Received date: 20 July 2012; Accepted date: 07 January 2013
BackgroundOne method utilised to improve the quality of health care is accreditation. Although accreditation has been extensively used in the acute care sector, its presence in primary care is limited and so is our understanding of its nature, uptake and associated outcomes. Because acute care and primary care environments are vastly different, our understanding of acute care accreditation cannot simply be translated to primary care. AimThe purpose of this paper was to explore the current state of primary care accreditation. MethodsAn extensive search was completed examining peer-reviewed and grey literature. In addition, interviews with key stakeholders involved in primary care accreditation were undertaken. ResultsFrom the 501 reviewed abstracts, 62 papers were used in this review in addition to 72 sources from grey literature. Eight interviews were also held with key informants. ConclusionsIn this review of the available literature of accreditation within primary care, it was found that accreditation in this sector is generally non-government funded and voluntary with some countries offering financial ncentives. It was evident that there is a dearth of research on the nature and uptake of accreditation in this sector, along with how accreditation affects outcomes of care, whether it is an effective method to improve quality, perceptions of care, healthcare utilisation and costs. These findings imply that further research is required to examine the possible impact accreditation may have on health care within primary care.
primary care, accreditation, quality improvement
Over the past decade, primary care has undergone major system changes enhancing the capacity to provide effective, high-quality, uniform and safe care. One means to improve the quality and safety of care delivered within the primary care sector is through implementation of quality improvement (QI) initiatives. There are many strategies to encourage the use of QI within primary care. One of these is to use external assessment mechanisms such as accreditation.
Accreditation is a self-assessment against a given set of standards, an on-site survey by peers from other organisations trained in assessment, an assessment of the degree of compliance with the standards, a written report with or without recommendations, and the granting or denial of accreditation status.[3–7] Accreditation measures individual practices against established standards and/or norms from other practices and as such offers a credible measure of the quality and safety in healthcare delivery.
Some countries have chosen accreditation as a means of measuring, reporting and promoting quality and QI in primary care. Accreditation standards for primary care were first established in Australia during the early 1990s. Since then, New Zealand (NZ), the USA, Indonesia and a number of Europe countries  have developed standards.
Accreditation has been successfully used to improve patient outcomes within the acute care setting, however, it is not known if these findings extend to primary care. As well, little is known on how QI processes and accreditation in primary care affect outcomes of care, patients’ perceptions of care, care utilisation and costs, and the perceptions of primary care providers. In addition, a compilation of which jurisdictions currently have primary care accreditation and the nature of accreditation within these jurisdictions has not been assembled.
The objectives of the current paper were to identify jurisdictions where primary care accreditation processes are in place, determine the nature (e.g. physician- or team-based, mandatory or voluntary, resource requirements, funding mechanisms) and uptake of accreditation, and lastly examine how accreditation processes in primary care have affected outcomes of care, care utilisation and costs, and the perceptions of primary care providers and patients towards accreditation.
A review of both peer-reviewed and grey literature as well as key stakeholder interviews were used to explore accreditation in primary care.
Peer-reviewed evidence about accreditation in primary care was found by searching multiple databases. Search parameters were restricted by year (1990– 2011) and language (English). Appendix A outlines the specific databases, search strategies and terms that were used. To identify additional information on accreditation in primary care, a Google ScholarTM search of the grey literature was performed. National and international accreditation organisations were identified using the search terms ‘accreditat* AND primary care AND (country)’. Websites of identified accreditation organisations were then searched using the following search terms: ‘accreditat*AND(primary care OR patient primary medical home) AND (standard OR process OR outcome) AND (Western Europe [emphasis on Great Britain, France, Netherlands, Denmark, and Sweden], United States, Canada, New Zealand, and Australia)’.
