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CHAPTER 18 Accreditation: A Global Regulatory Mechanism t
o Promote Quality and Safety
David Greenfield, Marjorie Pawsey, and Jeffrey Braithwaite
“What has eluded us thus far, however, is maintaining consisten
tly high levels of safety and quality over time and across all hea
lth care services
and settings.”
—Chassin and Loeb (2011, p. 562)
The accreditation of health care organizations is a regulatory me
chanism used in many countries around the world. Accreditation
is an important
strategy by which improvements in quality and safety have been
advocated and institutionalized. The purpose of this chapter is t
o provide an
overview of accreditation of health organizations. The chapter h
as five sections. The first section considers the purpose of accre

ditation, noting that
it has become a global phenomenon found in many industries an
d sectors of health care. The second section discusses the extent
of the
accreditation of health organizations, the maturing of accreditati
on 513514program philosophy from quality assurance to quality
improvement, and
the self-governing system that has been developed. The third se
ction explores the commonalities and differences in accreditatio
n programs, where
increasingly a common model of accreditation is enacted but wit
h variation in standards. The evidence base for accreditation is e
xamined in the
fourth section. Finally, the fifth section considers the issues and
challenges for accreditation stakeholders.
AN OVERVIEW OF ACCREDITATION
What Is Accreditation?
Accreditation is the formal declaration by a designated authorit
y that an organization, service, or individual has demonstrated c
ompetency,
authority, or credibility to meet a predetermined set of standard
s. Accreditation is a mechanism that seeks to reassure external s
takeholders that
quality and safety standards are demonstrated. A secondary and
more recent goal in some applications, notably health care, is to
provide a basis for
quality improvement initiatives (Davis et al., 2009; Gibberd et a
l., 2004; Williams et al., 2005). The shift to accreditation, notab
ly from the 1970s
onward, is representative of a shift in philosophy by governmen
ts whereby they have sought to provide a framework for the gov
ernance of
services rather than to provide those services themselves. Throu
gh accreditation and other regulation strategies, governments ha

ve sought
abatement or control of risks to society by indirect means (Sparr
ow, 2000).
Accreditation has become a ubiquitous part of our modern world
. For example, it can apply to any of the following:
• Industries, including organic food (Gabriel, 2007), tourism (A
ustralian Government, 2010), and telecommunications services (
Association of
TeleServices International, 2010)
• Institutions, including education (Stimson, 2003) and health (
Australian Council on Healthcare Standards [ACHS], 2007a) or
ganizations
• Products, including automobiles (Casper and Hancke, 1999) an
d software (Jones and Price, 2002)
514 515
• Systems, including management systems (Casile and Davis-Bl
ake, 2002) and laboratory processes (Gough and Reynolds, 2000
)
• Individuals, including health professionals (Australia’s Health
Workforce Online, 2008), statisticians (Statistical Society of A
ustralia, 2009), and
builders (Green Building Certificate Institute, 2010)
ACCREDITATION IN THE HEALTH CARE INDUSTRY
Accreditation is found extensively in health care industries arou
nd the world. Accreditation is an element in a network of activit
ies that seeks to
regulate conduct in the health sector. Health organizations, and
individual professionals, are networked together, and their beha
vior is assessed by
independent bodies through accreditation programs, standards, a
nd quality indicators. Regulation via this network has been calle
d “nodal
governance” (Shearing and Wood, 2003); that is, organizations,

services, and professional behavior in health care are shaped by
an increasing
variety of government and nongovernment bodies related to but
independent of each other.
Health care organizations are accredited for the management an
d provision of their services, including hospitals, general practi
ces, geriatric care
facilities, and public health (ACHS, 2007a; The Joint Commissi
on [TJC], 2010; Simone and Epstein, 2009). Within health organ
izations,
specialized health services can be accredited, such as tissue ban
ks (American Association of Tissue Banks, 2009), pharmacies (
American College
of Health-System Pharmacists, 2006), and aeromedical transport
ation services (Association of Air Medical Services, 2010). Add
itionally,
individual professionals from medical (American Academy of N
eurology, 2010), nursing (American Academy of Nurse Practitio
ners, 2010), and
allied health (American Physical Therapy Association, 2009; Co
uncil on Podiatric Medical Education, 2010) fields, and adminis
trators, including
medical administrators (American Academy of Medical Adminis
trators, 2010), are increasingly required to be certified. Given th
e breadth and
complexity of the accreditation measures in the health care indu
stry, this chapter takes as its focus the accreditation of health or
ganizations.
515 516
The Self-Governing System of Accreditation of Health Organiza
tions
Accreditation in health was first initiated in the United States th
rough the work of the American College of Surgeons, which in

