Literature Review - General
Practice Accreditation Report
Prepared for the Australian Commission on Safety and
Quality in Health Care
October 2014
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Linda Kurti
Senior Consultant
Sara Hudson and Diane Fase
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TABLE OF CONTENTS
Acronyms ........................................................................................................................................... i
1
1.1
Introduction ........................................................................................................................... 1
Scope of the review ...........................................................................................................................1
1.2
1.3
Methodology .....................................................................................................................................1
This report .........................................................................................................................................4
2
2.1
What is accreditation? ............................................................................................................ 5
Definitions .........................................................................................................................................5
2.2
3.1
Accreditation in general practice ......................................................................................................7
Health system structure ....................................................................................................................8
3.2
3.3
General practice training and certification .................................................................................... 10
Quality assurance and accreditation .............................................................................................. 10
4
New Zealand ........................................................................................................................ 15
4.1
4.2
4.3
Health system structure ................................................................................................................. 15
General practice training and certification .................................................................................... 18
Quality assurance and accreditation .............................................................................................. 18
5
5.1
5.2
5.3
England ................................................................................................................................ 21
Health system structure ................................................................................................................. 21
General practice training and certification .................................................................................... 23
Quality Assurance and Accreditation ............................................................................................. 23
6
6.2
6.3
Wales................................................................................................................................... 26
General practice training and certification .................................................................................... 28
Quality assurance and accreditation .............................................................................................. 28
7
7.1
7.2
7.3
Canada................................................................................................................................. 31
Health system structure ................................................................................................................. 31
General practice training and certification .................................................................................... 33
Quality Assurance and accreditation.............................................................................................. 33
8
Denmark .............................................................................................................................. 36
8.1
8.2
Health system structure ................................................................................................................. 36
General practice training and certification .................................................................................... 38
8.3
Quality assurance and accreditation .............................................................................................. 38
9
9.1
9.2
The Netherlands ................................................................................................................... 40
Health system structure ................................................................................................................. 40
General practice training and certification .................................................................................... 42
9.3
Quality assurance and accreditation .............................................................................................. 42
10
10.1
Comparative analysis ........................................................................................................... 49
The influence of health care structures ......................................................................................... 52
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10.2
Mandatory versus Voluntary accreditation .................................................................................... 52
10.3
10.4
10.5
10.6
Incentives and pay for performance .............................................................................................. 53
Variations in accreditation programs ............................................................................................. 54
The impact of accreditation on quality and safety ......................................................................... 55
Benefits of accreditation ................................................................................................................ 56
11
Summary ..............................................................................................................................57
Disclaimer ........................................................................................................................................59
Appendix A
Framework for describing accreditation schemes
Appendix B
Dutch Visitation Instrument Accreditation (VIA) process
Appendix C
Reference List
Appendix D
Table of evidence
FIGURES:
Figure 1 – Australian Health System..............................................................................................................9
Figure 2 – Hierarchy of Standards, criterion and indicators....................................................................... 11
Figure 3 – New Zealand Health System ...................................................................................................... 17
Figure 4 – English Health System................................................................................................................ 22
Figure 5 – Welsh Health System ................................................................................................................. 27
Figure 6 – Canadian Health System ............................................................................................................ 32
Figure 7 – Danish Health System ................................................................................................................ 37
Figure 8 – Dutch Health System ................................................................................................................. 41
TABLES:
Table 1 – Methodology..................................................................................................................................1
Table 2 - Health Care Inspectorate’s (IGZ) key mechanisms ...................................................................... 43
Table 3 – Key phases in the audit process .................................................................................................. 47
Table 4 – Mapping of general practice accreditation programs ................................................................ 49
Table 5 – Framework for describing accreditation schemes
Table 6 – Accessed Research Papers
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Acronyms
ACRONYMS
ACA
ACRRM
ACHS
ACSQHC/THE
COMMISSION
AGPAL
AHPRA
ANAO
AOs
BIG
CCFP
CCGs
CCT
CFPC
CGPSAT
COPD
CPD
CQC
DAK-E
DAMD
DANPEP
DDKM
DHB
HER
FMRAC
GMS
GP
GPA
HDANZ
HiT
HIW
HKZ
HTA
IGZ
IKAS
I LIVE PC
LHB
MBBS
MBS
MPAC
MRCGP
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Affordable Care Act
Australian College of Rural and Remote Medicine
Australian Council on Healthcare Standards
Australian Commission on Safety and Quality in Health care
Australian General Practice Accreditation Limited
Australian Health Practitioner Regulation Agency
Australian National Audit Office
Accreditation Organisations
Dutch Individual Healthcare Professions Act
Certification in the College of Family Physicians
Clinical Commissioning Groups
Certificate of Completion of Training
College of Family Physicians of Canada
Clinical Governance Practice Self-Assessment Tool
Chronic obstructive pulmonary disease
Continuing professional development
Care Quality Commission
Danish Quality Unit of General Practice
Danish General Practice Database
Danish Patients Evaluate Practice
Danish Healthcare Quality Program
District Health Board
Electronic Health Record System
Federation of Medical Regulatory Authorities of Canada
General Medical Subsidy
General Practitioner
GP Accreditation Plus
Health and Disability Auditing New Zealand Limited
Health Systems in Transition
Healthcare Inspectorate Wales
Dutch Harmonisation Quality of Care
Health Technology Assessment
Dutch Health Care Inspectorate
Danish Institute for Quality and Accreditation in Healthcare
International Learning on Increasing the Value and Effectiveness of Primary
Care
Local Health Board
Bachelor of Medicine/Bachelor of Surgery
Medicare Benefits Schedule
Medical Practice Assessment Committee
Member of the Royal College of General Practitioners
ACRONYMS
NDPB
NHG
NHS
NHSCB
NICE
NPA
NSQHS
Nza
OECD
P4P
PCQ
PCTs
PHC
PHCOs
PHOs
PIP
PMCPA
PPEP
QI
QOF
QPA
RACGP
RCGP
RHA
RNZCGP
ROGS
SCRGSP
SHA
UK
UNSW
VIA
WHO
WONCA
Non-departmental public body
Dutch College of General Practitioners
National Health Service
National Health Service Commissioning Board
National Institute for Health and Excellence
Dutch NHG Practice Accreditation Program
National Safety and Quality Health Services
Dutch Healthcare Authority
Organisation for Economic Cooperation and Development
Pay-for-performance
Primary Care Quality
Primary Care Trusts
Primary health care
Australian Primary Health Care Organisations
Primary Health Organisations
Practice Incentive Program
Primary Medical Care Provider Accreditation
Physician Practice Enhancement Program
Quality Improvement
Quality and Outcomes Framework
Quality Practice Award
Royal Australian College of General Practitioners
Royal College of General Practitioners
Regional Health Authority
Royal New Zealand College of General Practitioners
Report on Government Services
Steering Committee for the Review of Government Service Provision
Strategic Health Authority
United Kingdom
University of New South Wales
Dutch Visitation Instrument Accreditation
World Health Organisation
World Association of Family Doctors
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Executive summary
BACKGROUND TO THIS LITERATURE REVIEW
In June 2014, the Australian Commission on Safety and Quality in Health Care (the Commission)
commissioned Urbis to conduct a literature review on general practice accreditation. The main purpose
of the review is to assist the Commission and the Royal Australian College of General Practitioners
(RACGP) to:

identify key components of general practice accreditation models that support improvement and
quality of care in general practice

provide an evidence base to implement changes to the current general practice accreditation
scheme in Australia.
The specific aims of the review were to describe:

accreditation programs and processes in Australia, New Zealand, England and Wales, Canada,
Denmark and the Netherlands

monitoring and measurement of accreditation in Australia, New Zealand, England and Wales,
Canada, Denmark and the Netherlands

the evidence available on the impact of accreditation on the safety of general practice

the evidence available on the impact of accreditation on the quality of general practice

the evidence available on the costs and cost-benefits of general practice accreditation.
The review involved a mapping exercise of existing accreditation programs in six countries:

Australia

New Zealand

England and Wales

Canada

Denmark

the Netherlands.
The review has considered 138 documents and websites and has incorporated peer-reviewed as well as
grey literature. Four telephone or email interviews were conducted with international agencies to
confirm our knowledge or seek answers to queries.
KEY FACTORS SUPPORTING GENERAL PRACTICE ACCREDITATION
NATIONAL STRUCTURES
Primary healthcare organisations can play a role in supporting general practices to become accredited;
for example, the general practitioner (GP) cooperatives in the Netherlands assist general practices with
preparing for accreditation, providing support with data collection and feedback (Willcox et al, 2011).
Likewise, the Danish Quality Unit of General Practice (DAK-E) provides support to Danish GPs in the use
of monitoring data collected through their mandatory Sentinel Data Capture program, which will assist
in the future as accreditation is implemented in Denmark. Assisting practices with meeting accreditation
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requirements was also a role of the former Australian Divisions of General Practice (and then Medicare
Locals) (Nicholson et al, 2012). The Divisions of General Practice and their successor Medicare Locals
also supported GPs in undertaking ongoing professional development, as do primary health
organisations in other countries such as New Zealand and England (Nicholson et al, 2012).
The role of the professional colleges appears to be significant in encouraging uptake of accreditation
programs; Greenfield and Braithwaite (2008) have found a positive association between accreditation
and continuing professional development, and in several of the countries examined the colleges have
active roles in the development of standards. At the same time, the degree to which accreditation
processes are considered independent if they are “owned and controlled by the profession for the
profession” (Australian General Practice Accreditation Limited (AGPAL), quoted in Buetow &
Wellingham, 2003), remains a subject of debate in the literature.
In countries that do not have national primary healthcare organisations, such as Canada and Denmark,
there appear to be fewer incentives for general practices to provide holistic, integrated care or
undertake quality improvement activities.
RELATION TO REGULATION
Accreditation programs and quality improvement measures across the six countries are underpinned by
regulations which specify particular standards of practice in healthcare. Regulation is an important
component of health systems, ensuring that medical professionals deliver safe and quality care to the
public. All countries have a regulatory mechanism which licenses suitably qualified physicians to practise
medicine; this can be a national regulator, such as the Medical Board of Australia, or independent
provincial regulators such as those found in the states and territories of Canada. Differences between
the six countries are seen in the extent to which, once licensed, ongoing accreditation or some form of
continuing quality assessment is mandatory or voluntary.
It should be noted as well that, while regulation is a process by which an individual doctor is licensed to
practise medicine, accreditation is applied to a health service such as a general practice. Accreditation
therefore takes a broader and more systems-focussed view of health care than does regulation. As
noted by the Federation of Medical Regulatory Authorities of Canada (FMRAC) et al (2008:4), “Systemic
sources of risk significantly eclipse professional incompetence as the dominant cause of harm to
patients”. This understanding has contributed to the range of quality improvement and accreditation
processes implemented in the countries under discussion. The balance between professional autonomy
and public accountability has been traditionally maintained through the regulatory system (FMRAC et al
2008; Buetow & Wellingham, 2003); the public regulator assures public safety while self-regulation by
the profession maintains professional autonomy.
In the Australian health sector, the establishment of the Australian Health Practitioner Regulation
Agency (AHPRA) is an attempt to bring together the separate regulatory authorities of the 14 major
health professions to establish a more integrated regulatory structure. All medical practitioners are
required to register with the Medical Board of Australia but general practice accreditation is voluntary. It
is interesting to note that, perhaps due to the Practice Incentive Program (PIP), general practice has one
of the highest rates of voluntary accreditation participation of any health speciality in Australia (Willcox
et al, 2011).
INCENTIVES AND PAY FOR PERFORMANCE
Incentive schemes are one way that governments can influence general practice accreditation. There is
conflicting evidence as to whether the use of financial incentives, or pay for performance measures,
improves the quality of care. While there is evidence that such incentives can change the behaviour of
clinicians, it is not clear that these changes lead to improved health outcomes for patients, and there is
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some evidence that the quality of non-incentivised care may decline (Wright, 2012; Campbell et al
2009).
Where incentive schemes make up a larger proportion of GPs’ incomes, the percentage of participating
general practices appears to be higher. In England, payments under the QOF account for roughly 25 per
cent of GPs income and nearly 100 per cent of practices participate, whereas in Australia payments
under the PIP only account for 5.5 per cent of government funding for general practices and
approximately 67 per cent of general practices participate (Willcox et al, 2011; Campbell et al 2009). It
should be noted however that while accreditation is a prerequisite for the PIP scheme, it is not for the
QOF.
Non-monetary incentives to become accredited also exist, such as whether the status of their
accreditation is likely to be reported publicly. Lester et al (2012) note in their comparison of
accreditation schemes in nine European countries that six of the nine jurisdictions report accreditation
results publicly, although accreditation participation varies widely across the nine suggesting there is not
a single direct correlation between reporting of and participation in accreditation programs. The public
reporting of performance results, however, such as through the CQC in England and the HIW in Wales,
may have a greater impact on adherence to national standards, although this is not clear from the
literature at the moment.
At the same time, while it may be helpful to have some incentives to encourage higher rates of
accreditation and improvement in practices, there is evidence that incentives for general practices to
meet national targets have mixed results. In England, the QOF has been criticised for creating perverse
incentives (Starfield & Mangin, 2010; Wright, 2012; Campbell et al 2009). There is also literature which
suggests that the QOF has led to some practitioners manipulating results in order to receive the
incentive, and of patients missing out on consultations because GPs are focused on seeing patients with
incentivised diseases (Wright, 2012). Again, while the QOF is not an accreditation scheme, concerns
have been raised about the impact of QOF on the nature of the GP consultation and the dynamics of the
primary care team, with some arguing that there has been a decrease in the continuity of care and a loss
of professionalism (Wright, 2012; Campbell et al 2009). Accreditation programs also tend to focus on
measuring the measurable rather than other less easily quantifiable aspects of general practice that are
important to patients. One study in the UK argued that the focus of the QOF on recorded data misses
the assessment of professional values and other factors which influence quality of care, and suggests
that poor QOF scores may reflect poor organisational process rather than poor clinical care (Ashworth et
al, 2011), a possibility that may also apply to accreditation results.
VARIATIONS IN ACCREDITATION PROGRAMS
Variations in accreditation schemes have been found to be influenced by the characteristics of the
health system in which they operate, such as levels of centralisation, payment structures, and the role of
the GP within the larger health system.
The time period for the cycle of accreditation varied across the six countries ranging between two to five
years for a full accreditation cycle, with most accreditation cycles occurring every three to four years. In
addition, some countries have interim accreditation programs which help to support practices to
achieve full accreditation over a specific period of time. Other countries have annual maintenance
accreditation programs which not only encourage practices to maintain their standards but to also
implement continuous quality improvement processes. For example, in New Zealand once a practice has
been accredited they move into an annual maintenance program.
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There is limited evidence on whether the cost of accreditation inhibits general practices from
undertaking accreditation. However, what evidence there is suggests that it is not the cost of
accreditation that is the barrier (which from the information that could be gained ranges from A$3,284
to A$8,676), but the labour costs to the practice from the time involved preparing for and participating
in the assessment process. There is, however, no clear evidence quantifying these costs for practices,
and little discussion of the roles of general practice staff in the accreditation process. Greenfield &
Braithwaite (2008) have noted that the costs of accreditation are under-researched.
THE IMPACT OF ACCREDITATION ON QUALITY AND SAFETY
The literature suggests that GPs and their staff have varying views about the purpose and impact of
accreditation.
It is relatively easy to outline the steps needed to improve quality and safety in general practice, but it is
much more difficult to demonstrate the link between accreditation and improvements in patient
outcomes. A meta-analysis by O’Beirne et al (2012) found evidence that accreditation improved process
activities in accredited health centres, such as levels of clinical activity or risk management activities.
However, the effect on patient outcomes is more difficult to assess.
The Australian general practice context is similar; while the PIP scheme has helped increase rates of
accreditation, there is not clear evidence that the increasing number of accredited general practices has
led to increased safety and quality (ANAO, 2010).
Accreditation in general practice has not been established for as long as hospital accreditation (O’Beirne
et al, 2012) and it is reasonable to assume that it will take time to find the ideal mechanisms for
ensuring continuous quality improvement. In many cases, initial improvements level off (Wright, 2012)
and maintaining quality requires new and innovative approaches. In the countries discussed here,
professional associations, regulatory agencies, quality agencies and government policy makers are
working together to develop the best mechanisms for ensuring a minimum level of quality and safety in
general practice service delivery for the public. There is scope for continuing monitoring and evaluation
of the impacts of these initiatives.
BENEFITS OF ACCREDITATION
The literature did identify a number of benefits of accreditation for GPs and general practices
(Greenfield & Braithwaite, 2008; O’Beirne et al, 2012; Nicklin, 2014; Salmon et al, 2003; Mays, 2004;
Wright, 2012; Buetow & Wellingham, 2003; Willcox et al, 2011; Paccioni et al, 2007; Checkland &
Harrison, 2010), including evidence that accreditation:

improves organisational processes and quality improvement

encourages professional development

helps to manage risk

helps to market practice

improves team cohesion and organisational culture.
SUMMARY
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O’Beirne et al (2012) note that Australia is one of the world leaders with regard to the development of
primary care1 accreditation. Systems in Australia for the monitoring and improvement of general
practice, such as the RACGP Standards first developed in the 1980s, the accreditation agencies, and the
now-disbanded Divisions of General Practice, have contributed over a long period of time to a general
acceptance of the principles of quality improvement within general practice.
This review has examined the literature from a wide range of sources including peer reviewed articles,
publicly available reports, and websites. In all, over 138 documents and websites were considered in our
analysis of the accreditation systems for general practice in the six identified countries. Accreditation
and quality initiatives across countries are not directly comparable; in Canada, for example, the thirteen
provinces have different approaches to accreditation and quality assessment, and in Denmark the
accreditation agency IKAS does not include general practice at the time of writing. However, we have
attempted to draw out what can be learned about the ways in which the six countries have incorporated
quality measurement within their unique structures.
There does appear to be a gap within the Australian context in that some kinds of general practices are
ineligible for accreditation based on the definition of general practice used to determine eligibility. This
does not appear to be an issue in the other countries reviewed and would be worth further
consideration with regard to finding ways for general practices that do not fit the current definition of
general practice to engage in some level of assessment and accreditation. Alternatively, broadening the
scope to a wider focus on primary care, as is the case in other countries, might provide more
opportunity for a wider range of general practices to participate.
Broadly, the evidence suggests that accreditation does encourage a level of quality through adherence
to certain minimum safety and quality standards. There is scope both in Australia and internationally for
further research to demonstrate the link between accreditation and quality care within general practice.
KEY POINTS

Australia has a mature accreditation system for general practice. However, recent changes to the
definition of general practice have excluded some types of general practice and consideration could
be given to how to ensure some level of accreditation is available to all types of general practice.

There is little research on the impact of accreditation on patient health outcomes. As Australia has
had general practice accreditation in place for more than a decade, a considerable contribution to
the evidence base could be made if a retrospective, longitudinal analysis of patient outcomes in
accredited and non-accredited practices could be conducted to find out whether there are
measurable patient outcomes that can be attributed to accreditation status.

Participation in quality improvement programs appears to be more widely adopted where financial
incentives form a greater proportion of a GP’s income. Some studies from England suggest that this
may provide a perverse incentive and remove the focus of the exercise from quality to performance.

On the whole, it appears that most countries maintain accreditation as a voluntary and separate
system from professional regulation. This is changing in Canada with some provincial regulators now
requiring accreditation. The review team could find no evidence of the impact of mandatory versus
voluntary accreditation on patient outcomes.
1
Note: primary care is the term most commonly used in the international literature for what is considered ‘general practice’ in Australia;
another term used is ‘family practice’. Primary care tends to denote a wider range of services including those provided by other practice
staff such as nurses, midwives and allied health providers. This review uses the term ‘general practice’ throughout for consistency, except
where the original text is used.
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
vi
Several countries are increasingly seeking to align general practice or primary care standards to
national health care standards, including Australia where the standards for general practice include
several that align with the Commission’s National Safety and Quality Health Service Standards.
England and Wales both have established national health care standards that apply to all health
facilities including general practices, and Denmark is gradually moving in the direction of an inclusive
national accreditation program. This is a reflection of the increasingly integrated nature of health
services as well as the development of nationally consistent approaches.
EXECUTIVE SUMMARY
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Introduction
In June 2014, the Australian Commission on Safety and Quality in Health Care (the Commission) appointed
Urbis to conduct a literature review on general practice accreditation.
This literature review is intended to inform the Commission’s broader review of general practice
accreditation, currently being undertaken on behalf of the Commonwealth Department of Health.
The main purpose of the review is to assist the Commission and the Royal Australian College of General
Practitioners (RACGP) to:

identify key components of general practice accreditation models that support improvement and quality
of care in general practice

provide an evidence base to implement changes to the current general practice accreditation scheme in
Australia.
1.1
SCOPE OF THE REVIEW
The aims of the review were to describe:

accreditation programs and processes in Australia, New Zealand, England and Wales, Canada, Denmark
and the Netherlands

monitoring and measurement of accreditation in Australia, New Zealand, England and Wales, Canada,
Denmark and the Netherlands

the evidence available on the impact of accreditation on the safety of general practice

the evidence available on the impact of accreditation on the quality of general practice

the evidence available on the costs and cost-benefits of general practice accreditation.
It is important to note that the review focused on accreditation schemes rather than standards. There is a
close relationship between standards and accreditation schemes and procedures and, for this reason the
review includes some discussion about standards especially as they relate to assessment of quality in the
context of accreditation. However, the review does not analyse or comment in detail about the nature and
quality of the standards used in Australia or other countries.
1.2
METHODOLOGY
The methodology of the review involved four key stages, summarised in Table 1. Each key stage is explained
in more detail below.
TABLE 1 – METHODOLOGY
STAGES
Stage 1
Inception and project
planning
SPECIFICS
 Inception meeting
 Finalisation of project plan
Stage 2
Mapping accreditation
programs

Mapping of accreditation programs in Australia, the UK, Canada,
New Zealand, England and Wales, Denmark and the Netherlands
Stage 3
Assessing the impact and


Conducting formal literature review of agreed databases
Internet and other searches undertaken to identify other relevant
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STAGES
value of accreditation on
safety and quality
SPECIFICS
reports
Stage 4
Analysis and reporting





1.2.1
Analysis and report writing
Delivery of draft report
Validation interviews with organisations in England, Denmark, and
Canada (n=4)
Further revisions following comments from the Commission
Presentation of final report
STAGE 1: INCEPTION AND PROJECT PLANNING
The first stage of the project involved an inception meeting between the Commission and Urbis to ensure the
research team had a good understanding of the project objectives and context, and to clarify aspects of the
methodology, including potential stakeholders to be consulted to identify relevant grey literature.
1.2.2
STAGE 2: MAPPING ACCREDITATION PROGRAMS
Stage 2 of the project involved a mapping exercise of existing accreditation programs in six countries, as
identified by the Commission:

Australia

New Zealand

England and Wales

Canada

Denmark

the Netherlands.
The main purpose of this exercise was to identify key aspects of different accreditation schemes for each
country, including differences in health system structures, policies and practices.
In order to ensure a consistent approach in reviewing accreditation schemes for each country, a framework
was developed to inform the mapping exercise (see Appendix A). This framework set out a range of factors,
not all of which were included in the analysis, depending on availability and relevance of information.
The outcomes of the mapping exercise informed a comparison of accreditation schemes across the six
countries in order to provide insights into key differences and similarities in accreditation schemes, including
differences and similarities in policies, practices and processes.
During this stage, relevant literature was primarily identified through searches on websites of peak bodies
and relevant key organisations for each country, and by using search engines Google and Google Scholar.
Appendix C provides a full reference list of the literature (including websites) located through the use of
academic databases.
In order to report on the most recent developments in accreditation schemes for each country, with few
exceptions only literature produced within the last ten years or so has been used for this exercise.
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1.2.3
STAGE 3: ASSESSING THE IMPACT AND VALUE OF ACCREDITATION ON SAFETY AND QUALITY
The aim of the third stage of the project was to explore the impact and value of accreditation programs in
general.
During this stage, a literature search was mainly conducted by using academic databases:

Medline

PubMed

Academic Search Complete

Australia/New Zealand Reference Centre

SocINDEX.
The following Boolean term search was performed:
(accredit*) AND (“general pract*” OR “family physician* OR “family pract*” OR “primary care” OR
“primary health care”)
()
indicates that the enclosed search is performed first
“”
indicates that the retrieved records must contain the enclosed phrase
AND
indicates that the retrieved records must contain both terms
*
indicates unlimited truncation
Our primary focus was on literature produced within the last ten years. Earlier literature was only included if
it was a significant work which had influenced future approaches to accreditation or quality improvement.
We applied the following inclusion criteria:

recency
only material published in the past 10 years (2004 onwards); we have, however, included a few articles
outside of this timeframe where we felt they were relevant

relevancy
only material relevant to accreditation and general practice or primary health care

language
only material in English or Dutch will be included in the review (one of our Public Policy team members is
a native Dutch speaker and reviewed the literature in Dutch).
From an initial identification of 915 documents, the inclusion criteria brought the final number of references
down to 138.
1.2.4
STAGE 4: ANALYSIS AND REPORTING
Stage four in this project involved synthesising all identified literature and the delivery of a draft report to the
Commission. Following the receipt of comments from the Commission, Urbis undertook a revision of the
report and conducted a small number of confirmation interviews with relevant organisations in Denmark,
England, and Canada (n=4), to ensure that the information produced here was accurate.
This final report has been produced following consideration of comments from the Commission and further
revisions undertaken by Urbis.
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1.3
THIS REPORT
This report comprises the following sections:

Chapter 2: What is accreditation?

