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

Accreditation has been widely used to promote accountabilityin healthcare. However, with the rise of both purchaser and consumerdemand for broader and more detailed information onperformance beyond licensure and professional self-regulation,especially at the provider level, the role of accreditation is lessclear. We hypothesize that for accreditation to be a critical part ofa market-driven, consumer-focused healthcare system, accreditingbodies must enlarge their scope of assessment with an emphasis onclinical performance of providers, revise and expand their level ofreporting and transparency of assessment, and broaden the base oftheir governance. A new approach to accreditation could enhanceaccountability by (1) building on an existing framework and data-collectionstructure that are proven elements of quality assurancein multiple healthcare sectors; (2) expanding existing involvementof both public and private entities in the process; (3) building onexisting linkages to professional and regulatory bodies; (4) providinggreater flexibility, compared with regulation, in responding tochange; and (5) having a defined source of funding. By thesemeans, accrediting bodies will both improve accountability andsuccessfully drive quality improvement.

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

Accountability has been defined as "the procedureand process by which one party provides ajustification and is held responsible for itsactions by another party who has an interest in theaction."¹ Accountability in healthcare has been characterizedas being driven by 3 major forces: regulation,professionalism, and the market.² Parties that may seekaccountability include those directly affected by healthcareservices (patients, family) or those that directly orindirectly pay for the services (insurers, employers,employees, and taxpayers). We will refer collectively tothis group of interested parties as "the public."

Accountability can be achieved by informal, subjectivemeans or through the exchange of informationusing some formal set of metrics. One mechanism usedto foster accountability in healthcare is accreditationand/or certification. The accreditation process involvesan external entity evaluating a given organizationagainst a set of predetermined requirements, criticalattributes, or performance benchmarks.³ Certificationdenotes a similar process, but usually refers either todetermination of individual competency or to evaluationof a single program or set of activities.

The related, but separate, process of licensure derivesfrom legal and regulatory processes and involves thedetermination by a public agency of whether a givenentity or person meets basic qualifications or competenciesseen as necessary for providing services to the public.⁴ The processes of accreditation (or certification) andlicensure, and the concept of professionalism (specifically,professional self-regulation), have been closely linkedin the past. Indeed, accreditation most often is developedby a professional group or industry as a self-regulatoryalternative to more restrictive and extensive publicregulatory or licensure requirements.^5-8 However in therecent past, consumerism and the market have begun toplay more prominent roles in driving accountability.⁹

Our major premise is that the process and content ofaccreditation can, and should, be expanded to meet thegrowing demand by the public (consumers, insurers andpurchasers) for accountability beyond licensure andprofessional self-regulation. To this end, accreditingbodies must be willing to (1) broaden their focus ofassessment to include an emphasis on evidence-basedperformance, including clinical functions; (2) revise andexpand their level of reporting and transparency ofassessment; and (3) open and enlarge the base of theirgovernance. Although similar changes are needed (andare beginning to take place) in public-sector programsand within the areas of professional certification, thispaper will focus on private-sector accreditation.

THE IMPETUS FOR CHANGE

Although accreditation has played a substantial rolein ensuring accountability, its roots in professionalismand regulation, its traditional reliance on structuralassessment, and its use of "pass-fail" public reportingraise major concerns about its usefulness beyond providinga "floor" of accountability related to regulatory orprofessional issues. There are increasing concernsabout the effectiveness of professionalism and regulationas the primary forces driving accountability. Inaddition, there is increased public understanding ofquality and an enhanced ability to measure it.

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

A substantial literature, including several reportsfrom the Institute of Medicine (IOM), document markedvariation both in the quantity and quality of care providedby hospitals, health plans, and other accreditedentities.^10-15 Because the public has become increasinglyaware of this variation, demands for information onquality also have increased. These demands have comefrom public-sector and private-sector purchasers, consumers,and insurers.^16-18 Although consumer use ofperformance information appears to be rather limited,^19-22 both public and private purchasers and healthplans are actively using performance data to informconsumer choice, develop network tiers, or providefinancial and other rewards for performance.^16,17 TheIOM reports and the other studies cited also have castdoubt on our past and current reliance on professionalismand internal quality improvement mechanisms asthe primary means of ensuring accountability. A full discussionof the benefits and limitations of professionalismare beyond thescope of this paper;however, there is agrowing literatureexploring thisissue.^23,24

The IOM provides auseful list of desirableattributes for ourhealthcare system.¹⁰Moreover, the creationof reliable, valid, andfeasible measures ofclinical performance,such as the HealthPlan Employer Dataand Information Set(HEDIS^®) developed by National Committee for QualityAssurance (NCQA) and the Oryx^® set created by the JointCommission on Accreditation of HealthcareOrganizations (JCAHO), have greatly expanded thetools available for measurement.^5,6,9 In addition, theseorganizations have taken steps to ensure that measuresare timely and performance data are collected ina way that allows valid comparison between entities.These steps include development of detailed measurespecifications, use of sampling frames, auditing of collectionmethods, and ongoing review and maintenanceof the quality measures. Although the measures still areundergoing evolution, and there are technical and politicalissues related to extending measurement to theindividual physician level, the use of clinical performancemeasurement is growing rapidly. Finally, theefforts of the National Quality Forum to create bothstandardization of metrics (voluntary consensus standards)and a framework for accountability in healthcareare accelerating progress in measurement and use ofinformation on performance in healthcare.^25-27

