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The external assessment of health services - WHO

WORLD hospitals and health services | 13 The external assessment of health services24| World Hospitals and health services | the 1990s new accreditation programmes havedeveloped in many countries and, elsewhere,individual health care organisations can buy servicesfrom other countries. The independent assessments, and thestandards which they use increasingly reflect an emphasis onpatients, safety and clinical performance and thus theyappeal not just to health care managers but also to thepublic, purchasers and regulators. Who wants external assessment ?Before choosing a model or a provider of externalassessment, managers and regulators need to be clear abouttheir objectives, their customers and the potentialstakeholders. But frequently they choose first and then findout later whether it meets conflicting and managers the motive is often organisationaldevelopment (to build teams by systematically examiningpolicies, procedures and communications across theinstitution) which demands much internal effort, self- assessment and time.

Graduation of standards Typically, new national accreditation programmes used to begin by assessment against minimal standards of capacity

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Transcription of The external assessment of health services - WHO

1 WORLD hospitals and health services | 13 The external assessment of health services24| World Hospitals and health services | the 1990s new accreditation programmes havedeveloped in many countries and, elsewhere,individual health care organisations can buy servicesfrom other countries. The independent assessments, and thestandards which they use increasingly reflect an emphasis onpatients, safety and clinical performance and thus theyappeal not just to health care managers but also to thepublic, purchasers and regulators. Who wants external assessment ?Before choosing a model or a provider of externalassessment, managers and regulators need to be clear abouttheir objectives, their customers and the potentialstakeholders. But frequently they choose first and then findout later whether it meets conflicting and managers the motive is often organisationaldevelopment (to build teams by systematically examiningpolicies, procedures and communications across theinstitution) which demands much internal effort, self- assessment and time.

2 Others may be seeking a seal ofapproval, a badge which can be used for competitivemarketing and contracting, or just to comply with legalrequirements; here, the less effort required internally thebetter. But the strongest driver is the prospect of access toadditional funding (with or without pressure fromgovernment or other bodies which regulate professionaltraining, safety or public health ). Regulators and purchasers may use third-party assessmentas an economical and independent referee of legal orcontractual compliance, if the standards and criteria arecompatible. Many recent health reform projects include theestablishment of a national accreditation programme tomonitor the impact of changes (and the internationalinvestment) on health systems. What are the broad options?1A research project funded by the European Union2identified systematic approaches which link national (orinternational) standards to local practice, and which havebeen applied to the private or public sectors.

3 Theseapproaches have been systematically compared in a numberof studies of standards and methods used by industry-based(ISO certification, the Excellence model) and health carebased (peer review, accreditation) ,4,5,6 Eachprogramme, to varying degree, is voluntary and independentand uses explicit standards to combine internal self- assessment with external review by visits, surveys,assessments or audits7. Alongside these (usually) voluntaryprogrammes, are many specialised and generic systems ofstatutory inspection and countries have statutory inspectorates to monitorDR CHARLES SHAWDIRECTOR, AUDIT AND QUALITY, CLINICAL ACCOUNTABILITY, SERVICE PLANNING AND EVALUATION RESEARCH (CASPE) MANAGEMENT: external ASSESSMENTA bstractExternal assessment is increasingly used worldwide to regulate, improve and market health care providers,especially hospitals. The commonest models are peer review, accreditation, statutory inspection, ISO certificationand evaluation (usually internal) against the business excellence framework.

4 Each of these is progressivelyadapting to meet the changing demands of public accountability, clinical effectiveness and improvement of qualityand safety, but the most rapid development is in accreditation. Voir page 50 le r sum en fran ais. En la p gina 51 figura un resumen en espa hospitals and health services | 13compliance of hospitals with published regulations requiredfor licensing. More specialised versions typically relate to fire,hygiene, radiation, medical devices and medicines but somecountries include infection control and blood are in the public domain as legal regulationsand are thus difficult to update. They address the minimallegal requirements for a health care organization to operateand care for patients, in terms of structure and capacity toprotect basic public health and safety; they do not usuallyaddress clinical process or hospital performance. In manycountries, institutional licences are issued before a newinstitution opens and there is no systematic or regular followup; in some, operating licences are reissued in return forpayment of a fee with minimal or no inspection.

