Hospital accreditation has become a global trend for improving the quality and safety of health services.1 Though hospital accreditation has attracted global attention as a stimulus for organizational improvement, scholars have questioned its efficacy in improving clinical quality and patient outcomes.2 Previous studies have shown that many health care professionals view accreditation as bureaucratic and time-consuming and are skeptical of its benefits.3–5 In fact, hospital accreditation in Taiwan has also attracted some public criticism6,7 because of an unbalanced focus on paperwork and the attendant workload.8,9 A systematic review has called for further research investigating the positive and negative effects of hospital accreditation to address gaps and inconsistencies in the evidence base.10 Furthermore, the majority of research studies have been conducted in Western countries,2 leaving a knowledge gap regarding the effects of accreditation elsewhere.
Taiwan has implemented hospital accreditation since 1978; it was the fourth country in the world and the first in Asia to promote it.11 In 1995, Taiwan implemented a single-payer national health insurance (NHI) system. Under NHI, only care provided at accredited hospitals is eligible for reimbursement, leading most hospitals in the country to seek out accreditation.12 By the end of 2011, 477 out of 491 hospitals in Taiwan had been accredited, with a qualification rate of nearly 100%.13,14 Aside from accreditation for general hospitals, there are other accreditation programs for teaching hospitals, cancer hospitals, and psychiatric hospitals.14 Training for Taiwanese medical students and residents can only be provided by teaching hospitals, which must pass not only general accreditation for NHI reimbursement but also teaching hospital accreditation. Recently, a number of Taiwanese hospitals, including 11 teaching hospitals, have adopted international accreditations from organizations such as Joint Commission International.15
Although previous research on hospital accreditation has scrutinized its effects on the health care process, providers, and patients, the effects of hospital accreditation as perceived by medical students have not been investigated. We first became interested in this topic after informal discussion with students, who expressed concern over the tacit messages and hidden lessons they received from hospital accreditation. Some of these hidden lessons do not align with the intended effect of hospital accreditation, which is to enhance the quality and safety of health care. Addressing these issues is of paramount importance because the hidden curriculum literature16 has not explored the sphere of hospital accreditation, even as hospital accreditation has rapidly globalized and consumed considerable financial and human resources. To examine the impact of hospital accreditation on medical students, we conducted a qualitative study among clinical students in all 11 medical schools in Taiwan.
Consistent with grounded theory methodology,17 we used an iterative study design with simultaneous data collection and analysis. Two of us (H.C. and Y.C.) conducted confidential, semistructured, in-depth one-hour interviews with each participant. All interviews were conducted face-to-face or by teleconference from 2010 to 2012. This study took place within a larger study on the hidden curriculum in clinical settings, which also looked at the influence of role models and hospital systems on medical education. To probe the topic of hospital accreditation in particular, we asked the following questions: Have you observed hospital accreditation taking place? Does hospital accreditation have any positive or negative impacts on medical students? We followed up with clarifying questions when necessary. After responding to the semistructured questions, participants were encouraged to share additional thoughts.
Employing purposive sampling,18 we recruited 34 senior, clinical year students from all 11 medical schools in Taiwan. This sample came from a population of about 3,900 students (the government allows the 11 medical schools together to graduate a maximum number of 1,300 in one year). Because they had more clinical experience than students from other years, these students were more likely to have encountered hospital accreditation during their education. We recruited participants by posting notice on an online bulletin board system, a popular medium through which Taiwanese medical students exchange information. Participation was confidential, voluntary, and remunerated (U.S. $15). Sample size was based on “theoretical saturation”; that is, we stopped enrolling new participants when the interviews no longer added new information and the themes had stabilized. The study protocol was approved by the responsible research ethics committee.
The interviews were audiotaped, transcribed, and rendered anonymous for analysis. Initially, H.C. and Y.C., trained in qualitative research methods, coded the transcripts independently. Codes consisted of excerpts of sentences or paragraphs in the transcript that expressed a unified idea. We then compared, examined, and discussed the codes, noting connections and relationships between codes and sorting the codes into preliminary categories. We grouped related categories together to derive themes, which we then tabulated with illustrative quotations. When disagreements in coding and categorization occurred, we collectively reexamined the original transcripts to reach a consensus.
We used NVivo 9 software (QSR International Pty Ltd., Doncaster, Victoria, Australia) to facilitate the analysis process. The counts of code units generated by the software are also included to illustrate their relative prevalence; however, these should be interpreted with caution. Quotations are translated into English from Chinese and are referenced by the student’s deidentified number (S#).
Three major themes emerged from the data: (1) positive impacts of hospital accreditation, (2) negative impacts of hospital accreditation, and (3) questions and doubts related to hospital accreditation. Negative impacts could be further divided into negative impacts on staff, patients, environments, and students’ formal and informal learning. Descriptive quotes for all subthemes can be found in Table 1.
Positive impacts of hospital accreditation
Some students stated that they observed positive changes in the hospital before and during the accreditation period. For example, hospital facilities were renovated before the accreditation visit, rendering the hospital exceptionally clean. Many also noted that hospital authorities were more attentive to the complaints of staff and students, implementing changes in response to normally overlooked requests. Moreover, emphasis on patient safety and patient rights increased. Procedural standards were more seriously heeded by hospital administrators, and some continued to be enforced even after the accreditation. One comment remarked that the patient workload of interns and residents became more reasonable during the accreditation period, although only one student made this observation.
