public health accreditation learning from others paul k. halverson, drph, fache
TRANSCRIPT
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