The Role of Accreditation in an Era of Market-driven Accountability

Published Online: May 01, 2005
L. Gregory Pawlson, MD; Phyllis Torda, MA; Joachim Roski, PhD;

Accreditation has been widely used to promote accountability in healthcare. However, with the rise of both purchaser and consumer demand for broader and more detailed information on performance beyond licensure and professional self-regulation, especially at the provider level, the role of accreditation is less clear. We hypothesize that for accreditation to be a critical part of a market-driven, consumer-focused healthcare system, accrediting bodies must enlarge their scope of assessment with an emphasis on clinical performance of providers, revise and expand their level of reporting and transparency of assessment, and broaden the base of their governance. A new approach to accreditation could enhance accountability by (1) building on an existing framework and data-collection structure that are proven elements of quality assurance in multiple healthcare sectors; (2) expanding existing involvement of both public and private entities in the process; (3) building on existing linkages to professional and regulatory bodies; (4) providing greater flexibility, compared with regulation, in responding to change; and (5) having a defined source of funding. By these means, accrediting bodies will both improve accountability and successfully drive quality improvement.

(Am J Manag Care. 2005;11:290-293)

Accountability has been defined as "the procedure and process by which one party provides a justification and is held responsible for its actions by another party who has an interest in the action."1 Accountability in healthcare has been characterized as being driven by 3 major forces: regulation, professionalism, and the market.2 Parties that may seek accountability include those directly affected by healthcare services (patients, family) or those that directly or indirectly pay for the services (insurers, employers, employees, and taxpayers). We will refer collectively to this group of interested parties as "the public."

Accountability can be achieved by informal, subjective means or through the exchange of information using some formal set of metrics. One mechanism used to foster accountability in healthcare is accreditation and/or certification. The accreditation process involves an external entity evaluating a given organization against a set of predetermined requirements, critical attributes, or performance benchmarks.3 Certification denotes a similar process, but usually refers either to determination of individual competency or to evaluation of a single program or set of activities.

The related, but separate, process of licensure derives from legal and regulatory processes and involves the determination by a public agency of whether a given entity or person meets basic qualifications or competencies seen as necessary for providing services to the public.4 The processes of accreditation (or certification) and licensure, and the concept of professionalism (specifically, professional self-regulation), have been closely linked in the past. Indeed, accreditation most often is developed by a professional group or industry as a self-regulatory alternative to more restrictive and extensive public regulatory or licensure requirements.5-8 However in the recent past, consumerism and the market have begun to play more prominent roles in driving accountability.9

Our major premise is that the process and content of accreditation can, and should, be expanded to meet the growing demand by the public (consumers, insurers and purchasers) for accountability beyond licensure and professional self-regulation. To this end, accrediting bodies must be willing to (1) broaden their focus of assessment to include an emphasis on evidence-based performance, including clinical functions; (2) revise and expand their level of reporting and transparency of assessment; and (3) open and enlarge the base of their governance. Although similar changes are needed (and are beginning to take place) in public-sector programs and within the areas of professional certification, this paper will focus on private-sector accreditation.

THE IMPETUS FOR CHANGE

Although accreditation has played a substantial role in ensuring accountability, its roots in professionalism and regulation, its traditional reliance on structural assessment, and its use of "pass-fail" public reporting raise major concerns about its usefulness beyond providing a "floor" of accountability related to regulatory or professional issues. There are increasing concerns about the effectiveness of professionalism and regulation as the primary forces driving accountability. In addition, there is increased public understanding of quality and an enhanced ability to measure it.

Indeed, one of the hallmarks of an effective market is a high degree of symmetry of information between buyers and sellers, something that has clearly not been the case in healthcare in the past. If market forces are seen at least as balancing the forces of professionalism and regulation in driving and enhancing accountability in healthcare, there is a substantial need for more and more widely shared information on quality and cost in healthcare.

A substantial literature, including several reports from the Institute of Medicine (IOM), document marked variation both in the quantity and quality of care provided by hospitals, health plans, and other accredited entities.10-15 Because the public has become increasingly aware of this variation, demands for information on quality also have increased. These demands have come from public-sector and private-sector purchasers, consumers, and insurers.16-18 Although consumer use of performance information appears to be rather limited,19-22 both public and private purchasers and health plans are actively using performance data to inform consumer choice, develop network tiers, or provide financial and other rewards for performance.16,17 The IOM reports and the other studies cited also have cast doubt on our past and current reliance on professionalism and internal quality improvement mechanisms as the primary means of ensuring accountability. A full discussion of the benefits and limitations of professionalism are beyond the scope of this paper; however, there is a growing literature exploring this issue.23,24

The IOM provides a useful list of desirable attributes for our healthcare system.10 Moreover, the creation of reliable, valid, and feasible measures of clinical performance, such as the Health Plan Employer Data and Information Set (HEDIS®) developed by National Committee for Quality Assurance (NCQA) and the Oryx® set created by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), have greatly expanded the tools available for measurement.5,6,9 In addition, these organizations have taken steps to ensure that measures are timely and performance data are collected in a way that allows valid comparison between entities. These steps include development of detailed measure specifications, use of sampling frames, auditing of collection methods, and ongoing review and maintenance of the quality measures. Although the measures still are undergoing evolution, and there are technical and political issues related to extending measurement to the individual physician level, the use of clinical performance measurement is growing rapidly. Finally, the efforts of the National Quality Forum to create both standardization of metrics (voluntary consensus standards) and a framework for accountability in healthcare are accelerating progress in measurement and use of information on performance in healthcare.25-27

The emergence of a robust framework, an increased number and scope of valid measures, and greater market forces have heightened the call for more accountability in healthcare. However, there is no defined mechanism for gathering or reporting performance information for accountability purposes. Available options range from voluntary reporting by providers to creating regulatory or licensure-related requirements for reporting (Table 1). We propose, however, that a revised and expanded process of accreditation offers a number of important advantages, including:

Figure

  • Building on an existing framework and data-collection structure that are proven elements of quality assurance in multiple healthcare sectors.
  • Involvement of both public and private entities in the process.
  • linkages to both professional groups and regulatory bodies.
  • Greater flexibility, compared with regulation, in responding to change.
  • A defined source of funding.

The most problematic disadvantage is the semivoluntary nature of accreditation. However, strong pressure through contract requirements of private purchasers and health plans, or public purchasing and quasi-regulatory approaches that use "deemed status" for accredited entities (like the approach used by the Centers for Medicare & Medicaid Services [CMS] in the Medicare programs and by some states in regulation of hospitals and health plans) can go a long way to encouraging most, if not all, entities to undergo accreditation. For example, between state regulation and CMS requirements for participation in the Medicare program, nearly all hospitals undergo accreditation by a private entity through the regulatory doctrine of deemed status.

CHANGES NEEDED WITHIN THE ACCREDITATION PROCESS

Wider Involvement of Purchaser, Consumers, and Patients in Shaping Accreditation

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