International Journal for Quality in Health Care Advance Access originally published online on July 24, 2007
International Journal for Quality in Health Care 2007 19(5):296-300; doi:10.1093/intqhc/mzm026
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Involving consumers in accreditation: the Irish experience
Health Information and Quality Authority* Project Office, Regus House, Regus Centre, Harcourt Road, Dublin 2, Ireland
Address reprint requests to: Elaine O'Connor. Health Information and Quality Authority, Project Office, Regus House, Regus Centre, Harcourt Road, Dublin 2, Ireland. E-mail: eoconnor{at}hiqa.ie
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Abstract |
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Background. Following the 2004 review of the Acute Care Accreditation Scheme, the Irish Health Services Accreditation Board (IHSAB) decided to increase the level of consumer involvement in the accreditation process by including consumers as members of the review teams assessing healthcare organizations. Such consumers were known as service user (SU) surveyors where SUs were defined as any person who has used the Irish health system, i.e. a patient or relative/carer, etc.
Objective. Consumer surveyors first participated in surveys in 2005 and a total of seven surveys took place that year. An evaluation of the role and participation of the consumer surveyor was conducted in 2006.
Methods. All stakeholder groups were consulted, i.e. consumer and peer review surveyors, applicant organizations and IHSAB staff, and a combination of qualitative and quantitative techniques was used.
Results. Stakeholders considered that consumer involvement introduced greater objectivity and credibility. Characteristics such as good communication and interpersonal skills, excellent powers of observation and objectivity were identified as important traits for consumer surveyors. There were some issues in relation to the clarity and consistency of their role in terms of the rating of criteria and their contribution to the accreditation report. There was support among the stakeholder groups for greater consumer involvement in the process by participating in additional tours and interviews.
Conclusion. The evaluation highlights that the introduction of consumer surveyors has been successful but illustrates that their role and level of involvement in the process may need to be re-examined.
Keywords: consumers, involvement, accreditation
One of the significant trends in the development of modern healthcare is that of patient-centred care and patient/client involvement. It has been suggested that this is reflective of major societal trends over the past 60 years such as loss of deference towards figures in authority, a focus on patients as customers, a rise in litigation and the rise of managerialism that challenges professional hegemony [1].
As a result, over the past decade, patient/consumer involvement in healthcare has been advocated in policies and strategy documents in a number of countries. For example, the 2001 report Crossing the Quality Chasm: A New Health System for the 21st Century, by the Institute of Medicine in USA, outlined ten rules for re-design of the American healthcare system, which were consistent with a patient-centred approach [2]. Strategy documents were also produced in countries such as the UK [3–5], Ireland [6], Scotland [7], Wales [8], Northern Ireland [9, 10], New Zealand [11–13], Australia [14, 15], and Canada [16, 17].
Such strategies have resulted in many healthcare agencies, examining the manner in which they engage consumers, and consequently, a number of new avenues for consumer involvement in healthcare have evolved. These include guidelines development and external assessment of healthcare organizations. For example, the remit of the National Institute for Clinical Excellence (NICE) in England and Wales is to produce health technology, clinical practice and public health guidelines for the National Health Service (NHS) in these countries. All guidance is produced in stages with draft documents posted on the NICE website for members of the public to comment. All NICE committees and working groups are expected to include at least two lay members [18]. External assessment involves monitoring the performance of an organization against defined standards. NHS Quality Improvement Scotland (NHS QIS) involve patients and carers in external assessments, as two members of every review team, who assess the performance of a healthcare organization against NHS QIS standards, are members of the general public [19].
Accreditation is a self-assessment and external peer review (PR) process used by healthcare organizations to accurately assess their level of performance in relation to established standards and to implement ways to continuously improve the healthcare system [20].
There are numerous ways in which consumers or patients can be directly involved in the accreditation of healthcare services, including:
- providing input to the development/evaluation of accreditation standards and criteria;
- as a member of a management board, advisory agency or other internal committees in the accreditation agency;
- provision of feedback to the service and/or the review team about the quality of the service, which is seeking accreditation, e.g. through focus groups, public meetings, interviews or feedback surveys;
- as a member of the quality improvement or other team with responsibility for preparation, management or change implementation within the service, which is seeking accreditation;
- as a member of a team of reviewers who are assessing a service [21].
