Sot. Se;. Med. Vol. 17, No. 20, pp. 1573-1579. 1983 0277-9536/83 S3.00+0.00 Printed in Great Britain Pergamon Press Ltd CHANGING HOSPITALS: THE ROLE OF HOSPITAL ACCREDITATION S. J. DUCKE~~ School of Health Administration, University of New South Wales, P.O. Box 1, Kensington, New South Wales, Australia Abstract-Participation in the Australian Council on Hospital Standards’ accreditation program provides one of the important stimuli for change in Australian hospitals. This article analyses the impact of the accreditation program upon a random sample of 23 Australian hospitals which were monitored for two years. At the conclusion of the study, those hospitals which had applied for accreditation were compared and contrasted with those hospitals which had not applied. It was found that those hospitals which applied could be differentiated from those hospitals which had not by significant changes in six areas. The areas which showed the least change were those most directly associated with the medical staff. ‘Nursing Organisation’ and ‘Physical Facilities and Safety’ were the areas most affected by accreditation. A system of hospital accreditation has been in exis- tence in North America for over 50 years. The Australian hospital accreditation program was even- tually introduced in 1974 after a long period of negotiation and discussion. From 1960 onward, hos- pital accreditation had the support of the two major provider organisations: the Australian Hospital As- sociation and the Australian Medical Association. The interests of these two. groups were certainly not identical but there was a sufficient coincidence of interest to make the coalition a viable one. Briefly, hospitals probably saw the accreditation system as a means of influencing the behaviour of hospital medical staff; using the accreditation system to bring about changes in medical staff organisation, accountability relationships and to implement activ- ities such as peer review. In addition, hospitals would have seen accreditation as reducing their dependence on funding agencies by giving them another external validating agency [ 11. The Australian Medical Association, on the other hand, has continually worked towards enhancing the “complete and untrammelled professional freedom and control by medical men over areas of policy which they regard as purely medical” [2]. it is prob- able that the Association felt its involvement would yield some control over hospitals or, at least, reduce the possibility of increased government control of hospitals. Of course, these objectives were covert ones, over- tly the program was promoted as being designed to improve and assure the quality of health care in Australian hospitals. The Australian hospital accreditation program commenced in Victoria in 1974, New South Wales (NSW) in 1977, the Australian Capital Territory and Northern Territory in 1979 and South Australia in 1980. Between 1974 and 1982 the ACHS has surveyed 217 hospitals of which 145 have been accredited. The program is conducted by the Australian Council on Hospital Standards (ACHS), a non- government organisation established in 1974. Hospi- tals voluntarily apply for accreditation and pay a fee for participation. There are no official sanctions or rewards associated with the accreditation process and insurance reimbursement is independent of accred- itation status. Details of the program have been published elsewhere [3]. Recent years have seen increasing attention being paid to evaluating regulatory mechanisms and the United States system of hospital accreditation has been reviewed both academically and by government agencies (in 1976 and 1979). Although one relatively small study looked at the effect of accreditation on one hospital [4], generally academic study of accred- itation has concentrated on its role as an agent of social control rather than analysing accreditation’s impact on participating hospitals (5,6]. This article describes a study designed to discern the role of the ACHS’s accreditation program in changing hospitals in the state of New South Wales. Hospital accreditation is only one of the many factors which might cause change in hospitals. However, it has been promoted as an important catalyst and it is thus important that the effects of the program be identified and evaluated. The task of ‘evaluating’ the effect of the program is difficult: there are no clear statements of what accreditation is trying to achieve; the program has undergone a number of modifications and there is the added problem of quite dramatic changes in the environment of hospitals since the introduction of accreditation. MElTiOD As the hospital accreditation program is voluntary it is not possible to develop a random&d, experi- mental design for evaluation. Therefore, a stratified random sample of 25 hospitals, representative of NSW hospitals in both size and location was drawn. These hospitals were monitored over 2 years for their response to accreditation requirements and to genera1 changes in the environment of all hospitals. A com- parison was made at the end of this period between those hospitals which had not applied for accred- itation and those that had been surveyed. To illus- trate the timing of various changes in the process of being accredited and to provide an indication of the permanence of these changes, those hospitals that were to be surveyed for accreditation were compared 1573