Public Health Public Health AccreditationAccreditation

Learning from OthersLearning from Others

Paul K. Halverson, DrPH, FACHEPaul K. Halverson, DrPH, FACHE

LOWLOW

NORMALNORMAL

HIGHHIGH

Measurement Measurement

Why Accreditation in the Service Why Accreditation in the Service Sector?Sector?

The Governor asked, “Gentlemen, are you The Governor asked, “Gentlemen, are you concerned with advancing the health, concerned with advancing the health, safety, and welfare of the people …or are safety, and welfare of the people …or are you primarily interested in eliminating you primarily interested in eliminating competition and raising prices?”competition and raising prices?”

The spokesman smiled and said, “Governor, The spokesman smiled and said, “Governor, we’re interested in a little of each.”we’re interested in a little of each.”

─ ─ Council of State Governments, 1952Council of State Governments, 1952

Multiple Forms of “Regulation” Multiple Forms of “Regulation” in the Service Sectorin the Service Sector

Professional ControlProfessional Control

Governmental ControlGovernmental Control

Informal Peer PressureInformal Peer PressureInformal Peer PressureInformal Peer Pressure

Formal Peer ReviewFormal Peer ReviewFormal Peer ReviewFormal Peer Review

AccreditationAccreditationAccreditationAccreditation CertificationCertificationCertificationCertification

LicensureLicensureLicensureLicensure

Government ProvisionGovernment ProvisionGovernment ProvisionGovernment Provision

Opposing Economic Theories of Opposing Economic Theories of Accreditation, Certification, & LicensureAccreditation, Certification, & Licensure

Information AsymmetryInformation Asymmetry– service quality is difficult to verify ex ante service quality is difficult to verify ex ante

by the buyersby the buyers– ““lemons” problem may arise as low quality lemons” problem may arise as low quality

services drive out higher quality servicesservices drive out higher quality services

Industry CaptureIndustry Capture– service providers desire to differentiate, service providers desire to differentiate,

gain marketing advantage, limit gain marketing advantage, limit competitioncompetition

─ Stiglitz 1971Stiglitz 1971

Rationale for this StudyRationale for this Study

Public health now faces many of the same Public health now faces many of the same pressures that confronted other service pressures that confronted other service industriesindustries– Gaps in availability & qualityGaps in availability & quality– Variation in practiceVariation in practice– Coordination and interoperability issuesCoordination and interoperability issues– Growing demand for accountabilityGrowing demand for accountabilityIf accreditation has helped other If accreditation has helped other industries, does it hold promise for public industries, does it hold promise for public health?health?

Findings: Findings: Goals & Objectives Pursued by AccreditationGoals & Objectives Pursued by Accreditation

Objectives of Internal StakeholdersObjectives of Internal Stakeholders

Promote professionalization, visibility & legitimacy Promote professionalization, visibility & legitimacy

Increase demand for services produced by industryIncrease demand for services produced by industry

Distinguish services from competing industriesDistinguish services from competing industries

Limit entry of new and/or inferior organizations Limit entry of new and/or inferior organizations

Reduce need for direct governmental regulationReduce need for direct governmental regulation

Increase public and private investments in industryIncrease public and private investments in industry

Facilitate recruitment and retention of skilled staffFacilitate recruitment and retention of skilled staff

Provide a buffer against political influenceProvide a buffer against political influence

Findings: Findings: Goals & Objectives Pursued by AccreditationGoals & Objectives Pursued by Accreditation

Objectives of External StakeholdersObjectives of External StakeholdersAssure/improve overall quality and safetyAssure/improve overall quality and safetyAssure/improve cost-efficiency & value of Assure/improve cost-efficiency & value of services services Reduce variation in the type and nature of Reduce variation in the type and nature of services & ensure providers can deliver a services & ensure providers can deliver a standard set of servicesstandard set of servicesFacilitate coordination and interoperability of Facilitate coordination and interoperability of servicesservicesEnsure institutional and financial stability of Ensure institutional and financial stability of service organizationsservice organizations

Findings: Findings: Program DesignProgram Design

Basic ComponentsBasic ComponentsInternal-self assessmentInternal-self assessmentSite visit for external validation & assessmentSite visit for external validation & assessment– Direct observation of operationsDirect observation of operations– Review of policies & proceduresReview of policies & procedures– Review of administrative & clinical recordsReview of administrative & clinical records– Interviews with employees & clientsInterviews with employees & clientsSubmission of standardized performance Submission of standardized performance measures**measures**Summary assessment & scoringSummary assessment & scoring

Findings: Findings: Strong Incentives for AccreditationStrong Incentives for Accreditation

