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Abstract
Background External, independent accreditation assessments of healthcare organisations are necessary to ensure the nationally legislated minimum standards of quality and safety (QS) are met. The predetermined scheduling of the assessments continues to be criticised due to the high level of organisational emphasis on preparing for accreditation.
Objectives To determine the stakeholder perception of assessment thoroughness, staff resource requirements and workforce engagement changes if only 48 hours’ notice is given to an organisation prior to an accreditation assessment, compared with the standard-notice accreditation process.
Methods Logan and Beaudesert Hospitals in Brisbane, Australia, trialled the ‘Short-Notice Survey Accreditation Assessment Process’ (SNAAP) between August 2017 and December 2018. The organisation was given just 48 hours’ notice prior to an accreditation assessment. Staff perception of the standard-notice accreditation process and short-notice process was assessed using a 5-point Likert scale repeated measures questionnaire (pretrial, 6 and 12 months after SNAAP launch).
Results There was a statistically significant stakeholder opinion that SNAAP more effectively identified the true strengths and achievements of the organisation’s QS compared with ‘standard-notice’ survey (p=0.033). There was a significantly lower overall perceived proportion of staff resources required for SNAAP preparation in contrast to ‘standard-notice’ process (Baseline Av=21.38% vs Follow-up 1 and 2 Av=9.75%–6.25%, p=0.021). The questionnaire results reflected that SNAAP increased staff engagement in QS activities (Av=3.75 and 3.69, 95% CI=3.45–4.05 and 3.45–3.94).
Conclusions With sufficient cultural and operational preparation to move to SNAAP, hospitals can potentially use SNAAP as a truer validation of QS standards, require less staffing resources to prepare for accreditation assessments and improve staff engagement in QS assurance and improvement.
- accreditation
- quality improvement
- safety culture
- patient safety
- health quality improvement
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Footnotes
Contributors BV and MD conceived the concept of SNAAP in collaboration with WBHHS, ACHS and The Commission. HU, BV and MD conceived and designed the study in collaboration with WBHHS, ACHS and Lirata. HU and BV recruited the participants, and HU sent the participants the questionnaires via email. Lirata collected and presented the results of the questionnaires to HU, BV, MD, Queensland Health, ACHS and WBHHS. HU, MD, KS and VM drafted the manuscript. BV, MD, KS and VM critically reviewed the manuscript. All authors agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All authors read and approved the final manuscript.
Funding The trial study was partially funded by the State of Queensland Acting through Queensland Health (represented by Patient Safety Quality Improvement Service, Clinical Excellence Division). The funding was allocated directly to Lirata to collaborate with MSHHS, WBHHS and ACHS to develop the questionnaire and data collection tools, administer the questionnaires and collect the data, present findings, conduct workshops and write comprehensive reports including recommendations with respect to the trial. The sponsor nor Lirata contributed to the authorship of this article (excluding providing the actual data figures).
Disclaimer The views expressed in the submitted article are the authors' own, and not an official position of any of the institutions in partnership to conduct the trial.
Competing interests None declared.
Patient consent for publication Not required.
Ethics approval The study was approved by The Prince Charles Hospital (EC00168) Human Research Ethics Committee in Queensland, Australia, under the ethics application HREC/17/QPCH/270.
Provenance and peer review Not commissioned; externally peer reviewed.
Data availability statement Data are available upon reasonable request.