Mediators of change in healthcare organisations subject to external assessment: a systematic review with narrative synthesis

Abstract

ObjectivesExternal inspections are widely used to improve the quality of care. The effects of inspections remain unclear and little is known about how they may work. We conducted a narrative synthesis of research literature to identify mediators of change in healthcare organisations subject to external inspections.MethodsWe performed a literature search (1980–January 2020) to identify empirical studies addressing change in healthcare organisations subject to external inspection. Guided by the Consolidated Framework for Implementation Research, we performed a narrative synthesis to identify mediators of change.ResultsWe included 95 studies. Accreditation was the most frequent type of inspection (n=68), followed by statutory inspections (n=19), and external peer review (n=9). Our findings suggest that the regulatory context in which the inspections take place affect how they are acted on by those being inspected. The way inspections are conducted seem to be critical for how the inspection findings are perceived and followed up. Inspections can engage and involve staff, facilitate leader engagement, improve communication and enable the creation of new networks for reflection on clinical practice. Inspections can contribute to creating an awareness of the inspected organisation’s current practice and performance gaps, and a commitment to change. Moreover, they can contribute to facilitating the planning and implementation of change, as well as self-evaluation and the use of data to evaluate performance.ConclusionsExternal inspections can affect different mediators of organisational change. The way and to what extent they do depend on a range of factors related to the outer setting, the way inspections are conducted and how they are perceived and acted on by the inspected organisation. To improve the quality of care, the organisational change processes need to involve and impact the way care is delivered to the patients.

What Lies Behind Successful Regulation? A Qualitative Evaluation of Pilot Implementation of Kenya’s Health Facility Inspection Reforms

“…These issues have been highlighted more generally in the regulatory literature from LMIC and highincome countries, with greater legitimacy of regulatory systems argued to lead to higher levels of compliance without very heavy investment in policing performance. [32][33][34] For example, a systemic review of inspections, primarily in high income settings, underscored the importance of predictable and transparent inspection processes that are perceived as valid and reliable in encouraging change in response to inspection findings. 33 These design features were also potentially important in restricting the potential for bribery, together with random quality checks by World Bank field staff, and requiring different inspectors to conduct consecutive inspections.…”

“…[32][33][34] For example, a systemic review of inspections, primarily in high income settings, underscored the importance of predictable and transparent inspection processes that are perceived as valid and reliable in encouraging change in response to inspection findings. 33 These design features were also potentially important in restricting the potential for bribery, together with random quality checks by World Bank field staff, and requiring different inspectors to conduct consecutive inspections. According to study respondents, bribery was rampant in the pre-JHI inspection system, echoing findings from other LMIC contexts.…”

“… 32 - 34 For example, a systemic review of inspections, primarily in high income settings, underscored the importance of predictable and transparent inspection processes that are perceived as valid and reliable in encouraging change in response to inspection findings. 33 …”

What GPs do to meet accreditation standards – implementation activities and perceived improvements attributed to general practice accreditation

“…Yet, interventions with external inspections, such as accreditation, have the ability to engage and involve staff, facilitate leader engagement, improve communication and enable the creation of new networks for reflection on clinical practice. Also, inspections can contribute to creating an awareness of the inspected organisation’s current practice and performance gaps, and a commitment to change and facilitate planning and implementation of change [ 15 ]. Quantitative studies of the extent of the effect are few in a general practice setting [ 16 , 17 ], and results include positive, negative and mixed results [ 18 – 21 ].…”

Accreditation in health care: does it make any difference to patient outcomes?

“…Another systematic review showed that the external inspection process alone may mediate change. 3 Two papers in this edition of BMJ Quality & Safety further our understanding of how accreditation may improve outcomes. In the first, Sun and colleagues 4 conducted a large-scale evaluation of patients in accredited chest pain centres.…”