The impact of hospital accreditation on clinical documentation compliance: a life cycle explanation using interrupted time series analysis

OBJECTIVE To evaluate whether accredited hospitals maintain quality and patient safety standards over the accreditation cycle by testing a life cycle explanation of accreditation on quality measures. Four distinct phases of the accreditation life cycle were defined based on the Joint Commission International process. Predictions concerning the time series trend of compliance during each phase were specified and tested. DESIGN Interrupted time series (ITS) regression analysis of 23 quality and accreditation compliance measures. SETTING A 150-bed multispecialty hospital in Abu Dhabi, UAE. PARTICIPANTS Each month (over 48 months) a simple random sample of 24% of patient records was audited, resulting in 276,000 observations collected from 12,000 patient records, drawn from a population of 50,000. INTERVENTIONS The impact of hospital accreditation on the 23 quality measures was observed for 48 months, 1 year preaccreditation (2009) and 3-year postaccreditation (2010-2012). MAIN OUTCOME MEASURES The Life Cycle Model was evaluated by aggregating the data for 23 quality measures to produce a composite score (YC) and fitting an ITS regression equation to the unweighted monthly mean of the series. RESULTS The four phases of the life cycle are as follows: the initiation phase, the presurvey phase, the postaccreditation slump phase and the stagnation phase. The Life Cycle Model explains 87% of the variation in quality compliance measures (R(2)=0.87). The ITS model not only contains three significant variables (β1, β2 and β3) (p≤0.001), but also the size of the coefficients indicates that the effects of these variables are substantial (β1=2.19, β2=-3.95 (95% CI -6.39 to -1.51) and β3=-2.16 (95% CI -2.52 to -1.80). CONCLUSIONS Although there was a reduction in compliance immediately after the accreditation survey, the lack of subsequent fading in quality performance should be a reassurance to researchers, managers, clinicians and accreditors.