J Public Health (2011) 19:425432
DOI 10.1007/s10389-011-0408-4
ORIGINAL ARTICLE
International comparison of nine accreditation programmes
for ambulatory care facilities
Silke Auras & Max Geraedts
Received: 20 October 2010 / Accepted: 15 February 2011 / Published online: 23 March 2011
# Springer-Verlag 2011
Abstract
Aim In order to generate ideas for the improvement of
German accreditation programmes, we aimed at exploring
similarities and differences of nine international approaches
to the accreditation of ambulatory primary and specialist
care facilities.
Subjects and methods Nine accreditation programmes from
Germany, Switzerland, the Netherlands, Great Britain, the
USA, and Australia were included. Selective literature
review, systematic analysis of the documents identified,
and descriptive comparison of findings regarding key
information on accreditation standard development, con-
tents, and methods of accreditation; inclusion of patient
surveys; and special features were performed.
Results All practice accreditation programmes include a
consensus process to develop mainly quality management-
based criteria for practices structures and processes.
Several accreditation programmes require structured patient
surveys. All accreditation processes include a self-
assessment, a review and verification of documented
evidence, and a peer-based on-site visit. Some accreditation
programmes show unique features, such as a high degree of
external consultation and support, or a link of accreditation
to pay-for-performance programmes.
Conclusion Comparison of international accreditation pro-
grammes of ambulatory primary and specialist care facili-
ties reveals considerable similarities in regard to the
development of accreditation criteria, the criteria them-
selves, and the process of accreditation. German practice
S. Auras (*) : M. Geraedts
Institute for Health Systems Research,
Witten/Herdecke University,
Alfred-Herrhausen-Strasse 50,
58448 Witten, Germany
e-mail: silke.auras@uni-wh.de
accreditation programmes may benefit from including a
structured patient survey, a higher degree of consultative
support, and financial incentives.
Keywords Quality management . External quality
assessment . Ambulatory care . Accreditation
Background
Accreditation of medical facilities is currently being tested in
Germany and elsewhere as a way to assure and improve health
care quality. Accreditation usually represents a voluntary
(Court-Wienecke 2000; Dean Beaulieu and Epstein 2002;
Paccioni et al. 2008; Buetow and Wellingham 2003;
Klazinga 2000) form of external quality assurance (Court-
Wienecke 2000; Dean Beaulieu and Epstein 2002; Paccioni
et al. 2008; Buetow and Wellingham 2003; Viswanathan and
Salmon 2000). Compliance with explicit predetermined
standards (Court-Wienecke 2000; Paccioni et al. 2008;
Buetow and Wellingham 2003; Viswanathan and Salmon
2000; Kamiske and Brauer 1995), set by the accreditation
programmes, is holistically verified as part of a systematic
and comprehensive procedure. Unlike certification of com-
pliance with International Organisation for Standardisation
(ISO) 9000 series standards, not only the prerequisites for a
quality management (QM) system are assessed, but also with
the objective of continuous improvement, professional
performance and quality of health care are regularly assessed
and assigned for the whole facility. Accreditation comprises
aspects of external control (Court-Wienecke 2000; Paccioni
et al. 2008; Buetow and Wellingham 2003; Klazinga 2000;
Viswanathan and Salmon 2000) and elements of self-
regulation (Court-Wienecke 2000; Paccioni et al. 2008;
Buetow and Wellingham 2003; Viswanathan and Salmon
426
2000); it aims to protect public safety (Court-Wienecke
2000; Buetow and Wellingham 2003) and to enhance mutual
trust of stakeholders (Buetow and Wellingham 2003;
Klazinga 2000). The dissemination of facilities accreditation
status is intended to strengthen the role of patients as well as
stakeholders in medical decision making (Buetow and
Wellingham 2003; Viswanathan and Salmon 2000). Addi-
tionally, competition is to be promoted by comparison of
individual accreditation results with results from other
facilities (benchmarking) (Court-Wienecke 2000; Buetow
and Wellingham 2003). Hence, accreditation also serves as
an instrument to control and regulate health care systems
(Buetow and Wellingham 2003) that, besides the aspired to
goal of quality improvement, aims to enhance the efficiency
of health care systems (Viswanathan and Salmon 2000).
The concept of accreditation in health care was primarily