1917 developed the
“Minimum Standards for Hospitals.” This organization subseque
ntly collaborated with colleges and associations from the United
States and
Canada to create, in 1951, the Joint Commission on Accreditatio
n of Hospitals (Viswanathan and Salmon, 2000), which is now r
eferred to as The
Joint Commission (TJC). From this beginning, accreditation has
spread to be practiced across the world. A few figures highlight
the global extent
and reach of accreditation. Accreditation is now practiced in mo
re than 70 countries. There are 22 national bodies and an interna
tional agency, the
International Society for Quality in Health Care (ISQua), that ar
e focused on the issue (Greenfield and Braithwaite, 2008). In th
e United States,
TJC accredits more than 4,000 organizations, or 82% of the hos
pitals in the country (2010). The Haute Autorité de Santé (HAS)
accredits all acute
health care organizations in France, which total more than 700 h
ospitals (Touati and Pomey, 2009). Accreditation Canada (2008)
and the ACHS
(2007a) each accredit more than 1,000 organizations in their res
pective countries. These, and many other major international he
alth care
accreditation agencies, are independent, not-for-profit, nongove
rnment agencies.
Accreditation agencies assess organizations and services against
standards, and develop and supervise peer reviewers to maintai
n a surveyor
workforce. Additionally, some accreditation agencies set and re
vise their own standards. Accreditation involves assessment aga
inst minimum
standards and more recently has evolved, as a result of higher q
uality and safety expectations, to be a developmental process pr

omoting continuous
quality improvement (Cudney and Reinbold, 2002; Parsons and
Riley, 2009). This current trend is especially notable in public h
ealth in the United
States (Parsons and Riley, 2009). This model of accreditation is
reflective of practice in many countries, including, for example,
in the United
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States (Parsons and Riley, 2009). This model of accreditation is
reflective of practice in many countries, including, for example,
in the United
States (Viswanathan and Salmon, 2000), Australia (Greenfield,
Braithwaite, et al., 2008), Canada (Touati and Pomey, 2009), Fr
ance (Pomey et al.,
2004), and Lebanon (El-Jardali et al., 2008).
Accreditation programs in their initial phase typically focused o
n standards aimed at the structures and processes of organizatio
ns. As programs
516517have matured, and new ones have emerged, attention has
shifted so that organizations have been increasingly required to
demonstrate that
in addition to having structures and processes in place they are f

unctioning effectively. That is, there has been a philosophical s
hift from quality
assurance to quality improvement. The former is regarded as a p
rogram that strives to improve quality through defining and mea
suring it
(Silimperi et al., 2002). The latter incorporates both retrospecti
ve and prospective assessments and is aimed at developing strat
egies to make things
better and to create systems to prevent errors (McLaughlin and
Kaluzny, 2006; Parsons and Riley, 2009). In simple terms, quali
ty improvement
involves health professionals constantly asking themselves “Des
pite having the ‘right’ things in place to do the ‘right’ things, w
hat are we doing
now that we can do better?” Furthermore, accreditation is about
answering the question posed by external assessors: “What syste
ms have you
implemented, how do they work, and can you show me how you
are planning to do things better?”
The shift can be illustrated by an example concerning patient sa
tisfaction surveys. An accreditation program promoting a qualit
y assurance
approach would focus on a patient satisfaction survey and how i
t is developed and administered. In contrast, an accreditation pr
ogram with a
quality improvement philosophy would focus on the response ra
te of the surveys, the issues identified by the patients, the organ
ization’s actions,
and confirmation of improvement in subsequent surveys.
While the continuous quality improvement model is the domina
nt accreditation model for health care organizations, there is an
alternative, more
generic model that can be described as an “audit model.” In this
model, an external reviewer, with or without health care experi

ence, uses a generic
set of quality standards to assess the presence or absence of org
anizational quality activities. This model is endorsed by the Inte
rnational
Organization for Standardization, which accredits organizations
in many diverse industries, including health (see http://www.iso
.org).
There are external and internal motivations that drive health car
e organizations to seek accreditation (Greenfield and Braithwait
e, 2007). External
motivation comes from governments, insurers, and consumers re
quiring that organizations undertake efforts that demonstrate out
comes that
advance high-quality and safer health care (Accreditation Canad
a, 2009; ACHS, 2007b; El-Jardali et al., 2008; HAS, 2008b; TJ
C, 2010).
517518The internal impetus comes from staff who make up the
health organizations. They report a desire to improve their servi
ces and the care
they provide (Greenfield and Braithwaite, 2007). Together these
two motivations, which are mutually reinforcing, have combine
d to draw many
health care organizations under the umbrella of accreditation.
Accreditation agencies, involving many of their stakeholders, ha
ve constructed a self-governing system (Greenfield, Pawsey, Na
ylor, et al.,
2009a). It is a system responsive to the conduct and culture of t
hose being regulated; this approach has been labeled “responsiv
e regulation”
(Braithwaite et al., 2005). The system seeks to influence the atti
tudes and practices of those involved, whether they are in the ro
le of accreditation
agency personnel, surveyors, or health staff, in an organization
being accredited. Through participation in the development of a