The Irish Health Services Accreditation Board (IHSAB) and the Australian Council on Healthcare Standards (ACHS) involve consumers in the development of standards [22]. The IHSAB and the Canadian Council on Health Services Accreditation encourage applicant organizations to include patients/clients as members of their self-assessment teams, and during surveys, patients/clients are interviewed on a one on one basis or through focus groups by the review teams.
Following the 2004 review of the Acute Care Accreditation Scheme (ACAS), the IHSAB decided to increase the level of consumer involvement in the accreditation process by including consumers as members of the review teams assessing healthcare organizations. Such consumers were known as service user (SU) surveyors where SUs were defined as any person that has used the Irish health system, i.e. a patient or relative/carer etc. The inclusion of consumer surveyors in the survey process first took place in 2005 and a total of seven surveys occurred that year.
In 2001, the ACHS were involved in the Consumer Participation in Accreditation study [21]. The aim of the project was to explore and develop best practice relating to consumer participation, either at the healthcare facility level or as reviewers and surveyors in an accreditation team. Four pilots were conducted, two of which involved consumers working as surveyors/reviewers on accreditation teams. They demonstrated that consumer involvement as surveyors/reviewers could add real value to the accreditation survey. As a result, the ACHS recruited and implemented consumer surveyors in external reviews of mental health services [21]. Similarly, Quality Health New Zealand as a designated audit agency, assessing organizations against the National Mental Health Sector Standards, has consumers on the survey teams evaluating mental health, intellectual and physical disability service providers.
This paper documents the process undertaken by the IHSAB to recruit and train consumer surveyors and a subsequent evaluation of their role and participation in the PR survey process in its first year in operation.
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Selection and recruitment of consumer surveyors |
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The IHSAB contacted applicant organizations and asked them to nominate individuals from patient councils or advocacy groups as consumer surveyors. Consumer representative groups such as the Irish Heart Foundation and the Irish Kidney Association were also contacted to nominate individuals. IHSAB PR teams are well represented with senior members of clinical care and corporate management, and so to ensure true consumer input, individuals with a healthcare background are excluded. All nominated individuals were written to with an application form that included a self-assessment section. Candidates rated themselves against a set of seven core competency criteria by means of a five point scale where a score of ‘1’ means that they do not possess the requisite skills and a score of ‘5’ means that they have the appropriate skills (Table 1). They were also required to submit a Curriculum Vitae and the names of two referees. A short list of potential surveyors was compiled by members of the IHSAB senior executive, and they were then called for an interview. An interview was considered necessary in order to further assess competency and to validate that the individuals selected do not have a specific personal or political agenda. Nominees were also rated on the core competency criteria, which helped determine their suitability. A total of five were recruited using this process in 2004.
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Training and education
Training was provided to successful candidates in early 2005, outlining the process of surveying an organization and providing guidance on conducting tours, interview techniques and report writing, as they are expected to provide a report for inclusion in the hospital accreditation report. Consumer surveyors conduct their own tour of a hospital from the perspective of a user looking at aspects such as canteen and shop facilities, toilet facilities and waiting areas, and they also tour the clinical area at meal times. They participate in one care/service team tour and interview with the PR surveyors and speak with patients about their experiences in the hospital. Consumer surveyors take part in a minimum of one survey per year and may participate in more, depending on the number of surveys scheduled for the year and their availability for the survey dates.
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Methods |
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TopAbstractSelection and recruitment of...MethodsResultsDiscussionReferences |
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An evaluation of the role and participation of the consumer surveyor was conducted in 2006 and was inclusive of all seven surveys from 2005. Each consumer surveyor participated in one survey with two participating in two surveys each. All stakeholder groups, i.e. consumer and PR surveyors, applicant organizations and IHSAB staff, were consulted. A combination of qualitative and quantitative techniques was used.
Focus groups were conducted with consumer and PR surveyors and applicant organizations. In-depth interviews were conducted with three IHSAB staff members. All focus groups and in-depth interviews were transcribed, and themes that emerged cross-referenced collectively. Questionnaires were then developed in order to quantifiably capture the views of the consumer and PR surveyors and staff from applicant organizations. All questionnaires were distributed electronically and were returned either by e-mail or post. The questionnaires addressed issues such as selection and recruitment, training and education, the role of the consumer surveyor, and benefits and limitations of their involvement in the accreditation process.