ProgramProgram Incentives Incentives

JCAHO, CARF JCAHO, CARF Medicare deemed statusMedicare deemed status

CHAPCHAP Deemed status, Deemed status, benchmarking databenchmarking data

CHEACHEA Eligibility for grants/loans,Eligibility for grants/loans,transfer of creditstransfer of credits

NAEYCNAEYC Block grants targeted to Block grants targeted to accredited centers, accredited centers, differential paymentsdifferential payments

Findings: Findings: Moderate/Weak Incentives for AccreditationModerate/Weak Incentives for Accreditation

ProgramProgram IncentivesIncentives

NCQA, EAP, NCQA, EAP, Some employers give Some employers give URACURAC preference in purchasingpreference in purchasing

HRSAHRSA Exemption from OPR reviewExemption from OPR review

Fire depts.Fire depts. Insurance discountsInsurance discounts

CALEACALEA Lower liability costsLower liability costs

AMAPAMAP Some hospitals & plans Some hospitals & plans give preference in give preference in contracts**contracts**

Findings:Findings:Impact of AccreditationImpact of Accreditation

Selection EffectsSelection Effects:: accreditation accreditation attracts higher-quality organizationsattracts higher-quality organizations

Program Effects:Program Effects: accreditation accreditation causes organizations to improve causes organizations to improve qualityquality

Unintended EffectsUnintended Effects:: accreditation accreditation disrupts operations, reduces accessdisrupts operations, reduces access

Impact of AccreditationImpact of AccreditationUSAID South African Hospital Accreditation TrialUSAID South African Hospital Accreditation Trial

Source: Salmon et al. 2003Source: Salmon et al. 2003

Impact of AccreditationImpact of AccreditationSAMHSA Methadone Clinic TrialSAMHSA Methadone Clinic Trial

Source: D’Aunno and Pollack 2002Source: D’Aunno and Pollack 2002

Impact of AccreditationImpact of AccreditationJCAHO Hospital Accreditation and MI CareJCAHO Hospital Accreditation and MI Care

0

10

20

30

40

50

60

70

Aspirin onadmission

B-blockers onadmission

B-blockers duringhospitalization

30-day mortality

SurveyedNot surveyed

Source: Chen et al. 2003Source: Chen et al. 2003

Impact of AccreditationImpact of AccreditationHEDIS Accreditation for Health PlansHEDIS Accreditation for Health Plans

-8-6-4-202468

101214

1994 1995 1996 1997 1998

Accredited plans

Denied plans

Annual Percentage Change in Enrollment Relative toAnnual Percentage Change in Enrollment Relative toNon-Accredited Health PlansNon-Accredited Health Plans

Source: Beaulieu and Epstein 2002Source: Beaulieu and Epstein 2002

Conclusions & ImplicationsConclusions & Implications

Evidence suggests that Evidence suggests that accreditation holds potential for accreditation holds potential for improving service qualityimproving service quality

Costs are significant and must be Costs are significant and must be weighed against expected weighed against expected benefitsbenefits

Costs could generate disparities Costs could generate disparities in access to accreditationin access to accreditation

Conclusions & ImplicationsConclusions & Implications

Strong incentives are vital to Strong incentives are vital to successsuccess

Governance should be be broad Governance should be be broad & inclusive to ensure & inclusive to ensure responsiveness & credibilityresponsiveness & credibility

Need for evidence-based Need for evidence-based standards to ensure desired standards to ensure desired outcomes are achievedoutcomes are achieved

Conclusions & ImplicationsConclusions & Implications

Accreditation is not a silver bulletAccreditation is not a silver bullet

Should be considered as only part of the Should be considered as only part of the strategy:strategy:

– Performance measurement & reportingPerformance measurement & reporting

– Evidence-based guidelinesEvidence-based guidelines

– Continuous quality improvementContinuous quality improvement

– Workforce education & trainingWorkforce education & training

– Licensure and regulationLicensure and regulation

– Contracting, payment and compensationContracting, payment and compensation

On the Horizon…On the Horizon…

Collaborative process to develop a Collaborative process to develop a national accreditation program for PH national accreditation program for PH agenciesagencies–CDCCDC–National Association of County & National Association of County &

City Health OfficialsCity Health Officials–Association of State and Territorial Association of State and Territorial

Health OfficialsHealth Officials–Robert Wood Johnson FoundationRobert Wood Johnson Foundation

National Public Health National Public Health Performance Standards ProgramPerformance Standards Program

National Public Health National Public Health Performance Standards ProgramPerformance Standards Program

What getsWhat gets

MEASUREDMEASUREDgetsgets

DONE !DONE !

AccountabilityAccountability

Those who have the Those who have the political right to select political right to select and dismiss health and dismiss health officials should also officials should also be given an intelligent be given an intelligent right to to do so. I right to to do so. I believe public health believe public health work can be work can be standardized. standardized.

Rankin, Rankin, 19151915