ccreditation
programs or the accrediting of health care organizations, a com
mon understanding of standards and shared expectations is const
ructed.
Additionally, participants regulate their own and other colleagu
es’ behaviors to comply with the standards and expectations. Th
e system combines
internal assessment, or self-regulation, with self-directed impro
vement strategies overseen by external peer review. It is a cultu
ral control strategy
whose influence is significant on those directly involved (Green
field, Pawsey, Naylor, et al., 2009a). Those health professionals
who participate in
their organization’s accreditation activities generally report imp
rovements to quality and safety. However, as recent research ha
s shown, the
influence of accreditation can wane as participation in the progr
am declines (Paccioni et al., 2008). Health professionals not dir
ectly involved in
their organization’s accreditation activities are known to remain
skeptical about the purpose, value, and benefits of the program.
They question the
bureaucratic and time-consuming activities associated with an a
ccreditation program.
ISQua promotes self-governance through their accrediting of ac
creditation agencies. That is, ISQua provides guidelines, suppor
t, and assessment
of accreditation and surveyor training programs (see http://www
.isqua.org). Furthermore, the self-governance modality is reinfo
rced through
ISQua’s encouragement of participation in its organization and t
he international health quality and safety conferences it convene
s. Consequently,
the work of ISQua has evoked an international convergence of u
nderstanding about, and similarity in the enactment of, health ac

creditation
programs.
518 519
COMMONALITIES AND DIFFERENCES IN THE ACCREDIT
ATION MODEL
The Accreditation Model
A common model of accreditation is enacted by many health acc
reditation agencies (Accreditation Canada, 2009; ACHS, 2007b;
TJC, 2010). A
breakdown of the process typically involved in this model is as
follows. An organization seeking to be accredited develops, imp
lements, and
continuously reviews its quality improvement plan and self-asse
sses progress against the standards of the accreditation program.
It concludes this
task by providing a written self-assessment report to the accredi
ting agency. The accrediting agency assesses the organization’s
report and
dispatches an accreditation survey team, comprised of peer revi
ewers, to visit and assess the organization on site. The visit com
prises observations
of facilities, interviews with staff, and a review of documentatio
n. The survey team during and at the conclusion of the survey pr
ovides verbal
feedback to the organization. The accrediting agency receives a
written report from the survey team a short time after the visit.
The report
summarizes the survey team’s assessment of the organization’s
progress in achieving the standards and makes recommendations
or
commendations as appropriate. Following the correction of any
errors of fact by the organization, the report is then considered
by the accrediting
agency. The agency assesses the report and decides whether to a

ward accreditation status or not. Accreditation is for a defined p
eriod, depending
on the program, and typically for 3 to 5 years. It is common for
accrediting agencies to send survey teams to reassess an organiz
ation during the
accreditation period. The survey team reviews the organization’
s continual progress against the updated quality plan and accred
itation standards.
The surveyors provide verbal feedback, and, after endorsement
by the accrediting agency, a written report is provided to the or
ganization. The
improvement cycle continues, with the organization using the re
port to initiate further reflection and examination of its structur
es, processes, and
practices to identify and drive areas for ongoing improvement.
Accreditation Standards
Accrediting agencies are responsible for the development and re
vision of standards. It is common for agencies to develop standa
rds using
519520representatives drawn from the health industry. For exam
ple, in the United States (TJC, 2010), Canada (Accreditation Ca
nada, 2009),
France (HAS, 2008a), and Australia (ACHS, 2007b), standards a
re developed through consultation with a wide range of stakehol
ders, including
combinations of health care experts, researchers, representatives
from industry groups, consumers, and governmental agencies.
The number and
status of standards vary from accreditation program to program.
For example, the U.S. Public Health Accreditation Board progr
am has 32
standards (Parsons and Riley, 2009). For the accreditation of ho
spitals, Accreditation Canada uses 30 standards (Accreditation
Canada, 2009), and