The emergence of a robust framework, an increasednumber and scope of valid measures, and greater marketforces have heightened the call for more accountabilityin healthcare. However, there is no definedmechanism for gathering or reporting performanceinformation for accountability purposes. Available optionsrange from voluntary reporting by providers tocreating regulatory or licensure-related requirementsfor reporting (Table 1). We propose, however, that arevised and expanded process of accreditation offers anumber of important advantages, including:

• Building on an existing framework and data-collectionstructure that are proven elements of qualityassurance in multiple healthcare sectors.
• Involvement of both public and private entities inthe process.
• linkages to both professional groups and regulatorybodies.
• Greater flexibility, compared with regulation, inresponding to change.
• A defined source of funding.

The most problematic disadvantage is the semivoluntarynature of accreditation. However, strongpressure through contract requirements of private purchasersand health plans, or public purchasing andquasi-regulatory approaches that use "deemed status"for accredited entities (like the approach used by theCenters for Medicare & Medicaid Services [CMS] in theMedicare programs and by some states in regulation ofhospitals and health plans) can go a long way to encouragingmost, if not all, entities to undergo accreditation.For example, between state regulation and CMSrequirements for participation in the Medicare program,nearly all hospitals undergo accreditation by a privateentity through the regulatory doctrine of deemed status.

CHANGES NEEDED WITHIN THEACCREDITATION PROCESS

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

To be responsive to public as well as professionalneeds, the input to and control of the accreditingprocess will need to be expanded to include more fromconsumers, purchasers (public and private), and payers.Although this does not lessen the role of professionalsand those representing the entities that undergoaccreditation in setting the standards and desirable levelsof performance (especially for technical aspects ofcare), it does imply a higher degree of shared control.This shared governance will be increasingly importantas the healthcare system struggles to deal with issuesresulting from the public's demand for increasedaccountability: for example, balancing the harm of misclassificationof providers or plans (eg, ranking a personor entity low when they are actually performing well)against the public's need for information, or decidingwhether information about resource use and costshould be a part of evaluation and reporting. It is notclear whether shared governance can be accomplishedsimply by having advisory groups to accrediting bodies,or if fully shared control at board levels will benecessary. Some accrediting and certification entitieshave already created a broader role for public input.For example, public members now constitute about25% of JCAHO's 30-member board, and only 1 memberof NCQA's 18-person board is from an entity accreditedby NCQA.^28,29

Adopting a Broader Set of Evidence-basedPerformance Metrics and Data onRelative Performance

Most accreditation programs have relied primarily ondocumentation of structures and processes that demonstrateadherence to administrative standards. Althoughstructural standards are very useful in some situations,³⁰ their exclusive use as a quality measurementtool depends on the largely unproven assumption thatthere is a strong and consistent linkage between thespecified set of structures and performance in terms ofclinical processes and outcomes.

The expansion of measurement beyond structure oradministrative standards depends on the presence ofevidenced-based clinical guidelines, as well as on thecreation of reliable and valid measures of adherence tothose guidelines. Both of these requirements have beenmet in a number of clinical areas,^28,29 but substantialbarriers remain to adapting guidelines for measurementat the physician-practice level.²¹ Along with the developmentof reliable and valid clinical performance measures,standardized and well-tested measures of patients'experience of care have been created.^31-33 The additionof performance measures permits basing the accreditationdecision on a set of evaluations that conform to thebroad conception of quality articulated by both the IOMand the National Quality Forum.^7,28 Performance measuresalso provide information that can be reported bothto the provider for quality improvement and to the publicfor accountability.

Expanded Public Reporting of Evaluation

Accreditation decisions usually have been reportedon a pass or fail basis, or even by just listing thoseaccredited with no mention of those who attempted toachieve accreditation, but failed. However, where marketforces demand information for choice, a pass/faildesignation clearly is insufficient, especially in thosesituations where accreditation is essentially "required"for participation in an insurance program (eg, for hospitalsin the Medicare program). With an expanded set ofmetrics, accreditation could provide a much richer setof information beyond pass or fail. For example, NCQAreports health plan accreditation status as commendable,accredited, or provisional, and ranks each plan(using 1 to 4 stars) on specific areas including access toservice, credentials of providers, staying healthy, gettingbetter, and living with chronic illness.²⁸ In addition,NCQA publicly reports in Quality Compass^® the clinicalperformance of individual plans on a relatively broad setof HEDIS^® clinical performance measures.²⁸ JCAHOprovides similar expanded information on both administrativeand selected clinical performance measuresreported by hospitals that it accredits.²⁹

SUMMARY

Accreditation has played an important historical rolein demonstrating accountability within the healthcaresystem. As market demands for actionable informationand accountability for costs and quality become moreevident, accreditation could assume a pivotal role inensuring that such data are provided. However, this willnot come to pass without continued evolution of accreditingbodies to expand the scope of governance, measurement,and reporting.

From the National Committee for Quality Assurance, Washington, DC.

Address correspondence to: L. Gregory Pawlson, MD, National Committee forQuality Assurance, 2000 L Street, NW, Suite 500, Washington, DC 20036. E-mail: pawlson@ncqa.org.

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