Chapter 3: Australia

Chapter 4: New Zealand

Chapter 5: England

Chapter 6: Wales

Chapter 7: Canada

Chapter 8: Denmark

Chapter 9: The Netherlands

Chapter 10: Comparative analysis

Chapter 11: Summary.
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What is accreditation?
2.1
DEFINITIONS
2.1.1
ACCREDITATION AND QUALITY IMPROVEMENT
Accreditation is “an internationally recognised evaluation process used to assess and improve the quality,
efficiency, and effectiveness of health care organisations” (Nicklin 2014:1). Accreditation is voluntary or
mandated in a wide range of industries and services, and confers a public recognition of a level of excellence
achieved by an organisation or service. Increasingly, the assessment of service delivery against standards in
health care facilities is used not only to recognise service quality but to ensure national consistency and to
influence performance (Lester et al, 2012; Seddon et al 2003; Buetow & Wellingham, 2003; Greenfield &
Braithwaite 2008).
A useful summary of the process of accreditation is provided by the Canadian Foundation for Health Care
Improvement: “a self-assessment against a given set of standards, an on-site survey by peers from other
organisations trained in assessment, an assessment of the degree of compliance with the standards, a written
report with or without recommendations, and the granting or denial of accreditation status” (O’Beirne et al,
2012:2). This process is broadly followed in all of the countries reviewed for this report.
It is estimated that over 70 countries have some form of health service accreditation (Greenfield &
Braithwaite, 2009). Accreditation is a component of a larger health quality improvement framework in most
of the countries surveyed for this review. Quality improvement has been defined as: “a sustained effort to
improve health care quality that incorporates repeated performance measurement and feedback to health
care providers” (O’Beirne et al. 2012:2). Accreditation is one of several mechanisms that health care systems
use for quality improvement or assessment; others include credentialing, inspection, licensure and vocational
recognition (Buetow & Wellingham, 2003).
Accreditation programs vary widely and may be voluntary or mandated; integrated with regulatory
requirements or not; linked to financial payments for performance or other incentives or not. The increasing
prominence of accreditation as a quality mechanism in the last 60 years is partly attributable to public
concerns for safety and increased public demand for service quality and accountability (Nicklin 2014). Within
the health care sector, accreditation is one mechanism for responding to degrees of variability in service
delivery at a regional or national level, and providing a system for accountability for clinical and service
quality (Seddon et al, 2001). It can also be linked to parallel developments in industry with the introduction of
quality improvement systems (Booth et al, 2008), particularly the work of William Deming2, as well as to the
pioneering work of Avedis Donabedian (1966) with his triadic model for the assessment of health care quality
incorporating structure, process, and outcome measures.
2.1.2
GENERAL PRACTICE AND PRIMARY HEALTH CARE
General practice (also known internationally as primary care, family practice, or family medicine) is defined
slightly differently across the countries included in this review, but a common factor is the recognition that
care provided by a GP is different from that provided by physicians in other settings, and should therefore be
assessed by a different set of standards to those of hospitals or other health facilities. The development of
specific national standards for general practice has happened or is happening in all the countries reviewed
except Canada.
2
William Deming was a pioneer in the field of quality improvement; see www.deming.org for further information.
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In Australia, the definition of what constitutes a general practice is quite similar to that of other countries,
including the close link between general practice and primary care. The Royal Australian College of General
Practitioners (RACGP) defines general practice as:
… the provision of patient centred continuing comprehensive, coordinated primary care to
individuals, families and communities (RACGP, 2010:126).
At the same time, Australia is unique in having created a slightly different definition of general practice with
specific criteria for the purposes of determining what practices are eligible to be accredited against the
RACGP Standards. These criteria result in a definition which is narrower and, as a result, excludes from
accreditation some health services where GPs work.
The three core criteria which MUST be met if a general practice or health service wants to be
accredited against the Standards are:

the practice or health service operates within the model of general practice described in
the RACGP definition of a general practice [shown above] and

general practitioner services are predominantly of a general practice nature; and

the practice or health service is capable of meeting all mandatory indicators in the
Standards. (RACGP, n.d.)
In comparison, New Zealand and England have both adopted the European definition of general practice as
agreed by the World Association of Family Doctors (WONCA). The definition of general practice in New
Zealand, for instance, is very broad, and also suggests a primary health care orientation.
General practice is an academic and scientific discipline with its own educational content,
research, evidence base and clinical activity. It is a clinical specialty orientated to primary health
care. It is a first level service that requires improving, maintaining, restoring and co-ordinating
people's health. It focuses on patient needs and enhancing the network among local
communities, other health and non-health agencies. (Royal New Zealand College of General
Practitioners (RNZCGP), 2014a:16).
The British Royal College of General Practitioners (RCGP) defines general practice as:
…an academic and scientific discipline, with its own educational content, research base and
clinical activity, orientated to primary care and built on fundamental principles (Lakhani et al,
2007:4).
Like Australia, New Zealand and Canada, the RCGP includes general practice as a component of primary
health care, defined as:
…the first level contact with people taking action to improve health in a community. In a system
with a gatekeeper, all initial (non-emergency) consultations with doctors, nurses or other health
staff are termed primary care as opposed to secondary healthcare or referral services. General
practice is the building block of primary care in the UK, so we prefer to use the phrase ‘general
practice-based primary care’ (Lakhani, 2007:4).
This is similar to the definition of primary health care used by the Canadian Foundation for Health Care
Improvement:
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Primary health care is first contact, comprehensive health care that is sustained over time
(excludes care provided in an emergency room or walk in clinic) and is provided by generalists…
to populations undifferentiated by disease or organ system (O’Beirne et al, 2012:2).
To some extent, the terms general practice and primary care are used interchangeably in the literature. We
have attempted to maintain consistency in the use of the terms in this review by using the term ‘general
practice’ throughout, and to the extent possible by focusing discussion on those aspects which most closely
relate to Australian general practice (leaving aside, for instance, accreditation or quality improvement for
other primary health care providers). There is little available literature analysing the role of other general
practice staff in accreditation, although the literature carries an implicit assumption that practice staff are
involved; for instance, Paccioni et al (2008) refers to the process of ‘group introspection’ as part of the selfassessment that practices undertake, and the ANAO (2010) notes that the impact on staff is reported to be a
burden for some practices. However, in general there is little detail available regarding what this actually
entails and, for that reason, this discussion focusses primarily on the engagement of GPs in accreditation.
2.2
ACCREDITATION IN GENERAL PRACTICE
Lester et al (2012), in their review of European primary care accreditation schemes, note that two common
goals of accreditation are that of improving performance and encouraging professional development. This is
more challenging in the primary care setting than in hospitals, due to the varied context in which general
practice and other primary care services are provided as opposed to the more standardised activities found in
the hospital setting (Lester et al, 2012; Buetow and Wellingham, 2003).
Accreditation schemes have been in place for some time in Australia and other countries, and are increasingly
accepted as a means of ensuring quality and safety, as well as providing an external validation that can be
used to promote the clinic’s services to the general public (Buetow and Wellingham, 2003). In addition to
assessing the safety and quality of clinical care, accreditation schemes generally consider other aspects of
service delivery in a general practice, such as access, equity, and efficiency (Seddon, 2001). Effectiveness has
been acknowledged as an essential component of health care, including general practice (Greenfield &
Braithwaite, 2009; O’Beirne et al, 2012; Seddon et al 2001); however, assessing effectiveness in the general
practice setting is difficult due to the challenge of measuring and attributing patient outcomes, and for that
reason accreditation schemes tend to focus on process measures (O’Beirne et al, 2012; Nicklin, 2014).
Buetow and Wellingham (2003) argue that in addition to the challenge of assessing the quality of health care
services, accreditation schemes face their own challenges in demonstrating their effectiveness,
appropriateness, and legitimacy. The latter includes the tension between quality improvement and quality
assurance, focusing on compliance with an explicit or implicit punitive consequence for non-compliance. The
focus on compliance potentially threatens professional autonomy by requiring accountability to external
agencies. For that reason, while involving the profession in the development of standards is considered
essential to gaining GP support and participation, it has been suggested that accreditation processes (as
opposed to the development of standards) should be kept independent of the profession (Buetow and
Wellingham, 2003).
The next chapters describe the accreditation or quality assessment systems for general practice in Australia
and five other countries: New Zealand, Canada, Denmark, England and Wales, and the Netherlands.
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3
Australia
3.1
HEALTH SYSTEM STRUCTURE
Australia’s health system is primarily funded through general taxation, and is a complex structure
incorporating both public and private funders and providers (Healy et al, 2006; Duckett & Willcox, 2011).
Responsibility for funding and providing health services is divided between the Commonwealth Government
and the states and territories, with the Commonwealth retaining primary responsibility for general practice
and primary health care services.
GPs provide services on a fee-for-service model, with payment provided directly to GPs by the
Commonwealth through the Medicare Benefits Schedule (MBS). Doctors can choose to charge a small
additional co-payment to patients, and this practice has been increasing over time; individuals contributed
roughly 9% of total expenditure on general practice services in 2007-20083 (AIHW, 2010, presented in
Duckett & Willcox, 2011:162). However, services remain free at the point of care for about 80% of
consultations (Willcox et al, 2011).
A large component of Australia’s health care services are provided by private providers and funded through a
combination of public funding and private health insurance. Private health insurance does not, however,
cover general medical care in the primary care setting. General practices may be structured as private
businesses, for-profit organisations or not-for-profit organisations, and in each case will be funded through a
combination of public and private (service user) payments (Duckett & Willcox, 2011). There has been a trend
since the 1990s for GPs to merge into larger group practices, and only about 9% of practices in Australia
remain solo practices (Britt et al 2010, quoted in Willcox et al, 2011:3).
While general practice services are funded by the Commonwealth, GPs work within a structure including both
public and private providers, and services funded by both Commonwealth and state/territory governments.
3
8
The AIHW reports that individuals contributed 12% of total expenditure on medical services in 2011-2012, however this is not disaggregated by
speciality (AIHW 2013).
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FIGURE 1 – AUSTRALIAN HEALTH SYSTEM
Adapted from Healy et al 2006
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3.2
GENERAL PRACTICE TRAINING AND CERTIFICATION
GPs in Australia undertake a general medical degree, either a five or six year Bachelor of Medicine/Bachelor
of Surgery (MBBS) course or a shorter graduate entry medical degree. This degree is followed by a period of
supervised medical practice through a year of internship and at least one year of residency, followed by three
to four years of vocational training under the supervision of a GP; thus, it takes at least ten years to become a
GP (McNamara, 2012).
Achievement of the Fellowship exam within one of the two general practice colleges – the RACGP or the
Australian College of Rural and Remote Medicine (ACRRM) – provides certification that a doctor is qualified to
practice as a GP. Maintaining vocational registration requires a doctor to demonstrate a certain level of
continuing professional development through their medical college’s (RACGP’s or ACRRM’s) quality assurance
program. Maintaining vocational registration itself provides financial benefits to GPs through access to
increased remuneration (Booth et al, 2008).
3.3
QUALITY ASSURANCE AND ACCREDITATION
Medical practitioners are regulated through the Medical Board of Australia, itself a member of the national
regulatory agency AHPRA, established in 2009 to streamline the regulation agencies of 14 health provider
disciplines, including medicine. This has created a nationally consistent process for registration and regulation
for medical providers (and others) across all states and territories (see www.ahpra.org.au for further
information).
In 2006 the Australian Commission on Safety and Quality in Health Care (the Commission) was established to
develop a national strategic framework and associated work program to improve safety and quality across
the health care system in Australia. The Commission developed a set of safety and quality health service
standards that could be applied consistently across the health care system (ACSQHC, 2011). However, general
practices in Australia are not required to be accredited against the National Safety and Quality Health Service
(NSQHS) Standards. The two key initiatives that encourage improvements in safety and quality in the general
practice setting are the RACGP Standards for General Practice and the PIP. These are outlined briefly below.
3.3.1
RACGP STANDARDS
The Australian College of General Practitioners (now the RACGP) was established in 1958 (Booth et al, 2008)
and today is the largest representative body for general practitioners in Australia, with a mission to “improve
the health and wellbeing of all people in Australia by supporting GPs, general practice registrars and medical
students through its principal activities of education, training and research and by assessing doctors' skills and
knowledge, supplying ongoing professional development activities, developing resources and guidelines,
helping GPs with issues that affect their practice, and developing standards that general practices use to
ensure high quality healthcare” (RACGP, n.d.).
The RACGP is responsible for developing, maintaining and promoting an approved set of standards for
Australian general practice (Australian National Audit Office (ANAO), 2010). These were first introduced in the
1980s and have been subsequently revised. The 4th edition of the RACGP Standards, released in 2010,
includes four criteria consistent with the NSQHS Standards in order to align general practice more closely
with the national standards (RACGP, 2010). The RACGP Standards are structured in a hierarchy of four
components, as shown in figure 2 following.
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FIGURE 2 – HIERARCHY OF STANDARDS, CRITERION AND INDICATORS
Source: RACGP (2010)
Each standard is defined by a statement (eg, “our practice provides timely care and advice”), followed by a
number of criteria outlining specific and practical expectations for meeting the standard. Most criteria also
have a number of related indicators describing what practices need to do to meet the criterion. There are 14
standards, 41 criteria and 128 indicators covering the following areas:

access to care

information about the practice

health promotion and prevention of disease

diagnosis and management of health problems

continuity of care

coordination of care

content of patient health records

collaborating with patients

safety and quality

education and training

practice systems

facilities and access

equipment for comprehensive care

clinical support processes (RACGP, 2010).
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General practice accreditation is only one component within a comprehensive conceptual framework
developed by the RACGP to guide quality improvement for Australian general practice (Booth et al, 2008).
The multi-dimensional quality framework identifies the levels at which action can take place to improve care
(the individual levels of the practitioner and the clinical setting, and the population levels of the region and
the nation), and includes elements of quality improvement. The framework is built upon a foundation of six
dimensions or indicators of quality: acceptability, accessibility, appropriateness, effectiveness, efficiency, and
safety (Booth et al 2008:23).
3.3.2
REQUIREMENTS FOR GENERAL PRACTICE ACCREDITATION
In April 2013, the RACGP announced a revised definition of a general practice to be used for the purposes of
accreditation. As noted in chapter 2, this new definition includes three core criteria which specify the
threshold requirements for determining whether a particular general practice or health service is eligible to
be accredited against the RACGP Standards:
The three core criteria which MUST be met if a general practice or health service wants to be
accredited against the Standards are:

the practice or health service operates within the model of general practice described in
the RACGP definition of a general practice and

general practitioner services are predominantly of a general practice nature; and

the practice or health service is capable of meeting all mandatory indicators in the
Standards. (RACGP, n.d.)
As a result of this narrow definition not all practices where a general practitioner provides care are eligible to
be accredited to the RACGP Standards. The new requirements may also create barriers for small practices,
and for some Aboriginal medical services (ANAO, 2010).
3.3.3
ACCREDITATION AGENCIES
Accreditation of general practices is undertaken by one of two entities approved by the Government. One of
these entities, Australian General Practice Accreditation Limited (AGPAL), was established in early 1997 with
government assistance and is an industry‐organised body governed by members of the health profession
within a not‐for‐profit framework (AGPAL, 2014b). The second accrediting agency, GP Accreditation Plus
(GPA) was established in 1999 (GPA Accreditation Plus, 2014).
In 2002, accreditation became the sole entry point for access to a range of payments outside the traditional
fee-for-service payment structure (ANAO, 2010). These are discussed below in section 3.3.5.
3.3.4
ACCREDITATION SURVEYORS
According to the RACGP Standards (4th edition), “general practice surveyors are health professionals with
qualifications, experience and technical expertise relevant to general practice” (RACGP, 2010:131). The RACGP
requires that two surveyors undertake the survey and assessment process and that one of the surveyors is a
GP. The RACGP has guidelines for the selection of general practice surveyors, including that selection “needs
to be a reliable and transparent process”, with surveyors “selected to provide a balance of skills and
experience to match the needs and characteristics of individual general practices”. Surveyors need to
demonstrate: “contemporary knowledge of general practice, sufficient to make a reliable assessment of the
competence of the general practice; thorough knowledge of the RACGP Standards; familiarity with applicable
legislation; have knowledge of and experience in risk management; and have a health professional
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background with qualifications relevant to general practice and technical experience in at least one area
relevant to general practice”; effective communication skills and openness about conflicts of interest are also
essential (RACGP, 2010:131). The general practice to be accredited can choose whether or not to accept a
surveyor and is encouraged to consider information about the surveying team in advance in order to make an
informed decision (RACGP, 2010:132). Training, supervision and mentoring are provided to new surveyors to
help provide a consistent and credible service to general practice, and ongoing skill development is a
requirement (RACGP, 2010).
3.3.5
THE PROCESS OF ACCREDITATION
General practices wishing to become accredited can contact one of the two accrediting agencies. The
accreditation agency explains what is required and supports general practices throughout the process.
Preparation for an accreditation surveyor visit can take 12 months. AGPAL charges a fee at registration of
$500, with subsequent fees charged according to the number of full-time equivalent (FTE) GPs within the
practice (these fees are not disclosed) (AGPAL, 2014c). GPA fees are also not publicly available.
Practices can use a range of information sources to demonstrate that they meet required standards, criteria
and indicators including:

patient health records

practice documentation such as the practice policy and procedure manual, practice information sheet,
staff position descriptions, temperature data logs for vaccine refrigerators, quality improvement and
continuing professional development (QI&CPD) data, Health Insurance Commission data, appointment
schedules

