur.
A draft Feasibility Paper was circulated in August 1997 to a wide list of contacts. Comments were collated and over 130 people representing 42 countries were present for the Chicago Accreditation Symposium in late 1997. The ISQua Sub-Committee indicated that the new directions and mechanisms described in that paper would deliver far-reaching strategic and practical benefits.
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The Chicago Accreditation Symposium endorsed the plan for ISQua to establish an International Accreditation Federation and Council, as had been proposed, to finalise core international principles to underpin the national standards of health care accreditation organisations and to develop an international peer assessment process for these organisations.
Since 1994, ISQua had been hosting an annual accreditation symposium in association with its international conference program. From an initial exchange between various national health care accreditation organisations, interest in aligning health care standards and accreditation processes internationally developed significantly. With the continuing collaboration of these bodies, ISQua has emerged as a global entity with an international framework of principles and a peer assessment programme for national accreditation organisations that has gradually become defined as "accrediting the accreditors". These plans continue to be strongly endorsed by organisations in the accreditation field. The project has become known as ISQua’s Agenda for Leadership in Programs for Healthcare Accreditation, ALPHA, which was launched in April last year.
A range of support services is being implemented to allow national bodies to participate in these processes. ISQua is also committed to ongoing and formal review of the ALPHA programme.
Key International Principles for Standards
In formulating standards for health care services, most countries, and even regions within countries, create what is best suited to their individual needs at any given time. Most standards are also strongly based on what is deemed to be acceptable practice by those who will ultimately use them.
Since countries/regions are highly diverse and the development of their health care systems differs greatly, it was decided that ISQua should develop an international framework of principles that could be used to help guide the development and refinement of specific standards in use by various accrediting bodies. These principles would need to apply regardless of the state of evolution of standards over time.
ISQua’s ALPHA programme is now using this core set of principles that must be adhered to within the accreditation standards set by an accreditation body. These standards must also be developed, implemented and reviewed in a planned way in consultation with the health care industry.
Eligible accreditation bodies can now seek to have their national accreditation standards assessed in relation to the internationally agreed principles:
- Key concepts which underpin all standards regardless of how their content is presented should be required. Such concepts might include:
– A standards focus
- Accountability of health care providers
- Management
– Outreach. - The type of standards is clearly defined. These would include:
– Structure standards
– Process standards
– Outcome standards. - The scope of standards is clearly defined.
- The content of standards is comprehensive and clearly structured:
– Basic structure standards
– Departmental/functional standards
– Client/patient care focus. - Standards are formulated through a well-defined process.
- Standards are amenable to measurement of performance.
Accreditation for Accreditors
Health care accreditation bodies may now apply to ISQua to be internationally accredited.
National accreditation organisations can now be accredited after being independently surveyed and evaluated against approved international standards and expectations of performance for national health care accreditation bodies.
This process will always include the assessment of the organisation’s accreditation standards according to the principles summarised above.
ISQua’s ALPHA programme is the only global assessment and accreditation programme available to leading national standards and accreditation bodies in the health care sector. The survey framework and international standards were developed through active consultation with accreditation bodies and a pilot peer assessment programme carried out over several years.
Successful international accreditation of an accreditation organisation gives it credibility as a standards and monitoring body, confirms it as a quality organisation, reassures its clients, funders and policy makers that it has sound and consistent systems and processes and provides worldwide recognition of its achievement in the health care sector.
When an accreditation body meets the full requirements of the peer assessment process, the ISQua Executive Board will approve its accreditation and issue a certificate to this effect. This certificate of accreditation may be displayed for an agreed period, usually for four years.
ISQua is committed to promoting the ALPHA programme of assessment of standards and accreditation services and the names of successful accreditors. The programme will be promoted throughout the health care industry worldwide and to governments.
The peer assessment process is similar to the stages used by most national accreditation organisations. It includes:
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The comprehensive set of 10 standards for accrediting organisations covers:
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A full glossary of terms has also been prepared.
