The place and spirit of accreditation activities for improving healthcare

In 2016-2017, SETMA will be reaccredited by the following organizations:

1. NCQA Diabetes Recognition (accredited from 2010-2016) reaccreditation due April 2016

2. NCQA Heart and Stroke (accredited from 2013-2016) reaccreditation due June 2016

3. NCQA Medical Home (accredited from 2010-2016) reaccreditation due July. 2016

4. URAC Medical Home and Ambulatory Care (accredited from 2014-2017) reaccreditation due February 2017

5. The Joint Commission Medical Home and Ambulatory Care (accredited 2014-2017) reaccreditation due March 2017

6. The Joint Commission Laboratory Services (accredited from 2014-2016) reaccreditation due July 2016

7. Accreditation Association for Ambulatory Health Care (accredited from 2010-2017) reaccreditation due July 2017.

In November 2015, SETMA had a conversation by e-mail with an executive at one of these accreditation bodies. Because we think accreditation is an important part of excellence in healthcare oversight and compliance functions, and in quality improvement, I shared the following comment: “The spirit of accreditation examiners, which should be collegial and collaborative is addressed, as is the value of accreditation. If accreditation and/or oversight deteriorate into an adversarial dynamic, the positive effects of that oversight can and will be lost. This is true for accreditation organizations and for compliance officers, whether governmental or other.” 

The following are questions raised by this executive followed by SETMA’s answers:

Question: You note that, “The provider must be an extension of the family. This is the ultimate genius behind the concept of Medical Home, and it cannot be achieved by regulations, restrictions and rules.” Are you implying by this statement that there is no role for ‘regs, rules, and restrictions,’ or simply that they are insufficient to sustain long-term change?”

Answer: No doubt, as our accreditation efforts suggest, we believe that there is a key place for standards and guidelines. My point is directed at the government’s preoccupation with creating “change” with demands and dictates. I have often said to the Office of National Coordination (ONC), “if you demand that everyone must do the same thing, the same way, every time, you will eliminate creativity, generative thinking and transformation. Tell us what you want done and let us demonstrate our unique way of doing it. Then evaluate the different ways of doing the same thing and find the ‘best practice or best solution,’ and promote that.”

When change is driven only by external demands, it is not sustainable and will become dependent upon rewards to drive improvement. But when change is driven by internalized values and vision, being self-sustaining and generative in nature, it is sustained not by financial or other rewards, but by the passion of the participants. For change to be permanent, it must be driven by transformation rather than reform. Transformation is driven by internalized value and vision. Rules, regulations and requirements can be part of an external standard against which you can measure yourself, but they will never become a part of the energy which sustains change.

Question: “Also, would you consider ‘standards’ (such as those that certain accrediting bodies use) to be equivalent to ‘regs, rules, and restrictions,’ or do you see them as having value because they offer a blueprint that describes a desirable future state that is worth attaining/maintaining?”

Answer: As implied above, I think standards are important guideposts in starting us on our pilgrimage and in giving us guidance in what to do, and, often, even, in how to do it. Remember Lincoln’s famous quote in his 1858, House Divided Address to the Republican National Convention. He said, “If we can first know where we are and whither we are tending; we can better judge what to do and how to do it.” A healthcare GPS must tell you where you want to go – that is often expressed in standards, evidenced-based goals and quality outcomes – but if the GPS does not also tell you where you are – how far you are from where you want to be — you can never get to where you want to be.

Standards are what we measure ourselves against, as we create our future. Remember Peter Senge’s comment in “The Fifth Discipline” as he addresses “creative tension.” This is the pressure created by holding “your reality” – where you are — and “your vision” – where you want to be – in your mind at the same time. The “tension,” which cries out for resolution is created by standards which you have not yet met, but which you embrace as “the good.”

Yes, I believe in standards; that is why we sought accreditation and why we will renew it. That is why we objected to the original spirit of the surveyors as they announced in their first sentence, “If you are doing something wrong, we will find it.” It was a threat, when in fact that is why we sought accreditation in the beginning. We wanted surveyors to tell us both what we are doing wrong and more importantly to tell us what we are not doing right.

We WANTED to be measured by these standards; to discover where we needed improvement was not a threat, it was an expectation. The worst experience in bringing in a practice consultant is that after you have paid him/her $10,000, you are told, you are doing everything perfectly and the consultant can recommend no improvement. You have just wasted your consultation fee. If, however, you are told, “we can show you how to really improve.” That has great value.

The interesting thing about “creative tension,” as it drives you to move from your “reality” to your “vision,” is that as you approach your “vision,” and as your “vision” increasingly becomes your “reality,” you discover that your “vision” expands. Therefore, when you “arrive” at your former “vision,” it having become your “new reality,” it is challenged by a new, larger and more comprehensive “vision.” That should always be the goal, i.e., to have constantly changing goals.

I would hope that when we are reaccredited that we will have corrected the very few things which you pointed out before but that you will find more subtle and perhaps even more important things we can improve. That is not failure; that is progress and that is the dynamic for sustainable improvement and success.