Four of the five consumer surveyors returned completed questionnaires; one of them indicated that they did not wish to participate in the study. All PR surveyors (n = 30), who participated in the seven surveys in 2005, received a questionnaire. Sixteen completed questionnaires were returned representing a response rate of 53%. A total of 191 questionnaires were distributed to hospital staff in the seven hospitals. A total of 56 completed questionnaires were received, representing a response rate of 29%. Due to the small sample size, descriptive analysis detailing the frequency and percentage of respondents was carried out for each question and supplemented by information from the qualitative research phase.
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Results |
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Benefits of consumer surveyor involvement
Stakeholders considered the inclusion of consumer surveyors on survey teams to be beneficial in terms of lending credibility and balance to the accreditation process and as a catalyst for driving change and improvement in a hospital.
Gives a consumer viewpoint. Peer surveyors can be perceived to be involved in the system already and could even be accused of being biased towards the system. (PR Surveyor)
Seeing things from the patient's perspective gives a more balanced/rounded view to the survey process. (Hospital staff member)
Recruitment and pool of consumer surveyors
Characteristics such as good communication and interpersonal skills, excellent powers of observation and objectivity were identified as important traits for consumer surveyors by stakeholder groups.
The majority of PR surveyors (13/15–87% agree/strongly agree) and hospital staff (44/50–88% agree/strongly agree) thought that the consumer surveyor on their survey team possessed the characteristics/skills required of a consumer surveyor.
The majority of consumer surveyors (3–75% strongly agree) thought that the selection and recruitment process was comprehensive and that the self-assessment against the core competency criteria was particularly beneficial (4–100% strongly agree).
A PR Surveyor highlighted the importance of constantly refreshing the pool of consumer surveyors, as they felt that there was a danger of them becoming ‘professional surveyors’ if the same group are involved in surveys all the time. In addition, IHSAB staff indicated that the pool of consumer surveyors was not as representative of the Irish patient population as they would like it to be.
Training and education
All consumer surveyors thought that the education they received was adequate (4–100% agree) and that it gave them a good insight into their role (4–100% agree/strongly agree). Similarly, most PR surveyors (93% agree/strongly agree) and hospital staff (84% agree/strongly agree) considered that the consumer surveyor on their team was adequately prepared for their role. However, consumer surveyors considered the timeframe for the training (a day) to be too short. They also felt that it could be improved by introducing a shadow survey component and focusing more on report writing.
Role of the consumer surveyor
The study identified a number of issues in relation to the role of the consumer surveyor.
For example, they had different experiences with regard to the rating of care/service team criteria. Two indicated that they had been asked to contribute when the team was rating criteria whereas the other two were not asked. The focus group discussion illustrated that their contribution to the rating depended on the team leader and how they encouraged the consumer surveyors to actively participate in the survey.
In addition, not all consumer surveyors presented their information for the hospital accreditation report in the same manner. While all four indicated that they provided a verbal report on their findings, three out of the four indicated that they also prepared a written report.
Further participation
Consumer surveyors only spend a day and a half on survey due to the voluntary nature of the role and for financial and personal reasons. The results suggest that the current nature and level of their involvement may need to be re-examined. Thirty per cent of PR surveyors (5/15–33% disagree/strongly disagree) and 20% (10/49–20% disagree/strongly disagree) of hospital staff did not think that the length of time that the consumer surveyor spent on survey was appropriate. They thought that they could become more involved in the survey process by participating in more care/service team tours and interviews.
It would benefit all those involved if the SU Surveyor was involved in more than one team. (Hospital staff member)
In addition, both groups thought that there was a role for the consumer surveyor to provide specific feedback to hospital staff and management at the debriefing session on the last day of the survey.
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Discussion |
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TopAbstractSelection and recruitment of...MethodsResultsDiscussionReferences |
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The purpose of this paper was to describe the process undertaken by the IHSAB to recruit and train consumer surveyors and a subsequent evaluation of their participation in the accreditation process in its first year in operation. It highlighted some areas for improvement and clarification with regard to their participation in the survey process. As a result, a number of changes have been introduced to the overall process. These include the following:
- Selection and recruitment. The IHSAB publicly advertised for consumer surveyors in the national media in October 2006 in order to expand the pool of consumer surveyors to more accurately reflect the Irish patient population. Over 200 individuals expressed an interest and 16 surveyors have been recruited. The IHSAB are now looking into expanding the pool of surveyors to include adolescents.
- Training and education. Consumer surveyors now receive 2 days initial training, which includes a talk by experienced consumer surveyors. They also now shadow a survey as part of their training.
