Debate on Healthcare Accreditation (Against)

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Table of Contents

Introduction
History of the accreditation system
The Debate
Reasons for accreditation to be done by an external body
Alternatives to accreditation
Benefits of alternatives over accreditation
Six sigma
The European foundation for Quality Management (EFQM) Excellence model
Personal reflection
References

Introduction

Health care accreditation is defined as the formal process instituted by a recognized body with an aim of assessing and recognizing that an organization in the health sector meets the laid down standards (Rooney, A. and Ostenberg, V., (1999, p.3). The accreditation process is carried out mainly by the nongovernmental organization and is biased against preset and published standards in a given country (Braithwaite et al, 2006, p. 2) According to Wennberg (1991), accreditation has become a useful tool in the establishment of national-level standards important in enhancing uniformity in health care practice. This essay will look into the history and aim of accreditation, debate against the accreditation, and give possible alternatives as discussed by the team.

History of the accreditation system

Accreditation started with the setting of minimum standards for hospitals, which was done by the American College of Surgeons (ACS). It started with five standards which were mainly concerned with medical autonomy, medical record,s and availability of technical and scientific resources. Several improvements took place until the ACS transferred the standardization program to the joint commission on accreditation of hospitals to the Joint Commission of Accreditation of Hospitals (JCAH). There was a shift from minimum to optimally achievable standards in 1970. In 1987 JCAH changed to the Joint Commission on Accreditation of Health Care Organizations (JCAHO). Joint commission international was later formed with the mandate of accreditation in several continental blocks where more than 200 standards are in use (Suñol, Nicklin, Bruneau and Whittaker 2009, p.1). The main aim of accreditation was to improve the overall performance of health care institutions by ensuring adherence to recognized standards and improved quality health care (Roberts, Coale, and Redman, 1987).

The team composed of managers from different departments in the Ministry of Health has been looking into the viability of the accreditation process as a quality improvement benchmark. The aim of this paper is to prove why accreditation will not work for the health care organization. Accreditation will not work for the organization because of the high cost, resistance from managers, and the lack of evidence that it works. This stand will be supported by concrete arguments and evidence in order to prove beyond doubt that accreditation does not lead to improved quality health care.

The Debate

Accreditation has many advantages for the utilization of resources in terms of personnel, money, and time. It also acts as a source of advice for long-term strategies which can lead to the cost-effectiveness of health care management. Teamwork is encouraged due to the common desire for the achievement and maintenance of the accreditation status. However, the team thinks effective resource utilization cannot be achieved by merely acquiring accreditation status. According to Viswanathan and Salmon (2000, p.11), the financial cost and the time the organization has to set aside for this procedure are issues that are having major implications in the health care provision. Most hospitals find themselves facing the dilemma of losing on financial reimbursement or enhancing the quality of care in tandem with the requirements of the accreditation team. This forces some to opt for other standards such as ISO 9000. The frequent change of nomenclatures, nature and the processes related to accreditation has brought problems ineffective management of the whole process.

Accreditation is prone to manipulation, particularly where outcome measures are selected by the various providers. This puts into disarray the notion that accreditation ensures cost-effectiveness and quality care because a common tool is not in use in gauging these outcomes. According to Ovretveit (2001) and Shaw (2000, p.174), there is a lack of evidence on cost-effectiveness due to the limited number of evaluations that have been completed. It is believed that only a limited number of organizations have made improvements in achieving this (Suñol, Nicklin, Bruneau and Whittaker 2009, p.27). The team finds it unnecessary to implementation of accreditation programs that are not well monitored and evaluated in a bid to unearth their potential and progress.

The team strongly believes accreditation also serves to deny the patient his/her basic right through an overemphasis on quality enhancement process instead of directing it inpatient care (Shaw, 2000). The team asserts that teamwork and effective resource mobilization cannot be achieved and maintained through accreditations. This is because the organizations need to have dedicated members or management teams with the passion to serve for the betterment of the institution.

