Measurement
Public Health
Accreditation
HIGH
Learning from Others
NORMAL
Paul K. Halverson, DrPH, FACHE
LOW
Why Accreditation in the Service
Sector?
The Governor asked, “Gentlemen, are you
concerned with advancing the health,
safety, and welfare of the people …or are
you primarily interested in eliminating
competition and raising prices?”
Multiple Forms of “Regulation”
in the Service Sector
Professional Control
Informal
Informal Peer
Peer Pressure
Pressure
Formal
Formal Peer
Peer Review
Review
Accreditation
Accreditation
The spokesman smiled and said, “Governor,
we’re interested in a little of each.”
Certification
Certification
Licensure
Licensure
Government
Government Provision
Provision
─ Council of State Governments, 1952
Governmental Control
Opposing Economic Theories of
Accreditation, Certification, & Licensure
Information Asymmetry
– service quality is difficult to verify ex ante
by the buyers
– “lemons” problem may arise as low quality
services drive out higher quality services
Industry Capture
– service providers desire to differentiate,
gain marketing advantage, limit
competition
─ Stiglitz 1971
Rationale for this Study
Public health now faces many of the same
pressures that confronted other service
industries
– Gaps in availability & quality
– Variation in practice
– Coordination and interoperability issues
– Growing demand for accountability
If accreditation has helped other
industries, does it hold promise for public
health?
1
Findings:
Goals & Objectives Pursued by Accreditation
Objectives of Internal Stakeholders
Promote professionalization,
professionalization, visibility & legitimacy
Increase demand for services produced by industry
Distinguish services from competing industries
Limit entry of new and/or inferior organizations
Reduce need for direct governmental regulation
Increase public and private investments in industry
Facilitate recruitment and retention of skilled staff
Provide a buffer against political influence
Findings:
Program Design
Objectives of External Stakeholders
Assure/improve overall quality and safety
Assure/improve costcost-efficiency & value of
services
Reduce variation in the type and nature of
services & ensure providers can deliver a
standard set of services
Facilitate coordination and interoperability of
services
Ensure institutional and financial stability of
service organizations
Findings:
Strong Incentives for Accreditation
Program
Basic Components
InternalInternal-self assessment
Site visit for external validation & assessment
– Direct observation of operations
– Review of policies & procedures
– Review of administrative & clinical records
– Interviews with employees & clients
Submission of standardized performance
measures**
Summary assessment & scoring
Findings:
Moderate/Weak Incentives for Accreditation
Program
Findings:
Goals & Objectives Pursued by Accreditation
Incentives
NCQA, EAP,
URAC
Some employers give
preference in purchasing
HRSA
Exemption from OPR review
Fire depts.
Insurance discounts
CALEA
Lower liability costs
AMAP
Some hospitals & plans
give preference in
contracts**
Incentives
JCAHO, CARF
Medicare deemed status
CHAP
Deemed status,
benchmarking data
CHEA
Eligibility for grants/loans,
transfer of credits
NAEYC
Block grants targeted to
accredited centers,
differential payments
Findings:
Impact of Accreditation
Selection Effects:
Effects: accreditation
attracts higherhigher-quality organizations
Program Effects: accreditation
causes organizations to improve
quality
Unintended Effects:
Effects: accreditation
disrupts operations, reduces access
2
Impact of Accreditation
Impact of Accreditation
USAID South African Hospital Accreditation Trial
SAMHSA Methadone Clinic Trial
Source: Salmon et al. 2003
Source: D’Aunno and Pollack 2002
Impact of Accreditation
Impact of Accreditation
JCAHO Hospital Accreditation and MI Care
HEDIS Accreditation for Health Plans
70
60
Surveyed
Not surveyed
50
40
30
20
10
0
Aspirin on
admission
B-blockers on
admission
B-blockers during
hospitalization
30-day mortality
Source: Chen et al. 2003
Conclusions & Implications
Evidence suggests that
accreditation holds potential for
improving service quality
Costs are significant and must be
weighed against expected
benefits
Costs could generate disparities
in access to accreditation
14
12
10
8
6
4
2
0
-2
-4
-6
-8
Annual Percentage Change in Enrollment Relative to
NonNon-Accredited Health Plans
Accredited plans
Denied plans
1994
1995
1996
1997
1998
Source: Beaulieu and Epstein 2002
Conclusions & Implications
Strong incentives are vital to
success
Governance should be be broad
& inclusive to ensure
responsiveness & credibility
Need for evidenceevidence-based
standards to ensure desired
outcomes are achieved
3
Conclusions & Implications
Accreditation is not a silver bullet
Should be considered as only part of the
strategy:
– Performance measurement & reporting
– EvidenceEvidence-based guidelines
– Continuous quality improvement
– Workforce education & training
– Licensure and regulation
– Contracting, payment and compensation
On the Horizon…
Collaborative process to develop a
national accreditation program for
PH agencies
– CDC
– National Association of County &
City Health Officials
– Association of State and
Territorial Health Officials
– Robert Wood Johnson
Foundation
Accountability
National
National Public
Public Health
Health
Performance
Performance Standards
Standards Program
Program
What gets
MEASURED
gets
DONE !
Those who have the
political right to select
and dismiss health
officials should also
be given an intelligent
right to to do so. I
believe public health
work can be
standardized.
Rankin, 1915
4