HAS, the French accreditation agency, has only 13 standards, or
“priority practices,” as they are called (HAS, 2008a). ACHS, fr
om Australia, has
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HAS, the French accreditation agency, has only 13 standards, or
“priority practices,” as they are called (HAS, 2008a). ACHS, fr
om Australia, has
43 standards in its program, of which 19 are mandatory and 24 a
re nonmandatory (ACHS, 2007b). In the ACHS program, failure
to meet the
requirements of a mandatory standard will result in an organizat
ion not being accredited. However, an organization may be asse
ssed as meeting
mandatory standards but not meeting a nonmandatory standard a
nd still be conferred accreditation status.
Accreditation standards cover infrastructure, organizational, ser
vice, and continuum of patient care issues (Greenfield and Brait
hwaite, 2007; HAS,
2008a). Standards are focused on organizational processes and s
ystems and the availability of appropriate resources for the orga
nization to deliver
the defined services. Accrediting agencies are increasingly exa
mining strategies to expand standards to incorporate organizatio
nal performance and
clinical measures (Accreditation Canada, 2009; ACHS, 2007a;
HAS, 2008b; TJC, 2009). Accreditation Canada, with the introd
uction of its new
accreditation program “Qmentum,” has introduced performance
measures “to strengthen the rigor and objectivity of the accredit
ation process”
(Accreditation Canada, 2009). The measures are used to direct s
urveyors to examine particular parts of an organization requirin
g close assessment.
Alternatively, outcome measures are being reported upon separa
tely to accreditation surveys. Accreditation agencies are produci

ng reports of
organizational and clinical compliance with expected guidelines
to raise awareness across the industry. For example, in the Unit
ed States, since
2006, the TJC has tracked and reported upon quality of care mea
sures (TJC, 2009). These items are evidence-based, standardized
, national
measures that allow comparisons across organizations. Currentl
y, TJC is 520521reporting on 31 measures, with data drawn fro
m more than 3,000
accredited hospitals. In particular, the report documents, over th
e last 7 years, increased quality performance results for heart att
ack, heart failure,
and pneumonia care. Over shorter time periods, there have been
improvements on individual surgical care performance measures
(last 2 years),
individual heart attack (last 3 years), and pneumonia care (last 4
years) measures. Similarly, 1 year of measurement shows very
high compliance,
more than 99%, on two individual measures of quality relating t
o inpatient care for childhood asthma. Two measures were ident
ified as problematic
for many organizations: Providing fibrinolytic therapy to heart a
ttack patients within 30 minutes of arrival was achieved by just
over 50% of
hospitals, and only 60% provided antibiotics to intensive care u
nit pneumonia patients within 24 hours of arrival. Consequently
, the report notes
that improvement is still needed, and there remains unacceptabl
e variation between organizations.
As these examples demonstrate, the use of quality of care measu
res in accreditation surveys and the publication of compliance r
eports are strategies
by which accreditation agencies are working with health organiz
ations to assess, measure, and improve their care. Their use for

ms part of the
system of self-governance within and across health organization
s.
THE EVIDENCE BASE FOR THE ACCREDITATION OF HEA
LTH ORGANIZATIONS
While the accreditation of health services has expanded across t
he world, to the extent that it is now undertaken in more countri
es and covers more
health settings than ever before, the evidence base remains unde
rdeveloped. There is a pressing need for increased research, tran
sparency, and
innovation into accreditation (Greenfield and Braithwaite, 2009)
. This is not a new development, with calls having been made ov
er a number of
years for increased research into accreditation (Fernandopulle et
al., 2003; Øvretveit and Gustafson, 2003; Shaw, 2001). What is
new is that
accreditation agencies are reportedly undertaking research studi
es and programs. For example, in the last few years, substantial
research efforts
have been commenced by the HAS, TJC, Accreditation Canada,
the ACHS, the Italian Society for Quality of Health Care, the Iri
sh 521522Health
Services Accreditation Board, and the Spanish accrediting agenc
y Fundación Avedis Donabedian. What remains unclear is how t
ransparent the
accreditation agencies will be with their results (Greenfield and
Braithwaite, 2009).
Systematic Review of the Accreditation Research Literature
A systematic review of the accreditation research literature was
published in 2008 (Greenfield and Braithwaite, 2008). The revie
w initially

identified nearly 34,000 items of literature associated with accre
ditation and accrediting agencies. By focusing on substantive w
ork, the sample was
reduced to just over 3,000, less than 11% of the original search.
Subsequent analysis of the abstracts identified that the vast maj
ority were
discussion or commentary papers. There were 66 empirical rese
arch articles identified for the review. The studies were analyze
d and grouped
under 10 headings. The assessment of the accumulative findings
for each category is presented in Table 18–1.
TABLE 18–
1 Classification and Assessment of Accreditation Research Liter
ature
Literature Category Assessment of the Cumulative Findings
Consumer views or patient satisfactionInadequate studies to ass
ess
Public disclosure Inadequate studies to assess
Surveyor issues Inadequate studies to assess
Promotion of change Consistent
Professional development Consistent
Professions’ attitudes to accreditation Inconsistent
Organizational impact Inconsistent
Financial impact Inconsistent
Quality measures Inconsistent