Whereas accreditation may elicit wider acceptance from senior officials and enhance the motivation of the staff, the team notes that implications to management and staff in poorly run systems are far-reaching. Its acceptance has been derailed by the persistence of resistance to change owing to prevailing circumstances of locality and size of the health care organization. The team believes the unacceptability is due to the requirements of advanced training for staff in such organizations (Rooney & Ostenberg, 1999). The risk of losing one’s job due to limitations in attaining higher education and competitiveness in the health workforce makes accreditation an unfavorable consideration to many people. The need to improve or change the systems and processes to meet the set standards and their associated implications is a deterrent to acquiring this status. The team believes the cost associated with acquiring the status is disproportionately large particularly to small organizations. This adds up to the resistance since these small organizations might see a wider scheme by the bigger institution to lock them out of the health care business. Risk to morale and fear of losing revenue are other reasons that make accreditation unnecessary to the health care systems (WDG proprietary document, 2006, p.3).

The team also notes that there is no strong evidence to show the effectiveness of accreditation in the improvement of quality in-hospital care (Shaw, 2000). The implementation of the same standards in different places produces dissimilar results owing to other indirect factors such as financial management. The implementation is also affected by the prevailing conditions in the organization especially policies and other guidelines. Hirose, Imanaka, Ishizaki, and Evans (2003), asserts that the disparities that exist between the private and public hospitals in their overall running, and the wider gap that exist between rural and urban health facilities in terms of a number of staff and quality of medicare cannot be eliminated through accreditation. Braithwaite et al., (2006) showed how there is no consistent relationship that exists between clinical performance and accreditation of organizations. Although the team believes there are mechanisms for measuring the outcomes, it actually notes that the management of these organizations lacks the means of linking them to other indicators.

Accreditation has mixed effects on the public, staff, and management. This is due to the cost and the time associated with the adoption of the predetermined standards. The public benefits from regular publication information on the quality of health care which was inaccessible before that. This is due to the competition witnessed amongst the care providers. There are also assurances on the quality of health care services particularly if there are several accreditation bodies. This sets a foundation and acts as an impetus for improvement on quality assurance thus ensuring the patients enjoy the best services always. Nevertheless, accreditation may lead to a conflict of public accountability expected from institutions pertaining to the conduct of medical practitioners (WDG proprietary document, 2006, p.1-4).

According to Shaw (2000) and McAlery (1991), the patient is not assured of better services since there lacks a convincing link that accreditation increases the performance of organizations. The voluntary nature and the setting of low minimum standards expose the patients to low-quality services because only large organizations which serve high-end clients seek accreditation. Provision of low-quality services to the public is also perpetuated by lack of transparency in the process and inadequate oversight of the accrediting organizations (WDG proprietary document, 2006, p.1-4).

The staffs also suffer the brunt of accreditation in their organization since they are required to undergo further training in order to meet the minimum qualifications. According to Rooney and Ostenberg (1999), the staff is supposed to comply and adhere to the applied standards. However, the staff benefits from improved working conditions and efficiency that is a prerequisite for accreditation. The team believes that additional work and the strict observance of the laid down standards leave the staff exhausted.

The management is very upbeat about the expected improvement in production and image of the organization. The organization gets the permit to start receiving payments of approved higher status from insurance schemes. However, the manager is also faced with the stress of sourcing funds to meet the cost of acquiring new equipment, loss of revenue and reputation, and training of staff to maintain the status. Most managers feel that the cost associated with accreditation is high and may end up benefiting only the large-scale health providers (WDG proprietary document, 2006, p.1-4).

Reasons for accreditation to be done by an external body

The accreditation process should be left to an independent external body to avoid manipulation of the results in the favor of certain organizations. This ensures there is uniformity in the application of the standards (Rooney, A. and Ostenberg, V., 1999). It’s also pertinent the autonomy of the body to ensure fairness and credibility of the institutions that have received the status and also ensure uniformity of the process. Moreover, this should be done to safeguard the rights of patients who may become misguided by unreliable information from the institutions claiming to have achieved accreditation.

Alternatives to accreditation

The accreditation process is not the only way of ensuring the delivery of quality health care in hospitals. There are other alternatives which include Six Sigma, The European Foundation for Quality Management (EFQM) Excellence Model, International Organization for Standardization (ISO), external peer review program (ExPeRT), Visitatic Peer Review System, and Audit. ISO is an accreditation process that is commonly used in industries (Shaw, 2000, 169-175). It mainly concentrates on ensuring that organizations have sound, documented processes that are intended to improve the quality of the product so that it meets the requirements of the consumer.