established in the hospital environment (Dean Beaulieu and
Epstein 2002; Buetow and Wellingham 2003), and imple-
mentation in ambulatory settings turns out to be difficult
(Buetow and Wellingham 2003). To date, several organisa-
tions in Germany offer accreditation of ambulatory primary
and specialist care facilities, but only few practices are
accredited. Stiftung Praxissiegela provider of practice
accreditation in Germanycommissioned a comparison of
international accreditation programmes to gather information
on how to improve its own programme. International
comparisons of non-hospital accreditation are scarce.
Although these comparisons are difficult, they may be
beneficial. Applying general and fundamental international
lessons learned to national health care system frameworks
may help to generate ideas for improvement (Court-
Wienecke 2000; Buetow and Wellingham 2003; Klazinga
2000; Shaw 2006).
The aim of our study was to gain first insights into
international approaches to the accreditation of ambula-
tory primary and specialist care facilities. Differences and
similarities in the development of accreditation standards
and in contents and method of accreditation are described
and compared. Additionally, unique features of the
accreditation programmes, if any, are pointed out.
Finally, we try to generate ideas for the improvement of
German accreditation programmes.
Methods
Terminology in health care accreditation is not determined
uniformly on an international level. We use the term
accreditation programme for the predefined standards
and criteria assessed by prescribed procedures. Programme
development and programme application in medical facilities
usually are performed by different, independent organisations.
Some accreditation certificates are named after the developing
J Public Health (2011) 19:425432
organisation, some are named after the assessing organisation,
and some are named differently; however, we decided to
uniformly use the names of the accreditation certificates and
consistently refer to the underlying accreditation programmes.
Acting on a suggestion by Stiftung Praxissiegel, we
comparatively analysed nine international programmes for
the accreditation of ambulatory primary and specialist care
facilities. As mentioned before, comparative analyses of
accreditation programmes for ambulatory primary and
specialist care facilities are scarce. To gain first insights
into international approaches, we included programmes for
rather pragmatic reasons and without a lot of presupposi-
tions. We focussed on programmes in Germany, of course;
but we were also interested in what is done in Europe and
overseas. We decided to include three programmes in each
area. The programmes had to be internationally well known
and accessible for the methodological approach chosen. As
a consequence, other potentially applicable and important
programmes, such as ISO and the European Foundation for
QM (EFQM) Excellence Model, regrettably had to be left
out of this study.
For data collection purposes, a selective literature review
was carried out between October 2008 and March 2009.
Initially, the programmes Internet portals were identified.
Relevant documents and information were detected using
the menu navigation or the sites search function. To be
included, documents had to be relevant, up to date, and at
the same time freely available. Referrals to cooperating
organisations were also appraised. In cases where we were
unable to gain all desired information this way, a
responsible contact person at the organisation was con-
sulted via phone or e-mail. Nevertheless, our enquiry
remained unanswered for two programmes.
The following accreditation programmes and corresponding
Internet portals were selected:
& Stiftung Praxissiegel (STPS), Germany, www.praxissiegel.
de, accessed 1 July 2009
& Quality and Development in Practices (QEP), Germany,
www.kbv.de/qep, accessed 1 July 2009
& Cooperation for Transparency and Quality in Healthcare
(KTQ), Germany, www.ktq.de, accessed 6 July 2009
& External Quality Assurance in Medicine (EQUAM),
Switzerland, www.equam.ch, accessed 6 July 2009
& Dutch Association of General Practitioners (NHG)
Practice Accreditation (NPA), The Netherlands,
www.praktijkaccreditering.nl, accessed 6 July 2009
& Quality Practice Award (QPA), Great Britain, www.
rcgp.org.uk/professional_development/team_quality/
qpa.aspx, accessed 6 July 2009
& Australian General Practices Accreditation Limited
(AGPAL), Australia, www.qip.com.au/, accessed 6 July
2009
J Public Health (2011) 19:425432 427

