The purpose of this study was to identify and analyze research into accreditation and accreditation processes. A multi-method, systematic review of the accreditation literature was conducted from March to May 2007. The search identified articles researching accreditation. Discussion or commentary pieces were excluded. From the initial identification of over 3000 abstracts, 66 studies that met the search criteria by empirically examining accreditation were selected. The 66 studies were retrieved and analyzed. The results, examining the impact or effectiveness of accreditation, were classified into 10 categories: professions' attitudes to accreditation, promote change, organizational impact, financial impact, quality measures, program assessment, consumer views or patient satisfaction, public disclosure, professional development and surveyor issues. The analysis reveals a complex picture. In two categories consistent findings were recorded: promote change and professional development. Inconsistent findings were identified in five categories: professions' attitudes to accreditation, organizational impact, financial impact, quality measures and program assessment. The remaining three categories—consumer views or patient satisfaction, public disclosure and surveyor issues—did not have sufficient studies to draw any conclusion. The search identified a number of national health care accreditation organizations engaged in research activities. The health care accreditation industry appears to be purposefully moving towards constructing the evidence to ground our understanding of accreditation.

Workarounds circumvent or temporarily ‘fix’ perceived workflow hindrances to meet a goal or to achieve it more readily. Behaviours fitting the definition of workarounds often include violations, deviations, problem solving, improvisations, procedural failures and shortcuts. Clinicians implement workarounds in response to the complexity of delivering patient care. One imperative to understand workarounds lies in their influence on patient safety. This paper assesses the peer reviewed empirical evidence available on the use, proliferation, conceptualisation, rationalisation and perceived impact of nurses’ use of workarounds in acute care settings. A literature assessment was undertaken in 2011–2012. Snowballing technique, reference tracking, and a systematic search of twelve academic databases were conducted to identify peer reviewed published studies in acute care settings examining nurses’ workarounds. Selection criteria were applied across three phases. 58 studies were included in the final analysis and synthesis. Using an analytic frame, these studies were interrogated for: workarounds implemented in acute care settings by nurses; factors contributing to the development and proliferation of workarounds; the perceived impact of workarounds; and empirical evidence of nurses’ conceptualisation and rationalisation of workarounds. The majority of studies examining nurses’ workarounds have been published since 2008, predominantly in the United States. Studies conducted across a variety of acute care settings use diverse data collection methods. Nurses’ workarounds, primarily perceived negatively, are both individually and collectively enacted. Organisational, work process, patient-related, individual, social and professional factors contribute to the proliferation of workarounds. Group norms, local and organisational culture, ‘being competent’, and collegiality influence the implementation of workarounds. Workarounds enable, yet potentially compromise, the execution of patient care. In some contexts such improvisations may be deemed necessary to the successful implementation of quality care, in others they are counterproductive. Workarounds have individual and cooperative characteristics. Few studies examine nurses’ individual and collective conceptualisation and rationalisation of workarounds or measure their impact. The importance of displaying competency (image management), collegiality and organisational and cultural norms play a role in nurses’ use of workarounds.

Aims To systematically identify and synthesise health service accreditation literature. Methods A systematic identification and narrative synthesis of health service accreditation literature published prior to 2012 were conducted. The search identified 122 empirical studies that examined either the processes or impacts of accreditation programmes. Study components were recorded, including: dates of publication; research settings; levels of study evidence and quality using established rating frameworks; and key results. A content analysis was conducted to determine the frequency of key themes and subthemes examined in the literature and identify knowledge-gaps requiring research attention. Results The majority of studies (n=67) were published since 2006, occurred in the USA (n=60) and focused on acute care (n=79). Two thematic categories, that is, ‘organisational impacts’ and ‘relationship to quality measures’, were addressed 60 or more times in the literature. ‘Financial impacts’, ‘consumer or patient satisfaction’ and ‘survey and surveyor issues’ were each examined fewer than 15 times. The literature is limited in terms of the level of evidence and quality of studies, but highlights potential relationships among accreditation programmes, high quality organisational processes and safe clinical care. Conclusions Due to the limitations of the literature, it is not prudent to make strong claims about the effectiveness of health service accreditation. Nonetheless, several critical issues and knowledge-gaps were identified that may help stimulate and inform discussion among healthcare stakeholders. Ongoing effort is required to build upon the accreditation evidence-base by using high quality experimental study designs to examine the processes, effectiveness and financial value of accreditation programmes and their critical components in different healthcare domains.

Background Despite the widespread use of accreditation in many countries, and prevailing beliefs that accreditation is associated with variables contributing to clinical care and organisational outcomes, little systematic research has been conducted to examine its validity as a predictor of healthcare performance. Objective To determine whether accreditation performance is associated with self-reported clinical performance and independent ratings of four aspects of organisational performance. Design Independent blinded assessment of these variables in a random, stratified sample of health service organisations. Settings Acute care: large, medium and small health-service organisations in Australia. Study participants Nineteen health service organisations employing 16 448 staff treating 321 289 inpatients and 1 971 087 non-inpatient services annually, representing approximately 5% of the Australian acute care health system. Main measures Correlations of accreditation performance with organisational culture, organisational climate, consumer involvement, leadership and clinical performance. Results Accreditation performance was significantly positively correlated with organisational culture (rho=0.618, p=0.005) and leadership (rho=0.616, p=0.005). There was a trend between accreditation and clinical performance (rho=0.450, p=0.080). Accreditation was unrelated to organisational climate (rho=0.378, p=0.110) and consumer involvement (rho=0.215, p=0.377). Conclusions Accreditation results predict leadership behaviours and cultural characteristics of healthcare organisations but not organisational climate or consumer participation, and a positive trend between accreditation and clinical performance is noted.

Nevertheless, accreditation agencies continue to revise their programmes or standards and introduce new methods.7^–9 These initiatives are potentially important, and seem to reflect considerable improvements. The test for accreditation agencies is to publish in the peer-reviewed literature their evidence and rationale for change and improvement. At present this is uncommon. By way of example let us take two newer unrelated methods that have been recently implemented, or being considered by accreditation agencies: unannounced surveys and tracer methodology.