Getting Started with Accreditation
A commitment to providing support services for new and emerging health care standards and accreditation projects has been integral to ISQua’s work in developing these high level activities.
For example in Dublin in mid-September, ISQua will host the 7th International Accreditation Symposium as a pre-conference event associated with ISQua’s 17th International Conference. Programme content for both meetings will include guidance for new and emerging accreditation bodies.
New and emerging groups are asking for guidance on gaining interest and support, governance arrangements, developing the standards and accreditation process and defining critical success factors. ISQua is continuing with plans to develop services to help with these.
The ALPHA Council
Established accreditation organisations are institutional members of ISQua and are also full members of ISQua’s Accreditation Federation. A council of elected federation members reports to ISQua’s Executive Board and oversees the ALPHA programme. Current Alpha Council members represent each of the following organisations:
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The Council is chaired by Ms Barbara Donaldson, Quality Health New Zealand, and includes representatives from the World Bank and the International Hospital Federation. The Council also has a global liaison link with the World Health Organisation.
Accreditation as a Global Movement
In some countries, only one main accreditation programme for health care services can be identified while in others several accrediting organisations may be operating in parallel. Some have a specialised focus such as primary care, physiotherapy practices, rehabilitation services or to accredit services which aim to meet specific needs. In the UK, for example, a new organisation, United Kingdom Accreditation Federation (UKAF) is being developed to draw together the mutual interests of more than 30 accreditation organisations.
Along with the established organisations which are part of the ALPHA programme, ISQua is aware of new and emerging health care standards and accreditation programmes in several countries and related activities in many others. Among these are the Bahamas, Bangladesh, Belgium, Brazil, Chile, Colombia, Denmark, Egypt, France, Germany, Hungary, Indonesia, Ireland, Italy, Malaysia, Mexico, Norway, The Philippines, Poland, Russia, Saudi Arabia, Slovakia, Sweden, Switzerland, Syria, Taiwan, Thailand and Zambia.
ISQua has several other projects in addition to ALPHA. Another significant undertaking addresses indicators of clinical performance and the feasibility of establishing an international framework for such indicators. Principles for these indicators have already been drafted. Indicators are strongly linked to expectations of accreditation programmes but governments also need them. Along with its links to accreditation bodies, ISQua is currently seeking input on specific requirements from governments. These may be met through an international structure with performance benchmarks.
ALPHA’s development so far has been built on several years of effort and is a tribute to the generous advice and commitment of resources from many organisations and health care leaders representing accreditation interests in countries across the world. They have collaborated in finalising and endorsing ISQua’s international efforts.
Notes
More information about ISQua, ALPHA and other ISQua initiatives, including membership, publications and conferences, may be found on ISQua’s web site at: http://www.isqua.org.au/. Enquiries can also be faxed to ISQua (+61 3) 9417-6851 or by e-mail to: isqua@isqua.org.au.
ISQua publishes the International Journal for Quality in Health Care. This peer-reviewed publication makes activities and research available to a worldwide readership. A special issue published in June 2000 on "external evaluation of health care" is a landmark publication. ISQua also publishes the ALPHA Agenda which covers international accreditation issues. Additional copies of these publications are available. Contact ISQua for more details – see references below.
Terminology
Accreditation body is "the organisation responsible for the accreditation program and the granting of accreditation status" (Glossary, ALPHA Standards). Alternatives are accreditation organisation, accrediting organisation.
Accreditation Federation is "an international non-governmental, voluntary, professional federation of accreditation organisations and interested associates, as a committee/special interest group" of ISQua (Operating Rules).
Peer assessment is "a process whereby the performance of an organisation, individuals or groups are evaluated by members of similar organisations or the same profession or discipline and status as those delivering the services" (Glossary definition ISQua Accreditation Standards).
References
- ALPHA Agenda, International Society for Quality in Health Care, Vol 1:2, May, 2000
- External evaluation of health care, International Journal for Quality in Health Care, Vol 12:3 Special issue, June 2000
