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Summary of findings for the main comparison. External inspection of compliance with COHSASA hospital accreditation standards versus no external inspection

External inspection of compliance with COHSASA hospital accreditation standards versus no external inspection

Recipient: public hospitals

Settings: KwaZulu province, the Republic of South Africa

Intervention: external inspection of compliance with accreditation standards

Comparison: no inspection

Outcomes

Intervention effect (range)

No of studies

(hospitals)

Certainty of the evidence
(GRADE)

Comments

Compliance with COHSASA accreditation standards at 2 years' follow‐up

(change in total compliance score for 21/28 service elements ‐ for 7/28 service elements, data were not available)

I: pre: 48% (not reported), post: 78% (not reported)

C: pre: 43% (not reported), post: 43% (not reported)

Mean intervention effect: 30% (23% to 37%), P < 0.001

1

(18)

⊕⊖⊖⊖

Very low 1,2

Uncertain whether external inspection leads to improved compliance with standards.

Compliance with COHSASA accreditation standards ‐

subgroup of critical criteria analysed at 2 years' follow‐up

(compliance score for 19 generic service elements, involving 426 predefined critical criteria)

I: pre: 38% (21% to 46%), post: 76% (55% to 96%)

C: pre: 37% (28% to 47%), post: 38% (25% to 49%)

Mean intervention effect: 37% (not reported), P < 0.001

1

(18)

⊕⊖⊖⊖

Very low 1,2

Uncertain whether external inspection leads to improved compliance with standards.

Indicators for hospital quality of care at 2 years' follow‐up

Median intervention effect:

2.4% (‐1.9% to 11.8%)

1

(18)

⊕⊖⊖⊖

Very low 1,2

Uncertain whether external inspection improves median quality indicator scores.

Only 1 of the indicators was indicative of higher quality in accreditation hospitals.

Mortality and condition‐specific measures of outcome related to patients' health

‐

‐

‐

Not measured or reported.

Unanticipated/adverse consequences

‐

‐

‐

Not measured or reported.

Costs and cost effectiveness

‐

‐

‐

Not measured or reported.

High = This research provides a very good indication of the likely effect. The likelihood that the effect will be substantially different‡ is low.

Moderate = This research provides a good indication of the likely effect. The likelihood that the effect will be substantially different‡ is moderate.

Low = This research provides some indication of the likely effect. However, the likelihood that it will be substantially different‡ is high.

Very low = This research does not provide a reliable indication of the likely effect. The likelihood that the effect will be substantially different‡ is very high.

‡ Substantially different = a large enough difference that it might affect a decision.

1 Downgraded two levels for very serious risk of bias due to unclear blinding, baseline compliance and time differences in outcome measurements.

2 Downgraded one level for serious imprecision due to the small sample size and wide confidence intervals.

C: control; COHSASA: Council for Health Services Accreditation for South Africa; I: intervention.

Figuras y tablas -
Summary of findings for the main comparison. External inspection of compliance with COHSASA hospital accreditation standards versus no external inspection
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Summary of findings 2. External inspection of compliance with the Code of Practice and the law related to healthcare‐acquired infections

External inspection of compliance with the Code of Practice and the law related to healthcare‐acquired infections

Recipient: all acute trusts

Settings: England

Intervention: external inspection of compliance with the Code of Practice and the Health Act 2006 related to healthcare‐acquired infections

Comparison: no control group (time series)

Outcomes

Mean intervention effect (95% CI)

No of studies

(trusts)

Certainty of the evidence
(GRADE)

Comments

MRSA infection rate

At 3 months: ‐100 (‐221.0 to 21.5) cases per quarter (P = 0.096)
At 6 months' follow‐up: ‐75 (‐217.2 to 66.3) cases per quarter (P = 0.259)
At 12 months' follow‐up: ‐27 (‐222.1 to 168.2) cases per quarter (P = 0.762)
At 24 months' follow‐up: +70 (‐250.5 to 391.0) cases per quarter (P = 0.632)

1

(168)

⊕⊖⊖⊖

Very low1,2

Uncertain whether external inspection lowers MRSA infection rates.

