Integrated systems appear to be feasible and have the potential to reduce hospital and nursing home utilization without increasing costs.

BackgroundOne way to improve quality and safety in healthcare organizations (HCOs) is through accreditation. Accreditation is a rigorous external evaluation process that comprises self-assessment against a given set of standards, an on-site survey followed by a report with or without recommendations, and the award or refusal of accreditation status. This study evaluates how the accreditation process helps introduce organizational changes that enhance the quality and safety of care.MethodsWe used an embedded multiple case study design to explore organizational characteristics and identify changes linked to the accreditation process. We employed a theoretical framework to analyze various elements and for each case, we interviewed top managers, conducted focus groups with staff directly involved in the accreditation process, and analyzed self-assessment reports, accreditation reports and other case-related documents.ResultsThe context in which accreditation took place, including the organizational context, influenced the type of change dynamics that occurred in HCOs. Furthermore, while accreditation itself was not necessarily the element that initiated change, the accreditation process was a highly effective tool for (i) accelerating integration and stimulating a spirit of cooperation in newly merged HCOs; (ii) helping to introduce continuous quality improvement programs to newly accredited or not-yet-accredited organizations; (iii) creating new leadership for quality improvement initiatives; (iv) increasing social capital by giving staff the opportunity to develop relationships; and (v) fostering links between HCOs and other stakeholders. The study also found that HCOs' motivation to introduce accreditation-related changes dwindled over time.ConclusionsWe conclude that the accreditation process is an effective leitmotiv for the introduction of change but is nonetheless subject to a learning cycle and a learning curve. Institutions invest greatly to conform to the first accreditation visit and reap the greatest benefits in the next three accreditation cycles (3 to 10 years after initial accreditation). After 10 years, however, institutions begin to find accreditation less challenging. To maximize the benefits of the accreditation process, HCOs and accrediting bodies must seek ways to take full advantage of each stage of the accreditation process over time.

Examines the dynamics of change that operated following preparations for accreditation. The study was conducted from May 1995 to October 2001 in a university hospital center in France after the introduction in 1996 of mandatory accreditation. An embedded explanatory case study sought to explore the organizational changes: a theoretical framework for analyzing change was developed; semi-structured interviews, focus groups, and questionnaires addressed to the hospital's professionals were used and documents were collected; and qualitative and quantitative analyses were carried out. Professionals from clinical and medico-technical departments participated most. Preparations for accreditation provided an opportunity to reflect non-hierarchically on the treatment of patients and on the hospital's operational modalities by creating a locus for exchanges and collegial decision making. These preparations also led to giving greater consideration to results of exit surveys and to committing procedures to paper, and were a key opportunity for introducing a continuous quality program.

Organizational performance remains an elusive concept despite its importance to health care organizations' (HCOs') management and analysis. This paper uses Parsons' social system action theory to develop a comprehensive theoretically grounded framework by which to overcome the current fragmented approach to HCO performance management. The Parsonian perspective focuses on four fundamental functions that an HCO needs to ensure its survival. Organizational performance is determined by the dynamic equilibrium resulting from the continual interaction of, and interchange among, these four functions. The alignment interchanges allow the creation of bridges between traditional models of organizational performance that are usually used as independent and competing models. The attraction of the Parsonian model lies in its capacity to: (1) embody the various dominant models of organizational performance; (2) present a strong integrative framework in which the complementarity of various HCO performance perspectives are well integrated while their specificity is still well preserved; and (3) enrich the performance concept by making visible several dimensions of HCO performance that are usually neglected. A secondary objective of this paper is to lay the foundation for an integrative process of arbitration among competing indicators and perspectives which is absolutely necessary to make operational the Parsonian model of HCO performance. In this matter, we make reference to the theory of communicative action elaborated by Habermas. It offers, we think, a challenging and refreshing perspective on how to manage HCO performance evaluation processes.

Neste texto, partimos do pressuposto de que a integralidade da atenção é um eixo prioritário da investigação e avaliação dos serviços e sistemas de saúde, estruturados como redes assistenciais interorganizacionais que articulam dimensões clínicas, funcionais, normativas e sistêmicas em sua operacionalização, reconhecendo que nenhuma organização reúne a totalidade dos recursos e competências necessárias para a solução dos problemas de saúde de uma população, em seus diversos ciclos de vida. Em virtude da complexidade desse "sistema sem muros", que elimina as barreiras de acesso entre os diversos níveis de atenção, em resposta às necessidades de saúde nos âmbitos local e regional, julgamos oportuno compartilhar algumas "lições preliminares" aprendidas em experiências pessoais e na literatura sobre a integração de serviços, que nos parecem de interesse comum aos pesquisadores e gestores comprometidos com a sua implantação.