Abstracts were reviewed by two research team members to determine if they were eligible for inclusion (Table 1). If disagreement arose, a third team member reviewed the abstract and made the final decision for inclusion. The papers were then reviewed, and data were extracted and summarised. During review and summary, papers that did not meet criteria for inclusion were withdrawn. The references from all papers were reviewed for additional eligible studies. Abstracts of these additional studies were reviewed in the same manner as outlined above. Details are given in Table 1.
Key informants were identified through review of the literature and discussions with Accreditation Canada. Accrediting bodies fromcountries using accreditation standards in primary care were included. Semistructured interviews were used to ask key stakeholders about the nature and uptake of accreditation, barriers and facilitators to implementing the accreditation process and awareness of other jurisdictions using accreditation. Informed consent was obtained at the time of the interview. All interviews were recorded and themes were extracted from the audio files. Interview participants were sent a written synopsis of their country’s information for validation. Ethics approval was received from the Conjoint Health Research Ethics Board, University of Calgary.
Table 2 outlines the number of scholarly abstracts and papers reviewed and the final number of articles included. From the grey literature, a total of 72 sources were used. Eight interviews were conducted with representatives from Canada, the USA, the UK, the Netherlands, Denmark, Australia and New Zealand.
Three types of accreditation in primary care were identified: those developed as an extension of hospital accreditation systems (e.g. JointCommission on Accreditation of Healthcare Organisations – JCAHO); those developed specifically to address particular services (e.g. National Committee for Quality Assurance – NQCA); and those focusing on the competence of the provider rather than the organisation (e.g. American Medical Association). The peer-reviewed and grey literature, in addition to key stakeholder interviews revealed that Canada, the USA, Australia, New Zealand, the UK, the Netherlands and Denmark have accreditation programmes in the primary care sector.
Table 3 displays the varied processes and uptake among the countries identified as having accreditation programming in primary care.
Research investigating the impact of accreditation on the outcomes of patient care was sparse. Two studies provided evidence to suggest accreditation results improved care.[14,15] In a cross-sectional study, Braun et al found accredited centres were more likely to have staff dedicated to risk management, environmental safety and QI. In addition, those with accreditation status reported more quality assurance projects than non-accredited centres. When size and location were controlled for, accredited centres more frequently audited their clinical records, used credentialing methods, reviewed providers and trained staff. On a similar note, Wells et al found a positive association between facilities that were accredited and the level and quality of care patients received.
It has been suggested that accreditation results in improved teamwork,[16–24] improved access to care,[17,20,21] increased awareness of patient safety[16,25,26] improved practice systems and care processes,[17–19,25–27] and improved quality of care.[20,21]
Ultimately, accreditation is believed to improve patient safety[16,18,19,23,27] and aid in preventing patients from falling through the cracks. It is suggested that through the achievement of accreditation, organisations can truly demonstrate a commitment to providing high-quality, safe and effective care for their patients.[28–30]
In contrast to previous results, some authors concluded that it was difficult to determine if accreditation improved patient outcomes[25,31]and postulated that accreditation may not offer an effective way to control or improve quality as the minimumstandards required were unlikely to challenge many practices.
Overall, accreditation in primary care is costly,[3,17,27,32] requires significant work and resources,[17,25,27,31,33,34] and involves uncertainty over whether the benefits outweigh potentially significant costs. Unfortunately, data on the costs of accreditation are limited. Application fees paid to the accrediting organisation ranges from $3000CDN (£2000) to $5500CDN (£3500), varying with the method of assessment or programme used. However, this fee does not include preparing for the survey or making the required changes to comply with standards. Most often, the highest costs are incurred in the preparation stage, when the organisation is implementing required changes to meet standards set by the accreditation programme prior to the on-site visit. Preparation can take 10–12 months. Owing to the high costs, lack of resources and the voluntary nature of accreditation in primary care, uptake of this process has been limited.
Reducing costs associated with medical errors and system failures and implementing an effective performance improvement programme40 may allow accreditation to become more cost-effective by improving outcomes. Results suggested that accredited primary care organisations were more cost-effective than those who were not accredited.
