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. 2011 Nov 9:(11):CD008992.
doi: 10.1002/14651858.CD008992.pub2.

Effectiveness of external inspection of compliance with standards in improving healthcare organisation behaviour, healthcare professional behaviour or patient outcomes

Gerd Flodgren  1 , Marie-Pascale Pomey, Sarah A Taber, Martin P Eccles
Affiliations

Effectiveness of external inspection of compliance with standards in improving healthcare organisation behaviour, healthcare professional behaviour or patient outcomes

Gerd Flodgren et al. Cochrane Database Syst Rev. .

Update in

Abstract

Background: Inspection systems are used in health care to promote quality improvements, i.e. to achieve changes in organisational structures or processes, healthcare provider behaviour and patient outcomes. These systems are based on the assumption that externally promoted adherence to evidence-based standards (through inspection/assessment) will result in higher quality of health care. However, the benefits of external inspection in terms of organisational, provider and patient level outcomes are not clear.

Objectives: To evaluate the effectiveness of external inspection of compliance with standards in improving healthcare organisation behaviour, healthcare professional behaviour and patient outcomes.

Search methods: We searched the following electronic databases for studies: the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, CINAHL, Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effectiveness, Scopus, HMIC, Index to Theses and Intute from their inception dates up to May 2011. There was no language restriction and studies were included regardless of publication status. We searched the reference lists of included studies and contacted authors of relevant papers, accreditation bodies and the International Organization for Standardisation (ISO), regarding any further published or unpublished work.

Selection criteria: We included randomised controlled trials (RCTs), controlled clinical trials (CCTs), interrupted time-series (ITSs) and controlled before and after studies (CBAs) evaluating the effect of external inspection against external standards on healthcare organisation change, healthcare professional behaviour or patient outcomes in hospitals, primary healthcare organisations and other community-based healthcare organisations.

Data collection and analysis: Two review authors independently applied eligibility criteria, extracted data and assessed the risk of bias of each included study. Since meta-analysis was not possible, we produced a narrative results summary.

Main results: We identified one cluster-RCT involving 20 South African public hospitals (Salmon 2003) and one ITS involving all acute trusts in England (OPM 2009) for inclusion in this review.Salmon and colleagues (Salmon 2003) showed mixed effects of a hospital accreditation system on the compliance with COHSASA (the Council for Health Services Accreditation for South Africa) accreditation standards and eight indicators of hospital quality. Significantly improved total mean compliance score with COHSASA accreditation standards was found for 21/28 service elements: mean intervention effect (95% confidence interval (CI)) was 30% (23% to 57%) (P < 0.001). The score increased from 48% to 78% in intervention hospitals, while remaining the same in control hospitals (43%). A sub-analysis of 424 a priori identified critical criteria (19 service elements) showed significantly improved compliance with the critical standards (P < 0.001). The score increased from 41% (21% to 46%) to 75% (55% to 96%) in intervention hospitals, but was unchanged in control hospitals (37%). Only one of the nine intervention hospitals gained full accreditation status at the end of the study period, with two others reached pre-accreditation status.The median intervention effect (range) for the indicators of hospital quality of care was 2.4 (-1.9 to +11.8) and only one of the eight indicators: 'nurses perception of clinical quality, participation and teamwork' was significantly improved (mean intervention effect 5.7, P = 0.03).Re-analysis of the MRSA (methicillin-resistant Staphylococcus aureus) data showed statistically non-significant effects of the Healthcare Commissions Infection Inspection programme.

Authors' conclusions: We only identified two studies for inclusion in this review, which highlights the paucity of high-quality controlled evaluations of the effectiveness of external inspection systems. No firm conclusions could therefore be drawn about the effectiveness of external inspection on compliance with standards.

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Figures

Figure 1
Figure 1
Study flow diagram.
See this image and copyright information in PMC

References

References to studies included in this review

    1. OPM evaluation team Evaluation of the healthcare commission’s healthcare associated infections inspection programme. OPM report. 2009:1–23.
    1. Salmom JW, Heavens J, Lombard C, Tavrow P. Operations Research Results. issue 17. Vol. 2. U.S. Agency for International Development (USAID), Quality Assurance Project, University Research Co., LLC; Bethesda: 2003. The impact of accreditation on the quality of hospital care:KwaZulu-Natal Province, Republic of South Africa; pp. 1–49.

References to studies excluded from this review

    1. Al Tehewy N, Salem B, Habil I, El Okda S. Evaluation of accreditation program in non-governmental organisations’ health units in Egypt:short term outcomes. International Journal for Quality in Healthcare. 2009;21(3):183–9. - PubMed
    1. Brooke BS, Perler BA, Dominici F, Makary MA, Pronovost PJ. Reduction of in-hospital mortality among California hospitals meeting Leapfrog evidence-based standards for abdominal aortic aneurysm repair. Journal of Vascular Surgery. 2008;47(6):1155–6. 1163–4. - PubMed
    1. Frasco PE, Sprung J, Trentman TL. The impact of the joint commission for accreditation of healthcare organisational pain initiative on perioperative opiate consumption and recovery room length of stay. Anesthesia & Analgesia. 2005;100:162–8. - PubMed
    1. Kowiatek JG, Weber RJ, Schilling DE, McKaveney TP. Monitoring compliance with JCAHO standards using a medication-control review tool. American Journal of Health System Pharmacy. 2002;59(18):1763–7. - PubMed
    1. Laselle TJ, May SK. Medication orders are written clearly and transcribed accurately? Implementing Medication Management Standard 3.20 and National Patient Safety Goal 2b. Hospital Pharmacy. 2006;41:82–7.

Additional references

    1. The Department of Health Code of practice for the prevention and control of healthcare associated infections. The Health Act. 2006:1–41.
    1. EPOC Risk of bias tool. 2009 Available from http://epoc.cochrane.org/epoc-resources-review-authors.
    1. Greenfield D, Braithwaite J. Health sector accreditation research: a systematic review. International Journal for Quality in Health Care. 2008;20(3):172–83. - PubMed
    1. Higgins JPT, Altman DG, Higgins JPT, Green S, editors. Cochrane Handbook for Systematic Reviews of Interventions. 5.0.1 (updated September 2008) The Cochrane Collaboration; 2008. Chapter 8: Assessing risk of bias in included studies. Available from www.cochrane-handbook.org.
    1. Hopewell S, Loudon K, Clarke MJ, Oxman AD, Dickersin K. Publication bias in clinical trials due to statistical significance or direction of trial results. Cochrane Database of Systematic Reviews. 2009;(Issue 1) [DOI: 10.1002/14651858.MR000006.pub3] - PMC - PubMed

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