patient feedback questionnaires and patient feedback data

discussions between relevant members of the practice team and accreditation surveyors.
The process of accreditation, as in other countries, includes an initial period of self-assessment and
preparation followed by a survey visit by an approved accreditation team (AGPAL, 2014a). If areas of noncompliance are found, conditional accreditation will be awarded and practices will work with the accrediting
agency to implement improvements. After verifying all standards have been met, full accreditation will be
awarded. Information from an accreditation assessment is not made available publicly, either as identified or
de-identified data. To maintain accreditation general practices must undergo an onsite assessment every
three years.
Even though both accrediting agencies undertake very similar processes, each agency has developed their
own accreditation framework. While both AGPAL and GPA require practices to provide assurances that the
Standards are being followed between accreditation visits, these are not confirmed, and there is no “riskbased interim assessment process” (ANAO, 2010:23).
The RACGP Standards 4th edition (2010) state that the Standards are used by over 80 per cent of Australian
general practices for accreditation, although the Productivity Commission’s Report on Government Service
Provision states that 67 per cent of general practices were accredited nationally in June 2011, suggesting that
more practices may use the Standards than are actually accredited at any one time (Steering Committee for
the Review of Government Service Provision (SCRGSP), 2014).
3.3.6
THE PRACTICE INCENTIVES PROGRAM
The PIP was established in 1998, as a mechanism for influencing the quality of general practice care, through
the provision of a range of financial incentives to eligible general practices. One of the eligibility criteria for
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the PIP is accreditation and, according to the ANAO (2010:16), “access to PIP payments is the primary reason
for most practices attaining accreditation.” In addition to its focus on improving the quality of care, the PIP is
designed to balance the tendency for fee-for-service payments to encourage high patient throughout and to
encourage longer consultations and more tailored approaches to chronic disease management; like the MBS,
the PIP is also administered by Medicare (ANAO, 2010).
There are 10 individual incentives in the PIP4, including e-health, health screening, and monitoring of certain
diseases and chronic conditions. There is some evidence that the PIP has had an impact on GP behaviour and
provision of services, with 88% of PIP practices surveyed considering that PIP had contributed to quality
patient care and access (ANAO, 2010:85). One of the early PIP incentives was intended to improve childhood
immunisation and the payment was seen as a key factor in the increase in childhood immunisation rates in
the late 1990s (Wright, 2012). However, overall there is little evidence to date that PIP has driven
improvements in safety and quality (ANAO, 2010; Wright, 2012). In addition, although the impetus for the PIP
was to encourage longer consultations, the payment structure actually rewards practices that have greater
throughput rather than fewer, longer consultations (ANAO, 2010).
As of 2010, approximately 67 per cent of general practices in Australia were participating in PIP, and the
ANAO considered that the PIP scheme had helped to increase the number of general practices seeking
accreditation (ANAO, 2010). However, the ANAO found that Aboriginal medical services and smaller
practices, particularly those serving remote locations or non-English speaking communities, are often not
eligible to be assessed against the RACGP Standards or find the process of accreditation difficult. In a survey
conducted by the ANAO over 80 per cent of respondents said that the cost and work effort needed for
accreditation was high or very high. As a consequence, PIP participation rates among smaller practices,
remote practices, and Aboriginal medical services is lower than that of larger, more urban practices. This is a
particular problem as the incentives are intended to improve health outcomes for all Australians, not just for
people attending accredited practices (ANAO, 2010).
4
See the PIP website for further information: http://www.medicareaustralia.gov.au/provider/incentives/pip/).
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New Zealand
4.1
HEALTH SYSTEM STRUCTURE
The New Zealand Ministry for Health oversees the New Zealand health care and disability system. The New
Zealand Public Health and Disability Act 2000 sets out the roles and responsibilities of the Minister,
ministerial committees and health sector provider organisations (Ministry of Health, 2011a)
District Health Boards (DHBs) are responsible for providing health care services to their local region and
receive approximately three-quarters of the total public funding for health to plan and deliver regional health
services (Ministry of Health, 2013). DHBs fund all public hospitals and a majority of other public health
services in their region, including primary health organisations (PHOs) (Ministry of Health, 2013).
The DHBs report to the National Health Board against a DHB Accountability Framework, which includes
service performance measures and national priority health targets (Ministry of Health, 2014a). The National
Health Board and its two subcommittees (the Capital Investment Committee and the IT Health Board) work
with DHBs and the health sector as a whole to improve health outcomes and to increase access to quality
care (National Health Board, 2014). The National Health Board ensures all public health care entities comply
with relevant health regulations and monitors their performance (Ministry of Health, 2011b; Ministry of
Health, 2014b).
The administrative structure of primary health care in New Zealand changed with the introduction of the
Primary Health Care Strategy in 2002 and the establishment of PHOs to provide a new way of coordinating
primary health care services to meet local population health needs. Originally there were approximately 70
PHOs but these were reduced to around 40 by 2010 under a government restructure (Medical Technology
Association of New Zealand, 2010). While most general practices in New Zealand are privately owned, the
majority of GPs (80 per cent) are affiliated with a PHO (Goodyear-Smith, 2012). General practices must work
with other service providers affiliated with their PHO to achieve population-based health targets outlined in
the PHO Performance Management Programme (Ministry of Health, n.d.). The PHO Performance
Management Program is a joint initiative of the Ministry of Health and the DHBs to reduce health inequalities
and improve health outcomes. PHOs are rewarded for quality improvements and are assessed against three
indicator categories: clinical, process and capacity, and financial (Ministry of Health, n.d.).
The changes introduced with the Primary Health Care Strategy also changed the way general practices
received funding. Up until the early 2000s GPs received most of their income via fee-for-service funding
through a government general medical subsidy known as GMS (Ministry of Health, 2012a). However, over
time as the cost of providing health services increased, the GMS ceased to cover all of GPs’ costs and GPs
began to charge higher co-payments to cover their costs (Goodyear-Smith 2012). To increase patient access
to general practices, a capitation funding model was introduced under the newly established PHOs. The
capitation funding received is based on the characteristics of the enrolled patient population and additional
funding is available to improve health outcomes for high needs groups (Goodyear-Smith 2012 and Ministry of
Health, 2012a). Today, GMS funding is limited to a few specific types of patient visits and only comprises a
small proportion of GPs’ overall funding (Ministry of Health, 2012b).
GPs still retain their rights to set fees for services and patients still contribute a co-payment; however, this is
lower in a PHO enrolled practice than for an unaffiliated GP (The Commonwealth Fund, 2013). There are also
other benefits for patients belonging to PHO enrolled practice, such as reduced cost for prescription
medicines (Ministry for Health, 2014c). As a result of these benefits, 96% of New Zealanders are enrolled in a
PHO affiliated general practice (World Health Organisation (WHO) & the Ministry of Health, 2012).
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16
NEW ZEALAND
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FIGURE 3 – NEW ZEALAND HEALTH SYSTEM
Adapted from Ministry of Health – Manatū Hauora, 2014
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4.2
GENERAL PRACTICE TRAINING AND CERTIFICATION
In New Zealand, the pathway for general practice training is through the General Practice Education
Programme of the RNZCGP. Post-graduate training takes three years following completion of an
undergraduate medical degree of five to six years. After this and completion of the Fellowship exam, a doctor
is eligible to be registered as a GP (Medical Council of New Zealand, 2011a).
Medical registration in New Zealand is overseen by the Medical Council of New Zealand, as defined in the
Health Practitioners Competence Assurance Act 2003 (Medical Council of New Zealand, 2011b).
4.3
QUALITY ASSURANCE AND ACCREDITATION
4.3.1
GENERAL PRACTICE ACCREDITATION
General practice accreditation in New Zealand is owned and managed through the RNZCGP’s Cornerstone
program, using a set of standards that were first developed in 1999 and regularly revised since. The current
edition of the standards was revised in 2012. The accreditation process is managed by the RNZCGP although
an external validation process has been established so that, while RNZCGP surveyors conduct the assessment,
Health and Disability Auditing New Zealand Limited (HDANZ) actually makes the recommendation to award
accreditation. HDANZ is designated by the Director General of Health to function as an auditing agency
according to section 32 and 33 of the Health and Disability Services Safety Act 2001 (the Act), and in this role
they validate general practice accreditation assessment reports and endorse recommendations for
accreditation awards prepared by RNZCGP surveyors as part of the College's Cornerstone program (Buetow &
Wensing, 2008; RNZCGP, 2011; RNZCGP, 2014a).
The New Zealand Public Health and Disability Act 2000 mandated the establishment of a nationally consistent
quality improvement program to ensure patient safety in general practice, and the Cornerstone program
responds to that requirement (RNZCGP, 2011). The two elements of the New Zealand GP accreditation
program – the standards and the Cornerstone program itself– are discussed further below.
4.3.2
THE RNZCGP STANDARDS
The RNZCGP, as the professional body that provides training and ongoing professional development for GPs
and rural hospital generalists, first developed standards for general practice in 1999. The RNZCGP standards,
known as the Aiming for Excellence – standard for New Zealand general practice (Aiming for Excellence),
cover areas such as: patient experience and access; practice environment and safety; clinical processes; and
professional development. Each standard consists of one indicator and one or more criteria of care against
which practices are assessed. There are 36 indicators and over 170 criteria. Eleven of these are mandatory
criteria that need to be demonstrated each year; these are considered to be minimum standards and address
legal and safety requirements. In addition, once assessed, practices work through the 36 indicators over the
four-year accreditation cycle, choosing nine each year for self-assessment (RNZCGP, 2011; RNZCGP, 2014a).
General practice accreditation in New Zealand is voluntary, however, as of 2011 600 practices, roughly 60% of
the estimated 10005 general practices in New Zealand, were reported to be accredited against the standards
(RNZCGP, 2011). The fact that general practices also use accreditation to promote themselves could also be a
factor in the relatively high accreditation rates (see section 4.3.4 below).
5
Figure provided by General Practice New Zealand (personal communication).
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4.3.3
CORNERSTONE - REQUIREMENTS FOR ACCREDITATION
As in other countries, the accreditation process for general practice in New Zealand is based on a process of
self-assessment and external review, The RNZCGP designed Aiming for Excellence with the intention that it be
used as a mechanism for quality improvement rather than as a compliance exercise (RNZCGP, 2011).
Participation in the accreditation program is open to all registered GPs working in an identified general
practice. The scope of general practice as outlined in the Cornerstone program is quite broad and
comprehensive, and includes the following features:

provides personal, family and community oriented comprehensive primary care

provides the point of first medical contact within the health care system

makes efficient use of health care resources through the coordination and collaboration with other
providers

develops a patient-centred approach

establishes a relationship over time, creating effective communication between clinician and patient

is responsible for providing continuity of care according to patient need

is based on community and population needs assessment

diagnoses and manages both acute and chronic health problems of individual patients

diagnoses and manages illness

promotes health and well-being through appropriate and effective intervention

has a specific responsibility for health in the community

deals with health problems in their physical, psychological, spiritual, social and cultural dimensions.
(RNZCGP, 2014a)
4.3.4
PROCESS OF ACCREDITATION
The Cornerstone Program has three different accreditation program types:

Entry level accreditation – practices work over a 12 month period to meet all the mandatory criteria of
the Aiming for Excellence Standards and undergo an external assessment.

Annual program – upon receiving entry level accreditation practices move to the annual maintenance
program. The annual program runs over a four year cycle and practices are required to participate in
annual quality improvement activities.

Reaccreditation – practices work over 12 months to meet all the criteria of the Aiming for Excellence
Standards and undergo an external assessment. Once practices achieve reaccreditation they are moved
into the annual program. Practices are required to undergo external assessment at least once every four
years (RNZCGP, 2013).
All registered practices are required to submit data to the RNZCGP at various points throughout the
Cornerstone program. The RNZCGP contracts an external service provider to develop and maintain the secure
web-based portal used by practices to collect the required data. Practices are required to submit a ‘snapshot’
prior to attaining entry level accreditation. This snapshot provides a baseline impression of the practice, as
well as a self-assessment against the criteria found in Aiming for Excellence.
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External assessment of practices usually occurs over one day for a minimum of five hours and is conducted by
at least one GP and either a practice nurse or practice manager, who are contracted to the RNZCGP (RNZCGP,
2013).
Once accreditation is achieved and practices move into the annual program, all data evidence of quality
improvement activities are submitted using the same web-based system. Any document or evidence for
accreditation, such as policies and procedures for the practice, are uploaded into the portal and accessed by
assessors for the purposes of determining accreditation. However, the outcomes of the accreditation
assessment are not released and public reporting of accreditation status is at the discretion of the practice. In
saying this, a number of general practices who have received accreditation are listed on the RNZCGP website
and some general practices use their accreditation status to promote their clinic; for example, one general
practice in New Zealand has published the following on their website:
After completing the Cornerstone Program accreditation process in 2008, the Ngaio Medical Centre
became only the second Wellington practice to undergo the first three yearly 're-accreditation'
process in September 2011. The Ngaio Medical Centre is proud of achieving this very difficult but
voluntary indicator of practice high quality (Ngaio Medical Centre, 2014).
In April 2012 the Cornerstone Program was reformed as a result of feedback from the sector, which
recommended that accreditation move beyond minimum standards to include a cycle of continuous quality
improvement. The feedback resulted in the introduction of the annual program where practices participate in
annual quality improvement activities through the completion of:

11 Aiming for Excellence mandatory criteria

regionally selected or practice-selected criteria (minimum number of nine)

one quality improvement activity targeted at clinical care

one audit review of a topic of the practice’s choice, which may include a safety and quality issue
(although it can also be a non-clinical audit) (RNZCGP, 2013).
The costs for the accreditation process are the same for all participating practices and begin with a $7,000
NZD fee for the entry level accreditation process. Additional satellite clinics of a practice can be included for a
cost of $2,000 NZD per clinic. A practice that is undertaking a reaccreditation program pays $5,000 NZD, with
satellite clinics charged at $2,000 NZD (RNZCGP, 2013).
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England
5.1
HEALTH SYSTEM STRUCTURE
England has a publically funded healthcare system, known as the National Health Service (NHS). The NHS was
established in 1948 and is the oldest government funded healthcare system in the world (NHS, 2013a). The
Department of Health is the government body responsible for administering the NHS and developing policy
for public health and other health related areas, though some of the Department’s responsibilities have
reduced in recent years (Boyle, 2011; NHS, 2014). The Health and Social Care Act 2012 introduced significant
reforms to the structure of the public health system, including abolishing NHS Primary Care Trusts (PCTs) and
Strategic Health Authorities (SHAs) and establishing a new independent board, the NHS Commissioning Board
(NHSCB), and clinical commissioning groups (CCGs) (NHS, 2013b; NHS, 2012).
A new executive agency of the Department of Health, Public Health England, was also established under the
Health and Social Care Act 2012 Act on 1 April 2013. Public Health England now has responsibility for many of
the functions formerly delivered by (PCTs) and some of the functions of the Department of Health (NHS,
2014).
General practices in England provide general medical care, as well as nursing and other primary care services.
They also provide health prevention and education, simple surgical operations, dental and ophthalmic
medical care and pharmaceuticals. A majority of GPs in the UK work in larger group practices as opposed to
solo practices, with this in part a reaction to new contract models introduced in 2003 and an earlier focus on
a ‘primary care-led NHS’ (Deloitte Centre for Health Solutions, 2012).
Care needs can be assessed in a NHS walk-in centre which provides free access to health advice and
treatment, or via NHS Direct which provides a 24 hour telephone advice line. Patients in the UK must register
with a general practice to receive primary care services. All residents in the UK are entitled to apply to receive
NHS primary medical services at a general practice. GPs are employed directly by the NHS and are the main
commissioners of services by deciding what hospital and other specialist care to buy for their patients. By
being responsible for purchasing services GPs also act as a gate keeper for access to secondary or tertiary
services. As GPs are commissioned by the NHSCB they are required to meet the Commissioning Outcomes
Framework standards (Deloitte Centre for Health Solutions, 2012).
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FIGURE 4 – ENGLISH HEALTH SYSTEM
Adapted from Boyle, 2011 and Insight Public Affairs, 2013
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5.2
GENERAL PRACTICE TRAINING AND CERTIFICATION
In the UK, the pathway to practice as a GP generally commences with the completion of a five-year medical
degree, although some medical schools offer a four year programme and more flexible course structures to
assist high performing students achieve entry criteria. Following this initial training period (and receipt of a
Bachelor of Medicine/Bachelor of Surgery (MB/BS) degree) trainees enter the RCGP Foundation Programme –
a two year programme which provides a link between medical school and specialist training and must be
completed by all doctors. During Foundation Training, trainees gain experience through a series of
placements across a range of healthcare settings (RCGP, 2013).
On completion of Foundation Training, doctors must undertake a Certificate of Completion of Training (CCT)
Programme for at least three years to specialise in general practice. During this period, all GP trainees are
required to complete the Applied Knowledge Test, Clinical Skills Assessment and Workplace-Based
Assessment (all administered by the RCGP) to be able to practise as a GP in the UK. On completion of these
assessments and on being awarded the CCT, doctors are allowed to use the designation MRCGP (Member of
the Royal College of General Practitioners) and practise as a GP in the UK (RCGP, 2013).
5.3
QUALITY ASSURANCE AND ACCREDITATION
Responsibility for safety and quality in England has traditionally been decentralised in nature, with a number
of NHS-funded agencies within the UK, including the Department of Health, the National Institute for Health
and Excellence (NICE) and the RCGP. However, one of the biggest changes to primary care in the UK in recent
years has been an increased focus on centralised reporting and enforcement of the standards of care across
the UK. More specifically, from April 2013, “all general practices that provide regulated services are required
to register with the Care Quality Commission (CQC) which is also responsible for inspecting all practices”
(Deloitte Centre for Health Solutions, 2012, p.25). The CQC and other relevant NHS bodies are discussed
below.
5.3.1
THE CARE QUALITY COMMISSION
The CQC is the independent regulator of health and adult social care in England. The CQC is overseen by the
Department of Health and regulates against the requirements set out in the Health and Social Care Act 2008.
One of the core functions of the CQC is to share information on enforcement activities with the NHS
Commissioning Board, local authorities and a new regulatory agency called Monitor (CQC, 2014a). Monitor is
a non-departmental public body of the Department of Health and within England; its specific focus is to
ensure that:

“independent NHS foundation trusts are well-led so that they can provide quality care on a sustainable
basis

essential services are maintained if a provider gets into serious difficulties

the NHS payment system promotes quality and efficiency

procurement, choice and competition operate in the best interests of patients.” (Monitor.n.d.)
Working closely with the CQC, Monitor is responsible for issuing licences for practices which provide NHSfunded care.
Since 2010, as part of the drive for evidence-based accreditation, the CQC has been rolling out a process of
registering, monitoring and inspecting all providers of ‘regulated activities’ against the Essential Standard of
Quality and Safety (the Essential Standards). These Standards represent the minimum level of quality which
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all providers of regulated activities must achieve (CQC, 2013). In 2013 the CQC registered over 7,500
providers of general practice and other primary medical services (CQC, 2014b).
In total, there are 28 Essential Standards, 16 of which are designated as being ‘core’ standards for inspection.
The other 12 standards relate to routine day-to-day management of a service and assist the CQC to assess
whether the service is being run in a responsible manner (CQC, 2014c).
There are three possible types of inspections for general practices:

scheduled (where 48 hours’ notice is given)

responsive (where there are concerns or non-compliance from a previous inspection)

themed (examining the pathways for particular patients across different services or within a particular
type of organisation) (CQC, 2014d).
A Judgement Framework is used to determine whether or not a service meets each standard and judgements
are available on the CQC website for public access (CQC, 2014d).
5.3.2
THE NATIONAL INSTITUTE FOR HEALTH AND CARE EXCELLENCE (NICE)
The National Institute for Health and Care Excellence (NICE) provides national guidance and advice to
improve health and social care; while NICE is accountable to the Department of Health, it was established as
a non-departmental public body (NDPB) in 2013. At its highest level, NICE has responsibility for developing
guidance on quality care, with these standards being focused on clinical care for patients as opposed to
standards related to organisational quality (NICE, 2014).
The NHS Commissioning Board commission NICE to produce NICE Quality Standards, which are designed to
outline “what high quality care looks likes for a particular condition, pathway or patient group, covering the
majority of care that the NHS provides” (National Quality Board, 2013, p.17). The Standards themselves are
clinical standards, not standards for the accreditation of general practice. To align quality standards across
the health system, there is a clear link between the CQC Essential Standards and the NICE Quality Care
Standards (NICE Standards), with reference to a number of NICE Standards within CQC Essential Standards
(for example, on topics such as violence or meeting nutrition needs) (CQC, 2010).
5.3.3
GENERAL PRACTICE ACCREDITATION IN ENGLAND
The RCGP has developed two quality initiatives; the Practice Accreditation and the Quality Practice Award
(QPA), both of which aim to help practices improve their quality of care for patients. Both Practice
Accreditation and the QPA are voluntary awards and practices can, if they wish, apply for reaccreditation, but
there is no requirement for them to do so (RCGP,n.d.)
Practices that successfully complete practice accreditation can undertake the QPA, although there is no
requirement to do so. The RCGP recommends that “those practices that wish to aim for excellence should
embark on QPA from the offset. Practices that wish to improve their organisational process and begin a
journey of quality improvement should embark on Practice Accreditation” (RCGP, n.d.).
Both practice accreditation and the QPA have core standards that are the essential standards that every
practice should meet as a minimum and more than 80 per cent of the criteria are aligned with the CQC
essential standards (RCGP, n.d.). However, although there is alignment between the CQC standards and the
standards used in Practice Accreditation and the QPA there is no formal relationship, and achieving Practice
Accreditation does not guarantee CQC registration (RCGP personal communication, 2014).
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The process of practice accreditation is intended to be a simple, straightforward process which is able to be
implemented by practices of all sizes. As outlined by the RCGP, “The Practice Accreditation Standards reflect
key aspects of primary care, particularly the organisational systems and processes that ensure delivery of safe
and quality care, facilitate on-going team development and recognise the contribution to quality
improvement that can be made by the whole practice team” (RCGP, n.d.). The 78 Practice Accreditation
Standards were developed through a partnership between the RCGP and the University of Manchester, with
additional collaboration from other significant organisations including the Royal College of Nursing, Care
Quality Commission, Department of Health, NHS Confederation Primary Care Trusts, the British Medical
Association and Patient Groups (RCGP,n.d.).
The QPA has been in place since 1996 and is “a standards-based quality accreditation process designed to
improve patient care by encouraging and supporting practices to deliver the very highest quality care to their
patients” (RCGP, n.d.). To achieve the Award, practices must submit written evidence set against a number of
standards outlined in six key modules. On receipt of written evidence, a panel of three inspectors (including a
combination of GPs, nurses and managers) visit the practice to undertake a formal assessment process and
rule on the provision of the Award. The Award itself is the highest award obtainable from the RCGP (RCGP,
n.d.).
5.3.4
QUALITY OUTCOMES FRAMEWORK
Introduced in 2004 as a component of the General Medical Services Contract, the Quality and Outcomes
Framework (QOF) is a voluntary incentive scheme for general practices in the UK. The aim of the QOF is to
provide incentives to practices to improve quality, evidence-based practice (Health & Social Care Information
Centre (HSCIC), n.d.). The amount of the incentive payments is equivalent to approximately 20-25 per cent of
practice income (Wilcox, 2011).
The QOF has a range of national quality standards covering four domains:

clinical

organisational

patient experiences

additional services (HSCIC, 2013).
Each domain consists of a set of indicators (148 in total in 2012/2013), which are essentially achievement
measures against which practices score points relative to their performance (HSCIC, 2013). Patients are able
to publically access comparative results for their practice, enabling them to compare one practice against
another, nationally (Wilcox, 2011).
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6
Wales
6.1.1
HEALTH SYSTEM STRUCTURE
Historically, the Wales health system was largely administered through the United Kingdom Government’s
Welsh Office. However, since 1999 responsibility for most aspects of health policy has been devolved to the
administration of the Welsh Government. As a result, the Welsh health system has gradually diverged from
the English NHS (Longley et al, 2012).
Until 2009, public health care services were provided through 22 Local Health Boards (LHBs) and seven NHS
Trusts. However, there was a need for a less complex and bureaucratic system, which led to the replacement
of 22 LHBs with seven LHBs, and seven NHS Trusts with three Trusts (Longley et al, 2012). Since that time, the
seven LHBs have assumed responsibility for “all aspects of planning and providing health care services within
their geographical areas” (Longley et al, 2012; p.9).
The LHBs are supported by three NHS Trusts (for ambulance services, specialised cancer care and public
health), which fall under the Minister for Health and Social Services. LHBs operate within a policy framework
determined by the Welsh Government (Welsh Assembly Government, 2009; NHS Wales, n.d.), and are
responsible for the planning, coordination and delivery of all health services including primary care services.
Similar to England, primary care is mainly provided by GPs working as independent contractors, although a
nurse-led service, NHS Direct Wales, is also available 24 hours a day by telephone and internet as a first point
of call to provide primary triage and refer people to services as needed (Longley et al, 2012). In 2011, most
GPs were in a contractual relationship with a LHB (Longley et al, 2012).
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Adapted from Longley et al, 2012
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6.2
GENERAL PRACTICE TRAINING AND CERTIFICATION
Please refer to section 5.2, as the training requirements are the same for England and Wales.
6.3
QUALITY ASSURANCE AND ACCREDITATION
In general, NICE’s recommendations are followed in Wales and as the Quality Outcomes Framework (QOF) is
part of the monitoring element of the contract the NHS has with GPs, the QOF also applies in Wales.
However, instead of the Care Quality Commission Wales has its own Healthcare Inspectorate, covering both
the public and private health sectors (Timmins, 2013). Primary Care Quality (PCQ), a division of Public Health
Wales, also has a role in assisting GPs to improve the quality of the care they provide (Public Health Wales,
2014a).
6.3.1
HEALTHCARE INSPECTORATE WALES
As outlined by the Healthcare Inspectorate Wales (HIW), “HIW is the independent inspectorate and regulator
of all health care in Wales. HIW’s primary focus is on:

making a contribution to improving the safety and quality of healthcare services in Wales

improving citizens’ experience of healthcare in Wales whether as a patient, service user, carer, relative or
employee

strengthening the voice of patients and the public in the way health services are reviewed

ensuring that timely, useful, accessible and relevant information about the safety and quality of
healthcare in Wales is made available to all” (HIW, 2014a).
HIWs inspect health services across Wales and assess whether or not standards are being met. Inspections
are generally unannounced and take place on a regular basis. The inspection process involves the HIW
assessing experience of health services from a patient and staff perspective in addition to a review of process,
practice and procedure in relation to the standards. Following the inspection, the HIW makes a determination
as to whether the standards have been met and these judgements are then available publically on the HIW
website for review (HIW, 2014b).
In an effort to improve patient care, HIW is currently developing new inspection programs of general
practices. The inspection program is “designed to independently test the service actually provided to patients
by their GP” (HIW, 2014c). To reduce the burden on practices, the inspection process will draw on existing
tools and frameworks (to avoid duplication of requirements) and work in partnership with the Community
Health Councils who already conduct site visits to general practices. The revised inspection protocol will be
piloted in 2014-15 with the aim of introducing the full inspection programme by 2015-16 (HIW, 2014b).
6.3.2
PRIMARY CARE QUALITY
As outlined by Public Health Wales, “Primary Care Quality (PCQ), a division of Public Health Wales, assists
Health Boards, practice teams and individual primary care practitioners to improve the quality of the care that
they deliver by:

providing access to evidence-based quality improvement guidance and tools

providing data sets to encourage review, reflection and revision

provide training in quality assurance and improvement methodology” (Public Health Wales, 2014a).
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One of the primary roles for PCQ is to produce guidance to assist practices when undertaking ‘individual case
reviews’ as suggested within the General Medical Services contract 2014/15. The guidance is clustered into
two segments:

Part A provides guidance on the process of carrying out individual case reviews.