- Rating of care/service criteria. The role of the consumer surveyor in the rating of care/service team criteria has been emphasized and clarified in education sessions with PR and consumer surveyors. IHSAB staff have a role in facilitating the contribution of consumer surveyors in the rating of criteria on survey.
- Report writing. Existing consumer surveyors received additional training on report writing, and a report template was devised to assist in this capacity. Consumer surveyors may use this template to prepare their report, which is then collated into the overall hospital report by the lead surveyor and IHSAB staff member. IHSAB highlighted that the option of presenting information for the hospital report verbally or in written format was offered to consumer surveyors to take account of people's different education/literacy skills.
- Length of time on survey. Consumer surveyors are now involved in more tours while on survey, e.g. catering and radiology tours. IHSAB is now piloting the process of having them on survey for the entire week.
It is thought that such changes should enhance their contribution to the survey process and hence the resulting benefits. It may now be timely to undertake a similar study to evaluate the effectiveness of the additional changes introduced and the impact of increased consumer surveyor involvement in the survey process.
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Footnotes |
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* On the 15th May 2007, the Irish Health Services Accreditation Board became part of the new organization the Health Information and Quality Authority.
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References |
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|
TopAbstractSelection and recruitment of...MethodsResultsDiscussionReferences |
|---|
- Pietroni P, Winkler F, Graham L. Cultural revolution. BMJ (2003) 326:1304–6.
[Free Full Text] - Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. (2003) Washington, DC: National Academy Press.
- Department of Health. Patient and Public Involvement in the New NHS (1999) London: Department of Health.
- Department of Health. The NHS Plan: A Plan for Investment; A Plan for Reform (2000) London: Department of Health.
- Department of Health. Strengthening Accountability: Involving Patients and the Public, Policy Guidance, Section 11 of the Health and Social Care Act 2001 (2001) London: Department of Health.
- Department of Health and Children. Quality and Fairness: a Health System for you (2001) Dublin: Stationary Office.
- Scottish Executive Health Department. Our National Health: A Plan for Action, A Plan for Change (2000) Edinburgh: The Stationery Office.
- NHS Wales. Improving Health in Wales: A Plan for the NHS with Its Partners (2001) Cardiff: The National Assembly for Wales.
- Department of Health, Social Services and Public Safety. Investing for Health (2002) Belfast: DHSSPS.
- Department of Health, Social Services and Public Safety. A Healthier Future: A Twenty Year Vision for Health and Wellbeing in Northern Ireland 2005–2025 (2004) Belfast: DHSSPS.
- Minister of Health. The New Zealand Health Strategy (2000) Wellington: Ministry of Health.
- Minister for Disability Issues. The New Zealand Disability Strategy: Making a World of Difference Whakanui Oranga (2001) Wellington: Ministry of Health.
- Minister of Health. The Primary Health Care Strategy (2001) Wellington: Ministry of Health.
- National Expert Advisory Group on Safety and Quality in Australian Health Care. Implementing Safety and Quality Enhancement in Health Care. National Actions to Support Quality and Safety Improvement in Australian Health Care (1999) Australia.
- Australian Government Publishing Service. National Standards for Mental Health Services (1996) Canberra, Australia.
- Social Union Canada [homepage on the Internet]. A Framework to Improve the Social Union for Canadians. An agreement between the Government of Canada and the Governments of the Provinces and Territories, 4 February 1999 [cited 2006 February 17]. http://www.socialunion.ca/ (17 February 2006, date last accessed).
- Romanow RJ. Building on Values: The Future of Healthcare in Canada – Final Report (2002) Ottawa. http://www.hc.sc.ga.ca/(20 February 2006, date last accessed).
- National Institute for Clinical Excellence. Patient, Carer and Public Involvement Policy. http://www.nice.org.uk/(15 February 2006, date last accessed).
- NHS Quality Improvement Scotland. Patient Focus and Public Involvement Framework (2003) 11. Scotland.
- Irish Health Services Accreditation Board. Acute Care Accreditation Scheme A Framework for Quality and Safety (2004) 2nd edn, Revision 1. Dublin.
- Consumer Focus Collaboration. Consumer Participation in Accreditation Project Report (2001) Australia. http://www.participateinhealth.org.au/(14 May 2007, date last accessed).
- Australian Council on Healthcare Standards [homepage on the Internet]. Sydney: The Australian Council on Healthcare Standards; (2007) http://www.achs.org.au/(27 June 2007, date last accessed).
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