Case Study: Optimizing the value of accreditation: The story of two CEOs

1. What are the historical / traditional views of health services accreditation? What are
the benefits and risks to the traditional views? Compare these to the current views of
the value of accreditation.

Answer:

The historical / traditional view is one in which an accreditation is considered as a project or

event. The implication is that implementation of the standards is observed only during the
accreditation survey and may not persist between surveys. If compliance is temporary it may
not lead to sustained improvement in the quality of healthcare and may harm patients in the
long term. We know that on-site surveys are normally conducted every three or four years,
and surveyors only visit for 3-5 days. This means that the quality of care which met the
standards may not be implemented most of the time. Such practice may put patients, staff
and the organization at risk.

Current views of the value of accreditation are that it is considered as one of the tools for an
organization to make continuous improvements in providing high quality care. The
organization applies the standards in daily practice and it becomes the work culture of the
organization. The survey findings are used as lessons learned and areas for improvement.

The historical / traditional view of health service accreditation is that accreditation is

considered a project or event. The implication is that the application of accreditation
standards is only obeyed during the accreditation survey and may not last between surveys.
If compliance with accreditation standards is temporary, it may not have an impact on
continuous quality improvement and can endanger the patient in the long run. The
Accreditation Survey period is usually conducted every three or four years. This means that
quality of service that meets the standards may not be implemented most of the time. Such
practices can endanger patients, staff, and hospitals.

The current view of the value of accreditation is that accreditation is considered as one of the
tools for organizations to make continuous improvements in providing high quality services.
The organization implements standards that must be made necessary in daily practice so
that it becomes the work culture of the organization. Survey findings are used as learning
and areas for improvement

2. Compare and contrast the two situations outlined above. What are some similarities
and what are the differences?

Answer:

Similarities:
Both healthcare organizations (HCOs) have more than one site with one CEO. This indicates
both HCOs are complex in structures and processes.
The two organizations had a new CEO when the next survey was scheduled.
The differences are:

The CEO in case #1 felt that he did not have adequate time to prepare the organization for
the survey whereas the CEO in case #2 did not express concerns about the time required for
implementation.

The CEO in case #2 is familiar with the accreditation program as she is also a surveyor with
the Accreditation Organization, whereas the CEO in case #1 is not, so he needs to be
convinced by the CEO of the Accreditation Organization regarding the benefits of
participating in the program.

There had been significant difficulties for the HCO in case #1: financial crisis, conflicts
between Board and the medical staff, major disconnect between the administration and the
unions, and decreasing staff and patient satisfaction. However, this was not the situation in
case #2, however, the people in the organization had to be encouraged to change their view
on standards of accreditation – from reference every three or four year cycle to an on-going
reference in daily practice.

similarity:
a.. Both organizations have a new CEO when the next survey is scheduled
b. Both health service organizations (HCO) have more than one health service unit location
with only one CEO. This shows that both HCOs have complex problems in structure and
process

The difference
a. The CEO in case 1, seems to still have a traditional view of health service accreditation
where accreditation is considered as a project or event, so the CEO in Case 1 initially
wanted to postpone the accreditation survey to resolve organizational issues that were
considered more important. The CEO in case 2 has a more up-to-date view of health service
accreditation and is familiar with the accreditation program because of his experience as an
Accrediting Organization surveyor.

b. In case 1: There were significant problems for HCO such as financial crises, conflicts
between the Board and medical staff, deadlocked communication between management and
trade unions, and decreased staff and patient satisfaction. Whereas in case 2, the
organization does not have the complexity of the problem, however, people in the
organization in case 2 must be encouraged to change their view of accreditation standards -
from just being a reference every three or four years to being a reference in daily practice.

3. What are the lessons learned from these case studies of relevance for current CEOs/
leaders of health care organizations (e.g. whether acute care, long term care or
community)?

Answer:
These case studies show the necessity of shifting the paradigm of accreditation programs.
Accreditation should no longer be viewed as an ‘add on’ project or separate program from
other quality improvement and patient safety programs; instead it should be viewed as an
integral ongoing component of the organization’s quality improvement and patient safety
program. Leadership, at all levels, has the responsibility to lead this shift to provide
sustainable high quality care. Case #1 showed that significant difficulties in the organization
could be communicated and consulted with the survey team who might give assistance at
some stage to facilitate the organization in achieving their goals.

The case study above shows the need to shift the mindset towards the accreditation
program. Accreditation should no longer be seen as an 'additional' program or separate
program from quality improvement and other patient safety programs, but must be seen as
an integral and continuous component of the hospital patient quality and safety improvement
program. Leadership, at all levels, has the responsibility to lead this change to provide high
quality, sustainable services. Case examples show that significant difficulties in the
organization can be communicated and consulted with the surveyors who may provide
assistance at some stage to facilitate the organization in achieving their goals.

4. What steps can be taken to improve the value-add of accreditation; to reduce the
‘work’ of accreditation and enable it to be woven into the fabric of an organization’s
quality improvement program and strategic goals?

Answer:

The findings during the field survey should be used as lessons learned for the organization
to improve the quality of healthcare.
The standards are implemented in an ongoing basis and integral to the organization’s overall
quality and safety improvement program.
The CEO should lead the implementation, and appoint champions/teams as agent of change
in the organization. The individuals appointed can be the leader in the unit, showing his/her
strong commitment to quality improvement, and be a role model to other staff in
implementing the standards.
Staff who contribute to accreditation will learn through the experience and can take personal
pride in working for an organization which has increased its level of patient care through
accreditation.
problems identified during the field survey and input from the surveyors should be used as
lessons for organizations to improve the quality of health services.
This standard is applied continuously and is integrated with the overall quality improvement
and safety program of the organization.
The CEO must lead the implementation, and appoint someone as an agent of change in the
organization. The appointed individual can be the head of the unit, who shows a strong
commitment to quality improvement, and is a role model for other staff in applying standards.
Staff who contribute to accreditation will learn through experience and can feel proud
working for organizations that have improved the quality of health services through
accreditation
 5. How would you, as the CEO, strategically position accreditation to your Board and
the public? What would you communicate the value of accreditation?
Answer:
I would position accreditation as a major tool for making continuous quality improvement,
risk mitigation, patient safety, improved efficiency and accountability.
I would communicate the value of accreditation by using data, meaning that I would provide
measures of performance indicators in quality and safety, and also efficiency.
A healthcare organization which has successfully incorporated accreditation is more likely to
attract resources in terms of funding, staff and patients.