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Effectiveness of external inspection of compliance with standards in improving healthcare organisation behaviour, healthcare professional behaviour or patient outcomes

  1. Gerd Flodgren1,
  2. Marie-Pascale Pomey2,
  3. Sarah A Taber3,
  4. Martin P Eccles4,*

Editorial Group: Cochrane Effective Practice and Organisation of Care Group

Published Online: 9 NOV 2011

Assessed as up-to-date: 12 MAY 2010

DOI: 10.1002/14651858.CD008992.pub2


How to Cite

Flodgren G, Pomey MP, Taber SA, Eccles MP. Effectiveness of external inspection of compliance with standards in improving healthcare organisation behaviour, healthcare professional behaviour or patient outcomes. Cochrane Database of Systematic Reviews 2011, Issue 11. Art. No.: CD008992. DOI: 10.1002/14651858.CD008992.pub2.

Author Information

  1. 1

    University of Oxford, Department of Public Health, Headington, Oxford, UK

  2. 2

    University of Montreal, Department of Health Administration, IRSPUM, Faculty of Medicine, Montreal, Quebec, Canada

  3. 3

    Royal College of Physicians and Surgeons of Canada, Office of Education, Ottawa, Ontario, Canada

  4. 4

    Newcastle University, Institute of Health and Society, Newcastle upon Tyne, UK

*Martin P Eccles, Institute of Health and Society, Newcastle University, Badiley Clark Building, Richardson Road, Newcastle upon Tyne, NE2 4AX, UK. Martin.Eccles@newcastle.ac.uk.

Publication History

  1. Publication Status: New
  2. Published Online: 9 NOV 2011

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Characteristics of included studies [ordered by study ID]
OPM 2009

MethodsStudy design: ITS (uncontrolled before and after study re-analysed as a time series)

Data: data were gathered from: a national survey of trusts; in-depth case studies with 10 trusts, desk-research to map inspection process, analyse outcome indicators and analyse 80 published inspection reports, and that on the views of patients, service users and the public involving archive research, analysis of press coverage and discussion groups/telephone interviews with 25 stakeholders (these results were not re-analysable, and therefore not included in this review).

Data on hospital-acquired infections (MRSA rate) 1 year before the intervention and 2 years after the intervention (results re-analysable and included in the review).


ParticipantsRecipients: all acute trusts in England (168 acute trusts in 2009)

Country: England

Targeted behaviour: compliance with the Code of Practice and the law (the Healthcare Act, 2006) related to HCAIs


InterventionsDescription of the intervention:

The Healthcare Commissions Healthcare Associated Infections Inspections Programme - addressed hospital trusts' compliance with the Code of Practice (and the Healthcare Act) aiming at reducing HCAIs, including MRSA infections:

i) The selected trusts are notified that they will be inspected at any time point within the subsequent 3 months. Being aware of the forthcoming inspection may encourage the trust to take steps to improve the compliance with the Code of Practice, before the actual inspection.

ii) A pre-inspection report is produced by the assessors, using relevant data sent to them by the trusts.

iii) With the help of the pre-inspection report the assessors select a subset of duties described in the Code of Practice to be assessed at the inspection.

iv) During the inspection the inspection team will look for a likely breech of the Code of Practice, and this will feed into the formal inspection output, either an inspection report with recommendations or an improvement notice.

v) The inspection report highlights areas requiring improvements and makes recommendations as to how the trust needs to improve. The trusts will act on the comments and take steps to improve its practices. An improvement notice, on the other hand, requires the trusts to draw up an action plan and specify how it will remedy the material breeches of the code that have been identified.

vi) Once the steps to remedy the breeches to the Code of Practice have been followed the notice is lifted.

Type of external standard: the 'Code of Practice' and the 'Healthcare Act, 2006' - aimed at decreasing the number of hospital-acquired infections

Who developed the standards: in 2006 the Department of Health enacted new legislation: 'the Healthcare Act' supported by a 'Code of Practice' aiming at decreasing the number of HCAIs infections

Voluntary or mandatory review: mandatory

Universally or targeted review: universal

Who performed the review: the Healthcare Commission (now the Care Quality Commission); a governmental organisation

Purpose and focus of the review: to ensure that trusts are complying with the Code of Practice and by doing so bring about reductions in hospital-acquired, infection-related morbidity, as well as to improve patient and public confidence in health care