Regression analysis showed similar MRSA rate before and after the external inspection (difference in slope 24.27, 95% CI ‐10.4 to 58.9; P = 0.147).

Unanticipated/adverse consequences

‐

‐

‐

Not measured or reported.

Costs and cost effectiveness

‐

‐

‐

Not measured or reported.

High = This research provides a very good indication of the likely effect. The likelihood that the effect will be substantially different‡ is low.

Moderate = This research provides a good indication of the likely effect. The likelihood that the effect will be substantially different‡ is moderate.

Low = This research provides some indication of the likely effect. However, the likelihood that it will be substantially different‡ is high.

Very low = This research does not provide a reliable indication of the likely effect. The likelihood that the effect will be substantially different‡ is very high.

‡ Substantially different = a large enough difference that it might affect a decision.

1 Downgraded one level for serious risk of bias due to the probability that the intervention was not independent of other changes.

2 Downgraded one level for serious imprecision due to wide confidence intervals.

CI: confidence interval; MRSA: methicillin‐resistant Staphylococcus aureus.

Figuras y tablas -
Summary of findings 2. External inspection of compliance with the Code of Practice and the law related to healthcare‐acquired infections
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Table 1. Quality indicators: summary of mean scores for intervention and control hospitals over time, with intervention effect

Indicator

Intervention n = 10

Control n = 10

Intervention

effect

P value

Time 1

Time 2

Change

Time 1

Time 2

Change

1. Nurse perceptions

59.3

60.8

1.5

60.8

56.5

‐4.2

15.7

0.031

2. Patient satisfaction

86.9

91.5

4.6

87.0

90.1

3.1

1.5

0.484

3. Medical education

42.9

43.1

0.2

41.5

40.0

‐1.5

1.7

0.395

4. Medical records:

accessibility

85.4

77.5

‐7.9

79.4

68.4

‐11.0

3.1

0.492

5. Medical records:

completeness

47.1

49.1

2.0

48.6

44.9

‐3.7

5.7

0.114

6. Completeness of

perioperative notes

70.2

72.7

2.5

65.2

69.6

4.4

‐1.9

0.489

7. Ward stock labelling

66.0

81.8

15.8

45.6

49.6

4.0

11.8

0.112

8. Hospital sanitation

59.7

62.8

3.1

50.2

55.7

5.5

‐2.4

0.641

All scores were standardised to a 100‐point scale, with 100 as high. Positive intervention effects represent improvements in intervention hospitals that exceeded the improvements in control hospitals. P values are based on an analysis of variance (ANOVA) model with intervention group and hospital size as main effects.

Figuras y tablas -
Table 1. Quality indicators: summary of mean scores for intervention and control hospitals over time, with intervention effect
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Table 2. COHSASA standards compliance scores of intervention and control hospitals over time

Service elements

Intervention hospitals

Control hospitals

Mean

intervention effect

(95% CI)

P value

No of hospitals

Mean baseline

Mean external

Mean change

No of hospitals

Mean baseline

Mean external

Mean change

Management service

9

50

79

29

10

42

44

2

27 (17 to 37)

< 0.001

Administrative support

9

57

73

16

10

56

52

‐4

20 (4 to 36)

0.038

Nursing management

9

55

87

32

10

51

50

‐1

33 (24 to 43)

< 0.001

Health and safety

9

35

75

40

10

28

32

4

36 (23 to 51)

< 0.001

Infection control

9

45

88

43

10

39

42

3

40 (27 to 52)

< 0.001

Operating theatre

9

57

86

29

10

50

53

3

26 (16 to 35)

< 0.001

Sterilising and disinfectant

9

47

81

34

10

33

35

2

32 (22 to 41)

< 0.001

Medical inpatient

8

49

78

29

10

44

46

2

27 (17 to 35)

< 0.001

Pharmaceutical

9

41

75

34

10

42

38

‐4

38 (25 to 52)

