Methods & Tools

Measuring Quality

External Evaluation of Quality

There are three primary approaches for external evaluation of healthcare quality: Licensure, Accreditation, and Certification. All three approaches use standards to determine the level of quality achieved by an individual or organization. External quality evaluations can generate objective data to:

Support comparisons of performance between the public and private health sectors and more appropriate government oversight of the health sector
Shape healthcare services delivery in new settings by monitoring access, quality, and risk
Demonstrate whether a predetermined rate of beneficiary coverage for preventive services is being achieved
Ensure efficient use and allocation of limited healthcare resources
Identify and create centers of excellence (e.g., those facilities that can provide greater volume of services, greater efficiency, and lower per case costs)
Integrate structures and services of several organizations to improve coordination and efficiency of care and reduce administrative costs

Licensure

Established to protect basic public health and safety, licensure standards address the minimum legal requirements or qualifications healthcare professionals and organizations need to operate. They also guarantee appropriate adoption of new medical practices and provide a framework to accommodate amendments to existing practices.

Licensure programs for individuals may involve examination of credentials, inspection of educational programs, testing of professional qualifications, reciprocal granting of licenses to applicants of other countries, issuance of regulations establishing professional standards of practice, and investigation of charges of violations of standards.

In the United States, the Federation of State Medical Boards and its member boards use A Guide to the Essentials of a Modern Medical Practice Act, a document containing concepts and policy statements for establishing or improving systems of physician regulation or medical practice acts. Topic areas include:

Examinations
Requirements for full licensure
Granting of temporary and special licensure
Disciplinary action against licensees
Procedures for handling impaired or incompetent practitioners
Unlawful practice of medicine
Periodic renewal of registration

In most countries, hospitals and healthcare facilities must be licensed to provide care or services to patients. Governments or regulatory authorities grant licenses when facilities meet defined levels of quality or provide certain services (e.g., surgery, radiology, laboratory, round-the-clock nursing care, and pharmacy services). In some jurisdictions within the United States, the hospital or health center also may be required to demonstrate a need for the services within the local community before receiving a license to operate.

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Accreditation

Unlike licensure, which focuses on adherence to minimal standards intended to assure public safety, accreditation focuses on continuous improvement strategies, achievement of optimal quality standards, and ongoing education and consultation. Effective accreditation programs have well-defined missions, pre-determined infrastructure and authority for the program, participation from health professionals in standards development and interpretation, and relevant, objective, and measurable standards. A strong accreditation program:

Encourages professionals to continuously seek to improve quality despite resource limitations
Provides sustained management of field operations (e.g., selection and training of peer reviewers, supervision and ongoing education of surveyors, etc.)
Ensures a fair, valid, and credible process
Establishes an accreditation database of information to determine compliance, pinpoint problem areas, or highlight opportunities for improvement

Accreditation standards, which are usually developed by expert consensus, reflect state-of-the-art thinking about healthcare quality, advances in technology and treatments, and changes in health policy. Organized by key organizational processes or functions (e.g., patient assessment, human resource management) or by department (e.g., pharmacy services, nursing services), accreditation standards offer healthcare organizations a systematic way of organizing operations for optimal efficiency and effectiveness—a key tenet of quality assurance. Most healthcare accrediting bodies use a variety of evaluation strategies to determine compliance, performance, and quality of care, such as:

Document and record reviews
Interviews
Observations
Achievement evaluations
Facility inspections

Evaluation teams comprised of peer reviewers or surveyors visit facilities, either announced or unannounced, to evaluate compliance with accreditation standards. Announced evaluations guarantee greater participation in the process, although this allows organizations time to enhance surface appearances, potentially making it more difficult for a team to determine usual practices and operations. Once the evaluation is completed, an accreditation designation is given (e.g., accreditation with commendation, accredited with recommendations)..

For an accreditation program to flourish, decision makers should consider questions of sustainability and financial viability and identify funding sources for each phase of the program. Financial incentives, for example, can help to maintain the program, reward organizations’ superior performance, and stimulate professional commitment.

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Certification

Distinguished from accreditation by its application to both individuals and organizations, certification involves a recognized authority or board granting recognition to individuals who have demonstrated specialized knowledge and skill and to organizations that have the ability to practice in a certain area or specialty.

In the United States, The American Board of Medical Specialties (ABMS) and the American Medical Association Council on Medical Education (AMA/CME) review and approve medical specialty boards and work to standardize their approaches. The two organizations also maintain a rigorous process of application and review for new boards in emerging medical specialties (e.g., the American Board of Medical Genetics).

Most medical specialty boards require re-certification at periodic intervals, usually seven to 10 years. Re-certification usually involves evaluation of continuing experience, skills, proficiency, performance, and clinical outcomes. If an individual does not meet the standards, certification can be withdrawn. Verification of performance, however, does not typically include a review of actual care processes or patient outcomes.

In recent years, professional organizations, such as The American Medical Association, through its American Medical Accreditation Program, have started to evaluate individuals within their work environment. This voluntary, standards-based evaluation mechanism complements the formal medical specialty certification. Reviewers conduct an evaluation of credentials and qualifications, actual practice conditions, environment of care, clinical processes, and patient outcomes.

For organizations, lack of proper certification can affect funding, reimbursement for health services, and legal recognition. Certification distinguishes organizations as capable of practicing or delivering services in a specialty area.

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