Timing:

a) Frequency and number of inspections: one per trust

b) Duration of inspection: not stated


OutcomesMRSA infection rate was retrieved from http://www.hpa.org.uk/web/HPAwebFile/HPAweb_C/1229502459877, and was re-analysed as a time series

All other data provided in the report were uncontrolled before and after data, with less than 3 data points before, and three data points after the intervention, which prevented re-analysis being undertaken

Results:
Date; No of cases
April 2006 to June 2006; 1742
July 2006 to September 2006; 1651
October 2006 to December 2006; 1543
January 2007 to March 2007; 1447
April 2007 to June 2007; 1306. In June 2007, the Healthcare Commission began a series of unannounced inspections, focused specifically on assessing compliance with the 'Code of Practice'
July 2007 to September 2007; 1083
October 2007 to December 2007; 1092
January 2008 to March 2008; 970
April 2008 to June 2008; 839
July 2008 to September 2008; 724
October 2008 to December 2008; 678
January 2009 to March 2009; 694
April 2009 to June 2009; 509

Re-analysis of the MRSA data, as an ITS, showed statistically non-significant effects of the intervention. The difference (24.27, 95% CI -10.4 to 58.9) between the pre-slope (-107.6) and the post slope (-83.32) was not statistically significant (P = 0.147). When the downward trend in MRSA rate before the intervention had been taken into account, the results showed a mean (CI) decrease with 100 (-221.0 to 21.5) cases at 3 months (P = 0.096), 75 (-217.2 to 66.3) cases at 6 months (P = -0.259), 27 (-222.1 to 168.2) cases at 12 months (P = 0.62), and an increase with 70 (-250.5 to 391) cases per quarter at 24 months follow-up (P = 0.632).

The results of the MRSA data are summarised in  Summary of findings 2.

Other reported outcomes that could not be re-analysed and therefore not included in this review were:

  • rate of Clostridium difficile infections
  • patients' perceptions of hospital cleanliness and hand-washing among doctors and nurses
  • number and ‘sentiment’ of national media coverage of hospital-acquired infections over time
  • inspections conducted and trust performance
  • trusts' understanding of the purpose and the aim of the inspection programme
  • views on (i) pre-visit submission of relevant documents, (ii) unannounced visits (iii) the post reporting process, (iv) and experiences of the inspection visit
  • impact on (i) standards of infection control and (ii) overall standards of infection prevention and control, (iii) public satisfaction with, and confidence in, hospitals


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Incomplete outcome data (attrition bias)
All outcomes
Low riskThere were no incomplete outcome data, since quarterly reporting of MRSA infections by trusts are mandatory

Selective reporting (reporting bias)Low riskResults were presented for all outcomes described in the methods section

Other biasLow riskNo other risk of bias was identified

Intervention independent of other changesHigh riskp.16, para 4.2.1

"As shown in Figure 2, reported cases of MRSA have decreased from 1,742 cases in Apr-Jun 2006 to 509 cases in Apr-Jun 2009 a reduction of 71 per cent. The total number of cases has shown a steady downward trend during this time, except for slight increases in cases between Jul-Oct and Oct-Dec 2007 and between Oct-Dec and Jan-Mar 09. These increases may reflect seasonal trends.The vertical line on Figure 2 indicates when the inspection programme began, in June 2007; this is included for information and we do not imply that any observed trends are being attributed to the impact of the programme."

The 'Code of Practice' as well as the law related to HCAIs: The Healthcare Act, were enacted in 2006, which may explain the downward trend MRSA rate seen from June 2006.

Pre-specified shape of interventionLow riskData re-analysed by review authors

Intervention unlikely to affect data collectionLow riskSources and methods of data collection were the same before and after the intervention (The Health Protection Agency monitor quarterly mandatory reports of MRSA rates made by trusts)

Knowledge of allocation adequately protectedLow riskThe outcome measure was objective (MRSA infection rates)

Salmon 2003

MethodsStudy design: cluster-RCT

Data: survey data from COHSASA accreditation programme were used, measuring hospital structures and processes, along with 8 hospital quality indicators


ParticipantsRecipients: 20 randomly selected public hospitals: 10 intervention and 10 control. One of the hospitals dropped out half-way through the accreditation process, and a similar size hospital in the control group was therefore excluded, leaving 9 intervention and 9 control hospitals for the final analysis.

Characteristics of included hospitals:

Setting: Intervention: 5 urban, 3 peri-urban and 2 rural hospitals; Control: 2 urban, 2 peri-urban and 6 rural hospitals.

