Advancing the accreditation economy: a critical reflection.
- Publisher:
- Oxford University Press
- Publication Type:
- Journal Article
- Citation:
- International Journal for Quality in Health Care, 2021, 33, (4), pp. 1-2
- Issue Date:
- 2021-12
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n their recent paper, Greenfield et al. [1] outline the substantial and sustained accreditation economy that now exists in many countries. Stakeholders continue to be divided regarding the appropriate design, implementation and reporting mechanisms of programs, as well as their definitive impact on improving the safety and quality of health services [2]. Greenfield et al. [1] cite evidence from previous similar studies in 2000 and 2010 to present these issues as perennial, arguing that work remains to convince stakeholders of the value and sustainability of accreditation.
These debates occur in the context of new local programs being introduced annually, supplemented by transnational programs entering new markets—countries, sectors and clinical areas. In some circumstances, governments and donor agencies promote global expansion as a pathway to enabling ‘quality’ universal health coverage [3]. The International Society for Quality in Health Care (ISQua) encourages standardization of accreditation design and processes by facilitating a global community of practice through the ISQua External Evaluation Association.
To realize the value and sustainability of programs, the global accreditation economy must resonate with key stakeholders in low- and middle-income countries. Resource constraints and under-developed regulatory environments present clear challenges to effective uptake and diffusion [4], with historical professional and institutional cultures equally influential. For example, staff requirements to ‘speak up for safety’ and consumer engagement in organizational decision-making require new systems and processes to be implemented. The flexibility of transnational accreditation programs to accommodate local adaption of standards is a strength. However, the cross-cultural implementation of the values and goals of accreditation programs requires careful consideration and planning when doing so.
A stimulus for the uptake of voluntary programs in low- and middle-income countries has been medical tourism, but the implementation of statutory programs, often based on prominent transnational programs, is also frequently encouraged by donor agencies. This has led some commentators to interrogate the influence of commercial and political drivers on the expanding accreditation economy [5]. The source of funding for accreditation program evaluations is a further area that may require greater consideration and transparency.
There is a broad agreement that the accreditation evidence base is diverse and inconsistent [6], analogous to abstract art, which proponents and opponents interpret selectively as validation of their existing perceptions regarding the accreditation economy. However, this variability in the evidence base is hardly surprising, when accreditation is understood as a prototypical complex intervention, designed and implemented variably in complex, dynamic health systems, worldwide [7].
Instead of viewing accreditation as a panacea for low-quality care, and evaluating it accordingly, Greenfield et al. [1] extend the position of Mitchell et al. [8] in arguing that its main function could be the dissemination of sectoral, national and global languages through which to articulate and share system-based approaches for enculturating quality and safety improvement. This distinction may warrant a timely reorientation of the research agenda to better discern the positive impacts arising from the accreditation economy. Furthermore, in addition to pursuing robust evidence of effect, stakeholders may also want to consider the types of evidence that would justify the de-implementation of programs, as occurred in Denmark from 2015 [9].
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