Why Accreditation Must Evolve to Determine Accountability and Quality in Healthcare

| Marybeth Farquhar, PhD, MSN, RN

As the saying goes, the more things change, the more they stay the same. Healthcare is no exception. Quality and accountability are two buzzwords that began in the latter half of the 2000s and intensified with the passage of the Accountable Care Act in 2010.

Quality, a multi-faceted concept, lies in the eye of the beholder. Accountability, or the willingness to accept responsibility for one’s actions, can also be subjective. 

One mechanism that can be used to create accountability is accreditation. Accreditation is a process administered by an external entity that evaluates an organization against a set of predetermined requirements and publicly attest to the results. Accreditation exists when there is both a professional effort to develop and maintain standards and either regulatory or market pressures support it as an alternative to regulatory oversight. It is the self-monitoring historically granted by society through contracts, either implicit and explicit, that society establishes with professionals. 

Accreditation’s value, as documented in the literature extends from operational effectiveness and improved communication to capacity building, professional development and organizational learning to enhanced understanding of the care continuum. It is more flexible, is more accepted by healthcare providers, and can easily be modified to keep up with current practice. 

But accreditation is not a silver bullet. It is dependent on voluntary participation, is assessed at a minimum every few years which only provides a snapshot of the organization’s performance, and the accrediting body’s enforcement authority is limited. 

Other methods to ensure accountability and performance include legislation, market-based approaches, and professional societies. Legislation, which has the potential for widespread implementation and is supported by government enforcement is the most onerous. This approach has limited acceptance by providers, is inflexible once signed into law, and may be politically driven. 

Market-based approaches to promoting accountability and performance (e.g., The Leapfrog Group, eValue8, etc.) are voluntary, and use the power of the market to improve practice through inducements such as higher payments for better outcomes. The downside of these types of initiatives is that they are not universal, which may potentially increase the disparities in care quality among those not covered by the program. 

Professional societies standards for care are developed by providers themselves, which ensures ready acceptance in the industry. They are also flexible in that they can be modified easily, but they depend again on voluntary participation by clinicians, are minimally enforced, and have the potential for bias. 

Regardless, accreditation, in its various forms, is one way to contribute to accountability because it ensures a certain level of competence and has the potential to improve the quality of services. But for accreditation to be valuable in determining accountability and quality in the future, it must evolve with the healthcare industry.

The current processes for accreditation don’t fully capture activities adequately as accreditation models need to assess the continuum of care. With the growing trends toward outpatient services and the increasing need for hand-offs, accreditation must be more flexible, and include a variety of entities to fully assess performance. 

Other issues that will need to be addressed include care coordination and data sharing. Reducing redundant standards and measures should be a top priority in developing new models of accreditation. Otherwise, there is the potential to provide dysfunctional, redundant evaluations and increase costs. In the past, accreditation has been a method to provide assurances to stakeholders about an organization’s accountability in terms of quality and safety. In the future, if accreditation is to play a role in accountability, it must be flexible and inclusive, and be able to provide the public with reliable and valid information on safety and quality. 

image of Marybeth Farquhar

Marybeth Farquhar, PhD, MSN, RN, Vice President, Quality, Research, and Measurement.

Marybeth Farquhar, vice president of quality, research, & measurement, is responsible for conceptualizing and implementing URAC’s strategy for measurement and research. Farquhar has more than 30 years of experience in the field of nursing and healthcare administration, research, and quality measurement. Prior to her tenure at URAC, Farquhar was vice president of performance measurement at the National Quality Forum and was responsible for strategic oversight of the consensus development process. Prior to NQF, she led key activities of the Agency for Healthcare Research and Quality performance measure initiatives and worked with the Consumer Assessment of Healthcare Providers and Systems (CAHPS) team on several projects, including Hospital CAHPS.

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