Mean number of beds (SD): Intervention hospitals: 435 (± 440); Control hospitals: 467(± 526)

Country: KwaZulu-Province, The Republic of South Africa

Targeted behaviour: compliance with COHSASA accreditation standards (p.20, Table B), performance related to the hospital quality of care indicators (p. 8, Table 2)


InterventionsDescription of the intervention: p. 4, col1, para 2, and col 2, para 1.

The accreditation process:

During the 2-year study, COHSASA measured the accreditation variables twice and performed the rest of the programme as normal in the 9 intervention hospitals.

(i) COHSASA facilitators initially assisted each participating facility to understand the accreditation standards and to perform a self assessment (baseline survey) against the standards (that was validated by COHSASA surveyors).

(ii) Detailed written reports on the level of compliance with the standards and reasons for non-conformance were generated and sent to the hospitals for use in their quality improvement programme.

(iii) Next the facilitators assisted the hospitals in implementing a CQI to enable the facilities to improve on standards identified as sub-optimal in the baseline survey.

(iv) Lastly the hospital entered the accreditation (external) survey phase, when a team of COHSASA surveyors who were not involved in the preparatory phase conducted an audit.The accreditation team usually consists of a medical doctor, a nurse, and an administrator who spend an average 3 days evaluating the degree to which the hospital complies with the standards and recording the areas of non-compliance.

(v) Hospitals found by COHSASA's accreditation committee to comply substantially with the standards were awarded either pre-accreditation or full accreditation status. The former status encourages respective institution to continue with the CQI process, which should help it stay on the path to eventual full accreditation status.

Control condition:

The accreditation variables were measured as unobtrusively as possible in the 9 control hospitals. None of the other components of the accreditation programme were performed, meaning no feedback of results and no technical assistance, until after the research was completed. Meanwhile, a separate research team measured the research indicators in both the intervention and control hospitals.

Type of external standard: COHSASA accreditation standards and 8 indicators of hospital quality that had been developed by consensus of an advisory committee in South Africa.

Who developed the standards: to develop indicators for hospital quality, a workshop was held in South Africa in May 1999. Present at the workshop were South African healthcare professional leaders, the managing director of COHSASA, a representative from JCI, and the principal investigators for the research study.

Voluntary or mandatory inspection: mandatory

The Kwa-Zulu Natal (KZN) province signed a contract with COHSASA for the first province-wide public hospital accreditation activity in the country (p. 4, col 2, para 1). The hospitals did not volunteer to participate.

Universally or targeted inspection: universal (i.e. all groups of health professionals were involved).

Who performed the inspection: before and after measures of compliance with COHSASA accreditation standards were collected by COHSASA surveyors or teams hired by COHSASA, and indicators of hospital quality were collected by research assistants hired by the independent research team composed of South African and American investigators (p. 6, col 3, para 2).

Purpose and focus of the inspection: to improve compliance with COHSASA accreditation standards and performance related to the hospital quality of care indicators.

Timing:

a) Frequency and number of inspections: 2: 1 before the start of the accreditation programme (a self assessment of compliance with accreditation standards that were validated by a COHSASA team of surveyors or a team hired by COHSASA), and one inspection at the end of the 2-year period.

b) Duration of inspection: approximately 3 days for the on-site inspection (the time put down in between inspections is unclear).


OutcomesCompliance with COHSASA accreditation standards (6000 standards, and 28 service elements, see Figure 4 for details on the service elements) and 8 indicators of hospital quality of care (see Figure 2) were measured. See Figure 3 for details on how these outcomes were measured.

Initially there were 12 indicators, but after the first measurement 4 of them were dropped. Indicators of neonatal mortality, surgical wound infections and time to surgery, and financial solvency were dropped due to difficulties in achieving comparability between hospitals (see Appendix 3 for reasons). The 8 indicators of hospital quality of care that remained for the final analysis were: i) nurses perception of clinical care; ii) patient satisfaction with care; iii) patient medication education; iv) medical records: accessibility and accuracy; v) medical records: completeness; vi) completeness of peri-operative notes; vii) completeness of ward stock medicine labelling, and viii) hospital sanitation.

Results:

Compliance with COHSASA accreditation standards:

Results were reported for compliance with COHSASA accreditation standards (represented by 28 service elements), and 8 quality of care indicators.

The results showed that after the 2-year accreditation period, the total mean compliance score with COHSASA accreditation standards was significantly improved in intervention hospitals. The total compliance score for 21/28 service elements, for which comparisons were possible, rose from 48% to 78% in intervention hospitals, while control hospitals maintained the same compliance score throughout (43%). The mean intervention effect was 30 (23% to 37%).

