title: Effectiveness of external inspection of compliance with standards in improving healthcare organisation behaviour, healthcare professional behaviour or patient outcomes.
abstract: BACKGROUND
  Inspection systems are used in health care to promote quality improvements, i.e. to achieve changes in organisational structures or processes, healthcare provider behaviour and patient outcomes. These systems are based on the assumption that externally promoted adherence to evidence-based standards (through inspection/assessment) will result in higher quality of health care. However, the benefits of external inspection in terms of organisational, provider and patient level outcomes are not clear.
  
  
  OBJECTIVE
  To evaluate the effectiveness of external inspection of compliance with standards in improving healthcare organisation behaviour, healthcare professional behaviour and patient outcomes.
  
  
  METHODS
  We searched the following electronic databases for studies: the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, CINAHL, Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effectiveness, Scopus, HMIC, Index to Theses and Intute from their inception dates up to May 2011. There was no language restriction and studies were included regardless of publication status. We searched the reference lists of included studies and contacted authors of relevant papers, accreditation bodies and the International Organization for Standardisation (ISO), regarding any further published or unpublished work.
  
  
  METHODS
  We included randomised controlled trials (RCTs), controlled clinical trials (CCTs), interrupted time-series (ITSs) and controlled before and after studies (CBAs) evaluating the effect of external inspection against external standards on healthcare organisation change, healthcare professional behaviour or patient outcomes in hospitals, primary healthcare organisations and other community-based healthcare organisations.
  
  
  METHODS
  Two review authors independently applied eligibility criteria, extracted data and assessed the risk of bias of each included study. Since meta-analysis was not possible, we produced a narrative results summary.
  
  
  RESULTS
  We identified one cluster-RCT involving 20 South African public hospitals (Salmon 2003) and one ITS involving all acute trusts in England (OPM 2009) for inclusion in this review.Salmon and colleagues (Salmon 2003) showed mixed effects of a hospital accreditation system on the compliance with COHSASA (the Council for Health Services Accreditation for South Africa) accreditation standards and eight indicators of hospital quality. Significantly improved total mean compliance score with COHSASA accreditation standards was found for 21/28 service elements: mean intervention effect (95% confidence interval (CI)) was 30% (23% to 57%) (P < 0.001). The score increased from 48% to 78% in intervention hospitals, while remaining the same in control hospitals (43%). A sub-analysis of 424 a priori identified critical criteria (19 service elements) showed significantly improved compliance with the critical standards (P < 0.001). The score increased from 41% (21% to 46%) to 75% (55% to 96%) in intervention hospitals, but was unchanged in control hospitals (37%). Only one of the nine intervention hospitals gained full accreditation status at the end of the study period, with two others reached pre-accreditation status.The median intervention effect (range) for the indicators of hospital quality of care was 2.4 (-1.9 to +11.8) and only one of the eight indicators: 'nurses perception of clinical quality, participation and teamwork' was significantly improved (mean intervention effect 5.7, P = 0.03).Re-analysis of the MRSA (methicillin-resistant Staphylococcus aureus) data showed statistically non-significant effects of the Healthcare Commissions Infection Inspection programme.
  
  
  CONCLUSIONS
  We only identified two studies for inclusion in this review, which highlights the paucity of high-quality controlled evaluations of the effectiveness of external inspection systems. No firm conclusions could therefore be drawn about the effectiveness of external inspection on compliance with standards.
authors.affiliation: Department of PublicHealth,University ofOxford,Headington, UK.
authors.forename: Gerd
authors.initials: G
authors.lastname: Flodgren
authors.forename: Marie-Pascale
authors.initials: MP
authors.lastname: Pomey
authors.forename: Sarah A
authors.initials: SA
authors.lastname: Taber
authors.forename: Martin P
authors.initials: MP
authors.lastname: Eccles
mesh_terms: D000068:Accreditation / Q000592:standards*; D003133:Commission on Professional and Hospital Activities / Q000592:standards*; D003428:Cross Infection / Q000453:epidemiology; D004739:England; D019983:Guideline Adherence / Q000592:standards; D006761:Hospitals / Q000592:standards*; D055624:Methicillin-Resistant Staphylococcus aureus; D015279:Organizational Culture; D017063:Outcome Assessment, Health Care / Q000592:standards; D011364:Professional Practice / Q000592:standards*; D011785:Quality Assurance, Health Care / Q000592:standards*; D058996:Quality Improvement / Q000592:standards*; D016032:Randomized Controlled Trials as Topic; D013019:South Africa; D013203:Staphylococcal Infections / Q000453:epidemiology
references.citation: J Vasc Surg. 2008 Jun;47(6):1155-6; discussion 1163-4
references.pmid: 18514832
references.citation: Cochrane Database Syst Rev. 2009 Jan 21;(1):MR000006
references.pmid: 19160345
references.citation: Bull Am Coll Surg. 2008 Oct;93(10):13-7
references.pmid: 19469362
references.citation: Am J Health Syst Pharm. 2002 Sep 15;59(18):1763-7
references.pmid: 12298115
references.citation: Psychiatr Hosp. 1987 Summer;18(3):131-4
references.pmid: 10289831
references.citation: Laryngoscope. 2009 Apr;119(4):635-9
references.pmid: 19266585
references.citation: Clin Chim Acta. 2003 Jul 15;333(2):115-24
references.pmid: 12849894
references.citation: Int J Qual Health Care. 2008 Jun;20(3):172-83
references.pmid: 18339666
references.citation: Anesth Analg. 2005 Jan;100(1):162-168
references.pmid: 15616072
references.citation: Cochrane Database Syst Rev. 2006 Apr 19;(2):CD000259
references.pmid: 16625533
references.citation: Int J Qual Health Care. 2009 Jun;21(3):183-9
references.pmid: 19439444
references.citation: PLoS Med. 2009 Jul 21;6(7):e1000097
references.pmid: 19621072
references.citation: World Hosp Health Serv. 2004;40(1):24-7, 50, 51
references.pmid: 15114920