Virginia Mumford

ALL over Australia, acute, primary and aged care services undergo assessments by external surveyors from a variety of accreditation schemes against pre-approved standards.

Accreditation is required for all hospitals since the recent introduction of the National Safety and Quality in Health Service Standards, and has been a prerequisite for federal funding for aged care facilities since the Aged Care Act 1997.

For primary care, accreditation is voluntary and measured against standards developed by the Royal Australian College of General Practitioners. Accredited practices can qualify for a variety of incentives under the Practice Incentives Program (PIP).

Despite widespread implementation in Australia and overseas, in a review of the literature we found no evidence of a comprehensive body of studies that could measure whether the benefits of accreditation outweigh the costs.

Although Australia has led the way in developing cost-effectiveness techniques for assessing drugs and other medical technologies, less research has been done on how to measure the cost-effectiveness of a complex intervention such as accreditation that involves so many different parts of the health system.

We believe this may be partly due to the challenge of identifying the benefits of accreditation, but also some confusion over whether the primary role of accreditation is to provide an external audit to ensure health services comply with minimum safety requirements, or to create a continuous quality improvement tool.

Our literature search did reveal several studies analysing the costs of accreditation. Most of these were self-reported case studies from single hospitals, which identified the problem of isolating the costs of accreditation from the ongoing costs of complying with state and national policies and procedures relating to safety and quality.

The estimated costs ranged from 0.2% to 1.7% of total expenses when averaged over the accreditation cycle (typically 3 years in the US versus 4 years in Australia). These hospital-based figures can be compared to a 2003 Productivity Commission report which estimated the incremental costs of accreditation in primary care at 1.1% of total practice costs.

As with the costs studies, most of the benefit studies we reviewed were from the US. Outcomes were measured across a range of financial metrics, organisational culture, and clinical indicators.

This wide range of outcomes mirrors the changing priorities within the standards over time and also reflects the complexity of accreditation given the extensive range of topics covered by the standards.

One of the problems of measuring accreditation is that it is often implemented nationally, or is so widely implemented that developing a randomised controlled trial is not feasible. The creates problems in study design in that although some of the studies revealed an association between accreditation and better clinical or organisational outcomes, the lack of a proper control group makes it difficult to determine causality.

With significant investment indicated by the cost studies and the current debate about the role of accreditation in health care, we believe developing a framework to identify and measure the costs and benefits of accreditation is needed. This would create a more informed debate and provide a point of reference for measuring and monitoring any reforms in accreditation process.

A more transparent framework would also help ensure that the aims of accreditation were clearly identified and explained to all stakeholders, including patients and consumer bodies, health care workers, and health care system funders and regulators.

Finding one indicator that accurately measures accreditation may not be possible, but the incremental findings from our review can be used to construct the case for having a comprehensive and nationally implemented system to compare hospitals and encourage improvements in patient safety and quality of care.
 

Dr Virginia Mumford is a visiting fellow and Professor Jeffrey Braithwaite is the foundation director of the Australian Institute of Health Innovation, Faculty of Medicine, University of NSW.