UHC Forward: Towards Universal Health Coverage

A high-quality health system is defined by its cost-effectiveness, capacity to continuously learn from and prevent errors, and its commitment to the respect and dignity of the patients and families it serves.

Policymakers, payers, providers, patients and the public each have a role to play in achieving these goals; through collaboration, they can achieve an effective quality strategy that, combined with expansions in healthcare access, will achieve improvements in health outcomes.

Healthcare delivery systems must continuously improve to match the increased demand they face from patients. Empanelment, accreditation, and other external evaluation systems are widely-used tools for assuring a standard level of quality of care.

Kedar Mate, MD, vice president of the Institute for Healthcare Improvement (IHI) and assistant professor of medicine at Will Cornell Medical College, explains accreditation as a tool for improving the quality of healthcare

Jennifer Masters: Are there any standards or best practices on the table for laying out accreditation programs and engaging all stakeholders?

Kedar Mate: There are a number of reference points that are commonly used by national programs or by organizations in different parts of the world that are trying to set up accreditation efforts. A couple of big names are the Joint Commission International, Accreditation Canada, and the International Society for Quality in Healthcare (ISQua). What ISQua does is a little different from the first two in that it accredits the accreditors. For example, in India, the national accreditation board of hospitals, which is the national organization for accreditation, is itself accredited by ISQua to be an accreditor.

JM: Could you explain how these organizations get their credibility and what that process looks like?

KM: A lot of it is history on some level. Ernst Codman, an American surgeon in the 1920s, established the idea of standards-based practice. Codman’s notion at the time was that there needed to be a reference point for surgical practice, and that slowly but surely gained credibility and became something much broader—what we know accreditation to be now. His ideas led directly to the creation of the Joint Commission in the 1950s. How did it gain credibility? Like a lot of things, professional societies have a reputation. The Board of Internal Medicine, for example, has a reputation for performance, quality, and standards. The Royal Colleges in England are another example. They derive their legitimacy from within their ranks, from peer review, peer disciplinary practices, and so on, so there’s this sort of notion that the profession will maintain its own standards and quality. I think accreditation organizations are kind of similar. They get their authenticity, or credibility, from the fact that when you’re a JCI-, ISQua-, or Accreditation Canada-accredited institution, there’s a certain associated level of quality. And as their hospitals achieve high quality care, their reputation grows.

JM: Should countries (or regions) work together to standardize systems of accreditation? Or should every health system define its own needs?**

KM: There’s almost no question that countries absolutely should work together if it’s logical and feasible for them to do so. The problem is that in large measure it’s actually quite logistically challenging to do. My perspective is that absolutely people should work together if possible. It would certainly reduce the startup costs of developing an accreditation program. I was just talking with someone recently about the estimated costs of starting up an accreditation program. It’s a lot of reinvention of the wheel—recreating guidelines and standards from scratch. A lot of that work has been done before, and yet countries continue to invest in it anew. The cost is substantial and there’s absolutely no reason for that. Instead, you could understand the experience of others and build from there, and then customize and adapt. There’s going to have to be local customization and adaptation but you could save a lot of money and time if you had a stronger basis on which to grow your accreditation program.

JM: How is it best to deal with accountability for individual practitioners and for facilities? How do you hold the health system accountable without penalizing the people who need health services?

KM: Accreditation can be viewed as a punitive, audit-driven kind of approach or it can be viewed as a continuous learning process. If it’s regarded as part of a continuous learning process, when you have a facility that isn’t up to standard, it’s not “Should we shut it down” or “Make it go away” or “Cut it out of the system,” it’s “How can you make it better? How can that institution learn?” And even the best institutions can learn. There’s the Japanese concept of kaizen, and that’s this notion that every defect is a treasure and the idea that even organizations that are really high performing have opportunities for improvement. I think that accreditation and external peer review, which is really what accreditation is, can be looked at as a way of helping organizations to discover where their weaknesses are and where their strengths are so they can learn and grow and change.

JM: What is the difference between licensing and accreditation?

KM: Licensing typically is what’s done for individual practitioners. If you’re licensed to practice it signifies meeting the basic qualifications to do that. It’s not a full detailed assessment of what’s actually happening in an institution. It’s just did you meet the qualifications? It’s typically a non-voluntary process by which a government or other agency regulates an activity or profession. For example, in order to drive you need a driver’s license given to you by the DMV. When you apply for a driver’s license and you pass the driver’s test, it just means you met the criteria to pass the test; it doesn’t mean you’re a good driver. Accreditation on the other hand is typically a voluntary process of external peer review and it’s typically for institutions. It’s not really meant to be about the test, even though people treat it like it’s a test. It’s supposed to be about external peer review and learning. Licensure is actually more of a mandatory test, whereas accreditation is intended (although it doesn’t always happen) to be a learning process. It’s intended to be about collegial peers working together to learn together. It’s also meant to be done by a neutral third party.

JM: Should accreditation be mandatory or voluntary?

KM: In its ideal state, accreditation would be voluntary. Go back to the discussion about learning—when you are forced to learn something you are, I think, slightly less willing to be a good student. Whereas when you have an intrinsic desire to learn something, you are a far better student. I think that’s the difference. For a university student, for example, it’s the difference between the core required courses and the courses you elect to take. The courses you elect to take are a lot more enjoyable and you learn a lot more from them than the courses that you are mandated to take. I think that the notion of it being mandatory really confuses the idea of accreditation being a continuous learning exercise. The other issue is that, depending on who is mandating it, it can start to become regulation rather than accreditation.

JM: How are accreditation results being used? And how often are results reported?

KM: There’s a lot of variation—some are being used for purposes of reimbursement, public recognition, it varies significantly. As far as timing, ideally, some form of peer review should be constant in an institution, whether it’s one ward checking on another ward or a neighboring hospital coming to learn from another hospital. In an ideal health system, units within hospitals would learn from each other, departments within hospitals would learn from each other, and hospitals within a region would learn from each other on an almost constant basis. It wouldn’t be this effort every 3 or 5 years. I recognize that there are practical limitations to that but I think there are also conceptual limitations. I think people have gotten into this mindset that accreditation happens formally every 3 years or 5 years and that’s how it happens.

This limits the creativity about how to integrate external peer review into the normal and routine functioning of an institution. That said, I think that the more mature accreditation systems are promoting these ideas about what happens between external peer review visits. While the big accreditation visit might happen every three years, in between there’s all kinds of peer-to-peer exchanges of knowledge and information on an annual basis, and maybe ward-to-ward exchanges on an even more routine basis than that. Some businesses are propagating this idea of more continuous knowledge exchanges.

JM: Who or what institutional structure should be responsible for conducting accreditation processes?

KM: Although they can provide guidance and standards, organization like WHO or the World Bank shouldn’t be in charge of conducting accreditation. They don’t have the technical capacity to do that, but there needs to be an external third party organization. At the country level, if it’s the Ministry it becomes about regulation. If it’s the insurer it becomes all about payment. Providers could evaluate themselves in the standard way that professional societies behave, that sort of self-belief mechanism, but people might consider such a system to be biased. I think the most common arrangement and the best way is to have an external third-party provider with a board that’s composed of all the different stakeholders—Ministry of Health, insurers, providers, patients, etc., but behaves independently. It shouldn’t be affected by the decisions of the Ministry, it shouldn’t be influenced by its funders, and it shouldn’t be beholden to any one of those stakeholders alone.