Does accreditation stimulate change? A study of the impact of the accreditation process on Canadian healthcare organizations.

BACKGROUND: One way to improve quality and safety in healthcare organizations (HCOs) is through accreditation. Accreditation is a rigorous external evaluation process that comprises self-assessment against a given set of standards, an on-site survey followed by a report with or without recommendations, and the award or refusal of accreditation status. This study evaluates how the accreditation process helps introduce organizational changes that enhance the quality and safety of care. METHODS: We used an embedded multiple case study design to explore organizational characteristics and identify changes linked to the accreditation process. We employed a theoretical framework to analyze various elements and for each case, we interviewed top managers, conducted focus groups with staff directly involved in the accreditation process, and analyzed self-assessment reports, accreditation reports and other case-related documents. RESULTS: The context in which accreditation took place, including the organizational context, influenced the type of change dynamics that occurred in HCOs. Furthermore, while accreditation itself was not necessarily the element that initiated change, the accreditation process was a highly effective tool for (i) accelerating integration and stimulating a spirit of cooperation in newly merged HCOs; (ii) helping to introduce continuous quality improvement programs to newly accredited or not-yet-accredited organizations; (iii) creating new leadership for quality improvement initiatives; (iv) increasing social capital by giving staff the opportunity to develop relationships; and (v) fostering links between HCOs and other stakeholders. The study also found that HCOs' motivation to introduce accreditation-related changes dwindled over time. CONCLUSIONS: We conclude that the accreditation process is an effective leitmotiv for the introduction of change but is nonetheless subject to a learning cycle and a learning curve. Institutions invest greatly to conform to the first accreditation visit and reap the greatest benefits in the next three accreditation cycles (3 to 10 years after initial accreditation). After 10 years, however, institutions begin to find accreditation less challenging. To maximize the benefits of the accreditation process, HCOs and accrediting bodies must seek ways to take full advantage of each stage of the accreditation process over time.

Parents' needs following identification of childhood hearing loss.

PURPOSE: Appropriate support for families of children diagnosed with hearing impairment may have a direct impact on the success of early hearing detection and intervention programs in reducing the negative effects of permanent hearing loss. We conducted a qualitative study to explore parents' needs after learning of their child's hearing loss to better understand the important components of service delivery from families' perspectives. METHOD: Semistructured interviews were conducted with 17 families (21 parents) of preschool children in 4 centers in Ontario, Canada. Parents of children identified by neonatal screening as well as those identified through traditional referral routes participated. We asked parents to share their perceptions of the strengths and gaps in the care system. RESULTS: Although the majority of parents were satisfied with the range and quality of audiology and therapy services available, they identified gaps in the areas of service coordination, availability of information, and the integration of social service and parent support into the system. Access to audiology services appears to have been facilitated for children who were systematically screened. CONCLUSIONS: The findings provide insights into the services most valued by families. These findings highlight the importance of eliciting parents' perspectives in designing optimal care models for children and families.

Parents' perspectives on the impact of the early diagnosis of childhood hearing loss.

Newborn hearing screening has been widely implemented to improve outcomes for children with permanent hearing loss. This study examined benefits beyond those typically measured clinically, by exploring parents' perceptions of the effects of early/late identification of hearing loss. The parents of 17 children in Ontario, Canada, participated in the study. Seven children were identified through systematic screening and ten through traditional referral practices. All children were in oral rehabilitation programs. The study adopted a qualitative approach, examining parent's views through individual interviews. Purposive sampling was used to select a diverse group of parents to allow a broad range of perspectives to emerge. Benefits of early identification included improved communication development and early access to hearing. Negative aspects of late identification included regret for the family and family stress around the child's language gap. Although, screening programs may offer a seamless transition to audiology services, the transition to intervention services appeared less fluid for some families. Overall, parents strongly support infant hearing screening and identify benefits that are not easily quantifiable through traditional clinical measures.

Fitting audiology within the population health perspective.

The population health perspective has become increasingly apparent in the medical, public health, and policy literature. This article emphasizes the value of applying the population health perspective and associated frameworks to the rehabilitative sciences and particularly to the field of audiology. Key components of the population health perspective--including the determinants of health, the importance of evidence-based practice, and the value of transdisciplinarity--are used to illustrate the relevance of population health to the field of audiology. Using these key concepts from a population health framework and examples from audiology, the adoption of a population health perspective is proposed.

Economic evaluation of cardiac rehabilitation: a systematic review.

BACKGROUND: Economic evaluation is an important tool in the evaluation of competing healthcare interventions. Little is known about the economic benefits of different cardiac rehabilitation program delivery models. DESIGN: The goal of this study was to review and evaluate the methodological quality of published economic evaluations of cardiac rehabilitation services. METHODS: Electronic databases were searched for English language evaluations (trials, modeling studies) of the economic impact of cardiac rehabilitation. A review of study characteristics and methodological quality was completed using standardized tools. All costs are adjusted to 2004 US dollars. RESULTS: Fifteen economic evaluations were identified which met eligibility criteria but which displayed wide variation in the use of comparators, evaluation type, perspective and design. Evidence to support the cost-effectiveness of supervised cardiac rehabilitation in myocardial infarction and heart failure patients was identified. The range of cost per life year gained was estimated as from 2193 dollars to 28,193 dollars and from - 668 dollars to 16,118 dollars per quality adjusted life year gained. The level of evidence supporting the economic value of home-based cardiac rehabilitation interventions is limited to partial economic analyses. CONCLUSIONS: Evidence to support the cost-effectiveness of supervised cardiac rehabilitation compared with usual care in myocardial infarction and heart failure was identified. Further trials are required to support the cost-effectiveness of cardiac rehabilitation in cardiac patients who have under gone revascularization. The literature evaluating home-based and alternative delivery models of cardiac rehabilitation was insufficient to draw conclusions about their relative cost-effectiveness. The overall quality of published economic evaluations of cardiac rehabilitation is poor and further well-designed trials are required.

How should Canada fund the blood system? An evaluation of the chargeback proposal.

The Canadian blood system is a critical interface between public health and the delivery of patient care. The organization of the blood system plays a vital role in ensuring that its functions are effectively fulfilled. Previous structural problems in the blood system led to serious health consequences by contributing to the blood transmission of hepatitis C and HIV in the 1980s. To address these problems, the Canadian blood system has recently undergone considerable organizational reform. However, policy-makers, particularly in Ontario, are considering further structural reform specifically focusing on how the blood system is financed. This move for reform is partially motivated by the rising cost of blood products and the perception that the current system has failed to provide incentives for the efficient use of these products. The suggested payment mechanism, a "chargeback system," involves the provincial ministries of health funding hospitals so that hospitals can directly purchase blood products from the Canadian Blood Services. This approach would replace the current system in which the provinces directly fund the Canadian Blood Services, which in turn provides blood products free of charge to hospitals. Based on a review of documents and stakeholder interviews, we report the potential advantages and disadvantages of a change to a new system of funding and make recommendations on how provinces should proceed.