The business of accreditation

The accreditation and certification of health care facilities and individual providers by nongovernmental organizations are integral to contemporary medical practice. Some accreditation processes are functionally mandated because they are closely tied to reimbursement or securing practice privileges. Examples of this would include the American Board of Internal Medicine (ABIM) and its subspecialties for physicians and The Joint Commission for hospitals. Other accreditations are more voluntary and convey to others an expertise in a specialized area. Examples here would include the American Board of Clinical Lipidology for physicians and the American Nurses Credentialing Center Magnet Recognition Program for health care facilities. Accreditation and certification are widely used methods for demonstrating, through independent external review, a voluntary commitment by facilities and individuals to achieve accepted or exceptional standards as part of the health care system. Accreditations and certifications systems have expanded during the past several decades. Broadly, the goals of accreditations and certifications are to improve the quality of health care that we provide by various methods, such as creating and testing standard knowledge sets for individual providers, monitoring ongoing maintenance of knowledge and skills, developing and evaluating performance care metrics, and assuring facility processes and infrastructure for patient safety and quality. Many accreditations and certifications are a mutually beneficial relationship, bringing a sense of pride and accomplishment to the certified and expanding the reach of the certifier. The hope, of course, is that accreditations and certifications translate into better outcomes for our patients. For physician certification, some evidence of a modest benefit on outcomes have been described. Links between achievement of accepted metrics of quality care and improvement of patient outcomes have been difficult to demonstrate. When the Joint Commission adopted door-to-balloon time under 90 minutes as a quality metric in their accreditation process, times on the metric fell dramatically. The most recent analysis from the National Cardiovascular Data Registry, however, suggests that reducing this time has not translated into an improvement in in-hospital mortality. Accreditations and certifications are not without costs. In the year ending of December 2013, the Joint Commission reported revenue of $199,520,144, largely from accreditation and surveying fees. The consolidated revenues of the American Board of Medical Specialties and its subsidiaries were $16,547,000 as of December 2012. These financial reports also do not account for the substantial indirect costs to facilities and individuals in terms of labor, physical plant redesign, renovations, board review courses, and productivity opportunity costs required to achieve the accreditations and certifications. The expansion of some accreditation and certification services may be reaching a point of diminishing returns. The ABIM recently made significant changes to its maintenance of certification program and met with significant concerns from physicians and professional societies as the direct and indirect costs were dramatically increased with no appreciable change in the value to the certified physician or demonstrable improvement Reprint requests: David E. Winchester, MD, MS, Division of Cardiovascular Medicine, Department of Medicine, University of Florida College of Medicine, 1600 SW Archer Road, PO Box 100277, Gainesville, FL 32610-0277; david.winchester@medicine.ufl.edu J Nucl Cardiol 2015;22:504–6. 1071-3581/$34.00 Copyright 2014 American Society of Nuclear Cardiology.