Editorials

Accrediting hospitals

The separation between purchasers and providers in the NHS has posed a new set of problems in relation to quality assurance. Before 1991 the hierarchical command and control system was relied on to ensure the maintenance of quality standards in NHS hospitals. Hospitals and nursing homes in the independent sector were regulated through registration with health authorities, and the Hospital Advisory Service was responsible for monitoring the long stay sector in the NHS; additional systems for regulating standards were deemed largely unnecessary. Since 1991, however, purchasers have been required to seek new ways of ensuring that the services that they commission are of high quality. And providers, anxious to market their services, have sought ways to demonstrate their quality standards to purchasers.^{1 2} These twin pressures have increased interest in models of hospital accreditation.

Hospital accreditation is a system of non-governmental self regulation in which an independent agency defines and monitors quality standards in hospitals participating in such a scheme. The model was developed in the United States in 1917 as a result of an initiative of the medical profession. After many years of development the process is now managed through the Joint Commission on Accreditation of Health Care Organisations, which in 1993 covered 80% of American hospitals. Models building on the American approach have been developed in Canada and Australia.³

In Britain the development of accreditation has been far more limited. The King's Fund's organisational audit programme is the most highly developed scheme. Launched in 1989, it offers the opportunity for review and self assessment against a set of explicit national standards. By the beginning of the year it had worked with nearly 200 acute hospitals, and from next month it will award accreditation status.^{4 5}

Elsewhere, the South Western Regional Health Authority established a pilot hospital accreditation programme in 1990, which was aimed at small community hospitals. On p 781 Shaw and Collins describe the operation and impact of this programme.⁶ Fifty seven community hospitals in the region were offered the opportunity to participate in the programme. None of these hospitals had resident medical staff and all had fewer than 50 beds, mostly allocated to general practitioners. The standards for accreditation were drawn from the National Association of Health Authorities' publication Towards Good Practice in Small Hospitals.⁷ Forty three hospitals volunteered to be surveyed, and 37 were subsequently accredited for up to two years.

The main aims of the pilot programme were to enhance the effectiveness of community hospitals and to spread good organisational practice. As far as the second aim is concerned, there is some evidence of success. The interactive process between the auditors and hospital managers was reported as contributing both to the achievement of higher standards in individual hospitals and to greater networking among managers.

As with some other recent managerial initiatives, such as resource management, however,⁸ there was no evidence to suggest that the managerial "feel good" factor was translated into greater clinical effectiveness or enhanced benefits to patients. This deficiency derives largely from the programme's emphasis on measures of structure and process rather than on the outcomes of care. Those engaged in accreditation assume that efficient structures and processes correlate with good clinical outcomes,⁴ but this link is unproved.³ In this connection it is also relevant that, unlike in the United States and elsewhere, accreditation in Britain has not been driven by the medical profession and no attempt has been made to integrate clinical audit and accreditation.

Neglecting clinical effectiveness in the process of accreditation may be seen as a fundamental failing. Certainly, as Shaw and Collins report, purchasers in the South Western region criticised the programme on these grounds and were reluctant to fund it. Yet, despite the considerable practical problems of obtaining robust and reliable hospital wide measures, accreditation could be extended to include measures of clinical effectiveness. At a time when the Department of Health is considering future arrangements for both accreditation and clinical audit the scope for bringing them closer together merits serious attention.

Professor of health policy Institute for Health Policy Studies, University of Southampton, Southampton SO17 1BJ

Ray Robinson 

1. Drummond M, Maynard A, eds. Purchasing and providing cost-effective health care. Edinburgh: Churchill Livingstone, 1993.
2. Ovretveit J. Purchasing for health. Buckingham: Open University Press, 1995.
3. Scrivens E. Accreditation: protecting the professional or the consumer? Buckingham: Open University Press, (in press).
4. Brooks T. King's Fund organisational audit. King's Fund News, 1994;17(3):1-3.
5. King's Fund Organisational Audit. Hospital accreditation programme: organisational standards and criteria. London: King's Fund, 1994.
6. Shaw C, Collins C. Health service accreditation: report of a pilot programme for community hospitals. BMJ 1995;310:781-4. [Free Full Text]
7. Shaw C, Hurst M, Stone S. Towards good practice in small hospitals. Birmingham: National Association of Health Authorities, 1988.
8. Packwood T, Keen J, Buxton M. Hospitals in transition. Buckingham: Open University Press, 1991.