Impacts of accreditation on the performance of primary health care centres: A systematic review

Abstract Introduction: Evidence on the impacts of accreditation on primary health care (PHC) services is inconsistent. Thus, this study aimed to assess the impacts of accreditation on the performance of PHC centres. Method: This study systematically reviewed articles published from 2000 to 2019 in the Web of Science, Scopus, ScienceDirect, Springer, PubMed and ProQuest. The following keywords were used: ((primary care OR primary health care) AND (accreditation) AND (impact OR effect OR output OR outcome OR influence OR result OR consequences)). The database search yielded a total of41256 articles, among which 30 articles were finally included in the review. Results: Accreditation showed the most positive impacts on the quality, effectiveness, human resource management and strategic management of PHC services. Accreditation also positively affected safety, responsiveness, accessibility, customer satisfaction, documentation, leadership, efficiency and continuity of care. Few negative impacts were noted, including the possibility of accreditation being used as a bureaucratic tool, high cost of acquiring accreditation, difficulties in understanding the accreditation process, high staff turnover rate in accredited PHC centres and weak sustainability of some accreditation programmes. Conclusion: Given its numerous positive impacts, accreditation could be used to effectively improve the performance of PHC centres.


Introduction
Primary health care (PHC) is an integral component of health care systems.1It provides cost-e ective services such as maternal and child, environmental, professional and mental health care; immunisation for communicable diseases; treatment of non-communicable diseases (NCDs); school hygiene; good nutrition; and health education and promotion.PHC centres serve as the initial point of contact between medical practitioners and the population. 1 Evidence suggests that a welldeveloped health care system with misleading PHC networks could achieve better health outcomes. 2,3Accordingly, some countries have implemented health reforms aimed at strengthening their PHC systems in the last decades.Such reforms aim to control rising costs, with PHC services playing a central role in this aim and contributing to improving health equity. 2 the last few years, PHC services have encountered several challenges in the pursuit of improved quality and safety. 1,4Accreditation is one of the most known and applicable methods for assessing the performance of health care organisations (HCOs) and ensuring the quality and safety of health care service delivery. 5,6According to Rooney and Van Ostenberg, "accreditation is usually a voluntary programme, sponsored by a nongovernmental agency, in which trained external peer reviewers evaluate an HCO's compliance with pre-established performance standards". 7s process enables health care centres to benchmark themselves against top performers, making it one of the most in uential systems for assessing and improving health care performance. 8,9American College of Surgeons (ACS) was founded in 1913 with the objective of promoting hospital standardisation.It outlined speci c membership prerequisites for surgeons and physicians, including the submission of medical documents regarding their professional competencies and preparation of patients' records.In continuation of these e orts, the organisation established and implemented the Hospital Standardization Program in 1917.Finally, the ACS established the Joint REVIEW REVIEW Commission on Accreditation of Hospitals (JCAHO) in 1951 to meet the growing need for hospital accreditation.10,11 Surveys conducted during this period revealed that from 1951 to 1991, only eight accreditation programmes had been initiated.However, the number tripled in the next decade, especially in Europe.12,13 Yet, the implementation of accreditation in the PHC sector was delayed for a few decades.
e Joint Commission International (JCI), which is the international branch of the JCAHO, published the rst set of accreditation standards for PHC centres in 2008. 14Further, the Public Health Accreditation Board in the USA developed a set of standards for PHC accreditation in 2011, with the rst public health organisation achieving accreditation in 2013. 15hospital accreditation models used in Lebanon and Egypt have been recognised as the best and pioneering local accreditation models across the Eastern Mediterranean Region (EMR).16 In recent years, assessing and improving the quality of PHC services through accreditation have become a top priority in EMR countries.17 For example, Lebanon and Jordan initiated their PHC accreditation programmes in 2009, followed by Saudi Arabia in 2011 and Egypt in 2015, with technical assistance from the International Society for Quality in Healthcare (ISQua) and inspiration drawn from pioneering PHC accreditation models used in the USA and Canada.Similar programmes were also launched in other EMR countries such as Bahrain and Qatar.18,19 Several studies have evaluated the e ectiveness of accreditation, 20-23 but most of them have focused on hospital care.24 Accordingly, the understanding of the nature, acceptance and associated outcomes of accreditation in PHC settings is limited.25 In addition, the e ectiveness of accreditation, especially in enhancing clinical performance, organisational processes and nancial status, remains uncertain.26,27 Simultaneously, the use of accreditation in PHC settings is a relatively new concept, and its e ectiveness, particularly in terms of improving the performance of PHC centres, is unclear.15 Given the inconsistent ndings in the current literature regarding the impact of accreditation on PHC, further research is warranted.28 For instance, previous studies have indicated positive e ects of accreditation, including improved quality of care, enhanced strategic planning, e ective human resource management, better leadership, archiving and increased patient satisfaction. 29In contrast, some studies have highlighted negative impacts of accreditation, including high accreditation costs, substantial workload associated with the accreditation process and uncertainties of the bene ts of accreditation.25 Accordingly, the current study aimed to assess the impacts of accreditation on the performance of PHC centres.