< 0.001

Paediatric inpatient

8

51

78

27

10

44

46

2

25 (17 to 33)

< 0.001

Maternity inpatient

9

53

82

29

10

52

51

‐1

30 (23 to 36)

< 0.001

Surgical inpatient

9

48

81

33

10

46

46

0

33 (25 to 42)

< 0.001

Laundry

9

30

68

38

10

23

24

1

37 (26 to 47)

< 0.001

Housekeeping

9

37

73

36

10

33

32

‐1

37 (24 to 51)

< 0.001

Maintenance

9

51

74

23

10

43

44

1

22 (11 to 34)

0.004

Resuscitation

9

31

83

52

10

25

25

0

52 (43 to 61)

< 0.001

Food

9

41

73

32

10

38

38

0

32 (24 to 41)

< 0.001

Diagnostic

9

44

79

35

10

38

39

1

34 (22 to 46)

< 0.001

Critical care category 2

2

46

92

46

4

58

61

3

43 (15 to 70)

NA

Casual

7

48

81

33

5

40

43

3

30 (17 to 44)

NA

Outpatient

8

46

83

37

9

40

43

3

34 (20 to 47)

NA

Occupational

3

42

85

43

4

43

47

4

39 (16 to 62)

NA

Physiotherapy

7

46

84

38

4

38

42

4

34 (24 to 45)

NA

Laboratory

9

46

85

39

8

43

40

‐3

42 (31 to 53)

< 0.001

Medical life support

9

37

74

37

10

21

23

2

35 (22 to 49)

0.001

Community health

4

50

88

38

8

54

50

‐4

42 (28 to 56)

NA

Social work

4

53

82

29

5

40

44

4

25 (6 to 41)

NA

Medical practitioner

9

51

75

24

10

44

42

‐2

26 (13 to 40)

0.004

Overall services score

9

48

78

30

10

43

43

0

30 (23 to 37)

< 0.001

CI: confidence interval; COHSASA: Council for Health Services Accreditation for South Africa; NA: not available

Figuras y tablas -
Table 2. COHSASA standards compliance scores of intervention and control hospitals over time
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Table 3. Results: Salmon 2003

Author Year

Compliance with COHSASA accreditation standards (28 service elements)

Hospital quality indicators (n = 8)

Salmon 2003

At 2 years' follow‐up:

Total compliance score for 21/28 service elements, for which comparisons were possible, rose from 48% to 78% in intervention hospitals, while control hospitals maintained the same compliance score throughout (43%).

Mean intervention effect was 30% (23% to 37%).

Looking at the individual scores of compliance with the accreditation standards for each service element, the results were mixed, with 21/28 service elements showing a beneficial effect of the inspections.

Mean intervention effect ranged from 20% to 52%, while data for the remaining 7 service elements were not available, i.e. some of the service elements were only evaluated in the higher‐level hospitals, so comparisons between the intervention and control hospitals was not appropriate due to small sample size.

Subanalysis of the standards that a priori were deemed by the COHSASA as being 'critical' for a specific function was performed. As some of the 28 service elements evaluated in the accreditation process were not applicable for all hospitals, this left 19 generic service elements, yielding 424 critical criteria for the subanalysis. These critical criteria were mainly drawn from the following service elements: obstetric and maternity inpatient services; operating theatre and anaesthetic services; resuscitation services; paediatric services and medical inpatient services.

Subanalysis showed improved mean compliance with the critical standards in intervention hospitals: total score rose from 38% (range 21% to 46%) to 76% (range 55% to 96%).

Control hospitals maintained the same compliance score throughout: 37% (range 28% to 47%) before the intervention and 38% (range 25% to 49%) after the intervention. There was a difference in means between groups (P < 0.001).

Effects on the hospital quality indicators were mixed, with mean intervention effects ranging from ‐1.9 to +11.8, and only 1/8 indicators: 'nurses' perception of clinical care', showed a beneficial effect of the intervention (see below).

