What makes a local accreditation programme successful and how? A rapid realist review and in-depth consultation with senior nursing leaders.

Background: Locally driven ward and unit accreditation programmes provide a comprehensive tool to assess the quality of care delivered to patients, bringing together several measures in a single overarching framework. Reported outcomes of locally driven ward accreditation include reduced variation in care delivery, increased assurance of care quality and improved staff motivation. However, there is little empirical research that clarifies the underlying assumptions about what causes outcomes or the theoretical basis to explain how ward accreditation programmes work.

Design: A rapid realist review methodology with in-depth stakeholder consultation was adopted to explore the question "What are the key principles and processes of successfully implemented local ward accreditation programmes?"

Setting(s): Six study sites (NHS Trusts) across England participated in this review.

Participants: Sixteen senior nurse leaders at six study sites participated in focus groups lasting 90-120 min to elicit detailed reflections on how their accreditation programmes had been designed and implemented, to test out initial programme theories identified in the literature. These theories were then further scrutinised through a consultation group of key stakeholders.

Methods: Ten databases were searched, after screening 186 papers for relevance, 43 remained. An additional 11 papers were identified via a Google Scholar search. The 54 papers were then appraised for 'fitness for purpose', and thematically analysed for context, mechanisms and outcomes. A rapid realist review approach was adopted to develop and iteratively refine programme theories of locally driven ward accreditation programmes through evidence review, expert focus groups, and in-depth stakeholder consultation.

Results: Seven initial programme theories were identified from the literature: 1) Performance assessment; 2) Public disclosure and/as incentivisation; 3) Strengthening the Nursing voice; 4) Standardisation, consistency, accountability and shared governance; 5) Cultures of improvement; 6) Leadership development and 7) Teamwork and communication. These were discussed in focus groups with senior nursing teams and through a consultation group of key stakeholders. There was evidence for all seven initial programme theories, although some had more resonance with the senior nursing teams and stakeholders than others. No new theories were identified, demonstrating that the review comprehensively captured the reasons why locally driven ward accreditation programmes are thought to generate actions that lead to the outcomes the programmes are designed to produce.

Conclusions: This review provides an important and newly developed conceptual framework to underpin future empirical work and evaluate the effectiveness of locally driven ward and unit accreditation programmes to improve the quality and outcome of patient care.