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27 The accreditation process drives rapid quality improvement – continued review is critical

BMJ open quality, 2020-12, Vol.9 (Suppl 1), p.A28-A28 [Peer Reviewed Journal]

Author(s) (or their employer(s)) 2020. No commercial re-use. See rights and permissions. Published by BMJ. ;2020 Author(s) (or their employer(s)) 2020. No commercial re-use. See rights and permissions. Published by BMJ. ;EISSN: 2399-6641 ;DOI: 10.1136/bmjoq-2020-IHI.27

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  • Title:
    27 The accreditation process drives rapid quality improvement – continued review is critical
  • Author: McElgunn, Peggy ; Weiner, Bonnie
  • Subjects: Accreditation ; Audits ; Cardiac catheterization ; Organizational change ; Quality improvement ; Quality of care ; Total quality
  • Is Part Of: BMJ open quality, 2020-12, Vol.9 (Suppl 1), p.A28-A28
  • Description: BackgroundAccreditation for Cardiovascular Excellence (ACE) has reviewed over 100 organizations and 7023 cardiac catheterization cases. The review process includes identifying organizational characteristics relative to standards. The impact of accreditation on improving quality through corrective action plans and then reassessment through reaccreditation.ObjectivesTo review the impact accreditation has on quality and its maintenance and recognize the value of internally developed corrective action plans and their impact on sustainability of accreditation.MethodsOrganizations that have experienced both an initial accreditation and then a reaccreditation were reviewed. Researchers reviewed accreditation reports (n=32), comparing the percentage of facilities meeting accreditation standards for initial and second reviews. Corrective action plans were coded to provide an overview of areas for improvement and then were assessed against their reaccreditation review.ResultsFor 25/60 standards examined there was a significant difference in achievement between 1st and 2nd accreditation. Those organizations addressing standards that required improvement in their corrective action plans were sustained in their reaccreditation review. Of the 25, all but one saw improvement between the 2 reviews. ‘Does not meet’ was less commonly observed in 23/25 between reviews. 7 standards saw changes in the number of ‘NA’ from 1st to 2nd accreditation suggesting changed organizational structures to meet requirements.ConclusionsQualitative factors for organizational change indicate ‘quality’ as do clinical outcomes. These change-processes are unique, and must account for organizational capacity, context, and individualized systems. Accreditation should be understood as an ongoing process in the pursuit of quality, rather than a ‘stamp of approval,’ or one-time certification. The accreditation process results in organizational responses immediately in the form of corrective action plans which are then sustained through reaccreditation.
  • Publisher: London: BMJ Publishing Group LTD
  • Language: English
  • Identifier: EISSN: 2399-6641
    DOI: 10.1136/bmjoq-2020-IHI.27
  • Source: PubMed Central
    ProQuest Central
    DOAJ Directory of Open Access Journals
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