& Joint Commission on Accreditation of Health Care Results

Organizations (JCAHO), USA, www.jointcommission.
org, accessed 6 July 2009 Development of accreditation standards
& National Committee for Quality Assurance (NCQA),
USA, www.ncqa.org, accessed 6 July 2009 All standards, criteria, and quality indicators assessed in each
programme are developed by relevant stakeholders with
STPS and EQUAM both assess against the standards of
support of independent QM experts and scientists. Table 1
the European Practice Assessment (EPA)1 but have indi-
lists the developers of the accreditation programmes. Final
vidualised the basic concept; these different approaches are
decisions on which indicators to include are uniformly made
therefore described separately. For three accreditation
in a consensus process. None of the developing processes
programmes, the printed versions of criteria catalogues
includes a strict and structured assessment of the indicators
were used (Diel et al. 2005; KTQ 2004; NCQA 1998).
quality, such as their relevance, scientific soundness, or
Key descriptive information on all programmes is listed
feasibility.
in Table 1.
Subjects of our study were the development of accredita-
Contents of accreditation processes and inclusion of patient
tion standards; the contents of the accreditation processes and
surveys
the inclusion of patient surveys; the methods of accreditation
processes; and unique features of the accreditation pro-
All standards, criteria, and quality indicators assessed are
grammes, if any.
mostly QM-based and focus on practices structures and
We selected assessment criteria considered to be key
processes; outcome indicators are rarely included. Charac-
features of practice accreditation programmes and at the same
teristic QM aspects assessed apply to quality-orientated
time accessible for improvement, thereby following German
management, patient orientation, staff orientation, informa-
(Court-Wienecke 2000) and international (Viswanathan and
tion systems, and data safety.
Salmon 2000) publications. Due to the particular importance
The main differences can be found in the quantity of
of patient experiences in the comprehensive assessment of
indicators and the varying emphasis on certain elements.
medical care quality (Buetow and Wensing 2008; Elwyn et
Clinical quality indicators are an integral part of the NPA,
al. 2007; Evans et al. 2007), we also highlight patient
QPA, and NCQA accreditation programmes. Clinical
surveys as part of several practice accreditation programmes.
indicators may also be included by EQUAM excellence
The analysis was text based and informed by content
accreditation as part of its optional module (see below).
analysis. All documents identified were systematically
All accreditation programmes excluding KTQ require a
analysed with regards to the above-mentioned contents. In
patient survey; STPS, EQUAM, NPA, QPA, and NCQA
detail, the following questions were addressed:
prescribe the use of a structured patient survey questionnaire.
& How and by whom were the accreditation programmes AGPAL prescribes to choose at least one out of six
developed? patient survey methods (self-completed survey, telephone
& What kinds of topics are covered by the accreditation survey, face-to-face interviews, focus groups, practice
standards? Are (structured) patient surveys included in advisory groups, or suggestion schemes). AGPAL also
accreditation programmes? defines specific survey procedures for each patient survey
& How is conformity with accreditation standards veri- method and provides a structured patient questionnaire, but
fied? Which procedural steps need to be passed its use is not mandatory.
through? Are accreditation results available to the
public? Accreditation methodology
& Which accreditation programmes stand out because of
unique features? Which unique features are there? All programmes include a review and verification of
The relevant information was appraised individually for documented evidence and a peer-based on-site visit to verify
each accreditation programme and subsequently consoli- compliance with accreditation standards; main differences can
dated for comparison. Due to the nature of the data, be found in details of prescribed procedures. A form of self
statistical analysis of the results other than a description assessment has to be carried out in every programme. This
was not indicated. allows the document review to be performed prior to the
actual audit. STPS, KTQ, EQUAM, QPA, and AGPAL
verify all contents required for full accreditation by means of
the pre-visit self assessment. QEP, NPA, JCAHO, and
1
www.europaeisches-praxisassessment.de and www.topaseurope.eu, NCQA only analyse specific elements prior to the audit. Self
accessed 6 July 2009 assessment is conducted either on the basis of questionnaires,
428 J Public Health (2011) 19:425432