Nurses' perception of clinical care

Intervention hospitals: pre: 59.3%, post: 60.8% (change 1.5%); control hospitals: pre: 60.8%, post: 56.5% (change ‐4.2%); intervention effect: 5.7 percentage points (P = 0.031).

Patient satisfaction with care:

Intervention hospitals: pre: 86.9%, post: 91.5% (change 4.6%); control hospitals: pre: 87.0%, post: 90.1% (change 3.1%); intervention effect: 1.5 percentage points (P = 0.484).

Patient medication education:

Intervention hospitals: pre: 42.9%, post: 43.1% (change 0.2%); control hospitals: pre: 41.5%, post: 40.0% (change ‐1.5%); intervention effect: 1.7 percentage points (P = 0.395).

Medical records: accessibility:

Intervention hospitals: pre: 85.4%, post: 77.5% (change ‐7.9%); control hospitals: pre: 79.4%, post: 68.4% (change ‐11.0%); intervention effect: 3.1 percentage points (P = 0.492).

Medical records: completeness (consisting of 2 components: admissions and discharge):

Intervention hospitals: pre: 47.1%, post: 49.1% (change 2.0%); control hospitals: pre: 48.6%, post: 44.9% (change ‐3.7%); intervention effect: 5.7 percentage points (P = 0.114).

Completeness of peri‐operative notes:

Intervention hospitals: pre: 70.2%, post: 72.7% (change 2.5%); control hospitals: pre: 65.2%, post: 69.6% (change 4.4); intervention effect: ‐1.9 percentage points (P = 0.489).

Ward stock labelling:

Intervention hospitals: pre: 66.0%, post: 81.8% (change 15.8%); control hospitals: pre: 45.6%, post: 49.6% (change 4.0%); intervention effect: 11.8 percentage points (P = 0.112).

Hospital sanitation*:

Intervention hospitals: pre: 59.7%, post: 62.8% (change 3.1%); control hospitals: pre: 50.2%, post: 55.7% (change 5.5); intervention effect: ‐2.4 percentage points (P = 0.641).

* Consisted of the assessment of 6 items (availability of soap, water, paper towels and toilet paper and whether toilets were clean and in working order) of which a composite score was developed.

COHSASA: Council for Health Services Accreditation for South Africa.
Figuras y tablas -
Table 3. Results: Salmon 2003
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Table 4. Results: OPM 2009

Author

Year

Infection rate

OPM 2009

Date; No of cases
April 2006 to June 2006; 1742
July 2006 to September 2006; 1651
October 2006 to December 2006; 1543
January 2007 to March 2007; 1447
April 2007 to June 2007; 1306. In June 2007, the Healthcare Commission began a series of unannounced inspections, focused specifically on assessing compliance with the Code of Practice
July 2007 to September 2007; 1083
October 2007 to December 2007; 1092
January 2008 to March 2008; 970
April 2008 to June 2008; 839
July 2008 to September 2008; 724
October 2008 to December 2008; 678
January 2009 to March 2009; 694
April 2009 to June 2009; 509

Re‐analysis of the MRSA data, as an ITS:

Difference (24.27, 95% CI ‐10.4 to 58.9) between the preslope (‐107.6) and the postslope (‐83.32) suggested similar infection rates before and after the inspection (P = 0.147).

When the downward trend in MRSA rate before the intervention was considered, the results showed a mean (95% CI) decrease with 100 (‐221.0 to 21.5) cases at 3 months' follow‐up (P = 0.096), 75 (‐217.2 to 66.3) cases at 6 months' follow‐up (P = ‐0.259), 27 (‐222.1 to 168.2) cases at 12 months' follow‐up (P = 0.62), and an increase with 70 (‐250.5 to 391) cases per quarter at 24 months' follow‐up (P = 0.632).

CI: confidence interval; ITS: interrupted time series; MRSA: methicillin‐resistant Staphylococcus aureus.

Figuras y tablas -
Table 4. Results: OPM 2009
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