title: The standard of healthcare accreditation standards: a review of empirical research underpinning their development and impact.
abstract: BACKGROUND
  Healthcare accreditation standards are advocated as an important means of improving clinical practice and organisational performance. Standard development agencies have documented methodologies to promote open, transparent, inclusive development processes where standards are developed by members. They assert that their methodologies are effective and efficient at producing standards appropriate for the health industry. However, the evidence to support these claims requires scrutiny. The study's purpose was to examine the empirical research that grounds the development methods and application of healthcare accreditation standards.
  
  
  METHODS
  A multi-method strategy was employed over the period March 2010 to August 2011. Five academic health research databases (Medline, Psych INFO, Embase, Social work abstracts, and CINAHL) were interrogated, the websites of 36 agencies associated with the study topic were investigated, and a snowball search was undertaken. Search criteria included accreditation research studies, in English, addressing standards and their impact. Searching in stage 1 initially selected 9386 abstracts. In stage 2, this selection was refined against the inclusion criteria; empirical studies (n = 2111) were identified and refined to a selection of 140 papers with the exclusion of clinical or biomedical and commentary pieces. These were independently reviewed by two researchers and reduced to 13 articles that met the study criteria.
  
  
  RESULTS
  The 13 articles were analysed according to four categories: overall findings; standards development; implementation issues; and impact of standards. Studies have only occurred in the acute care setting, predominately in 2003 (n = 5) and 2009 (n = 4), and in the United States (n = 8). A multidisciplinary focus (n = 9) and mixed method approach (n = 11) are common characteristics. Three interventional studies were identified, with the remaining 10 studies having research designs to investigate clinical or organisational impacts. No study directly examined standards development or other issues associated with their progression. Only one study noted implementation issues, identifying several enablers and barriers. Standards were reported to improve organisational efficiency and staff circumstances. However, the impact on clinical quality was mixed, with both improvements and a lack of measurable effects recorded.
  
  
  CONCLUSIONS
  Standards are ubiquitous within healthcare and are generally considered to be an important means by which to improve clinical practice and organisational performance. However, there is a lack of robust empirical evidence examining the development, writing, implementation and impacts of healthcare accreditation standards.
authors.affiliation: Centre for Clinical Governance Research, Australian Institute of Health Innovation, University of New South Wales, Sydney, New South Wales 2052, Australia. d.greenfield@unsw.edu.au
authors.forename: David
authors.initials: D
authors.lastname: Greenfield
authors.forename: Marjorie
authors.initials: M
authors.lastname: Pawsey
authors.forename: Reece
authors.initials: R
authors.lastname: Hinchcliff
authors.forename: Max
authors.initials: M
authors.lastname: Moldovan
authors.forename: Jeffrey
authors.initials: J
authors.lastname: Braithwaite
mesh_terms: D000068:Accreditation / Q000592:standards*; D003695:Delivery of Health Care / Q000592:standards; D036262:Empirical Research; D006801:Humans; D019984:Quality Indicators, Health Care / Q000458:organization & administration / Q000592:standards*