Defending the Motion Jeffrey Braithwaite
Accreditation: amidst the data deluge, a data trickle
This is the era of big data sets and evidence-based approaches. Unlike patient safety, where many large-scale studies have provided publicly-available data on the rates of adverse events, accreditation has failed the test. Across the world, accreditation programs have gathered volumes of data on health services and organisations: huge numbers of surveyor reports, self assessments and performance data measured by clinical indicators, for example. Unfortunately, this valuable information has been treated as confidential and infrequently made publicly available. Health systems are the worse for this.
There are various reasons for this problem. Even in countries with long-standing accreditation systems like the US, Canada and Australia, there has been an ethos of treating the data they gather on the performance of their participating members as commercial in confidence. Many accreditation programs believe that no-one should use the data except the participating organisation, presumably so that its clinicians and managers can feed the information into their continuous improvement activities. The desire to avoid the public embarrassment of organisations who do not meet standards is an additional motivation and it is commonly espoused that these organisations should be able to improve quietly, out of the public glare. However, they might continue to offer poor standards of care, with consumers none the wiser.
This is misguided and potentially harmful to patient safety. Information gathered on health care organisations should be more than merely accessible: it should be configured in user friendly ways, made publicly available and promulgated widely, so consumers and other stakeholders can make informed choices. Data gathered for accreditation purposes should be used to create league tables, provide comparative data sets, feed into research designs and be a key instigator for change management strategies and systems improvement initiatives.
We spend large sums of money on accreditation internationally. In essence, it is a very large scale intervention based on the premise that we can establish standards, apply them to health services, monitor progress and improve performance by those means. If you also consider that accreditation systems periodically raise the bar on standards, methods of monitoring accreditation and modes of assessing compliance, you have a large PDSA cycle in operation in many countries and sectors including acute care, primary and aged care. Given the investment, energies expended and costly infrastructure supporting accreditation, shouldn’t we demand this data be available widely for all stakeholders to use? Shouldn’t we know whether accreditation is making a difference to quality of care?
Mind you, this will not be easy to do. It is never a trivial problem to take data gathered for one purpose – in this case, meeting standards, providing feedback and monitoring compliance – and utilize it for other purposes, such as comparative performance or systems improvement. But this is a challenge of manageable, not insurmountable, proportions. Just because we have fallen short in the past, doesn’t mean we should continue to fail in the future.
All in all, despite an increase in studies over the past decade, there is limited rigorous evidence supporting accreditation as a useful tool to stimulate improvement in health service organisations and promote high quality organisational processes. We may not be able to solve this problem instantly, but we can make the data emerging from accreditation systems public and, over time, useful.
So let us hold accreditation programs to account and demand that they turn the data tap to the ‘on’ position. We need to turn the trickle of information that occasionally leaks out from accreditation about performance of services and organisations into the data deluge to which other areas of health care are contributing. We must no longer accept arguments that say ‘it is too difficult’ or ‘accreditation data is not meant to be used for making comparisons’ or ‘we have historically had poor data on accreditation’ or ‘the information is commercial in confidence’. These are the tired old ideas of people stuck in the mindset of last century.
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