Program assessment Inconsistent
There was an inadequate number of studies to draw conclusions
about three issues: consumer views or patient satisfaction, publi
c disclosure, and
surveyor issues. There were consistent findings for two items on
ly. Studies showed that accreditation programs promoted change
and professional
development. Accreditation programs were noted to have impro
ved the organization of facilities, policies and guidelines, decisi
on making, and
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development. Accreditation programs were noted to have impro
ved the organization of facilities, policies and guidelines, decisi
on making, and
safety. 522523A link between professional development and acc
reditation was also identified. Accreditation programs were obs
erved to encourage
and support professional development, although the effect was c
onsidered to be small.
In the remaining five categories, there were inconsistent researc
h findings. Professionals expressed criticism and support for acc
reditation
programs. Concerns related to issues of cost, compliance, standa
rds, surveyor consistency, and what the program was perceived t
o add to patient
care. Conversely, professionals perceived accreditation program
s as a strategy for promoting and making transparent quality and

collegial decision
making; the programs resulted in improved organizational perfo
rmance. Many health professionals, whether they participate in
accreditation
activities directly, indirectly, or not at all, seem to hold strong o
pinions about the value and benefits, or lack thereof. It is an iss
ue that seems to
generate polarized views. The organizational impact of accredit
ation programs was unclear. Accredited and nonaccredited orga
nizations could not
be distinguished in one study, but organizational improvements
were noted in other research. The financial impact for accreditat
ion was reported as
proportionally greater for smaller organizations and considered
by some to be high overall. However, the argument has been ma
de that the costs
incurred are not additional but part of an organization’s require
d investment in quality.
At present, the relationship between accreditation and quality m
easures—
clinical indicators, quality indicators, or clinical performance m
easures—
is opaque. Accreditation has been shown to generate improveme
nt in some cases but not in others. The question has been raised
as to whether we
should expect to find a link between accreditation and different
quality measures, given they are developed and implemented se
parately and not
linked. Overall, the assessment of accreditation programs has pr
ovided mixed evidence. In some cases, programs were deemed c
redible; in others,
their value and results were questioned.
Findings from Further Research

Since the preceding review, completed in 2008, further research
has been published. Unfortunately, these studies do not clarify
the picture
significantly. One research investigation has argued that profess
ionals who fail to participate in accreditation efforts continue to
perceive the efforts
as external bureaucratic reporting mechanisms (Touati and Pom
ey, 2009). Other work shows that participating in accreditation
has cultivated
communication and cooperation among individuals and teams, t
hereby 523524promoting change in an organization (Paccioni et
al., 2008).
Accredited hospitals formalize, and at times realize, improveme
nts in quality management practices (Braithwaite et al., 2010; El
-Jardali et al., 2008;
Paccioni et al., 2008; Touati and Pomey, 2009). Another study f
ound a positive effect from accreditation on patient satisfaction
(Al Tehewy et al.,
2009).
There continues to be considerable discussion among stakeholde
rs about the relationship between accreditation and quality meas
ures. Concern has
been expressed about the lack of a relationship between the two,
and the argument persists that this issue needs further investiga
tion (Braithwaite et
al., 2010; Chuang and Inder, 2009). One large-scale randomized
study that examined accreditation as a predictor of health care
performance has
been conducted (Braithwaite et al., 2010). The study investigate
d relationships between accreditation performance and clinical p
erformance,
organizational culture, organizational climate, consumer involve
ment, and leadership. Positive correlations were found between
accreditation
performance and organizational culture and leadership. A positi

ve trend was noted with clinical performance. Accreditation was
unrelated to
organizational climate and consumer involvement.
In the period since the 2008 systematic review, there have been
a number of studies examining surveyor issues. Reliability in su
rveying has been
investigated. Reliability is noted as being a critical issue in accr
editation, and in health care more broadly. Being able to conduc
t consistent
assessments, interpretations, and judgments, individually and co
llectively, is a challenge for professionals working in many area
s of health care
(Greenfield, Pawsey, Naylor, et al., 2009a). As such, the challen
ges of consistency faced by accreditation surveyors are not uniq
ue, and surveyors
will have encountered them in their normal professional activiti
es. Recent research has highlighted that because accreditation s
urveying is an
activity based on document analysis, observations, and intervie
ws, survey findings need to be credible and verifiable (Greenfie
ld, Braithwaite, et
al., 2008; Greenfield, Pawsey, Naylor, et al., 2009a). Survey tea
ms use these three qualitative data collection methods (documen
t analysis,
observations, and interviews) to triangulate their assessments (
Denzin, 1989; Ely et al., 1991). The results produced through th
is complex process
are not precisely replicable, as human judgments are central to t
he data collection and analysis process. Nevertheless, striving f
or rigor in
application of standards, individual and team conduct, and trans
parency in interpretation and decision making is essential. Henc
e the finding that
“Where surveyors and survey teams achieve process consistency
and program interpretation from survey 524525to survey, their

