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Table 2 Assessment of empirical healthcare standards research

From: The standard of healthcare accreditation standards: a review of empirical research underpinning their development and impact

Study details Study characteristics Study quality
Author-year Country Sector Aim Methods Major findings and conclusions Intervention or Aetiology (I or A) (NHMRC hierarchy) Level of evidence (NHMRC hierarchy) Design Quality rating
Aiken et al. (2008) [35] United Kingdom Acute care To test the impact of the implementation of Magnet principles of improving nurses’ work environments. Survey Comparison with national sample Pre-survey: nurse work environment was less positive and they experienced less job satisfaction than the national sample. I IV Pre- and post- evaluation +++
Compar-ative study
      Post-survey: significant improvement in nurse practice environment, job satisfaction and appraisals of the quality of patient care; practice environment better than national sample. The implementation of the Magnet hospital program was associated with a significantly improved nursing work environment as well as improved job-related outcomes for nurses and markers for quality of patient care.     
Devers, Pham, Liu (2004) [34] United States Acute care To describe hospitals’ patient-safety initiatives, and the relative roles that regulation, markets and professionalism have in stimulating progress. Interviews with stakeholders Hospitals’ major patient-safety initiatives were primarily intended to meet Joint Commission (JC) requirements. A IV Cross sectional +++
Database analysis (CTS patient safety and Leapfrog Group survey data) Internal (professionalism, resources), external (regulation, markets) and contextual (research, organisational factors) facilitators and barriers identified.
      Impact on hospitals of increased attention to patient safety has been mixed and on patients it is unclear, because relevant data did not exist or were difficult to interpret. Professional and market initiatives have facilitated improvement, however quasi-regulatory forces, such as JC, are having the greatest impact on hospitals’ patient-safety efforts.     
Herr, Titler (2009) [17] United States Acute care To examine compliance with the new pain assessment and management standards of the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) for accredited health care organisations. Archival documents analysis Trends over time illustrate improvements in pain assessment practices, with a majority of patients having some documentation related to pain. However, only just over half the patients had medicines ordered. Practice improvement in the administration of medicine was noted. A III-2 Retrospective cross sectional, cohort study +++
      Pain assessment and management practices in the emergency departments showed improvements in line with the introduction of standards.     
Kozhimannil et al. (2009) [30] Philippines Acute care To examine the population-level impacts of two programs – national health insurance (PhilHealth) and a donor funded franchise of midwife clinics (Well Family Midwife Clinics) on achievement of minimum standards for prenatal and delivery care. Survey The PhilHealth insurance program scale was associated with increased odds of receiving at least four prenatal visits and receiving a visit during the first trimester of pregnancy. Exposure to midwife clinics was not associated with significant changes in achievement of prenatal care standards. The expansion of an insurance program with accreditation standards was associated with increases in achievement of minimal standards of prenatal care among women. A III-2 Pre- and post- evaluation, longitudinal study +++
Lamb et al. (2003) [29] United States Acute care To investigate how hospitals are dealing with the JCAHO standard that requires that all unanticipated outcomes of care are disclosed. Survey (Completion rate 51%) The vast majority of risk managers reported that their hospital’s practice was to disclose harm at least some of the time, although only one third of hospitals actually have board-approved policies in place. More than half of respondents reported they would always disclose death or serious injury, but when presented with actual clinical scenarios, respondents were much less likely to disclose preventable harms than to disclose non-preventable harms of comparable severity. Reluctance to disclose preventable harms was twice as likely to occur at hospitals having major concerns about malpractice implications of disclosure. A IV Stratified random sample of hospitals ++
Longo et al. (1995) [32] United States Acute care To examine compliance and characteristics of hospitals with tobacco control standards enacted by the Joint Commission on Accreditation of Healthcare Organisations. (JCAHO) Onsite assessment of hospitals during period 1992–3 (N = 3327) Archival data Two years after implementation, 95.6% of hospitals met the new JCAHO smoking ban standard; 90.9% of hospitals were in compliance with a second smoking standard requiring development and use of medical criteria for physician-ordered exceptions to the ban. Hospitals in tobacco-producing states had higher-than-average rates of compliance when compared to hospitals in other states. Hospitals providing psychiatric and/or substance abuse services had lower-than-average rates of compliance. A IV Cross sectional +++
      This first industry-wide smoking ban has been successful. However, hospitals should consider evaluating the use of medical exceptions to this policy.     