Part B provides guidance to assist the practice thematically to summarise findings from individual case
reviews, and contribute to its GP Cluster Network Meetings and the GP Cluster Annual Report (Public
Health Wales, 2014a).
The PCQ has also developed the Clinical Governance Practice Self-Assessment Tool (CGPSAT), which
“encourages practices to bridge the gap between understanding and thinking about their governance systems
and completing the actions needed to improve them” (Public Health Wales, 2014b). The CGPSAT is based on
the Standards for Healthcare Services in Wales (see section 6.3.4 below) and was made available to all Welsh
general practices in 2010. From a process perspective, the CGPSAT is relatively straightforward and is
comprised of a self-assessment process and internal review process which encourages practices to rank their
performance on a matrix of performance from Level 0 (non-achievement) through to Level 5 (continued
improvement and leadership) (Public Health Wales, 2014b).
6.3.3
THE ROYAL COLLEGE OF GENERAL PRACTITIONERS
Wales is represented in the RCGP by the RCGP Wales division. In line with the aims and objectives of the
RCGP more broadly, the RCGP Wales “facilitates the provision of high quality medical care in Wales by
promoting and supporting general practice and general practitioners” (RCGP Wales, n.d.). As described on
the RCGP Wales’ website, its activities include:

“delivering training courses and other educational activities

raising the quality of patient care through quality initiatives and training

responding to government consultations and representing GPs and members on Welsh Government
working groups

encouraging research in general practice to improve the evidence base for standards and guidance on
best practice

supporting the setting of standards and clinical guidelines for clinical care.” (RCGP Wales, n.d.)
6.3.4
STANDARDS FOR HEALTH SERVICES IN WALES
The Standards for Health Services in Wales, Doing Well, Doing Better were published in April 2010 and
address the requirement that Welsh Government Ministers make public the standards by which services are
judged, as stated in Section 47 of the Health and Social Care (Community Health and Standards) Act 2003.
The Standards are applicable to all NHS services, including general practice (Welsh Assembly Government
2010) and are correspondingly broad to provide flexibility in application across different settings. For
instance, Standard 4, ‘Civil Contingency and Emergency Planning Arrangements’, states that:
Organisations and services are able to deliver a robust response and ensure business and service
continuity in the event of any incident or emergency situation (Welsh Assembly Government
2010:9).
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Altogether, there are 26 standards ranging from governance and accountability to infection prevention and
control, and workforce planning (Welsh Assembly Government 2010; Public Health Wales and Royal College
of General Practice 2011).
However, according to the RCGP Wales, awareness and applicability of these standards among GPs is low. As
a result, guidelines for GPs on these standards were written by the Primary Care Quality Information Service.
The guidelines provide a description of how the standard may apply in general practice and some suggestions
as to what practices should consider in order to meet the standards (Public Health Wales and Royal College of
General Practitioners, 2011).
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Canada
7.1
HEALTH SYSTEM STRUCTURE
Canada's health care system incorporates government-funded health insurance plans that provide for access
to care for all Canadian citizens. All Canadian citizens are able to access preventative care and medical
treatments and, generally, all Canadian citizens are able to access health services regardless of their medical
history or income (Canadian Health Care, n.d.).
In Canada, the governance, organisation and delivery of health care services is highly decentralised, with this
being underpinned by:

funding for the delivery of health services being controlled at the provincial or territorial level

physicians being classified as independent contractors

the existence of multiple organisations (including Regional Health Authorities (RHAs) and privately
governed entities) which do not have strong links to provincial governments (Marchildon, 2013).
There is also wide variation in health care practices across the different provinces, with “most health
professionals self-regulate[ing] under legal frameworks established by provincial and territorial government”
(Marchildon, 2013:16). In addition, some provincial Ministries of Health and RHAs have quality councils and
specialised health technology assessment (HTA) agencies, while others do not (Marchildon, 2013).
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FIGURE 6 – CANADIAN HEALTH SYSTEM
Adapted from Marchildon, 2013
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7.2
GENERAL PRACTICE TRAINING AND CERTIFICATION
In Canada, a medical degree generally involves a three-year bachelor degree and a 4-year medical degree
(seven years in total). However, Quebec is the exception where a general medical degree is 5-years in total
(Pullon, 2011). After completion of a medical degree, medical students can enrol in a two-year GP vocational training.
This training involves “an integrated mix of hospital and community clinic rotations, embedded in a longitudinal
educational course, based at a ‘home’ family medicine teaching practice” (Pullon, 2011, p.83).
Certification in Canada is overseen by the College of Family Physicians of Canada (CFPC), the “professional
association and the legal certifying body for the specialty of family medicine” (CFPC, n.d.). The CFPC is a
national organisation focused on assisting members to continue to learn and develop throughout the course
of their career. Medical school graduates who complete an approved family medicine residency are eligible
to sit for certification examinations, successful completion of which allows them to use the designation
Certification in the College of Family Physicians (CCFP). Practising physicians who qualify earn certification by
providing evidence of approved training and practical experience (CFPC, n.d.).
7.3
QUALITY ASSURANCE AND ACCREDITATION
Reflecting the decentralised nature of health care in Canada, there is no formal accreditation requirement in
Canada for family physicians, and quality is controlled through regulation and voluntary quality assurance
programs.
Each province and territory in Canada has their own medical regulatory authority, although FMRAC is
recognised as the national organisation representing provincial and territorial medical regulatory authorities
and lists the different members for each of the 13 provinces and territories on its website. As a body, FMRAC
brings together its members for the purpose of developing national positions and approaches while
maintaining the independence of its members at the jurisdictional level (FMRAC, 2010a).
Three different approaches to regulation are operational in Canada:

Licensure: this grants members of a profession the exclusive right to provide a specific service, such as
medical services.

Certification: allows allows members and non-members of a profession (e.g. psychologists) to provide
services to the public, however, only certified or registered members can use the professional title

Controlled Acts System: regulates a specific task or activity (Marchildon, 2013).
Despite variation in regulation across provinces, physician professional groups generally self-regulate
(Marchildon, 2013). However, FMRAC has agreed that from 2012, “all licensed physicians in Canada must
participate in a recognised revalidation process in which they demonstrate their commitment to continued
competent performance through the recording of accredited continuing professional development” (FMRAC,
2010b). In British Columbia, the revalidation process came into effect January 1, 2010, and consists of
mandatory compliance with CPD requirements (College of Physicians and Surgeons of British Columbia, n.d.).
In some provinces, health quality councils have been established. These have been designed to work closely
with health care professionals and organisations to improve outcomes and quality standards and report on
performance. None of these councils, however, have the power to enforce or regulate against key quality
standards (Marchildon, 2013).
As there is no single national program of accreditation or quality assurance, two examples of different
Canadian quality assurance programs are discussed below.
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7.3.1
PHYSICIAN PRACTICE ENHANCEMENT PROGRAM
The Physician Practice Enhancement Program (PPEP) of British Columbia is a “collegial program that assesses
and educates physicians to ensure they meet high standards of practice throughout their professional lives”
(College of Physicians and Surgeons of British Columbia, n.d.)
The main focus of the Programme is on individual physicians, although the program also aims to promote
quality improvement by highlighting areas of excellence and identifying opportunities for personal
development and improvement. PPEP is comprised of three assessment components:

peer assessment of recorded care

physician multi-source feedback assessment – a 360-degree feedback survey covering topics including
clinical care and practice management

assessment of the standard of premises and processes (College of Physicians and Surgeons of British
Columbia, n.d.).
Physicians have the opportunity to view and understand their assessment report at the conclusion of all three
components and the results are also reviewed by the Medical Practice Assessment Committee (MPAC) as part
of a record of the physician’s practice (College of Physicians and Surgeons of British Columbia, n.d.).
7.3.2
QUALITY BOOK OF TOOLS
The Quality Book of Tools is “a key feature of the Quality Program for voluntary assessment by trained peer
assessors in family practices in Ontario” (Levitt & Hilts, 2010, p.14). The book itself is underpinned by a
conceptual framework of categories and associated values, at the heart of which are five core values:

a culture of continuous quality improvement

self-reflection

voluntary assessments

patient or customer involvement

interdisciplinary team development (Levitt & Hilts, 2010).
One of the key recommendations is the need for regular audits to assess whether key criteria outlined in the
Quality Book of Tools have been met, although there is a recognition that the audit requirements are
extremely complex and, in some jurisdictions (e.g. Ontario), the tools for assessment are not universally
available. As such, the Quality Book of Tools is, in some ways, intended as a guide to aid continuous quality
improvement, rather than a set of prescribed, required measures (Levitt & Hilts, 2010).
7.3.3
ACCREDITATION CANADA
Accreditation Canada is a voluntary, non-governmental organisation, which is funded by the organisations it
accredits. Accreditation Canada’s roles include the accreditation of primary care organisations as well as
hospitals. There is some ambiguity as to whether Accreditation Canada accredits general practices (or family
practices as they are called in Canada), with some sources suggesting they do and others that they do not
(Marchildon, 2013). The Royal College of Physicians and Surgeons of Canada requires facilities, including
general practices, to be accredited by Accreditation Canada in order to host residency programs
(Accreditation Canada, n.d.)
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8
Denmark
8.1
HEALTH SYSTEM STRUCTURE
Like other Scandinavian countries, Denmark has a strong welfare state with universal access to health care.
The health system is structured in three tiers: while the Danish Ministry of Health is in charge of the
administrative functions in relation to the organisation and financing of the healthcare system, services are
delivered through five regions and 98 smaller municipalities. Regional governments are responsible for
hospital services and primary care providers such as general practices, while the municipalities operate
community-based services such as home nursing, home help, school health services, rehabilitation, and child
dental services (Olejaz et al, 2012; Pedersen et al, 2012).
The Danish National Board of Health supervises all healthcare facilities including general practices and also
licenses GPs to practise. The Board of Health controls the number of GPs through the granting of provider
numbers to licensed doctors who are then able to provide services free to patients at the point of care. Entry
to the medical education system, as well as the provider number system, is used to control the supply of
doctors and, to a certain extent, expenditure (Olejaz et al, 2012; Pedersen et al, 2012).
The vast majority of funding for the Danish healthcare sector, approximately 80 per cent, is provided through
taxation. For residents who hold a public insurance card, all consultations with physicians, ambulatory care
services and hospital admissions are free at the point of care without a patient co-payment. Co-payments are
generally required for pharmaceuticals, dental care and physiotherapy. Patients who register with a specific
doctor avoid having to make a co-payment and, as a result, most of the population (97 per cent) are
registered with a specific GP. Those who do not register pay a small co-payment to access any primary care
physician (Frolich & Olesen, 2008; Pedersen et al, 2012).
GPs provide a gatekeeping role for the rest of the health service. Individuals are free to choose their own GP,
but once they have registered with a GP they must wait three months before changing again. Most GPs have
an average list of around 1560 patients; they are able to close their list when they reach a threshold of 1600
patients (Pedersen et al, 2012:S35). Remuneration comes from both capitation payments and fee-for-service
charges; the vast majority of GP income is derived from public funding. This blended payment model is
intended to encourage preventative care and continuity of care by ensuring a stability of income, while
inhibiting the tendency to over-treat to increase fee-for-service payments (Frolich & Olesen, 2008; Pedersen
et al, 2012).
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FIGURE 7 – DANISH HEALTH SYSTEM
Adapted from Olejaz et al, 2012
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8.2
GENERAL PRACTICE TRAINING AND CERTIFICATION
Becoming a GP in Denmark requires one year of internship and five years of specialist training following
graduation from a six-year undergraduate medical degree. Qualified GPs have the title Specialist in General
Medicine (Pedersen et al, 2012). Doctors are licensed by the Danish National Board of Health and, once
licensed, there is no requirement for relicensing. At the time of writing, there are no mandatory requirements
for ongoing continuing professional development, although this has been recognised as a need to be
addressed to improve consistency and quality of care (Olejaz et al, 2012).
8.3
QUALITY ASSURANCE AND ACCREDITATION
Denmark has developed structures and processes for monitoring and improving the quality of health care,
ranging from accreditation to clinical guidelines, quality registries, quality indicators and clinical information
systems. These include:

the Danish College of General Practice clinical guidelines – these are developed and provided to all Danish
GPs

the Danish Quality Unit of General Practice (DAK-E)

the Audit Project Odense – a GP data project providing a continuous feedback loop for quality
improvement purposes

the Danish Institute for Quality and Accreditation in Healthcare (IKAS)

the Danish Healthcare Quality Program

Danish Patients Evaluate Practice (DANPEP) – an ongoing national project of patient surveys (Pedersen et
al, 2012; Olejaz et al, 2012).
Denmark does not currently have a formal accreditation process for GPs although DAK-E and IKAS are in the
process of developing one. From 1 September 2015 all GPs will be required to be accredited within three
years (DAK-E, personal communication 2014).
8.3.1
THE DANISH QUALITY UNIT OF GENERAL PRACTICE (DAK-E)
The DAK-E coordinates quality improvement in general practice in collaboration with the regions. One of
DAK-E’s focus areas is the development of information technology tools used in general practices. DAK-E has
developed the program Sentinel Data Capture that collects general practices' data, including prescriptions,
laboratory tests, and information from hospitals. The data is collected automatically from a GP’s electronic
health record system (EHR) and transferred to the Danish General Practice Database (DAMD), which is
administered by DAK-E and located at the University of Southern Denmark. The purpose of the DAMD is to
promote quality improvement in general practice, as well as to provide data for further research concerning
general practice6. DAK-E provides a support function for GPs, assisting them to use the data to reflect on
results and monitor changes in practice and indicators over time (DAK-E, n.d.).
Participation in the DAMD is mandatory for GPs (DAK-E, personal communication, 2014) and within a period
of two years more than 96 per cent of Danish GPs have installed Sentinel Data Capture, which in turn
provides GPs with the data to monitor and improve management of chronic diseases such as diabetes,
6
Researchers are able to apply for data from DAMD and, when approved, DAMD provides an anonymous data extraction for the research projects.
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chronic obstructive pulmonary disease, cardiovascular disease and depression (DAK-E, n.d.). Feedback from
GPs has indicated that the data from the DAMD is useful, and is driving improvements in practice (DAK-E,
personal communication, 2014).
The Sentinel Data Capture program provides GPs with various reports, which are intended to encourage
general practices to engage in continuous quality improvement. The reports are generated individually for
each general practice and are available online through the use of a digital signature system, ensuring
confidentiality. The reports provide GPs with detailed information about the extent to which their treatments
are in line with established national clinical guidelines (DAK-E, n.d.).
DAK-E also runs DANPEP, an ongoing survey mechanism for patients to evaluate their doctors and general
practices. The results of the survey are provided to the GP with aggregated data for other local GPs so that
the report provides benchmarking data to encourage quality improvement (Pedersen et al, 2012).
8.3.2
THE DANISH INSTITUTE FOR QUALITY AND ACCREDITATION IN HEALTHCARE (IKAS)
IKAS was founded in 2005 to create a national model for health care quality, and today has responsibility for
developing, planning and managing the Danish Healthcare Quality Programme (DDKM) (see below). IKAS has
developed standards for hospitals and for some other primary and secondary providers (Olejaz et al, 2012);
general practice standards for accreditation are currently being developed in collaboration with DAK-E.
IKAS has responsibility for recruiting and training accreditation surveyors, and manages the accreditation
process. It is an independent organisation with a governing board including representatives from all tiers of
the health system, and health organisation peak industry bodies. The organisation is itself accredited with
ISQua (IKAS, n.d.).
8.3.3
DANISH HEALTHCARE QUALITY PROGRAM (DDKM)
DDKM is the accreditation program administered by IKAS. According to the program’s website, “the
governing vision behind the Danish Healthcare Quality Programme, states that DDKM should encompass all
health benefits and hereby aims to achieve:

a consistent and high level of quality across the full range of healthcare services - from doctor to hospital,
through pharmacies to home nursing and rehabilitation services

coherence in the patients' experience through the admission process

transparency in relation to the services and benefits of the Danish healthcare system

a culture where all employees and institutions engage in ongoing and mutual learning and thereby
generate and facilitate continuous quality development” (IKAS, 2014a).
There is an ambitious national aim to create an integrated national data system across all parts of the health
sector. For now, DDKM provides a process for providers to assess their organisation’s practice against the
national standards, using existing electronic data collection systems as much as possible to minimise burden
(IKAS, 2014b). As noted above, general practice is not yet included in this although there is already a
mandatory data collection system for GPs in place, which may eventually be linked with the DDKM.
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9
The Netherlands
9.1
HEALTH SYSTEM STRUCTURE
The Dutch health care system in the last decade has moved from one funded through both social and private
health insurance to a single national social insurance system (Schäfer et al 2010). An insurance market allows
Dutch citizens to choose their insurance provider; citizens contribute to this system through both employer
payroll deduction, and also through fees to their insurers (Schäfer et al 2010). Hospitals and other health
services are generally private; public health and health promotion activities are the responsibility of regional
health services, of which there are 29 serving 443 municipalities throughout the country (Schäfer et al 2010).
There are a number of primary care providers, including dentists, midwives and phyiotherapists, who can be
accessed directly by consumers. General practice remains the first point of contact for most health service
users, however, and GPs perform a gatekeeping role through referrals to secondary and tertiary services. GPs
are remunerated through a mix of fee-for-service and capitation (Schäfer et al 2010).
The Dutch government does not directly provide services but functions in an oversight and regulatory
capacity (Schäfer et al 2010). It uses various mechanisms to ensure and strengthen quality of care such as
legislation, guidelines and standards endorsed by health care sector and stakeholder groups including health
professional peak bodies and professional colleges.
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FIGURE 8 – DUTCH HEALTH SYSTEM
Adapted from Schäfer et al, 2010
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9.2
GENERAL PRACTICE TRAINING AND CERTIFICATION
In the Netherlands, the initial medical degree is a six-year program that comprises a bachelor and a master
degree. Both degrees are three years in duration. After completion of the medical degree graduates can enrol
in a three year GP vocational training program. Vocational GPs are required to primarily work at a general
practice during the first and third year. The second training year is focused on gaining work experience
outside of a general practice, for instance in nursing homes or mental health centres (Huisartsopleiding
Nederland, n.d.).
The provision of healthcare services, including general practice, is regulated by the Dutch Individual
Healthcare Professions Act (the Dutch acronym is ‘BIG’). The main purpose of the Act is to promote and
monitor quality of care, and to protect patients from receiving poor quality care (CIBG Ministerie van
Volksgezonheid, Welzijn en Sport, n.d.).
The BIG-register functions as a tool for implementing the Healthcare Professionals Act. Under the Act, GPs
are legally registered to function as a medical practitioner.
The BIG-register aims to provide transparency and clarity in care provider’s qualifications and entitlements to
practise. As stated on its website, being listed in the BIG-register means that health professionals (including
GPs):

may use the legally protected title(s) belonging to their profession

may practise their profession independently

may carry out certain reserved procedures independently

are subject to the disciplinary rules of the relevant professional association

can begin specialist training in a professional field (CIBG Ministerie van Volksgezonheid, Welzijn en Sport,
n.d.).
In order to receive a BIG-registration, health professionals need to meet specific conditions relating to work
experience, education qualifications, diplomas and other qualifications. Registration in the BIG register is time
limited: after five years, health professionals need to re-register.
A key criterion for re-registration is meeting a specific number of work hours of practice within those five
years. GPs are required to complete at least 2,080 hours of practice. If these hours are not met, GPs are
required to complete an education program based on the key competencies of general practice. The program
is not designed for up-skilling GPs in specific work areas, but to ensure that GPs maintain basic clinical skills
and knowledge.
9.3
QUALITY ASSURANCE AND ACCREDITATION
9.3.1
DUTCH HEALTHCARE AUTHORITY (NZA)
The Dutch Healthcare Authority (NZa) is the monitoring and compliance agency for the health care sector in
the Netherlands, including healthcare providers and insurers (Nederlandse Zorgautoriteit, n.d; Nederlandse
Zorgautoriteit, 2012).
The NZa monitors the development of the health system and informs policy development regarding health
service provision including service descriptions, cost allocation principles and smart price ceilings; it also has a
supervisory role concerning such issues as advertising. The NZa collaborates with different organisations and
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inspectorates such as the Health Care Inspectorate (IGZ), the Authority for Markets and Consumers and the
Dutch Data Protection Authority.
Within the context of primary care, there are key mechanisms that provide the NZa with information
regarding health care quality, such as the Health Care Inspectorate, the use of health care indicators, and
accreditation and certification programs. These are described below.
9.3.1.1
HEALTH CARE INSPECTORATE (IGZ)
The IGZ promotes public health through effective regulation of the quality of health services, prevention
measures and medical products. It advises ministers and uses advice, encouragement, and enforcement to
ensure that health care providers offer 'responsible' care (IGZ, VWS, n.d.). The IGZ assesses the quality and
safety of health care services in an independent capacity and functions independent of the government or
political processes.
The IGZ uses four types of key mechanisms in order to carry out its role, as summarised in the table below.
TABLE 2 - HEALTH CARE INSPECTORATE’S (IGZ) KEY MECHANISMS
TYPE OF MECHANISM
Enforcement measures
DESCRIPTION OF KEY ACTIVITIES
 Ensure compliance with legislation, (professional) standards and guidelines.
 Offer advice and recommendations to encourage improvement.
 Implement corrective or coercive measures towards disciplinary or criminal proceedings.
Phased supervision
 Ensure efficient and effective enforcement of legislation, through three phases:
-
Phase 1: identification of risks
Phase 2: inspection visits, assessments and selection of
appropriate measures
Phase 3: imposition of administrative or disciplinary measures,
or institution of criminal proceedings where appropriate.
Investigation of incidents  Review and follow up reports of incidents, unsatisfactory situations and ongoing
shortcomings to ensure quality of care.
 Apply remedial mechanisms ranging from advice and encouragement to correction or
coercion.
Monitoring based on
themes
 Monitor and review specific areas in the health care sector identified as ‘at risk’, such as
accessibility of GPs or provision of medication.
Source: Inspectie voor de Gezondheidszorg, 2011
9.3.1.2
HEALTH CARE INDICATORS
Prior to 2011, health care indicators were an informal component of the Dutch health care system. In 2011,
the Dutch Government supported the introduction of a uniform set of health care indicators to strengthen
the quality of care and transparency of information (Braspenning et al, 2010; Nederlands Huisartsen
Genootschap, 2014).
The development of the indicators was subsidised by the Ministry of Health, Welfare and Sport and was
undertaken by the Dutch College of General Practitioners (NHG). The College owns and publishes the
indicators. All the College’s activities in relation to health indicators are overseen by an independent steering
committee with representatives from various organisations and independent bodies including:

the Ministry of Health, Welfare and Sport

the Dutch College of General Practitioners

the National General Practitioners Association
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
the Federation of Patients and Consumer Organisations

the Consumers’ Association

IGZ

NZa (Van Althuis, 2008).
A total of 83 indicators were introduced, comprising 71 indicators related to medical practice and 12
indicators related to organisational practice. At present, health care indicators focus on the following areas of
health care:

asthma

chronic obstructive pulmonary disease

cardiovascular risk management

diabetes

mental health care

prevention in relation to influenza and cervical screening

prescribing medication.
In order to report on indicators, GPs collect data through their electronic information systems (Nederlands
Huisartsen Genootschap, 2014; Braspenning et al, 2010). However, at the time of writing there is no clear
evidence of a formal approach for GPs to report on health indicators.
Available information suggests that GPs should report on health indicators, although this appears not to be
standard practice. For example, the NZa stated in 2012 that GPs should report on health indicators to the
Netherlands Institute for Health Services and Research to monitor and benchmark performance. However, in
that same year a NZa survey among Dutch GPs showed that 21 per cent of respondents did not report on
health indicators. The results also indicated that only 25 per cent of survey respondents reported on health
indicators to health insurers. This number is particularly low, given that the website of the College of General
Practitioners states that GPs are required to share outcomes on health indicators with health insurers, to
inform their policies when purchasing care services and to enhance transparency to consumers (Nederlands
Huisartsen Genootschap, 2014).
9.3.2
ACCREDITATION IN GENERAL PRACTICE
According to the Dutch Healthcare Authority (2012), there are three main accreditation programs for Dutch
general practices. The most common and extensive program is developed by the Dutch College of General
Practitioners (NHG), called the NHG Practice Accreditation Program (NPA). Under this program, accredited
general practices meet specific standards in relation to risk management and quality of care.
Less common accreditation programs include the Harmonisation Quality of Care program (the Dutch acronym
is ‘HKZ’) and the DEKRA program. Both programs focus primarily on quality management and, to a lesser
degree, on medical practice.
While all three programs differ in scale and key area of focus, they share some key features, including that:

participation is voluntary

audits are conducted by private, independent accreditation organisations

costs are involved
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
general practices need to re-apply for an accreditation certificate every three years.
The literature suggests that Dutch general practices most often register for the NHG accreditation program
(Nederlandse Zorgautoriteit, 2012; Landelijke Huisartsen Vereniging (LHV) & NHG, 2012). For example, in
2011 there were 3,325 GPs participating in the NHG accreditation program, representing approximately 40
per cent of all Dutch GPs (NHG-Praktijk Accreditering BV, 2011 in: LHV & NHG, 2012). In contrast, the NZa
reports on 24 accredited HKZ general practices in 2012. According to the NZa, there is no available data on
the uptake of the DEKRA program (Nederlandse Zorgautoriteit, 2012).
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9.3.2.1
NHG PRACTICE ACCREDITATION PROGRAM (NPA)
Between 2002 and 2005, the NHG and the Radboud University of Nijmegen developed an accreditation
program to evaluate the quality of general practice. In 2005, the NHG established the NPA (NHG Praktijk
Accreditering b.v., n.d.) The overall aims of the NPA are providing GPs with a quality system to:

gain insight into the provision of health care services

learn how to enhance and guarantee quality of care.
Accredited general practitioners receive a NPA certification, indicating that a practice has:

implemented risk management systems and processes

met all accreditation requirements

collected patient and operational data to benchmark results with counterparts in order to evaluate and
enhance quality of health care generally

undertaken systematic action to improve quality of health care (NHG Praktijk Accreditering b.v, 2011).
In order to secure its independence, the NPA has its own management board, and is overseen by a College of
Experts, comprising a variety of stakeholders, including GPs, patients, health insurers and the Dutch Health
Care Inspectorate. The College plays an important role in defining requirements that GPs need to meet under
the accreditation program. It also aims to oversee the quality of the accreditation program and strives to
meet the interests of all involved stakeholders.
The uptake of the accreditation program has increased significantly in the last ten years, increasing from 34
accredited general practitioners in 2005 to 3,015 accredited general practitioners in 2012 (Nederlandse
Zorgautoriteit, 2012); there is no clear evidence of what has prompted this increase.
The NPA involves a Visitation Instrument Accreditation (VIA), developed by the NHG and the Radboud
University of Nijmegen (Braspenning et al, 2007). VIA is based on a Dutch visitation instrument available to
general practitioners since 1998. This ‘older’ visitation instrument provided general practitioners with insights
into patient satisfaction, operational processes and opportunities to enhance and strengthen the conduct of
general practice. Importantly, the visitation instrument was validated which underpinned the development of
VIA (Braspenning et al, 2007). The VIA and the process of accreditation is described in greater detail in
Appendix B. Participation in the program allows GPs to benchmark their practice against national data. Based
on 2014 rates, participation costs for a general practice with 2,350 patients are estimated at $2,470 AUD.
After being accredited, general practices will receive annually a one-day visit from a NPA-consultant for a
three- year period. The costs for each visitation are estimated at $2,050 AUD. General practices may receive
reimbursement from health insurance companies as an incentive for their participation in the scheme.
Reimbursement rates are often based on the number of registered insured patients per health clinic.
9.3.2.2
HKZ AND DEKRA
HKZ
HKZ is an independent accreditation program for Dutch health professionals (HKZ Certificaat, 2011). The
program is designed for a broad range of health care service providers, including GPs, dentists, mental health
professionals and physiotherapists. The program focuses primarily on quality care management, which
involves an extensive review of organisational processes, such as evaluating and reviewing business plans,
organisational goals, and risk management systems.
Participation in the program requires health service providers (including GPs) to have a ‘quality care system’
in place. Participants are offered the use of HKZ’s own quality care system, called the ‘Harmonisation model’,
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specifically designed as a blueprint for participants to meet all HKZ norms and standards. The Harmonisation
model comprises nine key areas of focus, including management processes in relation to provision of care
(eg. intake processes, patient health care plans), internal policies (eg. personnel processes, self-evaluation)
and innovation (eg. development of new products or services).
Independent authorities (auditors), certified by the Dutch College of Accreditation and legally contracted by
HKZ, undertake the audits. The audit process is composed of two key phases. Details of the phases are
summarised in the table below (HKZ Certificaat, 2011).
TABLE 3 – KEY PHASES IN THE AUDIT PROCESS
PHASE 1: DEVELOPMENT OF A QUALITY
MANAGEMENT SYSTEM
PHASE 2:
CERTIFICATION
Key goals
 Development of a quality management system.
 Receiving the HKZ-certificate.
Key
activities
 Identifying and describing work processes, activities,
roles and responsibilities.
 Arranging a visitation from the auditor.
 Developing a clear vision and objectives as an
organisation.
 Developing a quality management system by using the
HKZ ‘Harmonisation model’ as a blue print.
 Testing the quality management system
against the HKZ’s norms and standards.
 Achieving the HKZ-certificate if all conditions
are met.
The HKZ certificate is valid for three years. After a three-year period, the general practice needs to undergo a
new audit. In order to continuously meet the HKZ requirements, HKZ advises general practices to conduct
internal audits every six months and to undertake external audits annually.
In 2012, 24 general practices were operating under a HKZ certificate. There is no public information available
on costs for participation in the HKZ program.
DEKRA
DEKRA is an independent accreditation organisation, offering accreditation programs to many different
sectors, including health, agriculture, engineering and transport. Within primary health care, DEKRA offers an
accreditation program to GPs and GPs with in-house pharmacy services (NZa, 2012; DEKRA, n.d.).
Key features of the DEKRA-program are very similar to the HKZ-program, such as:

evaluation of quality management systems as key area of focus

enhancement of organisation processes and systems as key objectives

a requirement to have a quality management system in place.
Also similar to HKZ, DEKRA designed its own quality management system, called the ‘Value E-xelerator’
(DEKRA, n.d.). However, participants in the DEKRA-program are required to use DEKRA’s quality management
system, while the use of the HKZ management system is optional for participants.
The Value E-xelerator (previously called the VE Practice Monitor) is an online quality monitoring system.
Available information suggests that this system aims to enhance and strengthen operational processes and
management policies (DEKRA, n.d.). General practices are required to file key management documentation
and protocols in this system, such as annual reports, task descriptions and personnel documentation. There is
limited information available on how this system specifically assists general practices in quality management.
Part of the DEKRA program involves training in how to work with the quality management system. The
training also aims to prepare GPs for the audit, including training in how to conduct internal audits and
information on the audit process.
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Based on rates in 2013, costs for participation in the DEKRA-program are estimated at (in AUD):

training costs: $2,700

licence costs for the VE Practice Monitor: $720 per annum

certification costs $3,040.
According to the Dutch Healthcare Authority (NZa, 2012), there is no data available on the number of
accredited general practices by DEKRA.
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10
Comparative analysis
The following table provides a comparative summary of the accreditation or quality processes in place across the six nominated countries. As illustrated in the
table, variations are evident in factors such as the level of centralisation of the health system, the involvement of the medical profession in regulation,
reporting requirement structures, the employment status of GPs, and the role of incentives in the uptake of accreditation.
It is important to note that the countries analysed are not all directly comparable. Some have national certification while in others doctors are certified at the
provincial level; in others certification is undertaken by the professional association. In some, general practice is a distinct specialty while in others it is a more
generalist role within the medical profession. Some accreditation processes are mandated while others are voluntary. In some countries accreditation or
quality improvement programs are more integrated across specialties rather than applying solely to general practice. In the pages following Table 5 below
some of these differences are explored further with reference to what can be learned for general practice accreditation in Australia.
TABLE 4 – MAPPING OF GENERAL PRACTICE ACCREDITATION PROGRAMS
FACTORS
AUSTRALIA
NEW ZEALAND
ENGLAND AND WALES
CANADA
DENMARK
THE NETHERLANDS
Structure of health
system
Public/Private
Bulk bill or co-payment
Public/Private
Co-payment
Public
Zero co-payment
Public
Zero co-payment
Public
Minimal co-payment if
not on a GP list
Public/Private
Zero co-payment
Payment structure
Mainly fee for service
Fee-for-service, capitation Capitation and
performance-related pay
plus some limited fee for
service (eg
immunisations)
Although there is
variation across Canadian
provinces, there is a
general move towards
blended payment models
that favour capitation
over fee for service
Fee-for-service, capitation
- one third of a GP’s
income comes from
capitation payment from
patients on their list and
two-thirds come from
fee-for-service payments
Mainly capitation, but
with fee-for service
accounting for about onethird of payments
Employment status of
Private practitioners
Private practitioners
Independent contractors
(partners or salaried)
Private practitioners
Private practitioners
Private GPs with own
practice (75%), private
GPs without practice
(15%), salaried GPs (10%)
National Health Act 1953
The Australian Charter of
Healthcare Rights
Australian Health
Practitioner Regulation
Agency for individual GPs
The New Zealand Public
Health and Disability Act
The Medical Council of
New Zealand for
individual GPs
The Health and Social
Care Act 2008
The Care Quality
Commission Regulations
2009
The National Health
Service (Performers Lists)
(England) Regulations
2013
The National Health
The Federal Canadian
Health Act.
The Ontario Excellent
Care for All Act
The College of Family
Physicians of Canada
(CFPC) and the Royal
College of Physicians and
Surgeons of Canada for
individual GPs
Act on Patient Safety in
the Danish Health Care
System
The National Board of
Health supervises all
Danish healthcare
facilities, including GP
practices; it also licenses
GPs to practice
Individual Healthcare
Professions Act
GPs
Regulation
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FACTORS
AUSTRALIA
NEW ZEALAND
ENGLAND AND WALES
CANADA
DENMARK
THE NETHERLANDS
Service (Performers Lists)
(Wales) Regulations 2004
organisations
Medicare Locals (in
transition)
Primary Health
Organisations
Clinical Commissioning
Groups in England
Local health boards in
Wales
No – each province has a
different approach
GP cooperatives
There is no national
primary care organisation
– responsibility for
primary health through
regional governments
Patient lists/registration
No
Yes
Yes
No
Yes
Standards
The Royal Australian
College of General
Practitioners (RACGP)
Standards for general
practice (4th edition)
The Royal College of
General Practitioners
(RNZCGP) standards
Aiming for Excellence
The Essential Standard of
Quality and Safety
(minimum bench mark
which all providers must
achieve)
Quality Outcomes
Framework
No national standards for Standards for GPs in
GPs
development
Healthcare indicators and
guidelines of the Dutch
College of General
Practitioners (NHG)
Number of quality
14 standards
41 criteria
128 indicators
36 standards
36 indicators
170 criteria
The CQC Essential
Standards of Quality and
Safety have 28 standards
The PA has 78 criteria
Quality Outcomes
Framework has four
domains and a 148
indicators
Not applicable
Not applicable
83 indicators
Accreditation
Two general practice
accreditation agencies,
AGPAL and GPA
The Royal College of
General Practitioners
(RNZCGP) Cornerstone
General Practice
Accreditation Program
Two voluntary
accreditation schemes –
QPA and PA
The Care Quality
Commission inspects
general practices over a
two year period
Accreditation Canada for
health services, including
primary care services
Some provincial schemes
IKAS – currently in the
process of developing an
accreditation program for
GPs
Three different
accreditation programs,
the NPA, HKZ and DEKRA
programs
Mandatory accreditation
No
No
Mixture - two are
voluntary and the
Essential Standards of
Quality and Safety are
mandatory
Accreditation is
No accreditation process
mandatory in Quebec and for GPs as yet
Alberta.
No
Length of the
Three years
Four years
To retain an accredited
status the practice must
PA is valid for three years
QPA is valid for five years
Accreditation Canada
No accreditation process
programs:
as yet
Accreditation Primer lasts
Three years
Primary care
criteria
accreditation cycle
50
COMPARATIVE ANALYSIS
Yes
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FACTORS
AUSTRALIA
NEW ZEALAND
ENGLAND AND WALES
complete annual activities
Cost of accreditation7
AGPAL fees individually
calculated for each
practice - initial fee of
$550
Not available
PA costs €2,362 ($3,284
AUD)
QPA costs €4,690 ($6,521
AUD)
Yes
Yes
Yes
Yes (in some provinces)
No accreditation process
but patient surveys are
undertaken
Yes
Yes
Yes
Yes
Yes (in some provinces)
Yes, mandatory data
collection for quality
benchmarking purposes
Yes
No
Yes – accredited practices Yes
are published on the
RNZCGP website
Yes (in some provinces)
No
No
software programs in
accreditation process
7
€6,240 ($8,676 AUD)
Yes - included in contracts
with preferred health
insurer
surveys
accreditation status
Not applicable
No
views/satisfaction
Public reporting of
THE NETHERLANDS
Yes – non monetary
improvement
Use of IT systems,
DENMARK
two years
Qmentum has a four year
cycle
Yes - newly established
Yes - the Quality and
Integrated Performance
Outcomes Framework
and Incentive Framework
Yes - the Practice
accreditation and quality Incentive Program (PIP)
Incentives for
Inclusion of patient
Entry level costs $7,000
NZ ($6,306 AUD)
Reaccreditation costs
$5,000 NZ ($4,505 AUD)
There are reduced costs
for satellite clinics; 2012
prices
CANADA
Costs were sourced AGPAL 2014, Lester 2012; RNZCGP 2014; and Care Quality Commission n.d. It should be noted that the costs stated here are only the formal fees of the application and registration process, and
do not include additional costs that may be borne by the practice such as the costs of staff time, training, or other costs associated with the preparation for accreditation or maintenance of accreditation status.
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10.1
THE INFLUENCE OF HEALTH CARE STRUCTURES
A number of countries have established national structures to support, and influence, the quality of care
in general practice. For example in Australia, Divisions of General Practice (and then Medicare Locals)
were established to foster quality of care and create greater integration between general practices and
other health services through a number of collaborative programs and the use of clinical information
systems (Willcox et al, 2011, Nicholson et al, 2012). In England, the CCGs work with the NHSCB, NICE,
and professional and patient groups to measure health outcomes and the quality of care (including
patient reported outcomes and patient experience) (NHSCB, 2012).
Regional primary healthcare network organisations can also play a role in supporting general practices
to become accredited; for example, the GP cooperatives in the Netherlands assist general practices with
preparing for accreditation, providing support with data collection and feedback (Willcox et al, 2011).
Likewise, DAK-E provides support to Danish GPs in the use of monitoring data collected through their
mandatory Sentinel Data Capture program, which will assist in the future as accreditation is
implemented in Denmark. Assisting practices with meeting accreditation requirements was also a role of
the former Australian Divisions of General Practice (later Medicare Locals) (Nicholson et al, 2012). The
Divisions of General Practice and their successor Medicare Locals also supported GPs in undertaking
ongoing professional development, as do primary health organisations in other countries such as New
Zealand and England (Nicholson et al, 2012).
The role of the professional colleges appears to be significant in encouraging uptake of accreditation
programs; Greenfield and Braithwaite (2008) have found a positive association between accreditation
and continuing professional development. As an example, Buetow and Wensing (2008) point out that in
New Zealand while only five of 267 accredited practices were found to be compliant with standards (ie,
262 were non-compliant), only one did not achieve accreditation. This example affirms the tendency to
use accreditation as a quality improvement exercise, combined with significant support and assistance
from the medical college or other organisation, rather than as a regulatory enforcement of agreed
standards. In several of the countries examined, including Australia, the UK and the Netherlands, the
colleges have active roles in the development of standards. At the same time, the degree to which
accreditation processes are considered independent if they are “owned and controlled by the profession
for the profession” (AGPAL, quoted in Buetow & Wellingham, 2003), remains a subject of debate in the
literature.
In countries that do not have national primary healthcare organisations, such as Canada and Denmark,
there appear to be fewer incentives for general practices to provide holistic, integrated care or
undertake quality improvement activities. In both countries, most GPs are private practitioners and as
such operate their own businesses, working within but separate from the broader health system. The
majority of Danish GPs are self-employed and there are not clear structures integrating general practice
into the wider health system (Olejaz et al, 2012). Similarly, in Canada, the governance, organisation and
delivery of the health service is highly decentralised, with the provinces and territories responsible for
funding and delivering most health care services. There is wide variation in practices across the different
provinces and territories, with some having a more explicit focus on quality than others (Marchildon,
2013).
10.2
MANDATORY VERSUS VOLUNTARY ACCREDITATION
Accreditation programs and quality improvement measures across the six countries are underpinned by
regulations which specify particular standards of practice in healthcare. Regulation is an important
component of health systems, ensuring that medical professionals deliver safe and quality care to the
52
COMPARATIVE ANALYSIS
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public. All countries have a regulatory mechanism which licenses suitably qualified physicians to practise
medicine; this can be a national regulator, such as the Medical Board of Australia, or independent
provincial regulators such as those found in the states and territories of Canada. Differences between
the six countries are seen in the extent to which, once licensed, ongoing accreditation or some form of
continuing quality assessment is mandatory or voluntary.
It should be noted as well that, while regulation is a process by which an individual doctor is licensed to
practise medicine, accreditation is applied to a health service such as a general practice. Accreditation
therefore takes a broader and more systems-focussed view of health care than does regulation. As
noted by the FMRAC et al (2008:4), “Systemic sources of risk significantly eclipse professional
incompetence as the dominant cause of harm to patients”. This has contributed to the range of quality
improvement and accreditation processes implemented in the countries under discussion. The balance
between professional autonomy and public accountability has been traditionally maintained through
the regulatory system (FMRAC et al 2008; Buetow & Wellingham, 2003); the public regulator assures
public safety while self-regulation by the profession maintains professional autonomy.
In New Zealand, the RNZCGP’s Aiming for Excellence and the Cornerstone accreditation program address
the statutory requirement of the New Zealand Public Health and Disability Act 2000 to implement a
nationally consistent general practice quality improvement program (RNZCGP, 2014). However,
participation in the accreditation program is not mandatory for New Zealand GPs.
Likewise, in England the CQC regulates against the requirements set out in the Health and Social Care
Act 2008, and all general practitioners are required to register with the CQC (CQC, 2010). However,
participation in the accreditation and quality programs of the RACGP is voluntary.
In the Australian health sector, the establishment of the Australian Health Practitioner Regulation
Agency is an attempt to bring together the separate regulatory authorities of the 14 major health
professions to establish a more integrated regulatory structure. All medical practitioners are required to
register with the Medical Board of Australia but, as noted earlier in chapter 3, general practice
accreditation is separate and voluntary. It is interesting to note that, perhaps due to the PIP, general
practice has one of the highest rates of voluntary accreditation participation of any health speciality in
Australia (Willcox et al, 2011).
10.3
INCENTIVES AND PAY FOR PERFORMANCE
Incentive schemes are one way that governments can influence general practice accreditation. There is
conflicting evidence as to whether the use of financial incentives, or pay for performance measures,
improves the quality of care. While there is evidence that such incentives can change the behaviour of
clinicians, it is not clear that these changes lead to improved health outcomes for patients (Wright,
2012).
Where incentive schemes make up a larger proportion of GPs’ incomes the percentage of participating
general practices appears to be higher. In England, payments under the QOF account for roughly 25 per
cent of GPs income and nearly 100 per cent of practices participate, whereas in Australia payments
under the PIP only account for 5.5 per cent of government funding for general practices and
approximately 67 per cent of general practices participate (Willcox et al, 2011; Campbell et al 2009). It
should be noted however that while accreditation is a prerequisite for the PIP scheme, it is not for the
QOF.
Non-monetary incentives to become accredited also exist, such as whether the status of their
accreditation is likely to be reported publicly. Lester et al (2012) note in their comparison of
accreditation schemes in nine European countries that six of the nine report accreditation results
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53
publicly, although accreditation participation varies widely across the nine suggesting there is not a
single direct correlation between reporting of and participation in accreditation programs. The public
reporting of performance results, such as through the CQC in England and the HIW in Wales, may have a
greater impact on adherence to national standards, although this is not clear from the literature at the
moment.
At the same time, while it may be helpful to have some incentives to encourage higher rates of
accreditation and improvement in practices, there is evidence that incentives for general practices to
meet national targets have mixed results. In England, the QOF has been criticised for creating perverse
incentives (Starfield & Mangin, 2010; Wright, 2012; Campbell et al 2009). There is also literature which
suggests that the QOF has led to some practitioners manipulating results in order to receive the
incentive, and of patients missing out on consultations because GPs are focused on seeing patients with
incentivised diseases (Wright, 2012). Again, while the QOF is not an accreditation scheme, concerns
have been raised about the impact of QOF on the nature of the GP consultation and the dynamics of the
primary care team, with some arguing that there has been a decrease in the continuity of care and a loss
of professionalism (Wright, 2012; Campbell et al 2009). Accreditation programs also tend to focus on
measuring the measurable rather than other less easily quantifiable aspects of general practice that are
important to patients. One study in the UK argued that the focus of the QOF on recorded data misses
the assessment of professional values and other factors which influence quality of care, and suggests
that poor QOF scores may reflect poor organisational process rather than poor clinical care (Ashworth et
al, 2011), a possibility that may also apply to accreditation results.
10.4
VARIATIONS IN ACCREDITATION PROGRAMS
Variations in accreditation schemes have been found to be influenced by the type of characteristics
identified in Table 5, such as levels of centralisation, payment structures, and the role of the GP within
the larger health system (Lester et al, 2012).
The number of criteria required to meet accreditation standards varies immensely. For example, in the
Netherlands there are 83 indicators that practices are required to meet to become accredited, and in
Australia there are 41 criteria, while New Zealand has 11 mandatory criteria and 25 non-mandatory
criteria (Lester et al, 2012; RACGP, 2010; RNZCGP, 2014). To what extent this influences the decision to
undertake accreditation is not explored in detail in the literature, though some sources suggest that the
time and level of complexity involved to achieve accreditation can act as a barrier to practices
considering accreditation (Buetow & Wellingham, 2003).
The time period for the cycle of accreditation was similar for all six countries ranging between two to
five years for a full accreditation cycle, with most accreditation cycles occurring every three to four
years. In addition, some countries have interim accreditation programs which help to support practices
to achieve full accreditation over a specific period of time (Greenfield & Braithwaite 2008).
There is no evidence available that quantifies the time and other indirect costs to the practice of
participating in accreditation program. There is also little evidence on whether the cost of accreditation
inhibits general practices from undertaking accreditation. However, what evidence there is suggests that
it is not the cost of accreditation which is the barrier (which from the information that could be gained
ranges from $3,284 to $8,676), but the labour costs to the practice from the time involved in taking part
in the accreditation process (Buetow & Wellingham, 2003; O’Beirne et al, 2012). There is, however, no
clear evidence quantifying these costs for practices, and little discussion of the roles of general practice
staff in the accreditation process. Greenfield & Braithwaite (2008) have noted that the costs of
accreditation are under-researched.
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COMPARATIVE ANALYSIS
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Other countries have annual maintenance accreditation programs which not only encourage practices to
maintain their standards but to also implement continuous quality improvement processes. For
example, in New Zealand once a practice has been accredited they move into an annual maintenance
program. To retain their accredited status the practice must complete a series of annual activities each
year and upload evidence into the designated software system, designed to support the Cornerstone
program. The practice is then externally assessed again after four years (RNZCGP, 2014a). Evidence
suggests a non-punitive focus of the continuous quality improvement approach and the involvement of
practices at every stage of practice assessments help the rate of accreditation (Buetow & Wellingham,
2003).
10.5
THE IMPACT OF ACCREDITATION ON QUALITY AND SAFETY
The literature suggests that GPs and practice staff have varying views about the purpose and impact of
accreditation (Buetow & Wellingham, 2003; Campbell et al, 2010; Greenfield & Braithwaite, 2006). A
pilot of one practice accreditation scheme undertaken in England involving 36 general practices found
that participants valued the reflective and self-improvement aspects of the scheme, but had concerns
that simply measuring compliance (eg, ensuring that a certain protocol was in place) would not
demonstrate the benefits of quality care (Campbell et al, 2010). This suggests that professional
development and quality improvement may be greater motivators than compliance.
It is relatively easy to outline the steps needed to improve quality and safety in general practice, but it is
much more difficult to demonstrate the link between accreditation and improvements in patient
outcomes (Lester et al, 2012; O’Beirne et al, 2012; Nicklin, 2014). A meta-analysis by O’Beirne et al
(2012) found evidence that accreditation improved process activities in accredited health centres, such
as levels of clinical activity or risk management activities. However, the effect on patient outcomes is
more difficult to assess.
The Australian context is similar; while the PIP scheme in Australia has helped increase rates of
accreditation, there is not clear evidence that the increasing number of accredited general practices has
led to increased safety and quality (ANAO, 2010), or that continuing quality improvement activity
improves health outcomes (Buetow & Wellington, 2003). Data collection in itself is not enough, although
the mandatory Danish data system for GPs holds some potential for improving the standard of care
through national and local benchmarking. The QOF used in England and Wales also provides an
important example of a benchmarking mechanism, although its impact on the quality of care is varied
(Campbell et al 2009; Willcox et al 2011).
In New Zealand, the accreditation program enables systematic measurements and benchmarking, but
these tend to be measures of process rather than actual health outcomes. It is therefore difficult to
determine what impact accreditation has on patient outcomes (Buetow & Wellingham 2003). For this
reason, process measures are generally used as indicators of quality in general practice. This means it is
difficult to assess the benefits of accreditation on patients, beyond the associated benefits they may
receive from improvements to general practice processes.
Accreditation in general practice has not been established for as long as hospital accreditation (O’Beirne
et al, 2012), and it is reasonable to assume that it will take time to find the ideal mechanisms for
ensuring continuous quality improvement. In many cases, initial improvements level off (Wright, 2012)
and maintaining quality requires new and innovative approaches. In the countries discussed here,
professional associations, regulatory agencies, quality agencies and government policy makers are
working together to develop the best mechanisms for ensuring a minimum level of quality and safety in
general practice health service delivery for the public. There is scope for continuing monitoring and
evaluation of the impacts of these initiatives.
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10.6
BENEFITS OF ACCREDITATION
The literature did identify a number of benefits of accreditation for GPs and general practices, outlined
below:

