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International travel, medical tourism and trade have created a demand for reliable assessment of healthcare provision across borders, and for information which is accessible to patients, insurers and referring institutions. External assessment schemes for healthcare providers may be clustered into three types: statutory regulation and institutional licensing, International Standardization Organisation certification, and voluntary systems such as peer review and healthcare accreditation. Increasing complexity of healthcare provision, pressures for public accountability and expectations of professional self-governance place a burden on the inspectors and the inspected. If only to contain costs of external assessment and to increase access to reliable information for patients and insurers, the three approaches must work together rather than compete. This paper summarises the origins, aims, authority and methods of the three general models, describing current pressures and opportunities for convergence (between systems and across borders) in the UK and in Europe.

Background. Hospital accreditation and International Standardisation Organisation (ISO) certification offer alternative mechanisms for improving safety and quality, or as a mark of achievement. There is little published evidence on their relative merits. Objective. To identify systematic differences in quality management between hospitals that were accredited, or certificated, or neither. Research design. Analysis of compliance with measures of quality in 89 hospitals in six countries, as assessed by external auditors using a standardized tool, as part of the EC-funded Methods of Assessing Response to Quality Improvement Strategies project. Main outcome measures. Compliance scores in six dimensions of each hospital—grouped according to the achievement of accreditation, certification or neither. Results. Of the 89 hospitals selected for external audit, 34 were accredited (without ISO certification), 10 were certificated under ISO 9001 (without accreditation) and 27 had neither accreditation nor certification. Overall percentage scores for 229 criteria of quality and safety were 66.9, 60.0 and 51.2, respectively. Analysis confirmed statistically significant differences comparing mean scores by the type of external assessment (accreditation, certification or neither); however, it did not substantially differentiate between accreditation and certification only. Some of these associations with external assessments were confounded by the country in which the sample hospitals were located. Conclusions. It appears that quality and safety structures and procedures are more evident in hospitals with either the type of external assessment and suggest that some differences exist between accredited versus certified hospitals. Interpretation of these results, however, is limited by the sample size and confounded by variations in the application of accreditation and certification within and between countries.

Internal systems for quality and safety were assessed in 89 hospitals in six European states, by external teams using standardised criteria and procedures, as part of the Methods of Assessing Response to Quality Improvement Strategies (MARQuIS) project. The assessments were made primarily to identify the current use of quality management systems in the sample hospitals, and also to demonstrate a potential tool for comparable assessment of hospitals in general. The large majority of the hospitals had a formal, documented infrastructure to manage quality and safety, but a significant minority had no designated mission, programme or coordination. In two-thirds of hospitals, the governing body was active in defining policy and programmes for improvement, and received reports on quality, safety and patient satisfaction at least once a year. The brief on-site assessments identified systematic variations, within and between countries, in structures and processes of governance and to document the uptake of best practice. Unacceptable variations in practice could be reduced, to the benefit of consumers and providers, by developing and publishing basic organisational standards relevant to all European states. The simple assessment criteria designed for this project could be developed into a practical tool for self-assessment, peer review or benchmarking of hospitals across national borders. This assessment, combined with explicit, relevant and achievable standards, could provide a vehicle to promote the voluntary uptake of best practice and consistency in quality and safety among hospitals in Europe.

The 30 years of ISQua's existence and efforts have witnessed dramatic increases of knowledge about, and attention to, quality of health care. The ISQua founders had a vision of what was needed to promote quality and how this could be achieved through international cooperation and collaboration. And, the founders have continued to work to make this vision a reality. However, while much has been achieved in 30 years, there is still much more to be done. There is still need for vision for the future and visionaries who will carry things forward. Eight founders and early members of ISQua summarized what they had learned about quality in health care since the first Udine meeting 30 years earlier. There was a remarkable consensus, based on 240 years of practical experience and empirical evidence, that the problems lie less in defining and measuring visions, expectations and standards than in effective change management. It is important to recognize that the weakness of improvement strategies usually lies not in the strategies themselves, but in how they are implemented in a local context. From personal experience of what does and does not work, and often supported by formal publications, the ISQua veterans proposed pointers for improvement at institutional and system level. Policymakers and managers should involve patients and users of health services wherever possible in defining, measuring and improving standards of performance. Experience has shown that patients and users can contribute …

Sixty years ago, the new National Health Service promised that a doctor would be assured ‘freedom... to pursue his professional methods in his own individual way, and not to be subject to outside clinical interference’.1 But after thirty years, the Chief Medical Officer, Sir George Godber, set out to define a ‘Cogwheel’ structure for the accountability and self-regulation of hospital doctors,2 and soon a non-governmental inquiry reported ‘It is a necessary part of a doctor's professional responsibility to assess his work regularly in association with his colleagues.’3 In evidence to the Royal Commission on the NHS in 1977, the British Medical Association was ‘not convinced of the need for further supervision of a qualified doctor's standard of care’. In its final report, the Commission responded, ‘We are not convinced that the professions regard the introduction of medical audit and peer review with a proper sense of urgency.’4 Thus, thirty years ago, standards in the NHS referred not to clinical practice or services but to buildings, equipment, capacity and allocation of resources.5 Any defects in the system were blamed on shortage of staff, money or facilities—after all, the NHS was then one of the cheapest comprehensive health systems in the world. There was little effort to examine how those resources were used or whether they could yield better clinical results. There had been several public scandals about the treatment of patients, the behaviour of doctors and the management of institutions, particularly in long-term care. But few people were keen for improvement, or even recognized a need for it. Tradition and the stout defence of clinical freedom made the management of doctors as easy as herding cats.