Looking at the individual scores of compliance with the accreditation standards for each service element the results were mixed, with 21/28 fields showing a significant effect of the inspections (the mean intervention effect ranged from 20% to 52%, while for the remaining 7 service elements data were not available, i.e. some of the service elements were only evaluated in the higher level hospitals, so comparisons between the intervention and control arms was not appropriate due to small sample size.

Sub-analysis of the standards that a priori were deemed by the COHSASA as being ‘critical’ for a specific function was performed. As some of the 28 service elements evaluated in the accreditation process were not applicable for all hospitals, this left 19 generic service elements, yielding 424 critical criteria for the sub-analysis.

These critical criteria were mainly drawn from the following service elements: obstetric and maternity inpatient services; operating theatre and anaesthetic services; resuscitation services; paediatric services and medical inpatient services.

The sub-analysis showed significantly improved mean compliance with the critical standards in intervention hospitals: the total score rose from 38% (range 21% to 46%) to 76% (range 55% to 96%). Control hospitals maintained the same compliance score throughout: 37% (range 28% to 47%) before the intervention and 38% (range 25% to 49%) after the intervention. The difference in means between groups was statistically significant (P < 0.001).

Only 1 of the 9 intervention hospitals gained full accreditation status at the end of the study period, with 2 others reaching pre-accreditation status.

Hospital quality indicators:

The effects on the hospital quality indicators were mixed, with mean intervention effects ranging from -1.9 to +11.8, and only 1 of the 8 indicators: 'nurses perception of clinical care', showed a significant effect of the intervention (see below)

Nurses perception of clinical care

Intervention hospitals: Pre: 59.3%, Post: 60.8% (Change: 1.5); Control hospitals: Pre: 60.8% Post: 56.5% (Change: -4.2), Intervention effect: 5.7 percentage points (P = 0.031)

Patient satisfaction with care:

Intervention hospitals: Pre: 86.9%, Post: 91.5% (Change: 4.6); Control hospitals: Pre: 87.0%; Post: 90.1% (Change: 3.1), Intervention effect: 1.5 percentage points (P = 0.484).

Patient medication education:

Intervention hospitals: Pre: 42.9%, Post: 43.1% (Change: 0.2); Control hospitals: Pre: 41.5%, Post: 40.0% (Change:-1.5), Intervention effect: 1.7 percentage points (P = 0.395)

Medical records: accessibility:

Intervention hospitals: Pre: 85.4 %, Post:77.5 % (Change: -7.9); Control hospitals: Pre: 79.4%, Post: 68.4% (Change: -11.0), Intervention effect: 3.1 percentage points (P = 0.492)

Medical records: completeness (consisting of 2 components: admissions and discharge): Intervention hospitals: Pre: 47.1, Post: 49.1 (Change: 2.0 ), Control hospitals: Pre: 48.6% Post: 44.9% (Change: -3.7), Intervention effect: 5.7 percentage points (P = 0.114)

Completeness of peri-operative notes:

Intervention hospitals: Pre: 70.2%, Post: 72.7% (Change: 2.5); Control hospitals: Pre: 65.2%, Post: 69.6% (Change: 4.4), Intervention effect: -1.9 percentage points (P = 0.489)

Ward stock labelling:

Intervention hospitals: Pre: 66.0, Post: 81.8 (Change: 15.8); Control hospitals: Pre: 45.6, Post: 49.6 (Change: 4.0), Intervention effect: 11.8 percentage points (P = 0.112)

Hospital sanitation*:

Intervention hospitals: Pre: 59.7%, Post: 62.8% (Change: 3.1); Control hospitals: Pre: 50.2%, Post: 55.7% (Change: 5.5), Intervention effect: -2.4 percentage points (P = 0.641)

* Consisted of the assessment of 6 items (availability of soap, water, paper towels and toilet paper and whether toilets were clean and in working order) of which a composite score was developed


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low riskp.5, col 2, para.1

"To ensure a balanced design with respect to service and care characteristics, researchers stratified the hospitals by size (number of beds) into four categories. Within each stratum a simple random sample without replacement was drawn."

Allocation concealment (selection bias)Low riskThe allocation was made by the research team (i.e. centrally), but it is unclear if it was done by an independent statistician or not

Blinding (performance bias and detection bias)
All outcomes
High riskThe hospitals could not be blinded to the fact that they were part of an hospital accreditation programme or not, and it was not stated whether or not the assessors were blinded.