Table 1 Key descriptive information on the nine accreditation programmes studied

Programme Developed in Developed by Accreditation of

STPS, Germany 2004 EPA: General practices

QEP, Germany
KTQ, Germany
EQUAM, Switzerland
NPA, The Netherlands
QPA, Great Britain
AGPAL, Australia
JCAHO, United States of America
NCQA, United States of America
International study from 2001 to 2004 under leadership Specialists practices
of the Dutch Scientific Institute for Quality of
Healthcare at Radboud University, Nijmegen
STPS:
Representatives of SHI, private health insurance, and
physician and patient organisations
Dentists, physicians
2004 Representatives of the 17 regional and one national Ambulatory primary and specialist
associations of SHI physicians care facilities
Psychotherapeutic practices
Ambulatory health care centres
2004 Representatives of General practices
two German medical associations Psychotherapeutic practices
National confederation of the SHI funds Dental practices
German hospital federation
German nursing council
2004 EPA: Ambulatory primary and specialist care facilities
International study from 2001 to 2004 under leadership MCOs
of the Dutch Scientific Institute for Quality of
Healthcare at Radboud University, Nijmegen
EQUAM:
Representatives of three Swiss MCOs
2005 Dutch Association of General Practitioners (NHG) and General practices
The Dutch Scientific Institute for Quality of Health centres
Healthcare at Radboud University, Nijmegen
1997 North East Scotland faculty of the Royal College General practices
of General Practitioners
Parts of the Quality and Outcomes Framework, a
British pay-for-performance programme, are adopted
1997 Royal Australian College of General Practitioners General practices
Representatives of various Australian associations and
networks of several medical professions (general
practitioners, nurses, rural doctors)
Patient representatives
1975 Representatives of various American associations and Ambulatory care (medical, dental,
networks of several medical professions (physicians, and surgical health care facilities)
dentists) and health care sectors (e.g. hospitals)
1991a Representatives of Commercial health plans
Public and private employers
Managers of MCOs
Practitioners
Consumer associations
Experts in health care policy and quality assessment

STPS=Stiftung Praxissiegel, Germany

EPA=European Practice Assessment
SHI=Statutory Health Insurance
QEP=Quality and Development in Practices, Germany
KTQ=Cooperation for Transparency and Quality in Healthcare, Germany
EQUAM=External Quality Assurance in Medicine, Switzerland
MCOs=Managed Care Organisations
NPA=Dutch Association of General Practitioners (NHG)-Practice Accreditation, The Netherlands
QPA=Quality Practice Award, Great Britain
AGPAL=Australian General Practice Accreditation Limited, Australia
JCAHO=Joint Commission on Accreditation of Health Care Organizations, USA
NCQA=National Committee for Quality Assurance, USA
a
Accreditation of MCOs that finally led to health plan accreditation programmes
J Public Health (2011) 19:425432
checklists, or other documented evidence (STPS, EQUAM,
JCAHO, and NCQA), or by means of a comprehensive and
structured report (QEP, KTQ, NPA, and QPA). AGPAL
offers a software application to facilitate self-assessment.
During the actual on-site visit, surveyors verify confor-
mity with accreditation standards. Peers are used as
surveyors in all accreditation programmes; in the QPA
programme, patients may serve as additional surveyors (so-
called lay assessors).
All accreditation programmes publish successfully
accredited practices. Additionally, KTQ, JCAHO, and
NCQA make several individual results accessible to the
public.
Unique features of accreditation programmes
The accreditation programmes of NPA, JCAHO,
EQUAM, QPA, and AGPAL stand out because of substan-
tial particularities.
In the NPA programme, an initial test has to be passed
that verifies the conformity with certain minimum require-
ments. This test comprises, amongst others, core compe-
tencies and main fields of action of the eligible practice,
appropriate qualification of staff, and use of electronic
health records.
Furthermore, practices in the ongoing NPA accredita-
tion process receive continuous and comprehensive advice
and support. Practices may opt for an independent, NHG-
approved consultant, the so-called practice consultant, for
active support in complying with standards and passing
through the accreditation process. Another consultant, the
NPA consultant, carries out a pre-visit. If areas of
improvement are revealed during the pre-visit, adequate
improvement activities may be developed and implemented
prior to the actual audit.
During the on-site visit for a JCAHO accreditation, the
so-called tracer methodology is applied. In the framework
of the tracer methodology, pre-survey external data from
multiple sources (website, public sources) serve to identify
specific structures and processes in the practices as well as
a distinct group of patients. Structures and processes
identified are relevant to the safety and quality of care,
and patients identified reflect core competencies of the
facility. On this basis, some individual patient records are
selected as so-called tracers. During the on-site visit,
surveyors retrace the specific care processes of the selected
patients and thereby observe and appraise practices
compliance with standards.
Besides, as another special feature of the JCAHO
accreditation, the unannounced follow-up surveys are worth
mentioning. Whilst the on-site visit for the initial accreditation
award is scheduled with the practices, all organisations
accredited by JCAHO are eligible for resurvey on an
429
unannounced basis within an 1839-month window from
the previous, initial survey.
One version of the QPA accreditation programme and
one of the EQUAM accreditation programme are designed
in modular concepts.
In the modular QPA (mQPA), completion and subse-
quent attestation of single groups of QPA standards is
feasible. After complying with all modules and passing a
final comprehensive audit, QPA accreditation is awarded.
In contrast, EQUAM provides an accreditation status
superior to the regular accreditation by voluntarily passing a
supplemental module. As part of this so-called excellence
accreditation, exclusively clinical standards are verified.
Both the QPA and AGPAL accreditation programmes are
linked to pay-for-performance (P4P) programmes.
About 40% of quality standards included in the QPA trace
back to the Quality and Outcomes Framework (QOF), a
British P4P programme. As every QPA standard has to be met
for successful accreditation, an additional P4P payment by
QOF is available at the same time with QPA accreditation.
Australian general practices either accredited by AGPAL
or registered for AGPAL accreditation have access to the
Practice Incentives Program (PIP), an Australian P4P
programme. In contrast to the QPA and QOF, the PIP
requires meeting additional standards in order to receive the
P4P payment; PIP includes aspects like information
management and technology, after hours care, and the
asthma incentive programme.
Table 2 summarises the main findings of the comparative
analysis of the nine practice accreditation programmes.
Discussion
Our comparative analysis of nine international programmes
for accreditation of ambulatory primary and specialist care
facilities revealed an overall consistency in the development
of accreditation standards and in basic contents and methods
of accreditation. All programmes include a consensus process,
without structured assessment of the indicators quality, to
develop mainly QM-based accreditation criteria for practices
structures and processes. Furthermore, several accreditation
programmes require a structured patient survey. An accredi-
tation process including a self-assessment, a review and
verification of documented evidence, and a peer-based on-site
visit seems to be an internationally accepted standard. Some
accreditation programmes show unique features, such as a
high degree of external consultation and support during the
entire accreditation process or a link of accreditation to P4P
programmes.
Our results confirm international studies that show that
accreditation criteria usually are developed by all relevant
stakeholders and with participation of independent QM
430 J Public Health (2011) 19:425432