Benefits of alternatives over accreditation

The alternatives such as EFQM offer some benefits over the accreditation system, particularly in the health care sector. The simplicity of its applicability to existing management practices has helped small organizations to gradually improve their quality in management. This gives them the choice in the speed of its execution unlike in the accreditation system. The cost associated with these quality improvement models is low and hence attractive to the managers. According to Nabitz, Klazinga, and Walburg (2000, p.9), the EFQM approach offers the managers of health care institutions an attractive tool that does not require them to invest heavily. Its reliance on self-assessment gives it an edge over the accreditation system where the assessment is carried out by external bodies. The emphasis on organizational changes and innovation is another advantage the EFQM approach offers to health care institutions. This saves them time and money that could have gone into improvements of organizational structures as in the accreditation system. The alternatives are also better approaches when managers are interested in integrating quality management concepts in their organizations since these models do not delve into matters of clinical excellence (Nabitz, Klazinga, and Walburg, 2000, p.9).

Six sigma

Six Sigma is defined as a total management commitment and philosophy of excellence in customer focus, improvement of process, and the rule of measurement. It is mainly concerned with ensuring that every sector affiliated with the organization is bettered in order to address the customers’ ever-changing needs. It ensures that benefits are enjoyed by all stakeholders (employees, shareholders, and consumers). The six sigma idea was started by Bob Galvin who initiated the development of a quality program to improve the manufacturing operations of Motorola. Critics argue that the Six Sigma method was mainly focused on reduction of errors and defects experienced during the manufacturing process due to its over-reliance on statistical language. According to Freedman (2009), the method has evolved from being a statistical quality control to a philosophy that is more customer-focused. Six Sigma is based on six themes. These themes include customer focus, data, and fact-driven, processes are where the action begins, pro-active management, boundary-less collaboration, and the drive to release perfect end products. Six sigma has some features which made it more unique from previous initiatives. These features include an emphasis on strong and passionate management leadership and the use of verifiable data in making decisions. In order to optimize in their operations, organizations using the Six Sigma program need to change their corporate culture, systems and processes and in the way the staffs think. The Six Sigma program need s a lot of patience before its fruits can be quantified. For instance, an improvement in admissions and discharge processes was observed in about 90% of American hospitals that embraced Six Sigma program as the method of choice in quality improvement. This was a clear indicator of its applicability and a big boost to the health sector considering the increased push for cost effectiveness in delivery of health care in the United States (Freedman, 2009, p.1-5).

The European foundation for Quality Management (EFQM) Excellence model

The European foundation for Quality Management (EFQM) Excellence model has gained widespread acceptance in Europe. According to EFQM (2003), membership to EFQM stood at 800 organizations spread all over the continent. Its main aim is to assess organizations in a bid to improve them thus enhancing their growth and sustainability. The excellence model is basically led by several intertwined concepts which are put into practice to bring out desired benefits. These fundamental concepts include result oriented approach, customer focused approach, efficient leadership with constancy of purpose, management through coherent processes supported by solid facts, actualization on staff development and involvement, continuous learning to boost innovation and improvements in operations. Others include partnership development and acknowledgement the importance of corporate social responsibility in business modeling (EFQM, 2003). The EFQM model has gained popularity in health care institutions in Europe and in particular in Netherlands (Nabitz, Klazinga and Walburg, 2000, p.1).

Accreditation will not work because of the high cost and effort required to achieve the status. The lack of evidence that accreditation leads to improved performance and quality improvement is another factor that stresses this notion. Further more, the team believes its limited acceptability by health managers due to its cost implications should make the policy makers go back to the drawing board and come up with other suitable ways of improving quality in health care institutions. The team therefore is in disagreement that accreditation works towards improvement of performance in health care institutions. The other models of quality improvement offer the right approach and replacement of the accreditation system (RCSI Institute of Leadership, 2000).

Personal reflection

Team work is the most interesting learning scenario that helps cement ideas and facts while at the same time creating a plat form for identification of strengths and weaknesses in the members. According to Beblin approach, understanding of ones roles and strengths in a group setting is important in improving the overall performance of the team. My own experience with the team involved in the accreditation debate provided an insight into my strengths and weaknesses. This helped me find ways and advice on how I could better my participation in the team. In my personal reflection, I will discuss challenges in a group assignment, team working and how my learning changed as a result of the debate and the joint assignment.