Study design and search strategy
is systematic review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) protocol.Articles published from 2000 to 2019 were searched in the Web of Science, Scopus, ScienceDirect, Springer, PubMed and ProQuest.
e following keywords were used: ((primary care OR primary health care) AND (accreditation) AND (impact OR e ect OR output OR outcome OR in uence OR result OR consequences)).In addition, grey literature was incorporated into the review to reduce the risks associated with publication bias. 30,31According to Pappas and Williams, 'because of the delay between research and publication and because of the potential that some important research may never be published, access to innovative information is challenging.Grey literature is a tool to ll that void'. 32][34] e inclusion criterion was publication solely in the English language.e search strategy yielded a total of 41256 articles.

Selection process
e titles of all articles were reviewed.Initially, 12847 articles were excluded for duplication and 19354 articles for inconsistency with the study aim. 35Two senior researchers assessed 9055 abstracts, among which 8126 articles were excluded for irrelevance to the study aim.
ereafter, three senior researchers carefully assessed the full texts of 929 articles and excluded 899 articles.Finally, 30 articles were included in the review (Figure 1).To prevent the removal of related and useful articles, the researchers evaluated the articles in two independent groups.e article assessment lasted about 3 months.

Quality and risk-of-bias assessments
e quality of the included articles was assessed.In particular, the Strengthening the Reporting of Observational Studies in Epidemiology, Consolidated Standards of Reporting Trials, PRISMA and Critical Appraisal Skills Programme were followed to appraise the quality of the cross-sectional, interventional, systematic review and qualitative articles, respectively.
e responses for each item of the used tools were either 'yes' or 'no', which weighted 1 and 0, respectively.A 'yes' response indicated that the item was ful lled, while a 'no' response indicated that the item was not ful lled.Accordingly, the mean appraisal scores of the articles relative to the compliance to the protocol items were measured between 0 and 1 (as percentages).e scores were evaluated as follows: 0%-40% indicating a low quality; 41%-70%, moderate quality; and >70%, high quality. 36,37 articles that scored at least 70% were included in the analysis.37 e nal included articles achieved an average of 89% compliance to their related quality appraisal tool.
e senior researchers independently oversaw all review steps to minimise potential bias.Subsequently, the articles were unanimously selected.

Data analysis and reporting
All articles were reviewed to evaluate the impacts of accreditation on the performance of PHC centres.All identi ed impacts of PHC accreditation were extracted, summarised and categorised.Finally, the identi ed impacts were categorised based on the a ected performance indicators.