Negative impacts of hospital accreditation
Negative impact on staff.
For the majority of students, the positive impacts of accreditation were outweighed by the negative impacts. Students observed that most of the medical staff felt exhausted from unavoidable overwork, most often due to the addition of trivial documentation and paperwork. The hospital administrators instituted more recordkeeping rules and paid more attention to whether documents were signed and stamped properly. Students also reported that exaggerated measures were undertaken in response to the accreditation. They thought that the concepts of accreditation guidelines might have originally been appropriate; however, their implementation was often distorted into unreasonable rules and actions. They reasoned that many medical staff felt negative perceptions toward accreditation because of the increase in work pressure.
Negative impact on patients.
Students reported that patients were also negatively affected by the accreditation process. The paperwork overload meant that residents had less time to spend on their patients. Furthermore, students noted that some clinics were closed and the numbers of inpatients and operations decreased so that accreditation standards could be met and that attending physicians could have more time to handle the accreditation. Students also reported that the management of the patients, if not urgent, was delayed until the week after accreditation audits, especially for those patients with a higher possibility of complications.
Negative impact on the environment.
Two students felt that the accreditation was not environmentally friendly. Many documents were printed to show the accreditation surveyors, only to be thrown away afterward.
Negative impact on students.
Negative impact on students can be further divided into formal and informal learning. Formal learning refers to lectures, bedside teaching, and clinic or surgery observation; informal learning occurs through any daily interaction in the clinical environment outside structured educational activities.
Many students complained that their formal learning rights were compromised by hospital accreditation. Students reported that administrators were concerned that students might unintentionally ruin the image of the hospital, so they were granted leave during the accreditation audit period. During the accreditation preparation period, which could be as long as a year for international accreditation, attending physicians and residents had less time for instruction, and some clinical lectures and discussion meetings were either canceled or substituted with accreditation-related lessons. Students had to spend time filling out logbooks or other documents to meet accreditation criteria. They also stated that, in order to ensure that the hospital staff were fully prepared for the accreditation, many additional courses and standardized Q&A sessions were arranged regardless of whether the content reflected the reality of the hospital.
In terms of informal learning, many students reported that the changes caused by accreditation were not permanent and that the standards and regulations set for accreditation were generally discontinued after the accreditation was finished. It felt like a sensational drama performed for the accreditation surveyors, a fiction that did not reflect the reality of the hospital. Students also mentioned their experiences either observing or assisting with the forgery of documents and manipulation of records to fulfill accreditation criteria. The most common task was to stamp signatures of approval on medical records as proxies for physicians. Students were asked to assemble documents to form a “model medical history,” parts of which might be fabricated. In addition, several students considered that accreditation criteria were often transformed into superficial and meaningless measures, making accreditation a mere formality.
Questions and doubts about hospital accreditation
Students’ reactions to the accreditation included sentiments that it did not concern them and that it was unreasonable to request their involvement. Though hospital administrators had high expectations of quality improvement from the accreditation, most of the staff expressed reluctance and fatigue because some regulatory changes did not consider their feasibility or influence on hospital staff. Despite their frustration, very few of the staff and students voiced their indignation, instead resigning themselves to the changes because they doubted the possibility of effective protest.
A couple of students felt that the hospital staff were asked to expend enormous effort in upholding the image of the hospital, with little in the way of actual quality improvement. In other words, their efforts did not seem cost-effective. When the students were asked if they would like to have disclosed the real situation of the hospital to the accreditation surveyors, the majority declined for fear that the status and funding of their teaching hospitals would be affected if the hospitals didn’t pass accreditation. They were worried, as well, that hospital administrators would have an eye on them if they didn’t respond positively.
Some students questioned whether it was appropriate to adopt an accreditation system from Western countries without allowing for differences in cultural background and health systems. They thought it was not possible to meet the high standards of accreditation, such as patient–staff ratio, when considering the current heavy workload of hospital staff in Taiwan and the reality of how Taiwanese people use the free health care services. In particular, they felt that Taiwan’s substantially higher-than-average patient load should be taken into account when determining accreditation criteria.
Lastly, the students described trying to avoid contact with the accreditation surveyors. One student recalled an unpleasant interaction that raised concerns about the qualifications of accreditation surveyors. The student was asked a question beyond his year of study, and he thought it unfair to judge the academic quality of a teaching hospital in this manner.
Hospital accreditation can be a feasible measure to improve or ensure the quality of care and patient safety.1,19,20 Some research has shown that accreditation can improve the effectiveness and efficiency of operations and help standardize procedures, primarily structures, and processes in patient care.21–23 In teaching hospitals, the importance of accreditation in strengthening both undergraduate and postgraduate training programs has been demonstrated.24
However, despite the aforementioned advantages, our study found that accreditation might also produce negative influences. Previous research indicates an absence of compelling data surrounding medical school accreditation’s influence on the quality of medical education, the production of skilled doctors, and the refinement of patient care.25 To our knowledge, our study serves as the first to show an association between hospital accreditation and such unforeseen problems. In particular, our findings show that despite the potential benefits of accreditation, medical students were critical of hospital accreditation’s unfavorable impact on their formal and informal learning.
