An Overview of Accreditation and Certification for Improving Health Service Quality

I. Overview of Accreditation/Certification Models

Accreditation is the assessment of a health care organization's compliance with pre-established performance standards. It is usually a voluntary process linked to incentive systems and part of a more comprehensive quality improvement and assurance effort. Accreditation typically uses external review and assessment of compliance with standards, focusing on organizational rather than individual performance. Although practically all accreditation models reflect these basic characteristics, there are several ways by which accreditation schemes can be tailored to meet the needs of a given programmatic context. It is important to note that certification schemes function similarly but often use internal review bodies and processes. While the model variations discussed in this paper are applicable to both certification and accreditation schemes, we will simply use the term ‘accreditation' ease of reading. Below are descriptions of a range of options in twelve different aspects of the accreditation design and implementation processes.

1. Purpose One of the first steps in designing an accreditation model is to arrive at consensus on the goal of the accreditation initiative. Defining the overall purpose is a prerequisite for determining such things as the potential life span of the accreditation effort. The goal or purpose can range from a relatively short-term promotion of a specific type of service as is done under the Baby Friendly Hospital initiative, to a long-term, institutionalized process that focuses on assuring consistent compliance with quality or regulatory/legal requirements of health care provision. The latter option can be linked to established health insurance (public or private) financing schemes. An intermediate option is an accreditation process that serves as a mechanism to improve performance and service utilization as seen in models like the Egypt Gold Star or Brazil PROQUALI.

2. Incentives Another essential aspect of accreditation is the design of a sustainable, yet meaningful incentive and consequence scheme. Some accreditation models exclusively use non-monetary incentives such as public recognition, performance feedback and skill building opportunities. Others build in additional incentives like provision of equipment, increased operational budgets for the facility or even small monetary rewards. Finally, some models focus on monetary incentives provided through performance-based budget allocations and/or service remuneration systems. The latter are often linked to health insurance finance schemes.

3. Unit of Accreditation While the unit of accreditation may be individual providers, this is often referred to as certification. Another possibility is to grant accreditation to one type of health facility within the health system. For instance, if the overarching objective of the initiative is to strengthen prevention and primary health care, the focus of accreditation is likely to be only on primary care clinics. On the other hand, if the goal was to rationalize use of expensive curative procedures, the unit of accreditation may be hospitals. Lastly, some models include multiple types of facilities in order to ensure an effective continuum of care. The CaliRed initiative for maternal and neonatal health in Guatemala is an example of this option as it accredits quality in health posts, health centers, community maternities and hospitals. It is important to note that even in models that function at the facility or system-level, although individuals may not be ‘certified,' they are often recognized for their contributions to overall quality performance.

4. Range of Services The range of services included in an accreditation strategy can significantly impact its level of complexity and resource requirements. Based on institutional priorities and resource availability, it may be necessary to restrict the process to one type of service or related function. Examples of this focused accreditation approach have been implemented for quality in family planning services, infection prevention practices, or promotion of breastfeeding. Sometimes, however, it is programmatically difficult to completely focus on only one isolated type of service. In the Brazil PROQUALI initiative for example, a core set of quality standards for family planning were complemented by other standards for selected reproductive health services such as cervical cancer control, prevention of STIs, and prenatal care. Another option is to include a comprehensive range of health services or all services provided at a given facility-level (i.e. Canadian Council on Health Services Accreditation).

5. Sectoral Coverage Many accreditation programs in developing countries are restricted to one sector of health care provision be it public, private-for-profit or NGO. For instance, the Guatemalan Ministry of Health has introduced a model that accredits NGOs that provide primary care services. These accredited NGOs receive government financial support that serves to expand coverage in underserved areas of the country. Another option for sectoral coverage is quality accreditation for more than one sector. For instance, in the West Africa Gold Circle accreditation scheme, both Ministry of Health and NGO clinics are assessed and accredited based on one set of criteria. In other instances, different but complementary accreditation strategies may be implemented across sectors using different sets of standards. A third option is to apply one set of criteria and processes across all sectors providing health services.

6. Geographical Coverage Accreditation strategies range from very localized to national scales of coverage. A locally implemented strategy might focus on one or more districts in a select number of provinces. This is particularly appropriate when a particular model of accreditation is first being tested with the intention of scaling-up later. Other models seek greater coverage and implement on a regional, state, or provincial scale. This option is relevant in decentralized environments in which provincial or state units have significant levels of political, technical and administrative decision-making power. Schemes implemented for national coverage throughout a given country may be linked to nationwide health provision and financing schemes.

7. Management An effective accreditation program requires planning and coordination, and technical, administrative, and financial support. These functions could be performed in a centralized way, from just one managerial unit, as in the case of the Gold Star program in Egypt, or in a decentralized manner in which there is a substantial delegation of the managerial functions to the regional, provincial or district level. In the latter case, local authorities (state/provincial secretaries of health, or district/municipal mayors or secretaries of health) assume control of the process or have significant responsibilities and are largely involved in the design, planning, and implementation of the accreditation initiative. The central, provincial, and district levels can also jointly manage the accreditation program.

8. Type of Standards Some accreditation programs focus primarily on inputs and process standards, on outcome standards, or on a combination of both types of standards. Structure and process standards tend to be more detailed, whereas outcome standards are usually less detailed. However, outcome standards are frequently more difficult to assess and monitor, and might not accurately represent the actual quality of care provided. More detailed sets of standards for inputs and processes are typically required when basic infrastructure elements are not in place and the technical competence of the staff is substandard due to deficient pre-service training or introduction of new procedures.