Table 2 Summary of the main characteristics of the nine accreditation programmes studied

Main characteristics STPS QEP KTQ EQUAM NPA QPA AGPAL JCAHO NCQA

Standards, criteria, and quality indicators developed in Y Y Y Y Y Y Y Y Y

consensus procedures with direct participation of relevant
stakeholders and independent scientists
Quality indicator development process includes structured N N N N N N N N N
assessment of the indicators quality
Clinical quality indicators are integral part of the accreditation N N N Na Y Y N N Y
Publication of accreditation status Y Y Y Y Y Yb Yb Y Y
Publication of individual accreditation results N N Y N N N N Y Y
Accreditation includes self-assessment Y Y Y Y Y Y Y Y Y
Accreditation includes review and verification of documented Y Y Y Y Y Y Y Y Y
evidence
Accreditation includes peer-based on-site visit Y Y Y Y Y Y Y Y Y
Accreditation includes patient survey Y Y N Y Y Y Yc Y Y
Use of structured patient questionnaire required Y N N Y Y Y N N Y

STPS=Stiftung Praxissiegel, Germany

QEP=Quality and Development in Practices, Germany
KTQ=Cooperation for Transparency and Quality in Healthcare, Germany
EQUAM=External Quality Assurance in Medicine, Switzerland
NPA=NHG-Practice Accreditation, The Netherlands
NHG=Dutch Association of General Practitioners
QPA=Quality Practice Award, Great Britain
AGPAL=Australian General Practice Accreditation Limited, Australia
JCAHO=Joint Commission on Accreditation of Health Care Organizations, United States of America
NCQA=National Committee for Quality Assurance, United States of America
Y=yes; N=no
a
Clinical indicators may be included by the optional, supplemental module
b
Only practices with the best accreditation results are published
c
Collection of patient experience data by at least one of six predetermined methods