Previous studies reported that the requirements imposed by the accreditation process may trigger occupational stress and cause work overload for health care providers, especially because of the additional documentation and bureaucratic paperwork.4,26,27 Our study further found that the increased workload of providers also compromised the formal learning opportunities of medical students. Students harshly criticized their involvement in the assemblage of documentation to meet requirements. Students reported that what was shown during the accreditation visit was merely a performance instead of a reflection of reality. However, despite their dissatisfaction, they had no choice but to participate or else risk their teaching hospital’s losing its academic reputation and NHI payments. Similar situations have occurred in other countries where the government links accreditation to hospital contracts, and those hospitals considered accreditation as a serious threat for losing their contracts.28 It is therefore crucial for the authorities concerned to seek measures to avoid rote manipulation of documents and to improve the evaluation process.
We are also quite concerned that the perceived connection between accreditation and the forgery of documents may influence the development of medical professionalism. Professionalism in medicine is classically defined as the individual attributes expected of a doctor by the society,29,30 and as concluded in our previous research, integrity is key for integrating the different principles of medical professionalism within the social context of Taiwan.31 Medical professionalism has been shown to be greatly influenced by the hidden curriculum, which includes students’ experiences in the clinical environment and the socialization of professional norms and rituals.16 As students learn from conflicts between the ideals of medical professionalism and the behaviors of individual physicians observed in their daily work, medical schools and hospitals serve as a moral community for them to acquire knowledge and skills and to internalize values and virtues.32 If the hospital staff are not able to commit to the principle of integrity during the accreditation process, how could we expect students to develop medical professionalism in this learning environment? Our study engenders heightened caution regarding the implementation of accreditation under current global trends, which might convey the wrong message to health providers and students worldwide about what is and what is not important within the health care system.
The implementation of accreditation is further complicated by globalization. With the globalization of medicine, manifested by a growing number of migrating doctors and cross-border education providers, comes a call for global standards and accreditation in medical education.33,34 Although we agree with the emphasis on quality assurance for both medical education and health care services, we find that most of the global guidelines and standards have been initiated by Western countries. Despite the emerging literature urging that different traditions, cultures, and socioeconomic conditions be taken into account,33–36 many medical educators and hospital administrators continue to export and import Western frameworks and practices without critical consideration for local contexts.37 Although it is possible to achieve a productive balance between homogenization and outright rejection of global trends,38 the globalization of medical education often carries with it underlying assumptions about the cultural neutrality of Western medical education practices, assumptions that may obstruct the effective translation of such practices to new settings.39 Along this vein, Stevens and Goulbourne39 write of how problem-based learning, originally reflective of an “Anglo-Saxon model of teaching medicine,” was adopted in Jamaica and elsewhere on the assumption of its success in developed countries and its association with modernization. In the process, insufficient thought was given to “the cultural underpinnings and social structural requirements”39 necessary for its successful localization. The same critique may be leveled at proponents of hospital accreditation who view its implementation as a straightforward “panacea,”39 lacking in negative consequences. Many students in our interviews specifically pointed out that the workload of doctors in Taiwan, as measured by parameters such as the number of patient visits in outpatient clinics and the resident-to-patient ratio in inpatient wards, is much greater than that of Western countries. Our study suggests that accreditation agencies should place specific attention on avoiding the imposition of standards from Western countries that are incompatible with local health care system circumstances. In general, we advocate that greater consideration be given to deciding what criteria are essential and appropriate for global initiatives in medical education.
This study has some limitations. We relied on student volunteers’ self-reports, which could have led to bias obscuring results. However, the results are similar among students from all medical schools in Taiwan and are comparable to students’ informal discussions, both on the Internet40 and in person (personal communications with the authors). We attempted to control for memory bias by collecting multiple interviews from the same institutions for triangulation. Our study was also limited by the use of a nonrandomized sample, though the effect of this was controlled through theoretical saturation. An overarching concern with qualitative research of this kind asks whether the results can be trusted to indicate “real” problems with hospital accreditation or if negative perceptions are simply due to lack of communication between medical students and staff, resulting in insufficient understanding of the accreditation process. During our interviews, however, many students expressing criticism came across as well informed of the accreditation process, suggesting that the issue resides in hospital accreditation itself and not in students’ misperceptions.
In conclusion, this study cautions that hospital administrators and accreditation bodies must recognize not only accreditation’s positive aspects, such as improvement of patient safety and quality assurance, but also its unintended negative effects on medical education. As a global community of medical educators, we should prevent the implementation of accreditation from conveying tacit messages contradictory to our stated commitments to medical professionalism. In addition, we must ensure that differences in culture and health care systems are taken into account within the context of medicine’s globalization and localization.
Acknowledgments: The authors would like to thank Chi-Wei Lin and Kevin Shaw for research and editorial assistance. The authors also wish to thank all the medical students who participated in the interviews.
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