Piontek et al. (2003) [26] United States Acute care To compare the impact of trauma patient outcomes before and after Level II American College of Surgeons (ACS) verification was received in a not-for-profit community hospital. Database analysis Study variable exhibited statistically different outcomes: length of stay (LOS) 10% less (p < 0.000); ratio of costs was 5% lower (p < 0.000); and mortality observed /expected ratios significantly different (0.81 before versus 0.59 after [p < 0.000]). The resources consumed achieving ACS Level II trauma centre verification resulted in decreased LOS, reduced in-hospital mortality rates, reduced cost and improved contribution margins. A III-3 Case control ++
Rowe-Murray and Fisher (2003) [20] Australia Acute care To test the hypothesis that hospital practices in the immediate post partum period that are associated with operative intervention in delivery can affect the implementation of the Baby Friendly Hospital Initiative Step Four. Prospective longitudinal study Interview (n = 203) Document analysis Survey Women who had a caesarean section experienced significant delay in initiating breastfeeding compared with women giving birth vaginally with or without instrumental assistance (p < 0.001). A II Prospective cohort ++
      Significant differences were observed among hospitals with Baby Friendly performing significantly better than the other 3 hospitals (p < 0.001). Birth delivery affected the implementation of Baby Friendly Hospital Initiative Step Four.     
Salmon et al. (2003) [27] South Africa Acute care To test the impact of accreditation. Survey (hospital organisational process indicator data) Two years after the introduction of accreditation, the intervention group compliance with standards increased (38% to 76%) and the control group maintained level (37% top 38%). The accreditation program facilitated public hospitals’ compliance with standards. I II Randomised control trial ++
Stradling et al. (2007) [34] United States Acute care To examine stroke care delivery before and after Joint Commission stroke center certification. Document analysis Database analysis Certification improved clinical care (testing and medication) for patients with ischemic stroke. Clinical care improved with the certification of stroke centres. A IV Pre- and post- evaluation ++
Thornlow and Merwin (2009) [18] United States Acute care To examine the relationship between patient safety practices, as measured by accreditation standards, and patient safety outcomes as measured by hospital rates of infections, decubitus ulcers, postoperative respiratory failure, and failure to rescue. Database analysis (secondary data) Accreditation standards reflecting patient safety practices were related to some outcomes, but not others. Rates of infections and decubitus ulcers occurred more frequently in hospitals with poorer performance in utilizing patient safety practices, but no differences were noted in rates of postoperative respiratory failure or failure to rescue. Certain adverse events, such as infections and decubiti, may be reduced by preventive protocols that are reflected in accreditation standards, whereas other events, such as failure to rescues and postoperative respiratory failure, may require multifaceted strategies that are less easily translated unto protocols. A IV Cross-sectional +++
Valenstein et al. (2009) [31] United States Acute care To determine how document control is being implemented in practice and whether particular approaches result in better levels of compliance. Document analysis 35% fulfilled all 6 document control requirements (3113/8814); 97% met the requirements for the availability of the document; 50% fulfilled archiving requirements. Policies and procedures were more likely to fulfil document control requirements than forms and work aids. Document control practices significantly associated with higher compliance rates were unable to be identified. Most laboratories are not meeting regulatory and accreditation requirements related to the control of documents. A IV Prospective cross sectional ++
Weng et al. (2003) [28] Taiwan Acute care To examine the effect of the Baby Friendly Hospital Initiative (BFHI) on the Taiwanese breastfeeding rate and analyse factors related to BFHI qualification. Document analysis Mothers in qualified BFHI had higher breastfeeding rates than those in non-qualified hospitals whether they were surveyed while in maternity wards after delivery (88.1% vs 78.1%) or in their first post-natal month (67.6% vs 59.4%). Close correlation between BFHI qualification and location and grade of hospital. Factors related to qualification were: hospital fosters establishment of breastfeeding support groups; written breastfeeding policy; practise rooming-in available 24 hours a day; and health staff trained. Health policy intervention has had a significant impact on increasing the breastfeeding rate in Taiwan. A IV Retrospective cross sectional ++