experts and scientists in a consensus process (Court-
Wienecke 2000; Buetow and Wellingham 2003; Buetow
and Wensing 2008). None of the developing processes
includes a structured assessment of the indicators quality.
Appropriate measurement tools are provided, such as the
Appraisal of Indicators through Research and Evaluation
(AIRE) (deKoning J 2007) and the QUALIFY tool (Reiter
et al. 2008). The use of such measurement tools may be
beneficial to improve the significance and validity of
quality indicators (deKoning J 2007; Reiter et al. 2008),
thereby ensuring the credibility and reliability of quality
measurement during accreditation.
For the most part, QM-based standards and criteria are
assessed during accreditation, mostly differing in the
quantity and emphasis of specific elements (Buetow and
Wellingham 2003). QM systems, as assessed during
accreditation, are to improve medical care quality by
optimising management structures and processes (Dean
Beaulieu and Epstein 2002; Buetow and Wellingham
2003). This may be one explanation for the focus on
structures and processes in accreditation programmes
(Menachemi et al. 2008). Additionally, quality indicators
reflecting practice structures and processes are much easier
to observe and to measure than outcome indicators (Dean
Beaulieu and Epstein 2002; Viswanathan and Salmon
2000), and practices structures and processes are believed
to be entirely within the control of the practice being
accredited (Dean Beaulieu and Epstein 2002). However,
there is no compelling evidence that high performance in
structural and procedural aspects results in high quality
outcomes (Dean Beaulieu and Epstein 2002).
An adequate scientific understanding of the causes of
variation of outcome indicators is still lacking. There might
be organisational factors (practitioner skills or data com-
pleteness and accuracy), indicator specific factors (differing
data sources or population inclusion and exclusion criteria),
and external factors (random variation) (Gross et al. 2000),
all of which limit and complicate the use of outcome
indicators in accreditation. However, Collopy impressively
demonstrated that the inclusion of outcome indicators in the
hospital accreditation process entails a discussion of the
results at the time of the on-site visit during accreditation.
J Public Health (2011) 19:425432
As a consequence, many actions to improve patient care
were stimulated. But he also states that Measurement of
care in the ambulatory setting is likely to be a larger and
more costly task (Collopy 2000). Yet it is frequently
demanded to integrate outcome indicators more intensively
(Buetow and Wellingham 2003; Viswanathan and Salmon
2000) in accreditation programmes, such as patient experi-
ence data. The outstanding relevance of patient experiences
for a comprehensive assessment of the quality of medical
care is consistently acknowledged in international publica-
tions (Paccioni et al. 2008; Viswanathan and Salmon 2000;
Buetow and Wensing 2008; Elwyn et al. 2007; Evans et al.
2007). However, only five of the nine accreditation
programmes surveyed assess patient experience data, as
recommended, with structured instruments and standardised
procedures (Elwyn et al. 2007; Evans et al. 2007).
As in published literature, clinical indicators are not
consistently integrated in accreditation programmes
(Viswanathan and Salmon 2000; Buetow and Wensing
2008). Only three programmes compulsorily assess clin-
ical indicators.
Accreditation processes predominantly consist of a self-
assessment, a review and verification of documented
evidence, and an independent, peer-based, on-site visit
(Court-Wienecke 2000; Paccioni et al. 2008; Buetow and
Wellingham 2003; Viswanathan and Salmon 2000; Bohigas
and Heaton 2000; Buetow and Wensing 2008). This could
also be found in our study.
By means of a self-assessment, practices can familiarise
themselves with the quality standards required. Ideally, as
many members of the practice staff as possible actively
participate in this process (Paccioni et al. 2008).
An on-site visit, even if peer-based, always includes
elements of social control; practices may therefore feel
restricted in their organisational control and professional
autonomy (Buetow and Wellingham 2003). To minimise
these aspects of social control, it may be beneficial to put
an emphasis on education and practical assistance, as used
in the NPA accreditation programme (Buetow and
Wellingham 2003; Klazinga 2000). In particular, practices
that are widely dispersed and work on a freelance basis, as