Characteristics of the included studies
e analysis showed that only few studies investigated the impact of accreditation programmes on PHC services worldwide.e rst related article was published in 2008, while the majority of the articles were published in 2018.Among the 30 selected studies, eight were conducted in low-and middle-income countries (LMICs), particularly in the EMR.
ese LMICs developed their accreditation programmes in recent years with the aid of organisations such as the ISQua and pioneering countries such as the USA and Canada, signifying that LMICs identi ed accreditation programmes as e ective tools and, contrary to hospital accreditation, they embraced such programmes early.

Contents of the included studies
e related contents of the included articles (positive and negative impacts of PHC accreditation programmes) are listed in Table 1.1).

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e identi ed impacts of accreditation of PHC centres were categorised based on their performance indicators.
Quality was de ned as "the degree of excellence, extent to which an organisation meets clients' needs and exceeds their expectations". 12Its subdomains included quality improvement planning and policies, clinical management services and process orienting, and their related items were promoting and integrating quality, waiting area and time, improved culture, clinical practice, practice standardisation and patient/family education.
E ectiveness was de ned as 'the degree to which services, interventions or actions are provided in accordance with current best practice in order to meet goals and achieve optimal results'. 12Its subdomains included community involvement, internal and external collaboration and provision of cost-e ective services, and their related items were involvement of stakeholders, consultation mechanisms in self-assessment, communication within institutions, e ective performance improvement programmes, collaboration partners in the health care system and strengthening con dence in PHC services.
Human resources were de ned as 'the management of personnel requirements of the organisation'. 12Its subdomains included organisational culture, sta training and sta satisfaction, and their related items were extracted items such as socialisation of professionals, human resource development, support for practices, appropriate education and training, professional cultural development, teamworking, appointment systems, human resource utilisation, sta satisfaction and work conditions.Safety was de ned as 'the degree to which the potential risk and unintended results are avoided or minimised'. 12 subdomains included risk management planning, safety culture and safe resources, and their related items were analysis of critical incidents, sta dedication to risk management, environmental safety, prevention of falls, physical environment of general practice, equipment safety, sta awareness of patient safety and infection control.
Customer satisfaction "measured how products or services supplied by a company meet or surpass a customer's expectation". 12 subdomains included satisfaction improvement and complaint system, and their related items were patient and customer satisfaction, complaint management and sta satisfaction.
Responsiveness was de ned as 'the ability of the health system to ful l the legitimate expectations of individuals in interactions with the health system'. 12e subdomains included community needs, stakeholder education and service delivery environment, and their related items were responsiveness of PHC centres to the growing burden of NCD, responsiveness of centres when changes are to be implemented, support to ful l their accreditation responsibilities, patient and family education, cleanliness, waiting area, waiting time and appropriate patient education.Documentation was de ned as "a critical vehicle for conveying essential clinical information about each patient's diagnosis, treatment and outcomes and for communication between clinicians and payers". 12 subdomains included information requirements, purposeful medical records and provision of userfriendly indicators, and their related items were clinical record auditing, patient records, quality of documentation, information and analysis, production of documented outcomes and actions and clinical risk management documents.
Strategic management was de ned as "the formulation and implementation of the major goals and initiatives taken by a company's top management on behalf of owners, based on consideration of resources and an assessment of the internal and external environments in which the organisation competes". 12 subdomains included situation analysis, organisational values and objectives and action plan, and their related items were the understanding of and learning about the organisation, internalisation of organisational values with greater exibility, frequent amendment of the organisational action plan with strategic quality planning, evidence-based priority setting and comprehensive policies in PHC centres.
Leadership was de ned as the 'ability to provide direction and cope with change.It involves establishing a vision, developing strategies for producing the changes needed to implement the vision, aligning people and motivating and inspiring people to overcome obstacles'. 12e subdomains included organisational vision and organisational motivation system, and their related items were developing a exible and facilitator leadership, pursuing a leadership role, increasing motivation of sta , encouraging all employees to participate in the development of quality objectives and perceiving a positive impact on all values associated with cultural control.
Accessibility was de ned as the 'ability of clients or potential clients to obtain required or available services when needed within an appropriate time'. 12e subdomains included identifying and eliminating accessibility obstacles, and their related items were assessing access to care, simplifying certain bureaucratic processes, ensuring physical access and improving the availability of specialists and E ciency was de ned as 'the degree to which resources are brought together to achieve results with minimal waste, re-work and e ort'. 12e subdomains included cost-saving programme and cost-e ciency improvement, and their related items were enhancing e ciency and reducing costs by improving outcomes and controlling NCD-related expenditures.
Continuity of care was de ned as 'the provision of coordinated services within and across programmes and organisations over time'. 12 subdomains included the process of care and referral system, and their related items were patient ow, patient care continuum, patient follow-up and referral system.

