From International Journal for Quality in Health Care

Sustainable Healthcare Accreditation: Messages from Europe in 2009

Charles D. Shaw; Basia Kutryba; Jeffrey Braithwaite; Michal Bedlicki; Andrzej Warunek

Authors and Disclosures

Posted: 12/10/2010; International Journal for Quality in Health Care. 2010;22(5):341-350. © 2010 Oxford University Press

Abstract and Introduction

Abstract

Background. Healthcare accreditation has grown rapidly since the 1980s but critics question the value of accreditation rather than certification or inspection. Research has focused more on evidence of impact on provider institutions than on health systems; little has been published on the determinants of growth or decline of accreditation organizations and programmes.
Objective. To describe the development of national accreditation organizations in Europe in relation to incentives, funding and market position in 2009; to identify trends over time using data from previous surveys.
Methods. Contacts in 24 countries, identified by previous surveys, were invited to complete a web-based questionnaire comprising 183 items seeking numerical data or posing multiple choice options. Preliminary results were verified with respondents and agreed for publication.
Main Outcome Measures. National healthcare environment, incentives, government policy, legislation, regulation; programme governance, development, funding.
Results. The survey identified 18 active national accreditation organizations in Europe. Older ones tend to be independent, profession-dominated and self-financing; they have shown little growth in activity and coverage of the potential market. Newer ones have broad stakeholder governance, support from government policy and growth sustained by legal or financial incentives—giving wide coverage across the healthcare system. The traditional collegial model of accreditation is moving towards a semi-regulatory model of external assessment which could integrate minimal standards of licensing, public safety and accountability with aspirational standards for organizational development and improvement.
Conclusions. The principal challenges to sustainable accreditation appear to be market size, consistency of policy support, programme funding and financial incentives for participation.

Introduction

The growth of healthcare accreditation programmes accelerated globally in the 1980s^[1] and in Europe in the 1990s^[2] as regional and national strategies to improve the quality of health care. The earliest programmes were based on the North American models of the Joint Commission on Hospital Accreditation (now expanded to cover healthcare organizations) and the Canadian Council on Hospital Accreditation (now Accreditation Canada). They were initially hospital-focused, profession-driven, voluntary, self-financing and essentially non-governmental. The past fifteen years have seen an increasing emphasis on primary care, networks, health systems and regulation—driven largely by national and regional governments and international donor agencies. Many accreditation programmes, for political, economic or technical reasons, have failed to meet initial expectations but others have flourished.

Critics question the impact and value of investing in accreditation^[3] as compared with certification or inspection regimes. Enthusiasts look for technical solutions to make accreditation more robust, credible and consistent across borders. Research attention has focused more on evidence of impact on quality and safety in provider institutions^[4] than on stewardship of health systems. Publication bias has favoured analysis of successes, rather than the (relative) failures which governments, technical agencies and international donors rarely cherish as a learning opportunity to be shared.

This paper reports on a collaboration of programmes in Europe to meet the challenge for 'accreditation agencies to publish research and findings, both positive and negative, in the peer-reviewed literature'.^[5] It asks about the seed of accreditation and its relationship to the soil of the health system, and defines some apparent determinants of sustainability.

Section 1 of 6

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Table 1. Accreditation organizations active in Europe, April 2009

Country	Type	Origin	Programme	Website
Albania	G	2006	Albanian Accreditation Programme	qkcsaish.gov.al
Bosnia FBiH	M	2004	Accreditation programme for health institutions and family medicine teams (AKAZ)	akaz.ba
Bosnia RS	G	2002	Agency for Accreditation and Health Care Quality Improvement of Republika Srpska (AAQI)	aaqi.rs.ba
Bulgaria	G	2000	Accreditation of Healthcare Establishments
Czech Republic	I	1998	Spojená akreditační komise (SAK)	sakcr.cz
Denmark	M	2002	The Danish Healthcare Quality Programme (DDKM)	ikas.dk
Europe	I	2000	Joint Commission International, Europe (JCI)	jcrinc.com
Finland	I	1993	Social and Health Quality Service (SHQS)	qualitor.fi
France	G	1997	Accreditation Program for HCOs Haute Autorité de Santé (HAS)	has-sante.fr
Germany	I	2001	Kooperation für Transparenz und Qualität im Gesundheitswesen (KTQ)	ktq.de
Hungary	I	2006	Institute for Healthcare Quality Improvement and Hospital Engineering	emki.hu
Lithuania	G	2009	Accreditation programme for healthcare institutions	vaspvt.gov.lt
The Netherlands	I	1998	Netherlands Institute for Accreditation in Healthcare (NIAZ)	niaz.nl
Poland	G	1998	Program Akredytacji (NCQA)	cmj.org.pl
Serbia	M	2005	Agency for Accreditation of Health Care Institutions	azus.gov.rs
Spain	I	1996	FADA-JCI	fada.org
Switzerland	I	2001	SanaCERT Suisse	sanacert.ch
UK	I	1989	CHKS Accreditation	chks.co.uk

G, 'government' (managed within Ministry of Health or separate government agency); M, 'mixed' (independent agency with government representation); I, 'totally independent'.

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Table 2. Accreditation organizations in Europe becoming inactive since 1997

Country	Type	Origin
Portugal	G	1999	National Healthcare Quality Institute was dissolved at the end of 2006; programmes transferred to the General Directorate of Health January 2009 pending new law
Ireland	G	2002	Irish Hospitals Accreditation Board (establishment order 2002) ceased operations in 2008 in preparation for transition to a licensing programme under Health Information and Quality Authority HIQA
Croatia	G	2003	Programme ceased with a change in government policy. Now recommenced
Latvia	M	1997	Conformity assessment of healthcare organizations mandatory for healthcare organizations in anticipation of voluntary accreditation
Slovakia	G	1999	Centre for Quality and Accreditation in Healthcare financed by MoH

G, 'government' (managed within Ministry of Health or separate government agency); M, 'mixed' (independent agency with government representation).

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Table 6. Use of external sources in accreditation standards

Country	Licensing	Other legal	National advice	EC guidance	WHO guidance	ISQua principles
Albania			x		x
Bosnia FBiH						x
Bosnia RS	x	x				x
Bulgaria	x
Czech Republic	x	x			x	x
Denmark		x	x			x
Finland		x	x			x
France		x	x			x
Hungary			x			x
Lithuania	x
The Netherlands		x	x		x	x
Poland			x	x	x
Serbia						x
Spain		x	x
Switzerland	x
UK	x	x	x	x	x	x
Total	6	8	9	2	5	10

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International Journal for Quality in Health Care. 2010;22(5):341-350. © 2010 Oxford University Press
Copyright 2007 International Society for Quality in Health Care and Oxford University Press

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