5 Suchassessments by local government agents may be inconsistentnationally and do not provide a credibly independent checkon the public Organization for StandardizationThe International Organization for Standardization (ISO)8developed a series of standards (ISO 9000) which wereoriginally designed for the manufacturing industry (egmedicines, medical devices) but which has been used toassess quality systems in specific aspects of health servicesand in whole hospitals and clinics. Hospitals (or, morecommonly, parts of them) are assessed by independentauditors who are themselves regulated by a national accreditation agency. Performance is measured in terms ofcompliance with the ISO is widely available from independentcertificated auditors and is recognised in many other serviceand manufacturing industries, and across national the current ISO 9000 standards relate more toadministrative procedures than to hospital performance, andthe terminology is difficult to relate to health care, leading tovarying interpretations between national agencies9.

6 Theaudit process tests compliance with standards and is notintended in itself for organisational , the ISO 9000 series of standards for qualitysystems were adapted in 2000 to become more easilyapplied to health care and to include the assessment ofoutcomes and consumer satisfaction. There are initiatives inUSA (led by the major motor manufacturers who purchasehealth care for their employees) and in Europe (led by CEN)to interpret quality standards for health care. The morespecific ISO 15189 is becoming the international standardfor medical laboratories and includes issues of clinicaljudgement, process and modelThis assessment model is based on the Malcolm Baldrigecriteria for management systems which evolved from theUSA into national and international assessment programmessuch as in Australia (Australian Business Excellence Model)and in Europe (European Foundation for QualityManagement).

7 It is primarily a tool for self- assessment butsome countries offer national awards to the highest achieversfollowing external assessment . Many health care institutions10,11,and even accreditationprogrammes have adopted the framework of standards andstructure of review Reciprocal visiting is driven by professional and often uni-disciplinary organisations and has a long tradition as a form ofpeer review especially for the recognition of training posts. Ithas also been applied to service development, such as in thehospital specialties programme in the Netherlands (visitatie) review is generally supported and endorsed by clinicalprofessions as a means of self-regulation and clinicalimprovement, and integrates well with requirements forundergraduate, specialty and continuing professionaldevelopment. But it is specialty-based, not covering wholehospitals, and results are confidential and not Independent, voluntary programmes developed from a focuson training into multi-disciplinary assessments of health carefunctions, organisations and networks.

8 Their standards forassessment have been developed specifically for health of hospitals include internal self- assessment , external survey by multi-disciplinary team of healthprofessionals, and benchmarking of a limited range ofstatistical are available in many countries byindependent agencies which may be themselves accreditedunder international standards (ALPHA principles andstandards13). The measurement process includes testing ofinternal systems to improve patient orientation, clinicalprocess, outcome and organisational of accredited hospitals are generally published onindividual programme websites but details of survey resultsare not publicly available, except for governmentalprogrammes. Because criteria and assessment processes varybetween programmes, accreditation status cannot beassumed to be directly comparable with other countries.

9 Developments in accreditationUptake and growthA global study for WHO in 200014identified 36 nationwideaccreditation programmes and their rapid growth since1995, especially in Europe. A survey of the WHO EuropeanRegion in 200215identified 17 such programmes focusing onwhole hospitals. Mandatory programmes have recently beenadopted in Croatia, France16, Italy17and roleHalf of the programmes, especially during the past ten years,have been funded or managed directly by nationalgovernments which use them more as a means of regulationand public accountability, rather than voluntary self-development. | World Hospitals and health services | 25 MANAGEMENT: external ASSESSMENTG raduation of standardsTypically, new national accreditation programmes used tobegin by assessment against minimal standards of capacityin terms of structure; more recent and developedprogrammes are now characterised by using optimumstandards of performance in terms of process and transition from structure standards to optimumstandards of performance in terms of process and outcomeoccurs as systems develop.

10 Once the health system hasgenerally achieved high levels of performance againststructure standards then efforts can be directed to processes,and then to outcomes. In South Africa, Cohsasa offers aprogramme of graded recognition and facilitatedaccreditation which is designed to narrow the wide gapbetween rich and poor focusAs with quality improvement generally, accreditationtraditionally developed in hospitals and then moved inwardstowards clinical specialties20and outwards towardscommunity services and then to networks of preventive andcurative services . The shifting of emphasis towards primarycare may reflect a move to population-based medicinereinforced, particularly in developing countries, by thepolicies of donors of overseas programmes in North America accredit entire healthnetworks, and are beginning to shift from individual healthcare towards population health ; some recent governmentalprogrammes in Europe address public health priorities (suchas cardiac health , cancer services ) by assessing localperformance of preventive to tertiary services againstnational service national programmes, especially within Europe, haveagreed in principle to voluntary convergence of standardsand assessment processes according to the ALPHAP rinciples of the International Society for Quality in HealthCare.


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