findings can then
be said to be reliable” (Greenfield, Pawsey, Naylor, et al., 2009
a). In other words, accreditation agencies, rather than focusing
on reliability of
outcome, which is by definition unachievable, need to be encour
aged to implement strategies to promote and ensure reliability o
f process and
consistent application of standards. This recommendation is sup
ported by the findings of an empirical study examining two surv
ey teams in situ
(Greenfield, Pawsey, Naylor, et al., 2009b). While the study did
not unfold as planned—
the problems encountered highlighted the difficulties of
conducting in situ research into organizations—
the study confirmed the need for survey teams to ensure reliabil
ity of process and consistent
application of standards.
Reliability in surveying has been shown to be promoted or unde
rmined by six factors (Greenfield, Pawsey, Naylor, et al., 2009a
):
1. The accreditation program, including documentation requirem
ents for organizations and survey teams
2. Member relationship with the accrediting agency and survey t
eam
3. Accreditation agency personnel
4. Surveyor workforce renewal
5. Management of the surveyor workforce
6. Survey dynamics’ effect on the reliability of surveys directly
and indirectly
It is argued that reliability in the accreditation process is constr
ucted through the interplay of these factors. They construct shar
ed expectations and
conduct among stakeholders; together they promote standardize

d beliefs and action that become accreditation cultural norms (G
reenfield, Pawsey,
Naylor, et al., 2009a).
It is important to distinguish between intra- and inter-rater relia
bility. Intra-rater reliability is high when the assessments made
by an individual
surveyor or survey team are consistent from case to case. Inter-r
ater reliability is high when assessments made by different surv
eyors or survey
teams are consistent with one another. Reliability in accreditatio
n is a concern for accreditation agencies and organizations that
have been or are
considering going through the accreditation process. Two studie
s developed scenario exercises, using real data, for individual su
rveyors
525526and survey teams to examine the respective issues. Indiv
idual surveyors assessed, at two points in time, scenarios of indi
vidual standards
relating to a large hospital, and their results were compared. Th
e findings revealed that intra-rater reliability is problematic; tha
t is, individuals
struggle to consistently make consistent assessments. A 20% var
iation in surveyors’ individual assessments that potentially coul
d have affected
accreditation outcomes was noted (Greenfield, Pawsey, Braithw
aite, et al., 2009). Similarly, scenarios based on real data and co
mprising written
information and a role-play were developed and presented to sur
vey teams. In contrast to the intra-rater findings, the results sho
wed that the
examination of the inter-rater reliability of survey teams demon
strated more consistent agreement (Greenfield, Pawsey, et al., 2
008), thus

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examination of the inter-rater reliability of survey teams demon
strated more consistent agreement (Greenfield, Pawsey, et al., 2
008), thus
highlighting the mediating effect of teams on individuals.
A unique typology based on surveyor styles has been developed
from the empirical research into reliability (Greenfield, Braithw
aite, et al., 2008).
The typology, using the dimensions of recording (explicit/impli
cit) and questioning (opportunistic/structured), classifies four a
ccreditation surveyor
styles: the discusser, the explorer, the interrogator, and the ques
tioner. The typology is suggested for use by accreditation agenc
ies in their surveyor
training programs and offers the opportunity to match teams of
surveyors with a blend of approaches.
Research has been conducted to understand the value of surveyi
ng to volunteer surveyors and to the institutions in which they a
re regularly
employed (Lancaster et al., 2010). Health professionals who act
as volunteer surveyors derive four benefits from the activity: ex

posure to new
methods and innovations in health organizations, opportunity to
engage in a unique form of professional development, opportuni
ty to acquire
expertise to enhance quality within the institutions in which the
y are regularly employed, and opportunity to contribute to the p
rocess of quality
improvement and enhance public health in organizations beyond
their regular employment.
ISSUES AND CHALLENGES FOR ACCREDITATION PROGR
AMS
Accreditation stakeholders have a number of significant interrel
ated challenges to address. A list of these issues is presented in
Table 18–2.
526 527
TABLE 18–2 Challenges Facing Accreditation Stakeholders
Voluntary or mandated accreditation programs
Rigidity or flexibility of accreditation programs
Financial costs to address quality and safety issues
Standards: the role of process and quality indicators to foster im
provement
Surveyor workforce: sustainability, role, and reliability
Expanding the evidence base for accreditation
Voluntary or Mandated Accreditation Programs
A majority of accreditation programs, with a few notable except