Incomplete outcome data (attrition bias)
All outcomes
Low riskp.1, col 1, para 3

"One of the intervention hospitals dropped out of the accreditation midway through the study, and so to retain comparability of the intervention and control groups, a similar sized hospital was removed from the control group, leaving nine hospitals in the intervention group and nine in the control for this part of the study. Of the 20 randomised hospitals, 18 remained from the final analyses."

Selective reporting (reporting bias)Unclear riskp.7, col 1, last paragraph and col 2

"This process resulted in 12 indicators for the first round of data collection. However, based on preliminary analysis of data collected from the first round, the research team recommended to the steering committee that some indicators be dropped. The steering committee (composed of representatives from the research team, the sponsors of the research, COHSASA, and several South African medical experts) decided to drop the two indicators relating to surgical wound infections and time to surgery because only nine hospitals (six intervention and three control) performed surgery regularly and many of the records lacked information on infections and times. Despite its limitations, the committee did retain the indicator on completeness of peri-operative notes and extended this to include any form of significant incision or anaesthesia.
The committee also dropped the indicator of neonatal mortality rate, because the research assistants had great difficulty in finding reliable data due to the high variation in approaches to documenting neonatal deaths among the various hospitals. Transferring newborns soon after birth was common, but sometimes hospitals reported transfers even when they recorded deaths. Finally, the indicator of financial solvency was discarded because the KZN provincial government had implemented strict budgeting controls across all hospitals in the region with reportedly no additional funds being assigned. Hence, it was unlikely that the COHSASA process would affect this indicator. These decisions resulted in eight quality indicators (see Figure 2).

Other biasUnclear riskThe baseline survey of the compliance with the accreditation standards was not performed simultaneously in intervention and control hospitals, but on average 3 months later in control hospitals, so it is unclear whether or not the control measurements represent a true baseline. This especially since the COHSASA survey team did not only consult hospital records, but interviewed hospital staff, and observed procedures and operations to determine the degree to which the service elements met the requirements of the standards. It was, however, suggested by the authors, that the intervention hospital generally would wait to start working on improving the standards until they had seen the baseline survey report, which was about 2 months after the baseline survey was conducted.

Similar baseline characteristicsUnclear riskThe stratification of hospitals into intervention and control groups was by hospital size - but neither hospital size nor any of the other hospital characteristics reported at p.19, Table A, were tested for statistically significant differences between groups. See also comment under other risk of bias.

Similar baseline outcome measuresLow riskp.10, col 1, para 1, line 14-17

"At baseline the intervention and control hospitals showed similar levels of compliance to the critical standards."

Adequate protection against contaminationLow riskAllocation was by hospital

 
Characteristics of excluded studies [ordered by study ID]

StudyReason for exclusion

Al Tehewy 2009Not an external inspection intervention, but a comparison between naturally experimented clusters (submitted for accreditation) and control clusters on the compliance with standards (monitoring indicators set by the General Directorate of Quality in the Ministry of Health and Population, Egypt). Ineligible study design (survey).

Brooke 2008Not an external inspection intervention, but evaluates compliance with standards (Leapfrog evidence-based standards for abdominal aortic aneurysm repair set by the Leapfrog Group). Ineligible study design (questionnaire survey).

Frasco 2005Not an external inspection intervention, but evaluates the implementation of the JCAHO pain initiative. Ineligible study design (uncontrolled BA study).

Kowiatek 2002Not an external inspection intervention, but evaluates a new medication control review tool for monitoring compliance with JCAHO standards. Ineligible study design (case studies).

Lasalle 2002Not an external inspection intervention, but evaluates the implementation of standards (JCAHO medication management standards). Ineligible study design (retrospective survey).

Mattes 1987Not an external inspection intervention, evaluates only 2 different treatment planning conference ratings. Ineligible study design (uncontrolled BA study).

OPM 2007External inspection intervention, but ineligible study design (questionnaire survey)

OPM 2008aNot an external inspection intervention, but an evaluation of the Healthcare Commission's assessment process. Ineligible study design (case studies and surveys).

OPM 2008bNot an external inspection intervention, but an evaluation of the Healthcare Commission's inspection process. Ineligible study design (case studies and surveys).

Shaw 2003Not an intervention (overview paper)

Shonka 2009Not an external inspection intervention. Evaluates compliance with work hour regulations. Ineligible study design (retrospective review).

