The nature and value of accreditation in the UK

Citation

Hurst, K. (2002), "The nature and value of accreditation in the UK", International Journal of Health Care Quality Assurance, Vol. 15 No. 1. https://doi.org/10.1108/ijhcqa.2002.06215aaa.001

The nature and value of accreditation in the UK

The nature and value of accreditation in the UK

An interesting discussion with a group of postgraduate students (full-time senior NHS managers) on health care accreditation in the UK raised some interesting issues about their accreditation experiences – that, unlike Europe, North America and the Antipodes, etc., are relatively new in the UK. Our starting point was Scrivens' (1995, p. 21) definition from her seminal work on accreditation in the UK: "voluntary participation in a process of third-party assessment of health services". We quickly established, however, that her definition needed updating because some third-party assessments such as the Commission for Health Improvement's (CHI) rolling programme of inspecting all NHS trusts was not voluntary. However, our students of health care management literature noted that commentators on CHI's reports (available on its Web site) studiously avoid using "accreditation", preferring instead "regulation" and "monitoring". We weren't sure whether such subtle differences were needed.

Second, we noted that accreditation systems go down one of two routes in the UK. The more common one being scrutinising an health care trust's system for monitoring its policy and procedures and correcting structures and processes that fall down. This risk-management/problem-solving approach is a strong feature of North America's Joint Commission for the Accreditation of Hospitals (JCAH) approach. Assessors could, on the other hand, scrutinise selected outputs and outcomes before commenting on the trust's infrastructure. In practice, assessors do both but the group's experiences told us that the assessors' starting point was usually one or the other. Put another way, one system concentrates on managers and practitioners' control systems for minimising risk and encouraging best practice, while the other focuses on good or poor outputs/outcomes and their underlying reasons.

The next issue discussed was accreditation's role: developing or policing health care. Students felt that accreditation systems encourage one or the other, rarely both. That is, the "structure to outcome" system was judged developmental. The reverse, on the other hand, "working backwards from poor outputs and outcomes" felt like a policing function. However, deeper discussions by group members revealed that accreditation reporting systems, and the way findings were perceived by coal-face staff, and more importantly the media, led to the broader perception that the policing function of accreditation overrode its development role. Despite these negative perceptions, none felt that accreditation (or regulation) reports should be embargoed because the reports' educational value was inestimable, and a lack of openness would be disastrous. However, if it is because these (predominantly negative) findings are selectively reported orally or in print, which gives rise to feelings among staff of being punished by accreditation then hard working health care professionals will at least be demotivated by accreditation visits or worse resist the accreditation process (bearing in mind that accreditation is usually a top-down imposition on staff).

Several extreme recent examples were discussed by group members. Despite encouraging findings by accreditation assessors in these sites, senior managers were sacked or forced to resign owing to reports' negative findings – known as "non-conformance" in accreditation-speak. It was accepted by group members that the main tenet of clinical governance (the catalyst for UK health care accreditation) was that chief executives were as accountable for assuring the quality of health care as they were for corporate (fiscal) governance in their organisations. In the case of poor performance, on the other hand, isn't it better for all if accreditation assessors issue what are known in the trade as "improvement notes", which means that trust managers have, for example, six months to correct service deficiencies before a "non-conformance" is issued? That is, the improvement note to non-conformance method emphasises service development. On-the-spot non-conformance, on the other hand, epitomises going straight to jail without passing go and collecting £200. The group felt that if poor practice is unearthed then heads tend to roll rather than learning from experience; generally felt to be wrong. Criminal or negligent practices, as in the case of Shipman (a general practitioner convicted of murdering at least 12 of his patients); Allitt (a nurse convicted of murdering four child patients, attempted murder of three others and grievous bodily harm to six more); and Bristol (a hospital with substandard paediatric cardiac surgery practices whose managers ignored whistle-blowing by staff) aside, how long will it take before we automatically change structures rather than attitudes when dealing with health care problems?

Summary justice of this kind raises an interesting methodological point. Those postgraduate students with firsthand accreditation experience said that accreditation/regulation visits ranged from one to three days in length. Even with a first-class team of third-party reviewers, is it reasonable to expect their assessments to be so comprehensive that a full range of the trust's structures, processes, outputs and outcomes is rigorously assessed? Having assessed several trust directorates over a three-day accreditation visit, not only was I exhausted at the end of visit but also that there were niggling doubts that all stones had been looked under for either cans of worms or gems of good practice. In short, there's never going to be enough time when it's a case of striking a balance between garnering sufficient empirically-based data to make sound decisions or ending up with a visit that is prohibitively costly.

Although it's the trust's senior managers that carry the can when clinical, managerial or educational practice is flawed in the eyes of the assessors, practitioners in our group with firsthand experience felt marginalised and demoralised by the accreditation process. Some never saw the assessors let alone having an opportunity to demonstrate prized practices that had taken months to develop mostly with the accreditation visit in mind. Those more closely involved, despite their competence, felt vulnerable and anxious about letting the side down. Having been on the receiving end of accreditation visits, I concur. Should we, therefore, condemn practitioners for shunning health care accreditation to avoid the inevitable blame and search for sacrificial lambs that follows selective, negative reporting?

In short, what is it about the NHS that prevents us from celebrating its successes? We agreed, on the other hand, that it's early days and I'm sure that before long we'll see accounts of the pro's and con's of accreditation/regulation visits written by health care practitioners and managers published in International Journal of Health Care Quality Assurance. By then we'll be in a better position to evaluate the strengths and weaknesses of health care accreditation in the UK.

Keith Hurst Senior Lecturer, Nuffield Institute for Health, University of Leeds, Leeds, UK

Reference

Scrivens, E. (1995), Accreditation – The Way Forward for the NHS, Keele University Press.