We congratulate the Deeble Institute and the authors, Mr Ryan Swiers and Dr Rebecca Haddock, on the recent publication of the evidence brief (#18) titled “Assessing the value of accreditation to health systems and organisations”.  As a group of professionals committed to the contribution of accreditation to quality improvement in healthcare, this brief is one of value and raises some key issues.

We at the ISQua External Evaluation Association (IEEA) wish to present some additional perspectives about health services accreditation to complement the evidence brief.

1. Accreditation as a quality systematic evaluation is based on the core principles of Juran, i.e. quality planning, control, measurement and improvement. The impact, therefore, needs to be assessed within this framework.
2. We take a systems approach to external evaluation in keeping with the latest theories of how to improve complex adaptive systems.
3. Today we are accrediting more than facilities. We accredit healthcare organisations – many without walls across different systems such as home care and community-based programmes.  We are moving beyond the facility focus in order to reflect the continuum of care delivery.
4. While the brief notes that ‘the core function of healthcare accreditation remains assurance that a level of compliance to minimum standards is achieved’, the majority of our accreditation organisations develop standards which enable quality improvement with the goal of ‘raising the bar’, not basic safety standards. The basic safety standards primarily rest within the domain of regulatory bodies (and/or perhaps licensing). This quality improvement approach is fundamental.
5. There is a reference to the viewpoint of the workforce on accreditation, however, it is essential to note that current accreditation standards include a focus on elements such as focusing on and enabling a healthy workplace for all who work within that organisation, that the leadership is strong, that there is provider involvement in decision-making.
6. While there is a current focus on the impact of accreditation on outcomes, the impact of accreditation on structures and processes should also be recognised as these are inter-related. For example, there is a well-known link between hand washing compliance and infection rates. 
7. The brief acknowledges that ‘accreditation cannot simply be judged as a stand-alone entity’. We strongly support this statement as it fits in with the Juran construct.  Accreditation is a quality improvement tool of quality control management and improvement that requires planning by the leadership of the organisation. This complements other quality improvement strategies and methodologies that organisations adopt, such as LEAN and clinical pathways.  These should be part of an overall quality improvement programme of an organisation in which the strengths of each is recognised.
8. Accreditation fundamentally focuses on standards that nurture a culture which enables the provision of quality and safe healthcare, one in which caring for the staff and those providing care, directly and indirectly, is equally important to the provision of quality healthcare to the recipients and their families.
9. Finally, accreditation is a knowledge transfer and knowledge translation tool. It enables consistent communication using a common language through the standards across organisations and between professionals.  If standards reflect current evidence, they contribute to the knowledge of those providing the care and those in leadership positions. (We encourage the organisation leaders to utilise the standards in an ongoing way to assess and improve the care, and not only every 3 – 4 years, whatever the cycle of accreditation.)
10. We agree that the evidence base needs to be developed further and we encourage organisations to publish their data and to facilitate learning from what is an essential part of quality improvement implementation.

IEEA is an organisation committed to the value of external evaluation. It is essential that accreditation programmes continue to evolve and respond to the healthcare needs and environment, to be sensitive to changes in evidence and positively contribute to a healthier and safer healthcare system.

Wendy Nicklin, President of the IEEA and Steve Clark, IEEA Accreditation Council Chair