Improves organisational processes and quality improvement – there was some evidence that
accreditation helps to improve the systems and processes of general practices (Greenfield &
Braithwaite, 2008; O’Beirne et al, 2012; Nicklin, 2014). Greenfield and Braithwaite (2008) in their
meta-analysis found that in a number of studies participants identified benefits for their
organisation from participating in accreditation, including improving communication, increasing
quality activities, enhanced customer focus, and opportunities for staff management and
development. O’Beirne et al (2012) likewise identify that accredited practices tend to have more
quality improvement activities and processes in place, including processes for clinical aspects of care
such as infection control.

Encourages professional development - in the Netherlands practices receive ‘accreditation points’
for up-skilling staff. In order to receive extra points, staff are required to enrol in education courses
or activities accredited by the NHG. Similarly, the RACGP’s CPD points allow GPs to gain credit for
participating in accreditation, and are required of Australian GPs in order to retain their vocational
certification. In Canada, physicians are now required to record their attendance at accredited CPD
training.

Helps to manage risk – there was some evidence that accreditation helps to diminish the risk of
adverse events by helping general practices to identify and mitigate risks (René et al, 2006 in:
Nicklin, 2014; O’Beirne et al, 2012; Salmon et al, 2003; Mays, 2004; Wright, 2012). O’Beirne et al
(2012) report in their meta-analysis that accredited health facilities tend to have more mechanisms
in place to monitor and respond to risk.

Helps to market practice – undertaking accreditation can demonstrate practices’ commitment to
quality improvement measures. If the results are made public, then the general practice can use
them as a way to promote the practice. However, publication of accreditation status is rare (Buetow
& Wellingham, 2003). At the same time, individual general practices may advertise their
accreditation status, such as the placement of certification displayed in Australian general practices
or promotion by general practices in New Zealand, as noted above in section 4.3.4. Rates of
accreditation are higher where the results of accreditation are reported publicly (Willcox et al,
2011).

Improves team cohesion and organisational culture – some of the literature suggests that the
process of undertaking accreditation can be a team bonding experience because it encourages
different team members to communicate with one another about possible steps they could take to
improve processes; conversely, staff who are not involved appear not to be as engaged in the
‘quality culture’ that accreditation seeks to encourage (Paccioni et al, 2007; Checkland & Harrison,
2010). Accreditation can give practice nurses and other staff who might not have a voice in the
management structure of the practice an opportunity to provide feedback and to feel ownership in
the process of continuous quality improvement (Buetow & Wellingham, 2003).
In summary, while there is limited evidence on the impact of accreditation on patient outcomes, there is
evidence that accreditation brings benefits to GPs and practice staff through a greater focus on the
quality of service organisation and delivery. These are likely to deliver some benefits to patients in terms
of an improved service experience. In general, however, there remains a need for further rigorous
research into the impact of practice accreditation on both the patient experience and health outcomes.
56
COMPARATIVE ANALYSIS
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11
Summary
O’Beirne et al (2012) note that Australia is one of the world leaders with regard to the development of
primary care accreditation; as noted above, the words ‘primary care’ are used more commonly
internationally to describe the structures of what is known in Australia as ‘general practice’, although
the general principles and processes discussed in the context of primary care tend to be congruent with
Australian general practice. Systems in Australia for the monitoring and improvement of general
practice, such as the RACGP Standards first developed in the 1980s, the accreditation agencies, and the
now-disbanded Divisions of General Practice, have contributed over a long period of time to a general
acceptance of the principles of quality improvement within general practice.
This review has examined the literature from a wide range of sources including peer reviewed articles,
publicly available reports, and websites. In all, over 138 documents and websites were considered in our
analysis of the accreditation systems for general practice in the six identified countries. Accreditation
and quality initiatives across countries are not directly comparable; in Canada, for example, the thirteen
provinces have different approaches to accreditation and quality assessment, and in Denmark the
accreditation agency IKAS does not include general practice at the time of writing. However, we have
attempted to draw out what can be learned about the ways in which the six countries have incorporated
quality measurement within their unique structures.
In describing the general practice accreditation programs in Australia and internationally, we have
identified a number of factors that influence both the way accreditation is embedded into practice and
the level of uptake or acceptance of accreditation within general practices. These factors include:

whether accreditation is voluntary or mandatory

the relationship between accreditation and regulation

the relationship between accreditation and incentives for performance

the extent to which accreditation or performance results are made public.
Other factors that vary between jurisdictions, identified in the literature, include the use of technology
in data collection for accreditation, the inclusion of the consumer in the accreditation process, and the
role of professional organisations such as the medical colleges in developing and monitoring standards
for the profession.
There does appear to be a gap within the Australian context in that some types of general practices are
ineligible for accreditation due to their structure and activities, according to the definition of general
practice used in Australia. This does not appear to be an issue in the other countries reviewed and
would be worth further consideration with regard to finding ways for general practices that do not fit
the current definition of general practice to engage in some level of assessment and accreditation.
Alternatively, broadening the scope to a wider focus on primary care, as is the case in other countries,
might provide more opportunity for a wider range of general practices to participate.
A number of benefits to accreditation have been identified that extend beyond the immediate ones of
patient safety and service quality. There is evidence that GPs and practice staff value the process of
accreditation as one that encourages quality improvement and reflection on their work. The extent to
which this understanding can be promoted as a benefit to individuals and to teams may increase the
engagement of practices in the accreditation process.
There was little available information regarding the costs of accreditation. The information that was
available was not directly comparable and does not include indirect costs such as staff time and the
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57
impact of accreditation requirements on other service delivery activities. This would be an area for
further exploration, as well as exploring the level of cost that would be acceptable to GPs, for example,
the point at which the costs of accreditation outweigh the benefits for general practices.
There was also little available information regarding the long-term impact of accreditation on patient
health outcomes; this in fact may be unmeasurable given the difficulty of attribution. However, a
number of proxy measures exist and are widely used within accreditation processes to assess the
acceptable level of quality within a health service.
Broadly, the evidence suggests that accreditation does encourage a level of quality through adherence
to certain minimum safety and quality standards. There is scope both in Australia and internationally for
further research to demonstrate the link between accreditation and quality care within general practice.
KEY POINTS

Australia has a mature accreditation system for general practice. However, recent changes to the
definition of general practice may exclude some types of general practice from accreditation and
consideration could be given to how to ensure some level of accreditation is available to all types of
general practice.

There is little research on the impact of accreditation on patient health outcomes. As Australia has
had general practice accreditation in place for more than a decade, a considerable contribution to
the evidence base could be made if a retrospective, longitudinal analysis of patient outcomes in
accredited and non-accredited practices could be conducted to find out whether there are
measurable outcomes which can be attributed to improvements in health service quality.

Participation in quality improvement programs appears to be more widely adopted where financial
incentives form a greater proportion of a GP’s income. Some studies from England suggest that this
may provide a perverse incentive and remove the focus of the exercise from quality to performance.

On the whole, it appears that most countries maintain accreditation as a voluntary and separate
system from professional regulation. This is changing in Canada with some provincial regulators now
requiring accreditation. There is little evidence on the impact of mandatory verses voluntary
accreditation on patient outcomes.

Several countries are increasingly seeking to align general practice or primary care standards to
national health care standards, including Australia where the standards for general practice include
several that align with the Commission’s National Safety and Quality Health Service Standards.
England and Wales both have established national health care standards that apply to all health
facilities including general practices, and Denmark is gradually moving in the direction of an inclusive
national accreditation program. This is a reflection of the increasingly integrated nature of health
services as well as the development of nationally consistent approaches.
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SUMMARY
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Disclaimer
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Appendix A
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Framework for describing accreditation
schemes
APPENDICES
TABLE 5 – FRAMEWORK FOR DESCRIBING ACCREDITATION SCHEMES
CONTEXT
INPUTS
PROCESS
IMPACTS
 Stated purpose and goals of accreditation
 Requirements
 Description of accreditation process
 Benefits associated with accreditation
 Steps in accreditation
 Challenges associated with accreditation
 Types of accreditation
 Any evidence of changes to
 Who is responsible for/oversees the accreditation
scheme
 Who provides/undertakes accreditation assessment
and how are they accredited
 Voluntary/mandated
 Incentives
- practice level
- professional level
 Relevant regulations
- practice/organisation level,
including categories included
and excluded
- professional level, including
categories included and
excluded
 Costs and other resources
required
 Time involved
 Nature of assessment
- quality
- in person
- safety
- practice visits
- practice
- submissions
 Collection and monitoring of quality or
process indicators
 Standards used for accreditation
 Collection and monitoring of outcomes
data
 Who develops the standards
 Duration of accreditation
 What is in the standards
 Sanctions
 When accreditation was introduced/history
 Involvement of patients or consumers
 Public reporting of accreditation
 Transparency of process
 Public reporting of performance, incl comparative
performance
 Use of technology in accreditation process
 Rate of participation in accreditation
schemes/processes
 Perceptions of accreditation
 Unintended consequences, if any
 Integration of accreditation or standards in other
processes or standards
APPENDICES
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Appendix B
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Dutch Visitation Instrument
Accreditation (VIA) process
APPENDICES
The Dutch Visitation Instrument Accreditation (VIA) was developed by the NHG and the Radboud
University of Nijmegen and launched in 2005.
Key elements in VIA include measuring medical practice, organisational practice and patient experience
(Braspenning et al, 2007). Each key element will be explained in more detail below.

Medical practice
A main area of focus for medical practice is measuring process indicators. Process indicators provide
insight into the extent in which medical processes take place according to clinical guidelines. To less
extent, medical practice also involves measuring health performance outcomes by using the
national uniformed set of health care indicators. Data collection for medical practice mainly takes
place through general practices’ electronic information systems and national databases.

Organisational practice
Organisational practice involves measuring elements to fully understand how a health clinic is being
managed, including the clinic’s organisation processes, structures and systems. Key areas of focus
include:
 infrastructure – relates to a diverse mix of key elements, including availability of staff, the
physical workplace, the physical environment for patients, accessibility of care and hygiene.

team structure – relates to staff processes and policies to enhance and strengthen a cohesive
and resilient team

information flow and system – relates to patient information data bases and informing patients
during consultations

quality assurance – relates to systems and processes to monitor and evaluate quality of care and
up skill staff

finance – relates to financial management and budgeting.
Data collection for organisational practice involves online questionnaires for general practitioners
and other (supporting) staff a clinic, including nurses and management. It also involves a series of
observations conducted by NPA-consultants.

Patient experience
A third key element in VIA involves a patient questionnaire to provide insight into how patients
experience the provision of services and care. The questionnaire contains elements in relation to the
health clinic and the general practitioner, including:

the health clinic’s physical environment (eg. hygiene)

accessibility of the clinic, including waiting times

provision of care

privacy of provided services

humane elements in provided services (eg. personal, respectful)

continuity of services

provision of information
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
awareness of how a patient’s health conditions could impact the patient’s direct social
environment (eg. family).
The audit process requires 40 completed patient questionnaires. Patients will receive a paper
questionnaire after consultation with the general practitioner. They will be asked to anonymously
complete the questionnaire at the clinic. Completed questionnaires will be kept in a closed box for
further analysis by NPA-consultants.
Quality criteria
The NPA program classifies outcomes of the audit in three types of criteria (see Figure 9). The criteria
show a gradient scale of ‘hard’ criteria that general practices need to meet (eg. by law) in order to be
successfully accredited, towards softer criteria to inform general practices on performance and
outcomes. The criteria will be described in more detail below.
FIGURE 9 – NPA QUALITY CRITERIA
Signalling
criteria
Normative
criteria
Informative
criteria

Normative criteria
Normative criteria are criteria that general practices are required to meet in order to become and
remain accredited. These criteria are mainly based on organisational practice and mostly informed
by legislation and national guidelines. When requirements are not met, general practices will not
receive an accredited certification or the certification will be withdrawn.

Signalling criteria
Signalling criteria are also criteria that general practices need to meet in order to become and
remain accredited. However, when not meeting these requirements, general practices will be
provided with a three-year period to improve their performance. Some of these criteria are in
relation to organisational practice, other criteria relate to medical practice, particularly for diabetes,
chronic obstructive pulmonary disease, asthma and cardiovascular disease.

Informative criteria
Informative criteria inform a general practice on its performance and outcomes. While the results
do not impact the outcomes of the audit process, general practices are encouraged to use the
results as a starting point to identify and implement improvements in their work processes and
medical practice. Informative criteria mainly focus on quantitative data, such as the number of
employed staff and the number of work hours. It also contains data on medical practice, particularly
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for patients with diabetes, chronic obstructive pulmonary disease, asthma, cardiovascular disease
and mental health issues. The informative data includes an analysis of the outcomes of a general
practice compared to other general practices registered under the NPA-program (the national
benchmark).
Reporting
After the audit, general practices receive a report outlining the results of the audit for each criteria. As
described, the report includes an analysis of the general practice’s performance compared to the
national benchmark. More specifically, the benchmark shows the extent in which outcomes align with
the:

25% highest scores in the benchmark

50% scores between the 25% highest and 25% lowest scores

25% lowest scores the benchmark.
The main aim of comparing results against a national benchmark is providing general practices with a
solid starting point for improvements and future opportunities. The audit report aims to assist general
practices in designing improvement policies and implementing improving processes.
Incentives
In general, participation in the NPA-program does not involve incentives for general practices. However,
general practices could receive ‘accreditation points’ by up-skilling staff. In order to receive extra points,
staff are required to enrol in education courses or activities accredited by the Dutch College of General
Practitioners (NHG). However, these activities are optional for general practices and not a required
outcome of the program.
Costs
Costs for participation vary, based on the number of patients for each general practice (NHG Praktijk
Accreditering b.v., n.d.A). Based on 2014 rates, participation costs for a general practice with 2,350
patients are estimated at $2,470. After being accredited, general practices will receive annually a oneday visit from a NPA-consultant for a three- year period. The costs for each visitation are estimated at
$2,050. General practices may receive reimbursement from health insurance companies.
Reimbursement rates are often based on the number of registered insured patients per health clinic.
Process and timing
The NPA-program involves four different key phases (NHG Praktijk Accreditering b.v., n.d.B) (see Figure
10 below).
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FIGURE 10 – KEY PHASES IN THE NPA AUDIT PROCESS
Phase 4:
3-year period
with annual
visits
Phase 1:
Self-evaluation
Phase 3: Audit
Phase 2:
Pre-audit
Phase 1, 2 and 3 involve activities by a general practice in order to become accredited. Phase 4 is a
three-year period after accreditation, involving annual ‘control’ visitations by a NPA-consultant. After
three years, the general practice is required to re-apply for the NPA-certificate, undertaking all phases
again (NHG Praktijk Accreditering b.v., 2011; NHG Praktijk Accreditering b.v., n.d.).
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Appendix C
APPENDICES
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compare?, in: Journal of Primary Health Care, Vol. 3(1): 82-85
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Roland M, Guthrie B & Thomé DC 2012 Primary Medical Care in the United Kingdom, in: Journal of the
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August 2014,<https://www.rnzcgp.org.nz/cornerstone-general-practice-accreditation>
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Development (USAID) by the Quality Assurance Project, University Research Co., LLC.
Schäfer W, Kroneman M, Boerma W, van den Berg M, Westert G, Devillé W and van Ginneken E 2010
The Netherlands: Health system review, in: Health Systems in Transition, Vol. 12(1): 1–229
Seddon, M.E., M N Marshall, S M Campbell, M Roland 2001 Systematic review of studies of quality of
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Timmins N 2013 The four UK health systems Learning from each other, The King’s Fund: London
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APPENDICES
Appendix D
APPENDICES
Table of evidence
URBIS
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For the purpose of this literature review, Urbis identified and analysed over 110 articles, including research papers, policy reports and websites. Table 6
provides an overview of the 45 research papers underpinning the evidence base of the literature review, excluding descriptive papers, articles and websites.
The evidence base for each research paper has been rated against a three-point scale:

strong evidence: research or evaluation papers based on a systematic and comprehensive analysis, including quantitative and qualitative research
methodologies and systematic literature reviews

moderate evidence: research or evaluation papers underpinned by some form of systematic or comprehensive analysis