Systematic improvement of health services requires the objective measurement of people, practices and organisations against valid and explicit standards in order to identify and implement appropriate change. Effective quality systems must embrace a wide range of definitions of quality, and a similar variety of approaches to defining, measuring and improving. Clinical performance may be examined from three professional viewpoints--clinical competence: assessment of individual practitioners against explicit criteria to recognise achievement and to promote continuing development. Traditional mechanisms of training, registration and accreditation enable clinicians to reach career grades but responsibility for subsequent support is often unclear between employers, professions and registering bodies. Clinical practice: assessment of actual clinical process and outcomes against research-based "best practice" to identify and reduce variation. Peer review, clinical audit and confidential enquiries are examples of this approach, which may involve single or multiple professional groups and their interface with management. Service accreditation: systems to assess health care organisations against published standards in order to encourage best management practice. These are usually run on a regional or national basis and, though sensitive to expectations of patients, managers, clinicians, paying agencies and government, they are usually managed by an impartial but authoritative organisation.

Roundtable-at-a-Glance Background A roundtable held October 5–6 1999, in Maidstone, Kent, United Kingdom, was convened to identify current strategies and ongoing challenges in implementing evidence-based practice guidelines in health care. Despite numerous new medical research findings for improving health care and despite the dissemination of many practice guidelines, the recommendations from these efforts are not being uniformly adopted. Overuse, underuse, and misuse plague the practice of medicine today. Implementing guidelines Multiple implementation strategies are more likely to succeed than a single implementation method; local selection and adaptation of guidelines are critical; and reminders, educational outreach (for prescribing), and interactive educational workshops are generally effective. Experience in Europe In most countries, guideline development has progressed from consensus conference, to evidence-based statements, and finally to evidence-based guidelines that also consider cost-effectiveness. Guideline development is the most advanced in The Netherlands, where physicians have coordinated their efforts with the government to achieve more uniformity than is found elsewhere. Experience in the United States Designing systems that will facilitate change—not changing physician behavior—should be the focus. The concern for effecting improvement in health care is now more acute because of the increased attention being given to medical errors and patient safety. Summary statement Multifaceted approaches are clearly the most important method for improving care. Such approaches may include many improvement methods, none of which work well alone most of the time or any of the time.

This paper is a summary of the operation, findings and conclusions of a European Union project on external peer review techniques, termed 'ExPeRT', to research the scope, mechanisms and use of external quality mechanisms in the improvement of health care. Many of the themes outlined are described in detail in other papers that have been prepared specifically for this issue of The International Journal for Quality in Health Care. Although the emphasis of this project and of this issue of the Journal is on Europe, the conclusions are more widely relevant.

Accreditation is a formal process by which an authorized body assesses and recognizes an individual, an organization (like a hospital), a program, or a group as complying with requirements such as standards or criteria [1]. This article analyses and compares the activity and funding of six health care accrediting bodies which operate in five different countries, and which in 1994, accredited over 5000 health centres. The data included in this article could be useful for other institutions who wish to commence accreditation programmes for health care organizations. Copyright © 1996 Elsevier Science Ltd.

Objective: to describe global patterns among health-care accreditation organizations (AOs) and to identify determinants of sustainability and opportunities for improvement. Design. Web-based questionnaire survey. Participants: organizations offering accreditation services nationally or internationally to health-care provider institutions or networks at primary, secondary or tertiary level in 2010. Main Outcome Measure(s). External relationships, scope and activity public information. Results: forty-four AOs submitted data, compared with 33 in a survey 10 years earlier. Of the 30 AOs that reported survey activity in 2000 and 2010, 16 are still active and stable or growing. New and old programmes are increasingly linked to public funding and regulation. Conclusions: while the number of health-care AOs continues to grow, many fail to thrive. Successful organizations tend to complement mechanisms of regulation, health-care funding or governmental commitment to quality and health-care improvement that offer a supportive environment. Principal challenges include unstable business (e.g. limited market, low uptake) and unstable politics. Many organizations make only limited information available to patients and the public about standards, procedures or results. Refereed/Peer-reviewed

Representatives of seventeen existing and developing national accreditation systems for health services met in Treviso, Italy, in May 1994. The purpose was to identify common characteristics, challenges and solutions in order to help the younger programmes to build on the experience of the well-established, particularly those in the United States, Canada and Australia. General questions and conclusions are reported with respect to aims, organisation, funding, standards development, operation and evaluation but it is emphasized that individual programmes must be designed and developed to be sensitive to local needs.