in Germany, may benefit (Buetow and Wellingham 2003).
Responsibility for and supervision of the accreditation and
audit processes should be well balanced and shared among all
stakeholders (Buetow and Wellingham 2003). Accordingly,
the supplemental use of health system consumers (patients,
care-givers) as surveyors, as seen in the QPA accreditation
programme, has recently been discussed (Buetow and
Wellingham 2003; O"Connor et al. 2007).
There is a remarkable worldwide trend towards public
reporting (Klazinga 2000; Shaw 2006). The publication of
practices accreditation status or of information regarding
the quality of medical care delivered in a practice first of all
431
serves internal QM as it enables practices to monitor their
progress in quality standard completion continuously.
Additionally, an external comparison and benchmarking is
feasible. Transparency of the accreditation process to the
public is to be promoted so that patients and stakeholders,
respectively, may use accreditation information for decision
making. Therefore, public reporting serves as an instrument
to control and regulate health care systems (Buetow and
Wellingham 2003; Viswanathan and Salmon 2000). How-
ever, the actual effects, risks, and incentives of public
reporting as well as the attitudes of patients and stake-
holders towards public reporting are still mostly unexplored
(Greenfield and Braithwaite 2008).
Only the accreditation status awarded is usually pub-
lished as part of public reporting. Specific findings of the
accreditation process or the names of practices that failed to
achieve accreditation are not published for the most part
(Shaw 2006; Bohigas and Heaton 2000). These principles
of public reporting are also reflected in our study; only
KTQ, JCAHO, and NCQA publish some specific findings
of the individual accreditation processes.
Modular concepts of accreditation programmes are
rarely discussed in the international literature (Viswanathan
and Salmon 2000). A modular concept according to the
EQUAM type may be beneficial to meaningfully differen-
tiate between regularly and excellently accredited
practices, especially against the background of constantly
raising competitive pressure among practices.
To promote acceptance of practice accreditation among
non-hospital practitioners, there are frequent demands to
combine normative with formative aspects (Paccioni et al.
2008; Buetow and Wensing 2008) and to add financial
incentives (Buetow and Wellingham 2003; Shaw 2006).
Practices should not have to fear blame or punishment if
they fail to comply with some quality standards (Buetow
and Wellingham 2003; Giraud-Roufast and Chabot 2008).
Furthermore, cooperative participation of all stakeholders
(Buetow and Wellingham 2003; Shaw 2006; Buetow and
Wensing 2008) and transparent exchange of information at
all times may help diminish the threat to professional
autonomy (Buetow and Wellingham 2003; Giraud-Roufast
and Chabot 2008). The above-named principles are met
best by AGPAL and QPA as these accreditation pro-
grammes integrate financial incentives by linkage to P4P
programmes. However, all other aspects are, in varying
degrees, also represented by the other accreditation
programmes.
The methodology used for this study was restrictive in
its generic approach, which considerably limits the con-
clusions to be drawn from this study. We only gathered
information on general attributes of accreditation contents
and methods and on unique features, if any. Data collection
was mainly based on literature freely available online,
432
which possibly did not always include the most detailed and
up-to-date information. Future studies on this topic should be
designed to be less descriptive but more metaanalytical and
evaluative. It might be interesting to analyse aspects like the
costs of accreditation, the number of facilities accredited, and
the effectiveness of the programmes. However, data to analyse
these features in regard to the accreditation programmes
studied are not yet available.
Conclusion
International comparison of accreditation programmes for
ambulatory primary and specialist care facilities reveals
considerable similarities. Programmes including a consensus-
based process for developing accreditation criteria, QM-based
standards for practice structures and processes, a comprehen-
sive self-assessment, a review and verification of documented
evidence, and a peer-based on-site visit appear to be an
internationally accepted standard. German practice accredita-
tion programmes may benefit from including a structured