ions such as the French and Italian accreditation agencies, are v
oluntary programs.
However, this term is a misleading one. In many cases, health c
are organizations are required by external stakeholders to demo
nstrate efforts at
improving quality and safety, including through participation in
an accreditation program. Governments, insurers, and consumer
s, via industry
groups and voicing community expectations more generally, see
k to be reassured that organizations are making efforts to achiev
e published
standards or address quality and safety. The “choice” many orga
nizations have is not whether to participate but with which accr
editing agency and
program they will be associated. In effect, accreditation, in man
y countries, has become a requirement in practice but not in na
me. If accreditation
were made mandatory, what impact would this have on accrediti
ng agencies, health organizations, and surveyors? Would this ch
ange the practice
of accreditation? Would accreditation agencies and health organ
izations be under more pressure to achieve a favorable accredita
tion result?
Chapter 16 presents a discussion of voluntary and mandated pub
lic health accreditation initiatives in the United States. One exa
mple of successful
mandated accreditation is found in North Carolina, where a loca
l health department accreditation program has been in place sinc
e 2005, with more
than 50 of the state’s 85 health departments accredited through
2009. A second round of accreditation is under way, after a brie
f delay caused by
state funding shortages. A full evaluation of this program may y
ield some answers to these questions. See Case 15 in the compa
nion casebook

(McLaughlin et al., 2012) for further details.
527 528
Rigidity or Flexibility of Accreditation Programs
An issue that is confused with the question of voluntary or man
dated programs is the rigidity and flexibility within a program.
Some accreditation
programs have been shown to be rigid and flexible at the same t
ime. Research contrasting two programs, one mandated and the
other voluntary,
found that both programs incorporated compulsory and flexible
elements. There were positive impacts from both the mandated a
nd voluntary
programs, and it was noted that there was a convergence of the t
wo approaches (Touati and Pomey, 2009). The program conduct
ed by the ACHS
in Australia has firm and flexible aspects to it. As noted, there a
re standards that are classified as mandatory or nonmandatory (
ACHS, 2007b).
The rigidity and flexibility of accreditation programs remain lar
gely an unexamined issue. What is an appropriate degree of rigi
dity and flexibility
within an accreditation program? What are the effects of specifi
ed levels of rigidity and flexibility in an accreditation program?
Financial Costs to Address Quality and Safety Issues
Addressing quality and safety issues incurs costs, through consu
ming organizational resources and requiring health professional
s’ time. Where
accreditation is not considered part of an organization’s ongoin
g or routine activities, the challenge is determining the costs vs.
benefits. Separating
the costs and benefits associated with accreditation and those in
curred independently as part of an organization’s ongoing qualit

y and safety efforts
is a complicated task, and no one has yet constructed a convinci
ng study. This issue is a significant challenge for accreditation s
takeholders. Are
the costs incurred by participation in an accreditation program t
o be considered part of the ongoing organizational costs to addr
ess quality and
safety issues? If not, what is the cost vs. benefit analysis associ
ated with participation in an accreditation program?
Standards: The Role of Process vs. Outcome and Quality Indicat
ors
Accreditation programs are currently focused on assessing the o
rganizing and delivery of care. The standards have been termed
“process
indicators,” as they focus on how care is delivered rather than t
he outcomes of the activity. Opponents of programs have argued
that because they
do not reflect the outcomes of care, they are limited in what the
y can 528529contribute to our understanding of quality and safe
ty. Quality
indicators are advocated as being more effective measures. How
ever, the use of such indicators within an accreditation program
is an issue that
raises continuing debate (Braithwaite et al., 2010; Chuang and I
nder, 2009; Øvretveit, 2005; Touati and Pomey, 2009). Concern
is voiced that the
use of quality indicators is problematic until the relationship bet
ween accreditation and quality indicators is clarified (Braithwai
te et al., 2010). The
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use of quality indicators is problematic until the relationship bet
ween accreditation and quality indicators is clarified (Braithwai
te et al., 2010). The
issue remains unresolved as to whether they examine similar or
different aspects of health care performance and quality.

