External assessment of health care

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Abstract
A rash of external inspection is affecting the delivery of health care around the world. Governments, consumers, professions, managers, and insurers are hurrying to set up new schemes to ensure public accountability, transparency, self regulation, quality improvement, or value for money. But what do we know of such schemes' evidence base, the validity of their standards, the reliability of their assessments, or their ability to bring improvements for patients, staff, or the general population? ### Box 1: Characteristics of effective external assessment programmes Give clear framework of values —To describe elements of quality, and their weighting, such as the enablers and results defined by the European Foundation for Quality Management Publish validated standards —To provide an objective basis for assessment Focus on patients —To reflect horizontal clinical pathways rather than vertical management units Include clinical processes and results —To reflect perceptions of patients, staff, and public Encourage self assessment —To give time and tools to internalise assessment and development Train the assessors —To promote reliable assessments and reports Measure systematically —To describe and weight compliance with standards objectively Provide incentives —To give leverage for improvement and response to recommendations Communicate with other programmes —To promote consistency and reciprocity and to reduce duplication and burden of inspection Quantify improvement over time —To demonstrate effectiveness of programme Give public access to standards, assessment processes, and results —To be transparent and publicly accountable RETURN TO TEXT In short, not much. The standards, measurements, and results of management systems have not been, and largely cannot be, subjected to the same rigorous scrutiny and meta-analysis as clinical practice. No one has published a controlled trial, and there are too many confounding variables to prove that inspection causes better clinical outcomes, although there is evidence that organisations increase their compliance with standards if these are made explicit. But experience and consensus are gradually being codified into guidelines to …