The costs of accreditation are offset in some countries through financial incentives. In Australia and in some settings in the USA and the Netherlands, accredited practices were offered higher fee-for-service and support from insurance companies.[3,17,21,32,32,35,37]
The most significant financial incentive was the Practice Incentive Payment (PIP) in Australia.[9,42] The PIP initially covered 5–10% of a practitioner’s income, however, due to cutbacks now covered 2%. This decrease was met with resistance, resulting in some practices dropping out of accreditation programmes or choosing not to participate as money was a primary driver.
Only one study examining provider perceptions of primary care accreditation was found. This study examined the perceptions of providers in two primary care organisations. Administrators felt that accreditation brought greater collaboration, improved culture, fostered implementation of QI and brought greater understanding of their organisation, whereas some staff viewed accreditation as a bureaucratic control mechanism.
Provider views from Canada,16 New Zealand, and the UK43 favoured accreditation recognising the critical importance of investing in accreditation as a mechanism to improve care and to demonstrate commitment to QI and patient safety
Although positive attitudes towards accreditation exist, it is not widely accepted. In Australia, accreditation was still controversial despite having three- quarters of the general practices accredited. This resistance may be more prominent in physicians of retirement age (comprising 50% of Australian physicians) who were not interested in implementing potentially large changes, whereas newly trained Australian doctors desired to practice in accredited practices. In the USA, one of the biggest challenges to accreditation is primary care providers’ lack of recognition of the risks in their environment. Awareness and education surrounding accreditation is also deficient.  Practices commonly face a lack of resources, time and support to undergo accreditation.[23,44]
There is a void in research examining patients’ perceptions towards accreditation and its impact on patient care. One study found that patients generally lack awareness and concern for practice accreditation. In Australia, patient perceptions toward the changes implemented as a result of accreditation have been examined, but not their perceptions of accreditation itself.
The accreditation process involves a self-assessment on a given set of standards, an on-site survey by peers from an external organisations trained in assessment, an assessment of the degree of compliance with the standards, a written report with or without recommendations and the granting or denial of accreditation status.
High-quality research regarding the impact of accreditation on primary health care is limited. Primary care accreditation exists in Canada, the USA, Australia, New Zealand, the UK and the Netherlands, with Denmark launching their programming within the next one to two years. Since this review was completed, a study highlighting different accreditation schemes for primary care practice in Europe has been published. Notably missing from our data is the fact that Germany has an accreditation scheme for primary care. To date, primary care accreditation is mostly a non-government funded, voluntary process with some countries offering financial incentives.[23,47] The USA, Australia and Canada are most influential in the development of primary care accreditation throughout the world, with many of the standards highlighting patient-centred care.
Accreditation in primary health care is relatively new in comparison with its acute care counterpart. Through examination of the peer-reviewed and grey literature, along with key stakeholder interviews, it is evident there is a dearth of research in this area. Future efforts need to be undertaken to explore the nature and uptake of accreditation in primary care. Greater attention should be given to examining the outcomes of care resulting from accreditation, utilisation, costs of accreditation, and providers’ and patient’s perceptions towards accreditation, as these areas have the greatest void in research. There is much work that needs to be undertaken before we can definitively state that accreditation is useful for improving the care within the primary care domain.
We would also like to acknowledge Yi Wang for retrieving the articles used within this manuscript, Elizabeth Fradgley for retrieving the grey literature and Renee Torgerson, Rob Wedel, Jeanne Besner and John Abbott for their expertise.
This review was jointly funded by the Canadian Foundation for Healthcare Improvement and Health Quality Ontario, and supported in-kind by the Ward of the 21st Century Research Centre and Department of FamilyMedicine, University of Calgary and Workforce Research and Evaluation, Alberta Health Services.
Ethical Approval was obtained through the Conjoint Research Ethics Board, University of Calgary.
Not commissioned; externally Peer Reviewed