assessment of the indicators quality, more outcome and
clinical indicators, a structured patient survey, a higher degree
of consultative and supportive assistance, a modular design,
and financial incentives, for example, a link to P4P pro-
grammes. It seems to be of great importance to establish
transparency and accountability as well as a cooperative, non-
blame relationship among all stakeholders.
Acknowledgement The research presented in this article was based
on a commissioned work for Stiftung Praxissiegel, Gtersloh,
Germany. We thank S. Hennig (Stiftung Praxissiegel) for her
thoughtful comments on an earlier draft of this manuscript. The views
expressed here are those of the authors and do not necessarily reflect
those of Stiftung Praxissiegel.
Conflict of interest The authors declare that they have no conflict of
interest.
References
Bohigas L, Heaton C (2000) Methods for external evaluation of health
care institutions. Int J Qual Health Care 12:231238
Buetow SA, Wellingham J (2003) Accreditation of general practices:
challenges and lessons. Qual Saf Health Care 12:129135
Buetow S, Wensing M (2008) What might European general practice
learn from New Zealand experience of practice accreditation?
Eur J Gen Pract 14:4044
Collopy BT (2000) Clinical indicators in accreditation: an effective
stimulus to improve patient care. Int J Qual Health Care 12:211216
J Public Health (2011) 19:425432
Court-Wienecke S (2000) Zertifizierungsverfahren fr ambulante
Versorgung in den USA (Accreditation for ambulatory health
care in the USA). Z rztl Fortbild Qualittssich 94:634 638
Dean Beaulieu N, Epstein AM (2002) National Committee on Quality
Assurance health-plan accreditation: predictors, correlates of
performance, and market impact. Med Care 40:325337
deKoning J (2007) Development and validation of a measurement
instrument for appraising indicator quality: appraisal of indicators
through research and evaluation (AIRE) instrument. German
Medical Science. http://www.egms.de/de/meetings/gmds2007/
07gmds798.shtml. Accessed 21 May 2009
Diel F, Heinzmann G, Mecklenburg T, Stolz-Wagner S, Thoma E
(2005) Qualittsziel-Katalog kompakt (Compact Catalogue of
QEP Quality Targets). Deutscher rzteverlag, Cologne
Elwyn G, Buetow S, Hibbard J, Wensing M (2007) Measuring quality
through performance. Respecting the subjective: quality mea-
surement from the patient"s perspective. BMJ 335:10211022
Evans RG, Edwards A, Evans S, Elwyn B, Elwyn G (2007) Assessing
the practising physician using patient surveys: a systematic
review of instruments and feedback methods. Fam Pract
24:117127
Giraud-Roufast A, Chabot JM (2008) Medical acceptance of quality
assurance in health care: the French experience. JAMA
300:26632665
Greenfield D, Braithwaite J (2008) Health sector accreditation
research: a systematic review. Int J Qual Health Care 20:172
183
Gross PA, Braun BI, Kritchevsky SB, Simmons BP (2000) Comparison
of clinical indicators for performance measurement of health care
quality: a cautionary note. Clin Perform Qual Health Care 8:202
211
Kamiske G, Brauer J (1995) Qualittsmanagement von A-Z (Quality
Management from A to Z). Hanser, Munich
Klazinga N (2000) Re-engineering trust: the adoption and adaption of
four models for external quality assurance of health care services
in western European health care systems. Int J Qual Health Care
12:183189
KTQ (2004) KTQ-Manual inkl. KTQ-Katalog Version 2.0 fr den
"Niedergelassenen Bereich" (KTQ-Manual including KTQ-
Catalogue Version 2.0 for "Office-based Physicians"). Kllen
Druck and Verlag, Bonn
Menachemi N, Chukmaitov A, Brown LS, Saunders C, Brooks RG
(2008) Quality of care in accredited and nonaccredited
ambulatory surgical centers. Jt Comm J Qual Patient Saf
34:546551
NCQA (1998) Surveyor guidelines for the accreditation of managed
care organizations. NCQA, Washington
O"Connor E, Fortune T, Doran J, Boland R (2007) Involving
consumers in accreditation: the Irish experience. Int J Qual
Health Care 19:296300
Paccioni A, Sicotte C, Champagne F (2008) Accreditation: a cultural
control strategy. Int J Health Care Qual Assur 21:146158
Reiter A, Fischer B, Ktting J, Geraedts M, Jckel W, Dbler K
(2008) QUALIFY: Ein Instrument zur Bewertung von Qualitt-
sindikatoren (QUALIFY: A Tool for Assessing Quality Indica-
tors). Z rztl Fortbild Qualittssich 101:683688
Shaw CD (2006) Accreditation in European health care. Jt Comm J
Qual Patient Saf 32:266275
Viswanathan HN, Salmon JW (2000) Accrediting organizations and
quality improvement. Am J Manag Care 6:11171130
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.