Walsh and WalsheThe report could not be found and neither could the contact details of the authors

Winchester 2008Not an intervention (overview paper)

 
Summary of findings for the main comparison. Salmon 2003

External inspection of compliance with COHSASA hospital accreditation standards for improving healthcare organisation behaviour, healthcare professional behaviour or patient outcomes

Patient or population: hospitals, primary healthcare organisations and/or other community-based healthcare organisations containing health professionals

Settings: secondary care

Intervention: external inspection of compliance with accreditation standards and performance related to indicators for hospital quality of care

Comparison: no intervention

OutcomesIntervention effectNo of hospitals/no of service elements/indicators of hospital quality includedNo of studiesQuality of the evidence
(GRADE)
Comments

Compliance with COHSASA accreditation standardsMean intervention effect (95% CI)

30%1(23% to 37%), P < 0.001
18 hospitals (9 intervention and 9 control) - 21/28 service elements included in analysis1+000The total compliance score with the accreditation standards was significantly greater in intervention hospitals, as compared with control hospitals (P < 0.001)

Compliance with COHSASA accreditation standards - subgroup of critical criteria analysedI: Pre: 38% (21% to 46%), Post: 76% (55% to 96%)

C: Pre: 37% (28% to 47%), Post: 38% (25% to 49%)

Mean intervention effect: 37% (P < 0.001)
Unclear number of hospitals included in analysis - 19/28 service elements (and 426 pre-defined criteria) included in analysis1+000The compliance score for a sub-section of predefined critical criteria, deemed crucial for the function of the service elements, was significantly greater in intervention hospitals, as compared with control hospitals (P < 0.001)

Indicators for hospital quality of careMedian intervention effect (range)

2.4% (-1.9% to 11.8%)
18 hospitals (9 intervention and 9 control) - 8 indicators of hospital quality included in analysis1+000The median quality indicator score was non-significant. All but one of the indicators for hospital quality of care was non-significant.

1 Change in total compliance score for 21/28 service elements - for 7 of the 28 service elements data were not available

2 Sub-analysis of the compliance score for 19 generic service elements (involving 426 predefined critical criteria)

We downgraded the evidence on the basis of imprecision and publication bias.

++++

High. Further research is very unlikely to change our confidence in the estimate of effect or accuracy.

+++0

Moderate. Further research is likely to have an important impact on our confidence in the estimate of effect or accuracy and may change the estimate.

++00

Low. Further research is very likely to have an important impact on our confidence in the estimate of effect or accuracy and is likely to change the estimate.

+000

Very low. Any estimate of effect or accuracy is very uncertain.

 C: control
CI: confidence interval
COHSASA: Council for Health Services Accreditation for South Africa
I: intervention
 
Summary of findings 2. OPM 2009

External inspection of compliance with the 'Code of Practice' and the law related to healthcare-acquired infections for improving healthcare organisation behaviour, healthcare professional behaviour or patient outcomes

Patient or population: hospitals, primary healthcare organisations and/or other community-based healthcare organisations containing health professionals

Settings: secondary care

Intervention: external inspection of compliance with the Code of Practice and the Health Care Act related to healthcare-acquired infections

Comparison: no control group (time series)

OutcomesMean intervention effect (95% CI)No of acute trustsNo of studiesQuality of the evidence
(GRADE)
Comments

MRSA infection rateAt 3 months: -100 (-221.0 to 21.5) cases per quarter (P = 0.096)
At 6 months follow-up: -75 (-217.2to 66.3) cases per quarter (P = 0.259)
At 12 months follow-up: -27 (-222.1 to 168.2) cases per quarter (P = 0.762)
At 24 months follow-up: +70 (-250.5 to 391) cases per quarter (P = 0.632)
168 (in 2009)1+000Re-analysis of the quarterly reported rate of MRSA cases, as an interrupted time series, showed statistically non-significant effects of the Healthcare Commission's Infection Inspection Programme

We downgraded the evidence on the basis of imprecision and publication bias.

++++

High. Further research is very unlikely to change our confidence in the estimate of effect or accuracy.

+++0

Moderate. Further research is likely to have an important impact on our confidence in the estimate of effect or accuracy and may change the estimate.

++00

Low. Further research is very likely to have an important impact on our confidence in the estimate of effect or accuracy and is likely to change the estimate.

+000

Very low. Any estimate of effect or accuracy is very uncertain.

 MRSA: methicillin-resistant Staphylococcus aureus