Performance indicators more a ected by PHC accreditation
Although the implementation of accreditation programmes in PHC centres yielded numerous REVIEW positive e ects on various health system performance indicators, the number of stars acquired from the performance indicators (Table 2, vertically) showed that quality, e ectiveness, human resource management, strategic management, safety, responsiveness and accessibility received more positive impacts.
Table 2. Positive impacts of accreditation on the performance indicators of PHC centres.Although the study results highlighted several advantages of accreditation on the performance of PHC centres, some negative points were noted.In the reviewed articles, accreditation of PHC centres required substantial resources (money, workforce and time) and led to increased bureaucracy and centralisation in decision-making.Further, the accreditation process and its outcomes were not necessarily understood by most sta .Poor nancial support and sta shortage and turnover impacted the sustainability of the programme.A high sta turnover rate and marked sta shortage in some accredited health centres were also identi ed as negative impacts of accreditation.

Discussion
e study results showed that the implementation of accreditation programmes in PHC centres yielded numerous positive impacts on various performance indicators such as quality, e ectiveness, human resource management, strategic management, safety, responsiveness, accessibility, customer satisfaction, documentation, leadership, e ciency and continuity of care.Based on this nding, it can be concluded that accreditation has a positive impact on a wide range of performance indicators provided that accreditation standards emphasise main performance indicators adequately and the execution process is properly developed and implemented.
Although accreditation had positive impacts on many indicators, its in uence on qualityrelated indicators was greater than that on other performance indicators. is may be attributed to the fact that accreditation was traditionally designed to improve quality. 12,66 lesser impacts of accreditation on other performance indicators may be related to the lack of relevant standards addressing these key performance indicators within accreditation programmes.
e inclusion of appropriate standards related to other performance indicators in PHC accreditation models can help foster continuous improvement in the performance of PHC centres.
While accreditation standards traditionally emphasised quality and safety improvement, an evaluation of pioneering and successful accreditation programmes both globally and in the EMR revealed that their accreditation programmes covered the main performance indicators including high-quality care, safe care, accessibility of care, community-oriented care, continuity of care, appropriate and e ective management, human resource management, information management and customer rights and satisfaction. 31Comparing this scienti c evidence with the current study nding reveals that the inclusion of each performance indicator with proper related standards/ measures could improve the health performance indicators among PHC centres.
Although accreditation proves to be an e ective tool in improving performance in various settings, its positive impacts are more pronounced in LMICs.Herein, the studies that assessed the impacts of accreditation in Lebanon and Qatar revealed that their accreditation programmes in developing countries yielded more positive impacts on various performance indicators than did other accreditation programmes even in LMICs. 1,43,468][69][70] is may be related to the greater need to address all functional dimensions of PHC in LMICs than in HICs owing to their weaknesses in these dimensions. 71Further, the success of accreditation in LMICs could be linked to the limited utilisation of performance improvement tools prior to the implementation of accreditation. 16,72,73Notably, developing countries, especially those in the EMR, have experienced long delays in the adoption of hospital accreditation, making them the pioneers of PHC accreditation worldwide.Given that these countries started their PHC accreditation programmes with the technical help of experienced countries in the eld such as the USA and Canada, their rapid success is not surprising. 31

