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Title: Exploring Accreditation, Strategic Change and linkages with Patient Safety Culture: a study of NABH accredited hospitals in Mumbai
Authors: Shetty, Anupama
Keywords: Phenomenon
Patient Safety
School of Health Systems Studies
Harshad Thakur
Issue Date: 2015
Publisher: TISS
Abstract: Accreditation, unlike licensure, is voluntary, and sets its sights higher than the minimum or ideal achievable standards of quality (Montagu, 2003). Healthcare accreditation is a world-wide phenomenon with presence in over 70 countries (Greenfield & Braithwaite, 2008). In India, the National Accreditation Board for Hospitals and Healthcare providers (NABH) was established by the Quality Council of India (QCI) in 2006 (QCI, 2008). NABH currently accredits hospitals, medical laboratories, small healthcare organizations, primary and community healthcare centers, blood banks, dental facilities, as well as imaging facilities (NABH, 2012). Accreditation has been considered as an agent of organizational and strategic change affecting all areas of the organization and all actors (Duckett, 1983; Shaw & Collins, 1995; Pomey, Contandriopoulos, François, & Bertrand, 2004; Pomey, et. al, 2010). The necessity of exploring the role of context, both external and internal has helped in understanding challenges, facilitators and barriers faced by healthcare organizations in the course of strategic change consequent to adoption of newer practices. In the Indian context however, we have aggregated very little evidence on the uptake, compatibility, validity and outcomes of accreditation programmes. The current study aimed to address this research gap, the objective being an understanding of external and organizational contextual factors influencing private healthcare organizations to adopt NABH accreditation (the ‘why ‘of change); the content of change (the ‘what’ of change) as well as the strategic processes used in institutionalization of standards (the ‘how’ of change). Accreditation has also been found to be a predictor of patient safety culture in hospitals (El-Jardali, et al., 2011; Al-Awa, et al., 2012). In the Indian context, while studies have focused on clinical parameters as an index of patient safety, there has been lack of research on wider systemic issues such as the culture of patient safety. An additional aspect of the study was to explore the culture of safety in the accredited hospitals. A mixed methods research design was used (Campbell & Fiske, 1959). Multiple case studies with embedded units of analysis (Yin, 1984) and Safety Climate Surveys (Sexton & Thomas, 2006) were conducted. Two accredited private hospitals in Mumbai were theoretically selected based on accreditation experience, interest in the study and feasibility. At the organizational level, multi-level sampling (Onwuegbuzie & Leech, 2007) was carried out at macrosystem, mesosystem and clinical microsystem levels. Four embedded units were chosen per case, at clinical microsystem levels, based on degree of interface with patients. A total of 61 respondents were interviewed and 217 respondents participated in the safety climate survey across both the case studies. In addition 9 external stakeholders were interviewed to explore institutional forces influencing the adoption of accreditation. Document analysis and observation in select clinical microsystems were also carried out. External stakeholder perceptions on the motivations of healthcare organizations to join the Indian accreditation movement revealed largely normative and mimetic motivations. It was perceived that the drivers for accreditation in established hospitals were the need for organizational reputation, while in newer hospitals it was organizational legitimacy.Mimetic factors such as empanelment by insurance bodies or CGHS empanelment were driving forces especially in the northern States. Medical tourism was also perceived to have a role, albeit a smaller one in driving accreditation efforts. The mimetic motivations were perceived as playing a role in newer, mid-size tertiary or secondary care hospitals. Accreditation can be seen as influencing both strategic change as well as the safety culture of the organization. Tracing strategic change in the case studies revealed several changes, both intended and emergent across the accreditation cycles. A rethinking of structures and formalization was evidenced over time. The changes were broadly structural, procedural, infrastructural and regulatory. While the bulk of changes were seen in the pre-accreditation phase, these changes continued on a smaller scale during the first and second cycles of accreditation. Multi-disciplinary nature of teams supported the development of collective responsibility and wide dissemination of standards. Informal leaders emerged and were co-opted into the re-structuring process. Strategic teams looked at providing an overall framework for documentation change based on review of the standards while department coordinators or heads were responsible for training and implementation. Innovations were evidenced at a study site consistent with the notion of complexity leading to the generation of innovative ideas. Lack of involvement of clinicians in terms of documentation compliance was evident in both case studies. Both clinicians and nurses perceived that increased documentation would take time away from patient care. Extensive training frameworks were witnessed and directed at standardization with emergency procedure’s as well as improving performance on clinical indicators. Attrition among junior physicians as well as lack of physician engagement in training programmes posed challenges to the training program. The safety taxonomy changed greatly over the period with transition to more patient-centric medical terminology in lieu of NABH standards. Content of change in patient safety standards involved policy, procedure, medication management, risk assessment guidelines as well as training strategy. Adherence to standards was driven by continuous quality improvement activities and constant reviews at multiple levels in the form of departmental and organization-wide audits. The challenge posed to continuous quality improvement activities was the increasingly higher benchmarks being set by successive external NABH audits. It is posited that case A saw a move from adaptive learning to generative learning. (Singh, 2010). Learning in case B was more adaptive and evolved for the necessity of meeting NABH standards. Ultimately the frameworks established led to the concept of “organizational learning” as an outcome of the implementation process at the study sites. Both cases studies also witnessed a shared governance framework emerging among the nursing managerial cadre which served as the ideal dissipative structure to support the implementation of standards. Distributed leadership was also evidenced in case A, with collaborative distribution wherein leadership practice was generated in interaction of leaders, physicians, nurses, and non-clinical staff in the course of accreditation.
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02_Declaration.pdf33.78 kBAdobe PDFView/Open
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04_Acknowledgement.pdf37.7 kBAdobe PDFView/Open
05_Table of contents.pdf42.81 kBAdobe PDFView/Open
06_List of Abbreviations.pdf31.06 kBAdobe PDFView/Open
07_List of figures.pdf25.1 kBAdobe PDFView/Open
08_List of Tables.pdf33.96 kBAdobe PDFView/Open
09_Abstract.pdf62 kBAdobe PDFView/Open
10_Chapter 1.pdf241.9 kBAdobe PDFView/Open
11_Chapter 2.pdf407.47 kBAdobe PDFView/Open
12_Chapter 3.pdf113.43 kBAdobe PDFView/Open
13_Chapter 4.pdf924.37 kBAdobe PDFView/Open
14_Chapter 5.pdf752.37 kBAdobe PDFView/Open
15_Chapter 6.pdf336.93 kBAdobe PDFView/Open
16_Bibliography.pdf175.97 kBAdobe PDFView/Open
17_Annexure.pdf610.42 kBAdobe PDFView/Open

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