Working in a group is a good learning approach that can ensure that vital skills are learnt. These communication skills are later transferred to the work place. However, many challenges are encountered during group discussions and assignments. The group is usually faced with challenges from the start to the end of the assignment. Participation by group members is not equal. This is usually brought about by the culture in learning institutions where emphasis is given to individual work thus making students to adapt to working separately. Individualism is also due to competition amongst students where success is measured by the number of passes a student. For instance, a certain student in a group may think that involvement in discussion will result in sharing vital knowledge which may benefit other members or rivals. This leads to the students becoming passive resulting in dormancy in the discussion. Allocation of time that is convenient for all group members is another impediment to its success. Multitasking by students ensures little time is available for activities that lack or fail to show immediate benefits to them (Mind Tools, u.n).

In 1972, Steiner stated that the kind of task given to a group may be inappropriate as a group assignment. This results to scenario where the students piece several parts of literatures together and then submit in order to meet the deadline. Lack of having the same understanding of the questions or the task at hand is another reason associated with group malfunction. The students become embroiled in heated arguments over the interpretation thus losing much time that could have been used on other useful tasks.

Group assignments are instrumental in instilling team work, conflict resolution skills and presentation skills. Challenges encountered during team work include lack of cooperation and discipline in members, laziness and unwillingness to change (Indiana University, u.n). Lack of discipline in members may be manifested through inattentiveness and failure to listen to others opinions. According to Belbin, team roles are important in enhancing overall performance of the team. The team performance is compromised when some of the roles are not effectively handled leading to the goals of the team not been met. A diversified group produces the best team work since this is a different role for every member. Beblin noted that a balanced team is paramount in ensuring successful completion of a task.

I was able to learn to cooperate and be disciplined especially when it came to time management so as to ensure smooth an timely completion of the task. I also acquired skills in listening, talking, presentation an articulation of points to support our argument in the debate. I was able to learn that my strong point was in coordination of the team while my weakness was in the presentation of the points. The debate also helped me learn to back any claim with evidence in order to convince the opponents and the judges.

In conclusion, I believe continuous involvement of students in group assignments and team work is good in instilling skills important in succeeding in the work place.

References

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Freedman, Rick (2009) Six Sigma Changing Organizations for the Better. Tech Leadership, Vol. 6, No. 1-5.

Hirose M, Imanaka Y, Ishizaki T and Evans E.2003. How can we improve the quality of health care in Japan? Learning from JCQHC hospital accreditation, Health Policy, Vol. 66, pp. 29-49.

Indiana University. u.n IPSP Module Series. Web.

McAlery B. (1991). The reliability and validity of hospital accreditation in Australia. Journal of Advanced Nursing, Vol. 6, pp.409-11.

Mind tools. (u.n) Beblin role models. Mind Tools Ltd. 2010. Web.

Nabitz, Udo, Klazinga, Niek and Walburg, Jan. 2000. EFQM excellence model in HC, Euro & Dutch Experience. International Journal for Quality in Health Care, Vol. 12, No. 3, pp. 191-201.

Ovretveit, J. 2001 Quality evaluation and indicator comparisons in health care. International Journal of Health Plan Management, Vol. 16, pp. 229-241.

RCSI Institute of Leadership. (2000) EFQM and CQI. Rotterdam, RCSI Institute of Leadership.

Roberts, J., Coale, J. & Redman, R. (1987). A history of the joint commission on accreditation of hospitals. Journal of American Medical Association, Vol. 258, No. 21.

Rooney, A. & Ostenberg, V., 1999. Definitions of licensure, accreditation and certification. In: Quality Assurance Project: Licensure, Accreditation and Certification. Center for Human Services, Vol. 3.

Shaw, CD. 2000. External quality mechanisms for health care: summary of the expert project on Visitatie, accreditation, EFQM, and ISO assessment in European Union countries. International Journal for Quality in Health Care, Vol. 12, No. 3, pp. 169-175.

Shaw, C. D. (2001). External assessment of health care. British Medical Journal, Vol. 322, pp. 851-854.

Steiner, I. D., 1972, Group process and productivity. New York: Academic Press.

Suñol R, Nicklin W, Bruneau C and Whittaker S. 2009. Promoting research into Healthcare accreditation/external evaluation: Advancing an ISQua initiative. International Journal for Quality in Health Care, Vol. 21, No. 1, pp. 27–28.

Viswanathan, H. and Salmon, J. 2000. Accrediting Organizations and Quality Improvement. American Journal of Managed Care, Vol. 6, No. 10, pp. 1117-1131.

WDG proprietary document. 2006. About Accreditation. Web.

Wennberg, J. 1991. Unwanted variations in the rules of practice. Journal of American Medical Association, Vol. 265, pp.1306-1307.

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