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Accreditation programmes in LMICs have been developed through collaboration and technical support from organisations such as the ISQua and inspiration from pioneering accreditation programmes in OECD countries.
8][69] A part of this disparity could be attributed to the di erences in health personnel's understanding of quality.
e study results highlight some limitations of PHC accreditation programmes.One notable constraint is the need for substantial resources to perform the entire accreditation process.However, the outcomes are expected to o set the associated costs by preventing medical errors, increasing the quality of health services, increasing patient satisfaction and boosting the credibility of accredited health care centres. 12s can be viewed as a cost-saving process that concurrently improves e ciency. 12,25,43In addition, organisers and users of accreditation should be aware of its potential to introduce bureaucratic processes and resolve potential complications through process mapping and amendments with active involvement of sta .
In Denmark, hospital sta held a negative perspective on accreditation.ey believed the hospital accreditation programme as contributing to bureaucracy, overdocumentation, over-sta ng and undue focus on partial processes.is led to the abrogation of the country's accreditation programme in 2015. 74is re ects the result of inappropriate development and implementation of accreditation and oversight of existing challenges in successfully implementing an accreditation programme.
Considering the few avoidable negative impacts and the numerous positive impacts of accreditation in PHC settings, it could be presumed that applying PHC accreditation programmes will enhance the performance of health care centres.Given the numerous de ciencies in performance indicators within many health systems, the development of evidence-based and well-designed PHC accreditation programmes could improve the performance of PHC centres, especially those in LMICs. 4,71is could lead to more e ective responses to community needs and recti cation of existing shortcomings, particularly in terms of quality. 17main limitations of this study are the inclusion of few related studies and the lack of assessment of the impacts of accreditation on performance indicators in all PHC centres.Further, the study considered only articles published in English, which could introduce a bias by excluding ndings in other major languages related to the accreditation process.
Based on the study ndings, the research team suggests some implications for practice, including the following: expanding PHC accreditation programmes worldwide, especially in LMICs; using existing evidence, particularly the experiences of organisations such as the ISQua and pioneering accreditation programmes such as the JCI, in developing standards and processes; focusing on all functional indicators in health systems, such as quality and safety of standards and measures, to meet societal health needs; and facilitating continuous improvement of developed accreditation programmes based on their evaluation results, mainly from stakeholders' perspectives.

Conclusion
Accreditation yields the most positive impacts on the quality, e ectiveness, human resource management and strategic management of PHC services.
ere are only few negative impacts observed such as the possibility of illogical documentation in health care centres and the high primary cost and substantial e ort required for the accreditation process.Given its numerous positive impacts but few avoidable negative impacts, accreditation could be used to improve the performance of PHC services, akin to hospital care.

Figure 1 .
Figure 1.Flowchart of article selection for the systematic review.

El
N/M N/M N/M N/M N/M N/M O'Beirne et al.N/M N/M N/M N/M N/M N/M N/M N/M N/M N/M N/M N/M N/M N/M N/M N/M N/M Shen et al. (2018) * N/M N/M N/M N/M N/M N/M N/M N/M * N/M N/M Nur Seha et al. (2018) N/M N/M * N/M N/M N/M * N/M N/M N/M N/M N/M Fu et al. (2018) * * N/M N/M N/M N/M N/M N/M N/M N/M N/M N/M He ernan et al. (2018) * N/M N/M N/M N/M N/M N/M * N/M N/M N/M N/M N/M N/M N/M * * N/M N/M N/M Moe et al. (2019) * N/M * N/M N/M N/M N/M N/M N/M N/M * N/M Brugueras et al. (2019) * * N/M N/M N/M N/M N/M N/M N/M N/M N/M N/M Valerie et al. (2019) N/M N/M * N/M N/M N/M N/M N/M N/M N/M N/M N/M *Shows the positive impacts of accreditation on performance indicators N/M, not mentioned

Table 1 .
Identi ed impacts of accreditation on the performance of PHC centres.