Experiences with the expansion of hospital accreditation into the developing world

Abstract

More developing countries are adopting hospital accreditation to improve the quality of their health systems, but it is uncertain whether accreditation standards and processes, largely borrowed from Western countries, are being adapted to fit each country's context. Three qualitative studies explore issues in assimilating hospital accreditation into developing countries, drawing mainly from experiences of two Southern African countries, Lesotho and Swaziland. Data sources included: archival records, documentary information, interviews, focus groups, expert panel surveys, and direct observations. Study 1, Explaining the expansion of hospital accreditation in the developing world, investigates the proposition that institutional theory largely explains the adoption of hospital accreditation in developing countries and how this external motivation influences the innovation process. Adoption of accreditation in developing countries is associated with the perceived contribution of accreditation to quality care in developed countries, endorsement of accreditation by key international players, and substantial donor support for implementing accreditation. This can result in less adaptation of Western accreditation practices, and this lack of local adaptation can hinder true assimilation and sustainability. Study 2, Connecting hospital accreditation with other quality improvement efforts in the developing world, explores the perceived connection between hospital accreditation and other quality improvement efforts and the effects of this com1ection on subsequent improvement efforts. This study found that hospital accreditation is laying important groundwork and establishing norms for future quality efforts, but is not being tied to more comprehensive national strategies for quality assurance and quality improvement. Study 3, Considerations in implementing hospital accreditation in the developing world, examines perceived appropriateness of hospital accreditation standards and processes implemented in Lesotho and Swaziland according to stakeholders in those health systems. Standards were perceived to be of high importance, fairly strong relevance, and moderate feasibility due to limited financial and human resources. Perceptions of the appropriateness of accreditation processes were strongly influenced by how accreditation was introduced to hospital staff, its gradual implementation, inclusion of hospital staff in the process, clearly defined role responsibilities, leadership commitment to accreditation, and implementation support. Overall, lower perceived control over accreditation standards and processes was linked to lower perceptions of appropriateness among hospital staff.