weak evidence: reviews or discussion papers primarily based on existing articles, without the conduct of a systematic analysis.
TABLE 6 – ACCESSED RESEARCH PAPERS
FORM AND SOURCE OF RESEARCH DESIGN/METHODOLOGY
PUBLICATION
KEY CONCLUSIONS
1. Ashworth M,
Schofield P, Seed P,
Durbaba S, Kordowicz
M & Jones R 2011
Identifying poorly
performing general
practices in England:
a longitudinal study
using data from the
Quality and
Outcomes
Framework, in:
Journal of Health
Services Research &
Policy, Vol. 16(1): 21–
27
Research paper which aims to determine the
characteristics of general practices which perform poorly
in terms of Quality and Outcome (QOF) performance
indicators in England’s NHS.
The research methodology involved a four year
longitudinal study, from 2005 to 2008. Data were
obtained from 8,515 practices (99% of practices in
England) in year 1, 8,264 (98%) in year 2, 8,192 (98%) in
year 3 and 8,256 (99%) in year 4. Outcome measures
included QOF performance scores; social deprivation
(IMD-2007) and ethnicity from the 2001 national census;
general practice characteristics.
2. Australian National
Audit Office (ANAO)
2010 Practice
Incentives Program,
Audit Report No.5
The Australian National Audit Office (ANAO) undertook Recommendations to the former Commonwealth
an independent performance audit of the Department of Department of Health and Ageing included:
Health and Ageing and Medicare Australia in accordance  the development of a capability to model the
with the authority contained in the Auditor-General Act
effect of PIP design features on the likely uptake
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RATING OF COUNTRY
EVIDENCE OF FOCUS
Outcomes defined a cohort of 212 practices (3% of Strong
all practices in England) which remained in the
bottom decile of QOF performance during each of
the first four years since the introduction of the
QOF. The strongest predictors of poor QOF
performance were singlehanded and small
practices, and practices staffed by elderly GPs.
Particular shortfalls were noted for indicators in the
chronic disease categories of depression, psychotic
illness, palliative care and epilepsy. Large shortfalls
in individual targets were observed, particularly
those relating to mental health issues or the
demonstration of clinical records containing clinical
summaries, or ‘problem lists’.
Moderate
England
Australia
APPENDICES
FORM AND SOURCE OF RESEARCH DESIGN/METHODOLOGY
PUBLICATION
KEY CONCLUSIONS
RATING OF COUNTRY
EVIDENCE OF FOCUS
2010–11 Performance 1997.
and success of proposed incentive payments
Audit, Australian
The objective of the audit was to assess DoHA’s
 the development of an evaluation strategy for the
National Audit Office: effectiveness:
overall program and the program’s individual
Canberra
incentives that includes the identification and
 in undertaking PIP program planning, program
monitoring of key performance indicators
monitoring and review;
 annual public reports on relevant high-level
 with Medicare Australia, in ensuring PIP program
indicators
delivery to general practices and their medical
practitioners.
 the development of the means of the program to
inform the quality of general practice
In undertaking the audit, the ANAO considered the 12
accreditation.
incentives that comprised the PIP up to August 2009.
The audit primarily comprised an analysis of census data,
literature and quantitative survey data collected by
ANAO during previous surveys.
3. Booth BJ, Snowdon T, Narrative literature review which aims to aims to provide
Harris MF & Tomlins a general practice perspective on quality and safety in
R 2008 Safety and
primary health care.
Quality in Primary
Care: The View from
General Practice, in:
Australian Journal of
Primary Health, Vol.
14(2): 19-27
Key conclusions highlight the significant changes in Weak
the international health system to enhance quality
of care. The review aims to demonstrate that
improvements in performance of 5 % to 15% appear
to be maximum achievements in randomised
controlled trials. The review also addresses changes
in the Australian general practice, moving from an
educational paradigm to a more whole-of-system
approach. It argues that the quality framework
developed by the Royal Australian College of
General Practitioners could enhance and strengthen
quality activities and strategic awareness to guide
future initiatives.
Australia
4. Braspenning J, Bouma
M, Van Doorn A, Van
den Hombergh P & in
't Veld P 2010
Huisartsen leggen
verantwoording af.
The paper argues for the need of an open discussion Weak
on how, when and why outcomes on health care
indicators can be reported to the open public.
The
Netherlands
APPENDICES
Discussion paper on the use of health care indicators to
enhance public transparency in the Dutch health care
system. The paper includes an overview of the
development and the use of health care indicators in
Dutch general practice.
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FORM AND SOURCE OF RESEARCH DESIGN/METHODOLOGY
PUBLICATION
KEY CONCLUSIONS
RATING OF COUNTRY
EVIDENCE OF FOCUS
Nieuwe basisset
indicatioren geschikt
voor publiek gebruik,
in: Medisch Contact
(65) 6: 254-257
5. Deloitte Centre for
Health Solutions 2012
Primary care: Today
and tomorrow.
Improving general
practice by working
differently, Deloitte
LLP: London
First publication by Deloitte UK Centre for Health
Solutions on general practice in primary care. The report
outlines the Centre’s views on:
 the current and future role of general practice
 the main challenges faced by the general practice
workforce
 a range of evidence based solutions.
Findings and recommendations are based on data
analysis, a literature review and collected views of
policymakers, professional representative groups,
practitioners and patient groups.
The report proposes refinements in primary care to Moderate
improve delivery of care. It suggests different
models and approaches for consideration to meet
the increased demand for primary care and to
address growing constraints on capacity and
capability.
United
Kingdom
6. Booth BJ, Snowdon T,
Harris MF & Tomlins
R 2008 Safety and
quality in primary
care: The view from
general practice, in:
Australian Journal of
Primary Health, Vol.
14(2): 19 - 27
This article provides a historical overview of the
Australian general practice perspective on quality and
safety in primary health care. It is written by
professionals/practitioners including representatives
from the Royal Australian College of General
Practitioners.
Quality initiatives in Australian general practice have Moderate
changed considerably - moving from an educational
paradigm to a more whole-of-system approach.
They have been introduced or emerged in ways that
are sometimes coherent, sometimes not.
An example of how the RACGP quality framework
has been used is provided – eg to improve
immunisation rates in Australia.
Australia
7. Buetow SA &
Wellingham J 2003
Accreditation of
general practices:
challenges and
lessons in: BMJ
Quality & Safety,
This paper aimed to provide a personal response to four
questions:
 What is practice accreditation?
 What is it meant to achieve?
 What challenges does it face?
 What can be learnt?
Lessons from Australia and New Zealand include:
Weak
the need to reward quality practices, loosen
professional control over accreditation, trade some
consistency of standards for validity, develop
standards that acknowledge cultural diversity, and
be transparent. Another lesson is to separate quality
control from quality improvement within
New
Zealand
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APPENDICES
FORM AND SOURCE OF RESEARCH DESIGN/METHODOLOGY
PUBLICATION
2003 Vol. 12: 129-135 The response to the first three questions is developed as
a result of a non-systematic review of relevant research
literature in English. This literature was identified from
personal files, electronic databases, the Internet,
reference lists of retrieved works, and conversations
with colleagues.
The response to the fourth question is opinion-based
and underpinned by lessons learnt from Australian and
New Zealand - and personal experience with the 2001
Royal New Zealand College of General Practitioners
(RNZCGP) trial of practice accreditation standards.
8. Buetow SA &
This paper is a limited literature review providing a crossWensing M 2008
cultural comparison between accreditation practices in
What might European New Zealand and recent practices in Europe.
general practice learn
from New Zealand
experience of
practice
accreditation? in:
European Journal of
General Practice, Vol.
14: 40-44
APPENDICES
KEY CONCLUSIONS
RATING OF COUNTRY
EVIDENCE OF FOCUS
coordinated systems based framework, with
practices being helped to pay for accreditation and
quality improvement. Such assistance is important
because, in the presence of unintended variations in
practice service delivery, all practices should have to
show that they meet or exceed minimum standards
while aiming for excellence.
This paper considers the lessons that the NZ
experience of externally assessing practices for
accreditation, whilst encouraging quality
improvement, might have for European general
practice. In particular, it argues that a formative
ethos of organisational development can be
incorporated at all stages of the systems review for
quality assurance and the approach taken to
improve quality. The paper also argues that it is
desirable and feasible for all practices to anticipate
and achieve accreditation.
Weak
New
Zealand
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9. Campbell S M,
Chauhan U & Lester H
2010 Primary Medical
Care Provider
Accreditation
(PMCPA): pilot
evaluation, in: British
Journal of General
Practice: 295-304
URBIS
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The article aimed to describe the development, content
and piloting of Version 1 of the Primary Medical Care
Provider Accreditation (PMCPA) scheme. The study took
place in thirty two nationally representative practices
across England, between June and December 2008 and
involved interviews with GPs, practice managers, nurses
and other relevant staff from the participating practices.
Interviews were conducted, audiotaped, transcribed, and
analysed using a thematic approach. For each practice,
the number of core criteria that had received either a
‘good’ or ‘satisfactory’ rating from a RCGP-trained
assessment team, was counted and expressed as a
percentage.
KEY CONCLUSIONS
RATING OF COUNTRY
EVIDENCE OF FOCUS
Thirty-two practices completed the scheme, with
Moderate
nine practices passing 100% of core criteria (range:
27–100%).
There were no statistical differences in achievement
between practices of different sizes and in different
localities. Practice feedback highlighted seven key
issues:
(1) Overall view of PMCPA was generally positive –
while there was an overall positive view on
PMCPA, outcomes showed that the scheme was
too heavily populated by criteria where the
evidence for external assessment focused on
demonstrating the existence of a protocol or
procedure, rather than on the evidence of
change of benefit to the practice.
(2) The role of accreditation – There was general
consensus about the value of accreditation, but
there were different interpretations of its role.
The RCGP was seen as the arbiter of
professional standards, and their leadership of
the scheme was seen as key.
(3) Motivations for taking part – Practices had
different reasons for taking part in the
accreditation pilot. The most common reason
was a team-development exercise focusing on
practice quality improvement, but also to fix a
perceived problem (eg. current standards or
deficiencies in team working).
(4) Workload – Practice managers dominated the
workload and the workload was often higher
than expected.
(5) Facilitators for implementation – Success factors
in implementing PMCPA included elements in
England
APPENDICES
FORM AND SOURCE OF RESEARCH DESIGN/METHODOLOGY
PUBLICATION
KEY CONCLUSIONS
RATING OF COUNTRY
EVIDENCE OF FOCUS
relation to team engagement. Those practices
that did not complete PMCPA were usually
those where only the manager was truly
engaged in the scheme.
(6) Patient benefit – PMCPA led to direct patient
benefits relevant to the practice population.
(7) Recommendations for improving the scheme –
Recommendations included an emphasis on 2–3
years as a realistic timeframe for completing the
scheme, a focus on using evidence of
implementation and learning rather than a
written protocol and greater emphasis on
patient benefit and patient responsiveness.
10.Campbell SM, Reeves
D, Kontopantelis E,
Sibbald B & Roland
M 2009 Effects of Pay
for Performance on
the Quality of Primary
Care in England, in:
The New England
Journal of Medicine:
361:368-78
A impact analysis of pay-for-performance scheme on
quality of care. The methodology involved an interrupted
time-series analysis of clinical data on chronic disease
(asthma, diabetes or coronary heart disease) at two
points before implementation of the scheme (1998 and
2003) and at two points after implementation (2005 and
2007). Data was analysed from medical records kept by
42 family practices. The analysis also involved an
electronic patient survey during each study year,
targeting a random sample of 200 registered adult
patients in each practice. The response rate to the
survey was 38% in 1998, 47% in 2003, 45% in 2005, and
38% in 2007.
11.Eriksson T, Hundborg Discussion paper on the Danish Healthcare Quality Programme
in relation to enhancement of the Danish accreditation
K & Friborg S 2009
system.
Accreditation of
Danish general
practice. Integrated
APPENDICES
The study found that the scheme accelerated
Strong
improvements in quality for two of three chronic
conditions in the short term. However, once targets
were reached, the improvement in the quality of
care for patients with these conditions slowed, and
the quality of care declined for two conditions that
had not been linked to incentives. Continuity of care
was reduced after the introduction of the scheme.
There were no significant changes in patients’
reports on access to care or on interpersonal
aspects of care.
England
The paper recommends an information and
communication technology-based system of
accreditation, feedback and facilitated systematic
development and continuous medical education.
Denmark
Weak
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PUBLICATION
KEY CONCLUSIONS
RATING OF COUNTRY
EVIDENCE OF FOCUS
quality development
and continuing
education, in: Ugeskr
Laeger, 171(20):16848
12.Foot C, Naylor C &
Imison C 2010 The
quality of GP
diagnosis and
referral, the Kings
Fund: London
URBIS
DOCUMENT1
This report forms part of the wider inquiry into the
quality of general practice in England commissioned by
The King’s Fund, and focuses specifically on the quality of
diagnosis and referral.
The report is based on a systematic literature review.
Search algorithms were constructed to search three
bibliographic databases – PubMed, HMIC and ASSIA – for
articles on GP diagnosis or referral. A data extraction
framework was developed to allow the content of
identified articles to be recorded systematically and
analysed. A total of 372 published articles were included
in the review.
The authors tested the findings from this review using a
validation event attended by GPs and other
professionals.
The review demonstrated a lack of comprehensive Strong
national data sets on which to base assessments of
quality. It was therefore not possible to make a
definitive assessment of the quality of diagnosis and
referral in primary care. However, there was ample
evidence to show significant variations in practice,
and opportunities for quality improvement in a
number of areas.
Research evidence suggested variation in the quality
of diagnosis, and associated opportunities for
quality improvement. Factors likely to affect the
quality of diagnosis in general practice included
presentation issues, individual practitioner level
issues and system issues.
The review also identified evidence suggesting
improvements in referral processes with distinct
challenges within different specialties, and for
different types of referrals.
Recommendations included: discouraging the use of
overall referral rates as a performance management
measure in primary care; exploration of
mechanisms and incentives for improving
communication between GPs and specialists; a
stronger clinical governance framework to better
understand and improve the quality of clinical
decision-making within general practice; longer
consultation times to support improved decisionmaking around diagnosis and referral; and more
United
Kingdom
APPENDICES
FORM AND SOURCE OF RESEARCH DESIGN/METHODOLOGY
PUBLICATION
KEY CONCLUSIONS
RATING OF COUNTRY
EVIDENCE OF FOCUS
research to link diagnostic and referral practices
with clinical outcomes.
13.Goodyear-Smith F,
Gauld R, Cumming J,
O’Keefe B, Pert H &
McCormack P 2012
International
Learning on
Increasing the Value
and Effectiveness of
Primary Care (I LIVE
PC) New Zealand, in:
Journal of the
American Board of
Family Medicine
(JABFM), 25 (S): 39-44
Narrative literature review on reforms to primary care
arrangements in New Zealand over the past two
decades. The paper reflects on the lessons learned, their
relevance to health care reforms in the United States,
and issues that remain to be resolved.
The article argues that the New Zealand experience Weak
precedes and endorses the concept of patientcentred medical homes providing population-based,
nonepisodic care supported by network
organisations.
Several lessons for the United States may be
gleaned from the New Zealand experience. On the
downside, regular government- imposed
restructuring of the broader health system and of
primary care was seen as a distraction over the
years. However, the New Zealand experience
suggests that there is considerable value in
organised primary care and that clinicians can play
an important leadership role in this.
New
Zealand
14.Greenfield D &
Braithwaite J 2008
Health sector
accreditation
research: a
systematic review, in:
International Journal
for Quality in Health
Care, Vol. 20(3): 172–
183
A multi-method, systematic review of accreditation
literature was conducted from March to May 2007. The
search identified articles researching accreditation.
Discussion or commentary pieces were excluded. From
the initial identification of over 3,000 abstracts, 66
studies that met the search criteria by empirically
examining accreditation were selected. The 66 studies
were retrieved and analysed. The results, examining the
impact or effectiveness of accreditation, were classified
into ten categories: professions’ attitudes to
accreditation; promote change; organizational impact;
financial impact; quality measures; program assessment;
consumer views or patient satisfaction; public disclosure;
professional development; and surveyor issues.
The analysis reveals a complex picture. In two
Strong
categories consistent findings were recorded:
promote change and professional development.
Inconsistent findings were identified in five
categories: professions’ attitudes to accreditation;
organisational impact; financial impact; quality
measures; and program assessment. The remaining
three categories—consumer views or patient
satisfaction, public disclosure and surveyor issues—
did not have sufficient studies to draw any
conclusion.
The search identified a number of national health
care accreditation organisations and researchers
engaged in empirical research activities.
Australia
15.Greenfield D &
Braithwaite J 2009
Developing the
Discussion paper on evidence base for accreditation of
healthcare organisations.
While the discussion paper recognises the increased Weak
number of accreditation agencies in Europe,
Australia and Canada, there is a need for more
N/A (based
on
internationa
APPENDICES
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FORM AND SOURCE OF RESEARCH DESIGN/METHODOLOGY
PUBLICATION
evidence base for
accreditation of
healthcare
organisations: a call
for transparency and
innovation, in:
Quality Safety Health
Care, Vol. 18(3): 162163
16.Greenfield D,
Moldovan M,
Westbrook M, Jones
D, Low L, Johnston B
et al 2011 An
empirical test of short
notice surveys in two
accreditation
programmes, in:
International Journal
for Quality in Health
Care, 2012; Vol.
24(1): 65–71
URBIS
DOCUMENT1
Research paper to evaluate short notice surveys
compared with the advanced notification survey method
in two independent accreditation programmes. The
study sought to investigate the viability and outcomes of
short notice surveys before considering their
incorporation into accreditation processes in Australia.
Two trials using short notice surveys were conducted
independently: a study of 20 healthcare organisations
with the Australian Council on Healthcare Standards
(ACHS) and a study of 7 general practices with the
Australian General Practice Accreditation Limited
(AGPAL).
ACHS and AGPAL selected 17 and 13 surveyors,
respectively, and provided training for them on short
notice surveys.
Short notice surveys assessed accreditation programme
criteria or indicators that corresponded to the Australian
Commission on Safety and Quality in Health Care’s
priority issues. Fifteen (out of 45) ACHS criteria and 48
(out of 174) AGPAL indicators that aligned to the
Commission’s criteria were evaluated.
KEY CONCLUSIONS
RATING OF COUNTRY
EVIDENCE OF FOCUS
transparency in sharing results. It argues that the
main challenge for accreditation agencies is to
publish research protocols and their findings in
peer-reviewed literature. In doing so, these agencies
will be explicitly displaying leadership, transparency
and evidence of improvement.
l review)
The study showed that short notice surveys were
Moderate
more critical in their assessment of clinical than
administrative or corporate items. Short notice
surveys, while broadly comparable with existing
advanced notification survey practice, produced
different accreditation outcomes for a significant
proportion of the study organisations. The overall
value and worth of short notice surveys remained to
be proved.
Australia
APPENDICES
FORM AND SOURCE OF RESEARCH DESIGN/METHODOLOGY
PUBLICATION
KEY CONCLUSIONS
17.Gregory, S 2009
General practice in
England: An
overview, the Kings
Fund: London
A narrative literature review exploring:
 how general practice in England is organised,
contracted and financed
 the impact of recent government policy on general
practice
 future trends in general practice.
18.Inspectie voor de
Gezondheidszorg
2011
Meerjarenbeleidsplan
. Voor
gerechtvaardigd
vertrouwen in
verantwoorde zorg
(II) 2012-2015,
Inspectie voor de
Gezondheidszorg:
Utrecht
Policy document outlining the Dutch health care strategy  Strategy builds upon five key areas of focus,
for the period 2012-2015. Developed by the Health Care
including enhancement of monitoring
Inspectorate, the document proposes the sector’s vision
accountability for quality and safety.
for the next period, including its key area of focus and
 The strategy includes the development of new
key objectives.
indicators in collaboration with health insurers to
enhance monitoring the provision of health care.
The policy document is underpinned by a review of
emerging trends impacting the Dutch public health
system.
19.Lester HE, Eriksson T,
Dijkstra R, Martinson,
K, Tomasik T &
Sparrow 2012 Debate
& Analysis. Practice
accreditation: the
A commissioned piece of work that was not externally
peer reviewed. A survey was conducted with
representatives from all member countries (24 in total)
of the European Association of Quality in General
Practice (EQuiP). The survey explored each country’s
health system and practice accreditation scheme. The
APPENDICES
RATING OF COUNTRY
EVIDENCE OF FOCUS
Key discussion points highlight how changes in the Weak
contracts and financing of general practice created
greater incentives for quality. Due to greater
incentives and increased regulation, the review
argues that quality of health services is likely to
come under greater scrutiny. It predicts an increase
in the range of treatments offered in general
practice and an expanded role in terms of
commissioning local services and supporting those
with long-term conditions. These demands could
lead to the development of new delivery models,
which may transform general practice in England
towards larger organisational groups and
‘federations’ of multidisciplinary professionals.
Weak
Results showed that at the time of the survey:
Weak
 nine countries had practice accreditation schemes
(Czech Republic, Estonia, Germany, the
Netherlands, Poland, Portugal, Romania, Turkey,
and the UK)
 five countries were piloting a practice
England
The
Netherlands
N/A
(European
orientated)
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European
perspective, in:
British Journal of
General Practice,
e390-e392, DOI:
10.3399/bjgp12X641
627
20.Longley M, Riley N,
Davies P &
Hernández-Quevedo
C 2012 United
Kingdom (Wales):
Health system
review, in: Health
Systems in Transition,
Vol. 14(11): 1-84
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KEY CONCLUSIONS
RATING OF COUNTRY
EVIDENCE OF FOCUS
survey reached a 100% response rate.
accreditation schemes (Belgium, Croatia.
Denmark, Slovenia, and Spain)
 ten countries did not have plans to develop a
practice accreditation scheme (Austria, Finland,
France, Greece, Ireland, Israel, Italy, Norway,
Sweden, and Switzerland).
The review identified an increasing number of
countries developing and implementing country
specific and locally-owned accreditation schemes. It
also highlighted Estonia as a country with a largely
developmental and innovative accreditation
scheme. The review also suggested that
implementation remained slow and the evidence
base underpinning the value of accreditation for
patients, practices, and policy makers remained
limited.
The Health Systems in Transition (HiT) series consists of
country-based reviews that provide a detailed
description of a health system and of reform and policy
initiatives in progress or under development in a specific
country. Each review was produced by country experts in
collaboration with the European Observatory on Health
System and Polices staff. In order to facilitate
comparisons between countries, reviews are based on a
template, which is revised periodically.
The review is primarily based on an analysis of literature
and census data.
The review shows many similarities between the
Moderate
health system in Wales and the United Kingdom,
including similarities in key features and challenges.
Challenges are mainly in relation to long-term rising
demand and the need for a strategic shift from
hospital to community services.
Main differences between Wales and the United
Kingdom arise from the use of a quasi-market and
other mechanisms in the UK, while Wales continues
to use a unified system to reach maximum equity of
provision.
The review predicts specific financial challenges in
Welsh health policy due to expected declines in
health expenditure. It also raises concerns about the
financial sustainability of the Welsh health care
system and expresses the need for additional funds
to meet rising demands of care.
Wales
APPENDICES
FORM AND SOURCE OF RESEARCH DESIGN/METHODOLOGY
PUBLICATION
KEY CONCLUSIONS
RATING OF COUNTRY
EVIDENCE OF FOCUS
21.Macinko J, Starfield B
& Shi L 2003 The
Contribution of
Primary Care Systems
to Health Outcomes
within Organization
for Economic
Cooperation and
Development (OECD)
Countries, 1970–
1998, in: HSR: Health
Services Research,
Vol. 38(3): 831-865
The article assessed the contribution of primary care
Key results indicated that:
Moderate
systems on a variety of health outcomes in 18 wealthy
 the financing, organisation, and delivery of
Organisation for Economic Cooperation and
primary care appear to have a significant impact
Development (OECD) countries over three decades (incl.
on health outcomes at the national level
Australia, United Kingdom, Denmark, the Netherlands
 health reform in OECD countries has not
and Canada).
uniformly targeted primary care. Those countries
that began to reform their primary care systems in
Data were primarily derived from OECD Health Data
the 1970s and 1980s have made progress in
2001 and from published literature. The unit of analysis
improving both structural features and practice
was each of 18 wealthy OECD countries from 1970 to
characteristics of these systems
1998 (total n= 504).
 countries with the weakest primary care systems,
and therefore those with the most potential to
benefit from improvements, have, in general, not
made much progress in improving either primary
care structure or practice.
N/A (crosscountry
comparison)
22.Marchildon GP 2013
Canada: Health
system review, in:
Health Systems in
Transition, Vol. 15(1):
1-179
Review of the Canadian health system as part of the
‘Health Systems in Transition (HiT)’ series published by
the European Observatory on Health Systems and
Policies.
The review was narrative in nature, primarily based on
existing articles and census data.
Provides a detailed description of the Canadian
Moderate
health care system in the last few decades, including
information on health care policies and reforms.
Provides general information on Accreditation
Canada but does not specifically report on
accreditation processes for general practitioners.
Canada
23.Mays GP 2004 Can
accreditation work in
public health?
Lessons from other
service industries.
Working paper
prepared for the
Robert Wood
Johnson Foundation,
Department of Health
Policy and
Management, College
Systematic literature review on the experiences and
outcomes of existing accreditation programs (primarily in
the United States) in health and social service industries
in order to derive implications about the potential
benefits and costs of accreditation for public health
agencies. The review focused on accreditation programs
developed in health care, education, social service, and
public service industries.
Telephone interviews with stakeholders were also
conducted to identify additional literature (eg. grey
literature). A total of 94 documents were identified.
Relevant information was abstracted into a database for
Findings showed that that existing accreditation
programs have developed to achieve a variety of
different goals and objectives, ranging from
improving service quality and standardizing service
offerings, to improving the competitiveness of the
service industry and insulating the field from
political influence.
There were relatively few accreditation programs
that relied on evidence-based performance
standards tightly linked to desired service
outcomes.
United
States
APPENDICES
Moderate
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of Public Health,
University of
Arkansas for Medical
Sciences:Arkansas.
analysis and synthesis.
KEY CONCLUSIONS
RATING OF COUNTRY
EVIDENCE OF FOCUS
Limited but encouraging evidence exists to suggest
that accreditation programs produce positive effects
on service quality, service outcomes, and the
operations of service providers.
However, costs incurred by organizations that
undergo accreditation have the potential to create
significant barriers to accreditation for many
organizations that perhaps could benefit most from
the process.
24.McNamara S 2012
Discussion paper on the length of medical school and
Does it take too long prevocational training. Views are based on qualitative
to become a doctor? consultations with various key stakeholders in the field.
Part 1: Medical school
and prevocational
training, in: Medical
Journal of Australia,
Vol. 196(8): 528-530
The paper argues that there is a need for improved Weak
coordination between different stakeholders –
including universities, teaching hospitals and
medical colleges – so doctors can progress more
efficiently. It also addresses the need for an
overhaul of the prevocational training system,
although there is contention about striking the right
balance between specialist and generalist training.
Ideas include imposing a limit on the number of
years doctors spend in unaccredited positions, or
streaming doctors into specialty training earlier.
Australia
25.Nederlandse
Zorgautoriteit 2012
Marktscan
Huisartsenzorg.
Weergave van de
markt tot en met
2011, accessed at 15
August 2014
<http://www.nza.nl/1
04107/105773/47560
5/Marktscan_Huisart
senzorg.pdf>
Policy document providing an overview of primary health
care in the Netherlands through to 2011, including a
review of the market structure, market behaviour,
quality, accessibility and affordability.
Findings were based on an analysis of census data,
national databases and a quantitative survey with
general practitioners and health insurers.
The report describes performance outcomes across Moderate
different key areas in the primary health care
sector, including the market structure, market
behaviour, health care quality, accessibility and
affordability.
The report also reported on the NHG-practice
accreditation program as the most common
accreditation program for Dutch GPs, followed by
HKZ and DEKRA.
The
Netherlands
26.Nicholson C, Jackson
A narrative literature review of how the introduction of
The review identified how PHCOs have helped the
Australia
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Weak
APPENDICES
FORM AND SOURCE OF RESEARCH DESIGN/METHODOLOGY
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CL, Marley JE & Wells
R 2012 The Australian
Experiment: How
Primary Health Care
Organizations
Supported the
Evolution of a
Primary Health Care
System, in: Journal of
the American Board
of Family Medicine
(JABFM), 25 (S): 18-26
KEY CONCLUSIONS
RATING OF COUNTRY
EVIDENCE OF FOCUS
Australian primary health care organisations (PHCOs) has
transformed the PHC landscape. The review is based on
exploring three key questions:
 How did the implementation of PHCOs in the
Australian PHC system create opportunity for adoption
of key PHC features?
 What is an effective health care governance model for
integrated primary/secondary care in Australia?
 What are the future challenges?
Australian primary health care system evolve by
supporting the roll-out of various initiatives,
including national practice accreditation. It also
addressed challenges, including equitable access
and the supply and distribution of a primary care
workforce and overcoming the fragmentation of
funding and accountability in the Australian system.
27.Nicklin W 2014 The
Value and Impact of
Health Care
Accreditation: A
Literature Review,
Accreditation Canada
Summary of literature findings on the value and impact
of health care accreditation. It includes results and
conclusions from research, grey literature, and
experience-based articles.
Review of literature, clustered in six key areas of
focus:
 quality improvement
 the benefits of accreditation
 areas of accreditation requiring further study
 recent trends and innovations in health care
 accreditation
 need for additional literature
 trend toward mandatory accreditation
 transparency of accreditation decisions.
28.O’Beirne M, Oelke
ND, Sterling P, Lait J,
Zwicker K, Ghali W,
Robertson HL &
Kochagina M 2012 A
Synthesis of Quality
Improvement and
Accreditation
Mechanisms in
Primary Healthcare,
Canadian Foundation
Systematic literature review on how quality
improvement (QI) processes and accreditation in primary
healthcare affect outcomes of care, patients’ perceptions
of care, healthcare utilization and costs, and the
perceptions of primary healthcare providers.
The search approach involved restrictions of search
parameters by year (1990-2011) and language (English).
Abstracts were reviewed by two research team members
to determine if they were eligible for inclusion. If there
was disagreement between reviewers, a third team
member reviewed the abstract. Close to 800 abstracts
The review showed evidence of varying support and Strong
strength of the effects of QI on outcomes in primary
healthcare. It identified sufficient evidence for
positive outcomes of QI in specific areas. However,
the review recommends further research to expand
the use of QI to improve other outcomes of care.
The review also addressed a lack of randomized
controlled trials, controlled before-after studies and
time series research on the effect of QI on patients’
perceptions of care, healthcare utilization and costs,
and the perceptions of primary healthcare
APPENDICES
Weak
N/A
(internation
al review)
Canada
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for Healthcare
Improvement:
Ottawa
KEY CONCLUSIONS
RATING OF COUNTRY
EVIDENCE OF FOCUS
were reviewed for QI and 500 for accreditation.
A smaller element in the review entailed stakeholder
interviews. Stakeholders were identified through the
literature review and discussions with Accreditation
Canada. Eight interviews were conducted with
representatives from Canada, United States, United
Kingdom, Netherlands, Denmark, Australia and New
Zealand.
providers. Many studies use different QI
approaches. More research is required on the most
effective QI approaches for primary healthcare
settings.
29.Olejaz M, Juul Nielsen
A, Rudkjøbing A,
Okkels Birk H, Krasnik
A, HernándezQuevedo C. 2012
Denmark: Health
system review, in:
Health Systems in
Transition, Vol. 14(2):
1-192
Review of the Danish health system as part of the Health
Systems in Transition (HiT) series. The review was
primarily based on the analysis of literature and census
data.
The review includes a description of the Danish
Moderate
Institute for Quality and Accreditation in Healthcare
that manages the Danish Healthcare Quality
Programme (DDKM).
Denmark
30.Paccioni A, Sicotte C
& Champagne F 2007
Accreditation: a
cultural control
strategy, in:
International Journal
of Health Care Quality
Assurance, Vol. 21(2):
146-158
A research paper which aims to describe and understand
the effects of the accreditation process on organisational
control and quality management practices in two
Quebec primary-care health organisations.
A longitudinal study was conducted, involving a
qualitative and quantitative approach. Research data
were collected through group interviews, interviews of
key informers, non-participant observations, a literature
review, and quantitative questionnaires for all the
employees working in both institutions.
Key outcomes showed that the accreditation
process reinforced cohesiveness in the selfassessment teams. Formulating expectations and
exchanges with administrators enhanced
communication in the institutions. Accreditation
had limited effect on the perceptions of employees
not directly involved in the process, and for them,
the accreditation process appears to remain an
external, bureaucratic control instrument.
Canada
31.Pedersen KM,
Andersen JS &
Søndergaard J 2012
General Practice and
Primary Health Care
A narrative literature review of the Danish primary
health care system. Provides a description of the Danish
primary health care system, based on existing data and
available literature.
The review describes key characteristics for Danish Weak
general practice, including a brief description of the
Danish Quality Unit of General Practice (DAK-E) for
quality development in the primary care.
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Moderate
Denmark
APPENDICES
FORM AND SOURCE OF RESEARCH DESIGN/METHODOLOGY
PUBLICATION
KEY CONCLUSIONS
RATING OF COUNTRY
EVIDENCE OF FOCUS
in Denmark, in:
Journal of the
American Board of
Family Medicine
(JABFM), 25 (S): 34-38
32.Philips L 2012
International
Learning on
Increasing the Value
and Effectiveness of
Primary Care (I LIVE
PC), in: Journal of the
American Board of
Family Medicine
(JABFM), 25 (S): 1-5
Conference paper to inform the roll out of the Patient
Protection and Affordable Care Act (ACA) in the United
States. The conference was held in 2011, and six
countries participated in the conference (Australia,
Canada, Denmark, The Netherlands, New Zealand, the
United Kingdom and the United States). The paper is a
literature review of best practice in primary health care
in each of these countries.
33.Pomey MP, François Discussion paper on the accreditation system in the
P, Contandriopoulos French healthcare system. The paper involves a
AP, Tosh A &
literature review.
Bertrand D 2005
Paradoxes of French
accreditation, in:
Quality & Safety in
Health Care, Vol. 14: ,
51–55
APPENDICES
The paper identifies six key areas as best practice
Weak
for the roll out of ACA to improve access to primary
care. One of the key areas of best practice is
‘Quality and Safety’, which highlights different
mechanisms and initiatives in European countries
and Canada.
N/A (crosscountry
comparison)
The paper describes five key characteristics of the
Weak
French health care accreditation system, but does
not specifically refer to an accreditation system for
general practices.
The paper also highlights potential risks in the
French accreditation system:
 the mandatory component of the French
accreditation system could be associated with
inspection processes rather than accreditation
processes
 decision makers have access to accreditation
reports which could lead to strategic behaviours
primarily aimed at complying with the
accreditation processes
 health service providers could create a tendency
to reduce quality processes primarily based on the
completion of accreditation.
France
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34.Pomey MP, LemieuxCharles L, Champagne
F, Angus D, Shabah A
& Contandriopoulos
AP 2010 Does
accreditation
stimulate change? A
study of the impact of
the accreditation
process on Canadian
health care
organizations, in:
Implementation
Science, Vol. 5: 31–44
RATING OF COUNTRY
EVIDENCE OF FOCUS
Outcomes showed that accreditation processes
Strong
could:
 accelerate integration and stimulate a spirit of
cooperation in newly merged health care
organisations
 help to introduce continuous quality improvement
programs to newly accredited or not-yetaccredited organisations
 create new leadership for quality improvement
initiatives
 increase social capital by giving staff the
opportunity to develop relationships
 foster links between health care organisations and
other stakeholders.
Canada
35.Pullon S 2011
Discussion paper on GP vocational training in New
Training for family
Zealand and Canada.
medicine in Canada
and general practice
in New Zealand: how
do we compare?, in:
Journal of Primary
Health Care, Vol. 3(1):
82-85
Based on identified differences in GP vocational
Weak
training programs between the two countries, the
paper argues for recommendations in the New
Zealand GP training program:
 commencing GP vocational training at PGY2
level, i.e. one-year post-graduation
 incorporating both hospital and community
clinical placements
 integrating all clinical placements into a threeyear educational programme
 retaining several five-month-long immersion
general practice placements
 security of trainee employment for the duration
of the programme;
 utilisation of both College and university
expertise, staff and student support.
New
Zealand
36.Roland M, Guthrie B Narrative literature review on the health system in the
& Thomé DC 2012
United Kingdom, including a review of recent reforms in
Primary Medical Care relation to quality improvement initiatives and the
Key conclusions include that:
Weak
 primary care practitioners have responsibility for a
defined population which enables them to be held
United
Kingdom
URBIS
DOCUMENT1
This article is a Canadian evaluation study on how
accreditation could improve organisational changes to
enhance the quality and safety of care. The evaluation
was conducted through a multiple case study design
which included focus groups and consultations with staff
and managers from five Canadian health care
organisations and a review of case related documents
(eg. accreditation reports, self-assessment reports). In
order to measure change, a theoretical framework was
adopted which was previously used for a similar
evaluation study in France.
KEY CONCLUSIONS
APPENDICES
FORM AND SOURCE OF RESEARCH DESIGN/METHODOLOGY
PUBLICATION
in the United
introduction of a pay-for-performance scheme (P4P).
Kingdom, in: Journal
of the American
Board of Family
Medicine (JABFM), 25
(S): 6-11
KEY CONCLUSIONS
RATING OF COUNTRY
EVIDENCE OF FOCUS
accountable for the quality of care they provide.
 quality of care in the United Kingdom has
improved substantially in the last 10 years, most
evidently in chronic disease management, which
has been associated with multiple quality
improvement strategies, including P4P.
37.Salmon J, Heavens J,
Lombard C et al 2003
The Impact of
Accreditation on the
Quality of Hospital
Care: KwaZulu-Natal
Province Republic of
South Africa,
Published for the U.S.
Agency for
International
Development (USAID)
by the Quality
Assurance Project,
University Research
Co., LLC.
Research paper to assess the effects of an accreditation
program on public hospitals’ processes and outcomes in
a developing country setting. The study was designed to
examine the impact of an accreditation program on: (a)
the standards identified for measurement and
improvement by the accrediting organisation (in this
case, the Council for Health Services Accreditation of
Southern Africa), and (b) quality indicators developed by
an independent research team.
The study design was a prospective, randomized control
trial with hospitals as the units of analysis. The study
used survey data from the Council for Health Services
Accreditation of Southern Africa’s accreditation program
and quality indicator data collected by an independent
research team composed of South African and American
investigators.
Twenty randomly selected public hospitals (all located in
the in the KwaZulu-Natal province), stratified by size,
were part of the study. Ten of these hospitals entered
the accreditation program in 1998; the other ten, which
served as a control, entered about two years later.
The study measured the effects of the Council for
Strong
Health Services Accreditation of Southern Africa’s
hospital accreditation program on various indicators
of hospital care. About two years after accreditation
began, the study found that intervention hospitals
significantly improved their average compliance
with accreditation standards from 38 per cent to 76
per cent, while no appreciable increase was
observed in the control hospitals (from 37 per cent
to 38 per cent). This improvement of the
intervention hospitals relative to the controls was
statistically significant and seems likely to have been
due to the accreditation program. However, the
independent research team observed little or no
effect of the intervention on the eight quality
indicators.
South Africa
38.SCRGSP (Steering
Committee for the
Review of
Government Service
Provision) 2014,
Report on
This report is part of the annual Report on Government
Services (ROGS) to provide information on the equity,
effectiveness and efficiency of government services in
Australia. Findings are primarily based on a review of
census data and literature.
The report provides a description on accreditation
Weak
programs for general practitioners. It also emphasis
that accreditation of general practice is a voluntary
process of independent third-party peer review that
involves the assessment of general practices against
a set of standards developed by the RACGP.
Australia
APPENDICES
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FORM AND SOURCE OF RESEARCH DESIGN/METHODOLOGY
PUBLICATION
Government Services
2014, vol. E, Health,
Productivity
Commission,
Canberra
KEY CONCLUSIONS
RATING OF COUNTRY
EVIDENCE OF FOCUS
Accredited practices, therefore, have been assessed
as complying with a set of national standards.
Findings include a review of the uptake of
accreditation services by general practitioners. Data
was unavailable for the 2014 report. According to
previous data from 2011, there were nationally
4,783 accredited general practices, representing
67.4 per cent of general practices.
39.Seddon, M.E., M N
Marshall, S M
Campbell, M Roland
2001 Systematic
review of studies of
quality of clinical care
in general practice in
the UK, Australia and
New Zealand, in:
Quality in Health
Care, Vol. 10:152–158
A systematic literature review of 90 published studies
assessing the quality of clinical care in general practice
for the period 1995–1999 (80 from the UK, six from
Australia, and four from New Zealand).
Data was mainly extracted from descriptive studies that
specifically aimed to assess quality of care, evaluations of
audit programs and intervention studies.
Findings showed that most of the care for common
and chronic conditions is provided in general
practice. The review identified a lack of evidence
base on the quality of clinical care in terms of
methodological rigor and comprehensiveness. In
almost all studies reviewed the quality of care did
not attain acceptable standard of practice.
The review argues that practitioners and policy
makers need to develop systematic ways of
improving the quality of clinical care in general
practice.
40.Shaw CD, Braithwaite
J, Moldovan M,
Nicklin W, Grgic I,
Fortune T &
Whittaker S 2013
Profiling health-care
accreditation
organizations: an
international survey,
in: International
Journal for Quality in
Health Care, Vol. 25
(3): 222–231
A repeat study following an earlier study (from 2000) to
provide updated insights into international
developments in accreditation. Key objectives were to
describe global patterns among health-care
Accreditation Organisations (AOs) and to identify
determinants of sustainability and opportunities for
improvement.
The methodology involved a quantitative online
questionnaire, exploring key issues related to policy and
governance, development, funding, training and
facilitation, report management, scope of services and
activities in hospital and primary care.
A total of 61 AOs were included in the study, of which 44
Results indicated a growing trend of programs
Moderate
linked to public funding and regulation.
Successful accreditation organisations tended to
complement mechanisms of regulation, health-care
funding or governmental commitment to quality
and health-care improvement that offer a
supportive environment.
Principal challenges included unstable business (e.g.
limited market, low uptake) and unstable politics.
Results also described that many organisations only
provide limited information to patients and the
public about standards, procedures or results.
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Strong
N/A (crosscountry
comparison)
N/A (crosscountry
comparison)
APPENDICES
FORM AND SOURCE OF RESEARCH DESIGN/METHODOLOGY
PUBLICATION
KEY CONCLUSIONS
RATING OF COUNTRY
EVIDENCE OF FOCUS
(n=44) completed the survey. Participating AOs were
from different countries, including Australia, Denmark,
England, Germany, India, Japan, Malaysia, South Africa,
Spain and the Netherlands.
Primary data collection was managed by Accreditation
Canada. The resulting database was transferred to the
Australian University of New South Wales (UNSW) for
validation and analysis in November 2010.
41.Starfield B & Mangin Discussion paper on the pay-for-performance system in
D 2010 An
UK general practice – the Quality and Outcomes
international
Framework (QOF) – from an international viewpoint.
perspective on the
basis for payment for
performance, in:
Quality in Primary
Care, Vol. 18: 399-404
This paper argues that there is limited evidence on Weak
the impact of QOF on health services and outcomes.
The framework for the QOF does not align well with
the scope of primary care, making its basis as a tool
for quality measurement questionable. The extent
of impact of the QOF on health outcomes and on
equity of health outcomes needs further
examination. Alternative modes of improving
patient care may be better than the QOF.
United
Kingdom
42.Timmins N 2013 The Discussion paper on recent reforms and health policies in The paper argues for strengthening and increasing Weak
four UK health
England, Scotland, Wales and Northern Ireland.
collaboration between the four countries in order to
systems Learning
enhance the health care system.
from each other, The
King’s Fund: London
United
Kingdom
43.Van Althuis TR 2008
Uniforme Rapportage
en Indicatoren voor
de kwaliteit van de
huisartsenzorg,
Nederlands
Huisartsen
Genootschap (NHG)
Proposal document on the development of a uniform set
of health care indicators in the Dutch health care system,
including the key steps in the process of the
development.
The document outlines risks and restrictions in the
use of health care indicators in general, particularly
in relation to the validity of outcomes of data
collection processes.
Weak
The
Netherlands
44.Willcox S, Lewis G &
Narrative literature review on primary care systems in
The review identified quality improvement
Weak
N/A (cross-
APPENDICES
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PUBLICATION
Burgers J 2011
Strengthening
Primary Care: Recent
Reforms and
Achievements in
Australia, England,
and the Netherlands,
in: The
Commonwealth
Fund, pub. 1564, Vol.
27: 1-19
45.Wright M 2012 Payfor-performance
programs. Do they
improve the quality
of primary care? in:
Australian Family
Physician, Vol. 41
(12): 989-991
URBIS
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KEY CONCLUSIONS
RATING OF COUNTRY
EVIDENCE OF FOCUS
Australia, England and the Netherlands to inform the
health care system in the United States. The review
aimed to examine key strategies in each country for
strengthening primary care:
 promoting coordination of care
 reforming primary care payment
 improving quality and access.
strategies in each country, including postgraduate
training programs for family physicians,
accreditation of general practitioner practices, and
efforts to modify professional behaviours.
The review also addressed payment reform as a key
element of English and Australian reforms, with
both countries having introduced payment-forquality initiatives. Dutch payment reform has
stressed financial incentives for better management
of chronic disease.
country
comparison)
Narrative literature review examining evidence on the
impact of pay-for-performance (P4P) programs on the
quality of primary care.
The review points out that although P4P programs Weak
in primary care appear to have an effect on the
behaviour of general practitioners, there is little
evidence that these programs in their current form
improve health outcomes or healthcare system
quality. Further research is needed into the effect of
these programs on healthcare quality before they
are introduced into Australian general practice.
Australia
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