9. Definition of Standards There are a variety of approaches to defining standards. Accreditation standards usually incorporate evidence-based technical norms and protocols. This may happen in a top-down process in which standards are defined at a central level by groups of experts in relevant fields. Standards, on the other hand, could also be developed based on client preferences and definitions of quality as explored through qualitative or quantitative market research methods. This latter approach helps set the stage for increased levels of community involvement and ownership in quality initiatives. Increasingly, however, accreditation standards are developed using a combination of both approaches, with the addition of the front-line provider's perspective. The West Africa Gold Circle and PROQUALI models both reflect this approach.

10. Accreditation Body The group of people who assess level of performance and grant accreditation can be either internal or external to the institution that owns or manages the unit being assessed. Use of internal accreditation bodies is usually linked to institutional supervision structures, and is part of an internal quality improvement effort. However, other accreditation models seek to maximize objectivity of the assessment and use external assessors (e.g. Joint Commission for Health Services Accreditation and ISO 9000). An external accreditation body reinforces the credibility of the process and is particularly suitable for service provision that already operates under sophisticated health management and financing schemes. An intermediate option that increases the credibility of accreditation processes, yet allows for closer follow-up in areas where standards are not met, is an accrediting body made up of a combination of internal and external assessors. When building such a group, one may choose to include university faculty, members of professional associations, or community and civil society representatives.

11. Staffing Planning, coordination, and implementation responsibilities for accreditation may simply be added to existing responsibilities and tasks of a service delivery organization's staff. This is most feasible when the accreditation effort is small in geographic coverage, technically focused, and built upon internal supervision systems. However, when the accreditation program is more complex or an effective supervision system is not in place at the local-level, it is often necessary to have full-time staff dedicated solely to assessment activities. Similarly, external accreditation bodies such as the Joint Health commission use consultants or have full-time staff dedicated to quality assessment tasks. Design of internal accreditation bodies might take a variety of forms depending on the complexity of the accreditation process and the availability of resources. They may use their own staff on a full, part-time or seasonal basis.

12. Process An accreditation process may be limited to the verification of compliance with pre-established standards through an external review and assessment. In this case, if the standards are met, the accrediting body simply grants the accreditation to the facility. On the other hand, if the standards are not met, the reviewers provide detailed feedback on the status of the facility and identified performance issues. Other accreditation processes, in addition to the review and feedback, offer technical assistance on demand in order to overcome the shortcomings identified. Finally, some accreditation models, such as Brazil's PROQUALI and West Africa‘s Gold Circle, provide proactive support and follow-up to help the facilities successfully perform at the level of accreditation standards. Approaches such as facilitative supervision or performance improvement are typically used in this facilitated accreditation process.

Benefits of Accreditation

Experiences in other developing countries have shown that well-designed and implemented accreditation processes usually result in improved quality of health services as defined by predefined standards. In developing countries, this is especially true when the accreditation scheme is integrated into a larger quality improvement and recognition program. In several cases, a significant increase in the utilization of health facilities has also been observed. Better health outcomes such as improved continuation rates for contraceptive utilization are another benefit of accreditation processes that increase client-oriented quality of services.

Accreditation processes also can improve organizational efficiency though the reduction of waste, better staff time utilization, streamlined management procedures. They can have a positive impact on provider motivation and satisfaction, especially when they include an effective combination of non-monetary and monetary incentives. Likewise, client satisfaction levels have shown to improve with the provision of more responsive, effective, efficient and humanized care.

Finally, accreditation initiatives have served to draw the attention of local leaders and decision- makers to the important issue of health. This has in some instances resulted in increased local investment of both financial and human resources to health-related efforts. This particular benefit of accreditation is especially relevant in the context of the decentralization processes currently being implemented in many countries.

Challenges of Accreditation

While there are multiple benefits of accreditation, implementation of an effective scheme presents several challenges, some of them significant. Gaining institutional involvement and commitment is one initial challenge. This is particularly complex when key stakeholders are not fully convinced of the potential benefits or consequences of the accreditation initiative. Reaching consensus on the design of the model to be implemented, on the standards for accreditation, and on the processes to be followed is another usually time-consuming and difficult task that might take a significant amount of time at the beginning of the process. This step can be greatly facilitated, however, if there is consensus and clarity on the purposes of the accreditation effort early on.

The identification of meaningful and sustainable incentives, and the establishment of consequences of performance are also critical and complex aspects. It is not always easy to find the right combination of non-monetary and monetary incentives. Moreover, some incentives can potentially introduce distortions in the provision of health services. For instance, productivity incentives might discourage providers from performing important but time-consuming procedures.

Accreditation initiatives that result in quality of service improvements usually require additional resource investment up front. The total amount of additional resources needed for a large-scale or national accreditation and quality improvement initiative could be significant and sometimes unaffordable. It is extremely important to consider the amount of the additional resources that would be needed and the potential sources of funding at the very beginning of the design phase of the accreditation effort.

The elaboration of practical and simple tools for large-scale replication of the accreditation models, particularly the facilitated accreditation models, is one component in particular that requires a significant time commitment. The development of such tools frequently requires not only technical expertise, but also a critical review of current paradigms of health service provision and quality improvement.

Finally, because accreditation initiatives are usually part of more comprehensive quality improvement and assurance efforts, they frequently imply some substantial organizational changes. In order to achieve the goals of any accreditation program, it is critical that people in positions of leadership demonstrate a steadfast commitment to a larger vision of quality and have the ability to successfully manage complex change processes.

Options for Accreditation Model Design and Implementation

References

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