This issue is an important one with which to come to terms. Ho
w do organizations use the results from process and quality indi
cators and
accreditation programs? Are they to be used independently or to
gether? How do we resolve the differences in their findings? A
closely related
issue is whether accreditation programs foster quality improvem
ent, and if so, how? (See Case 15 in the companion casebook [M
cLaughlin et al.,
2012], which addresses this issue relative to local public health
department accreditation in North Carolina.) With each revision
of standards, do we
keep raising the bar to stimulate efforts to improve, or will this
strategy promote adverse behaviors? Knowing how best to stimu
late improvements
in quality and safety in health systems facing significant cost pr
essures and increasing demands is a challenge for accreditation
agencies.
Surveyor Workforce: Sustainability, Role, and Reliability Issues
Surveyors are an important element of accreditation programs.
Accrediting agencies can have surveyor workforces comprised o
f full-time or part-
time (usually volunteer) surveyors. The ongoing support and de
velopment of this workforce requires careful management. Surv
eyor workforce
sustainability and the reliability of their surveys are ongoing ch
allenges for accreditation agencies. Accrediting agencies face di
fficulties in being
able to continually recruit appropriately experienced health prof
essionals as surveyors. The demands of their regular employmen
t can be
incompatible with the time required to participate as a surveyor.
The surveyor role is a demanding one. It can include educator,

judge, evaluator,
regulator, or a combination of these functions (Greenfield, Brait
hwaite, et al., 2008; Plebani, 2001). The status of the accreditati
on program,
whether mandatory or voluntary, will shape the focus of the role
and how it is perceived by others. A health professional taking
on the surveyor
role may be comfortable with some part but not others, or with c
ombining the roles. Additionally, potential 529530or perceived
conflict of interest
issues have been raised when health professionals are surveying
colleagues and organizations with which they have ties or with
which they may
seek to work in the future (Bohigas et al., 1998; Plebani, 2001).
Furthermore, when enacting the surveyor role, intra- and inter-r
ater reliability are
issues of note (Greenfield, Pawsey, Braithwaite, et al., 2009; Gr
eenfield, Pawsey, Naylor, et al., 2009a).
Accreditation agencies that use full-time surveyors see this as a
strategy that can work toward increasing the mastery of survey t
echniques and
more consistent interpretation of standards. Conversely, part-ti
me surveyors have current knowledge of the health system, man
agement practices,
and clinical expectations, but may not be as consistent in survey
ing as their full-time colleagues. How then is it possible to susta
in, develop, and
manage a surveyor workforce to increase the reliability of asses
sment?
Expanding the Evidence Base for Accreditation
The necessity to expand the evidence base for accreditation is n
oted in the literature (Greenfield and Braithwaite, 2008; Greenfi
eld and Braithwaite,

2009). Securing more empirically derived findings is necessary
to provide a firmer foundation for accreditation programs. It is
hoped that studies
in progress will be published in the peer-reviewed literature. Do
ing so will work toward resolving inconsistencies and gaps in u
nderstanding.
Transparency of findings is important for individual program cr
edibility and contributes to the broader knowledge base (Greenf
ield and
Braithwaite, 2009). In particular, it is worth noting the positive
contribution made by ISQua in encouraging and assisting the sp
read of knowledge
between practitioners and accreditation agencies in different co
untries. Consolidating and expanding the evidence base for accr
editation is important
to secure its ongoing utility and effectiveness. How can the cred
ibility of accreditation be strengthened? What actions can be tak
en to expand the
evidence base and the publication of results?
CONCLUSIONS
Accreditation has been instituted, and has become institutionali
zed, in health care sectors and jurisdictions around the world. It
is a governance
strategy that enables health organizations individually and colle
ctively to self-govern their efforts at improving quality and safe
ty. Empirical studies
as to the value and contribution of accreditation present an inco
mplete 530531and somewhat mixed picture for stakeholders. Th
e research evidence
demonstrates that accreditation has resulted in improvements an
d benefits in some areas and is uncertain in other respects. The
challenges facing
accreditation stakeholders are significant and include the follow
ing:

• Deciding whether programs should be voluntary or mandated
• Achieving a balance between flexibility and rigidity within a p
rogram
• Managing the financial costs associated with accreditation
• Understanding the role of process and quality indicators withi
n an accreditation program or their relationship to accreditation
results
• Creating a reliable and sustainable surveyor workforce
• Expanding the evidence base for accreditation programs
Accreditation agencies and their partners are actively taking ste
ps to better understand the organizational and clinical impacts o
f accreditation
programs. Further work is necessary, as is the sharing of the kn
owledge generated, to build upon and continue the improvement
s made. How the
challenges are addressed will shape the regulation of health care
and, ultimately, the quality and safety of care provided to cons
umers.
Cross-References to the Companion Casebook
(McLaughlin, C. P., Johnson, J. K., and Sollecito, W. A. [Eds.].
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Implementing Continuous Quality Improvement in Health Care:
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Case Study
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12 Quality in Pediatric Subspecialty Care
William A. Sollecito, Peter A. Margolis, Paul V. Miles, Robert

Perelman,
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15 North Carolina local Health Departments
accreditation Program
David Stone and Mary V. Davis
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