Voluntary accreditation in the United Kingdom is being used by health care providers to improve and market their services and by commissioners to define and monitor service contracts. In a three year pilot scheme in the south west of England, 43 out of 57 eligible community hospitals volunteered to be surveyed; 37 of them were ultimately accredited for up to two years by the hospital accreditation programme. The main causes for non-accreditation related to safety, clinical records, and medical organisation. Follow up visits in 10 hospitals showed that, overall, 69% of recommendations were implemented. An independent survey of participating hospitals showed the perceived benefits to include team building, review of operational policies, improvement of data systems, and the generation of local prestige. Purchasers are increasingly influenced by accreditation status but are mostly unwilling to finance the process directly. None the less, the concept may become an important factor moderating the quality of service in the new NHS. The concept of accrediting hospitals as suitable environments for training was developed by the American College of Surgeons from 1917, and accreditation became a national yardstick for the organisation of hospitals for many other purposes. Accreditation has subsequently been adapted and adopted in Canada and Australia and, particularly over the past five years, in many other countries, including the United Kingdom. All accreditation systems have explicit standards for organisation against which the participating hospital assesses itself before a structured visit by outside surveyors, who submit a written report to the hospital with commendations and recommendations for development before a follow up survey.1 Accreditation may be awarded for a fixed term or may be withheld by an independent assessment board if the hospital does not meet a defined threshold of standards. Functioning national schemes in the United Kingdom include the King's Fund organisational …

Objective: The study aim was twofold: to investigate and describe the organizational attributes of accreditation programmes in low- and middle-income countries (LMICs) to determine how or to what extent these differ from those in higher-income countries (HICs) and to identify contextual factors that sustain or are barriers to their survival. Design: Web-based questionnaire survey. Participants: National healthcare accreditation providers and those offering international services. In total, 44 accreditation agencies completed the survey. Main outcome measure(s): Income distinctions, accreditation programme features, organizational attributes and cross-national divergence. Results: Accreditation programmes of LMICs exhibit similar characteristics to those of HICs. The consistent model of accreditation worldwide, centres on promoting improvements, applying standards and providing feedback. Where they do differ, the divergence is over specialized features rather than the general logic. LMICs were less likely than HICs to include an evaluation component to programmes, more likely to have certification processes for trainee surveyors and more likely to make decisions on the accreditation status based on a formulaic, mathematically oriented approach. Accreditation programme sustainability, irrespective of country characteristics, is influenced by ongoing policy support from government, a sufficient large healthcare market size, stable programme funding, diverse incentives to encourage participation in accreditation by Health Care Organizations as well as the continual refinement and improvement in accreditation agency operations and programme delivery. Conclusions: Understanding the similarities, differences and factors that sustain accreditation programmes in LMICs, and HICs, can be applied to benefit programmes around the world. A flourishing accreditation programme is one element of the institutional basis for high-quality health care. © The Author 2012. Published by Oxford University Press in association with the International Society for Quality in Health Care; all rights reserved.

This research is supported under Australian Research Council's Linkage Projects scheme (project LP100200586). Human Research Ethics Committee approval for its conduct was granted by the University of New South Wales (HREC 10274). We acknowledge the staff of the industry partners (ACHS, AGPAL, ACSAA) and the quality improvement agencies (ACSQHC, CEC) who provided support for the project. We appreciate Ms Danielle Marks' valuable research assistance in the development of this paper. Background: Service accreditation is a structured process of recognising and promoting performance and adherence to standards. Typically, accreditation agencies either receive standards from an authorized body or develop new and upgrade existing standards through research and expert views. They then apply standards, criteria and performance indicators, testing their effects, and monitoring compliance with them. The accreditation process has been widely adopted. The international investments in accreditation are considerable. However, reliable evidence of its efficiency or effectiveness in achieving organizational improvements is sparse and the value of accreditation in cost-benefit terms has yet to be demonstrated. Although some evidence suggests that accreditation promotes the improvement and standardization of care, there have been calls to strengthen its research base. In response, the ACCREDIT (Accreditation Collaborative for the Conduct of Research, Evaluation and Designated Investigations through Teamwork) project has been established to evaluate the effectiveness of Australian accreditation in achieving its goals. ACCREDIT is a partnership of key researchers, policymakers and agencies. Findings. We present the framework for our studies in accreditation. Four specific aims of the ACCREDIT project, which will direct our findings, are to: (i) evaluate current accreditation processes; (ii) analyse the costs and benefits of accreditation; (iii) improve future accreditation via evidence; and (iv) develop and apply new standards of consumer involvement in accreditation. These will be addressed through 12 interrelated studies designed to examine specific issues identified as a high priority. Novel techniques, a mix of qualitative and quantitative methods, and randomized designs relevant for health-care research have been developed. These methods allow us to circumvent the fragmented and incommensurate findings that can be generated in small-scale, project-based studies. The overall approach for our research is a multi-level, multi-study design. Discussion. The ACCREDIT project will examine the utility, reliability, relevance and cost effectiveness of differing forms of accreditation, focused on general practice, aged care and acute care settings in Australia. Empirically, there are potential research gains to be made by understanding accreditation and extending existing knowledge; theoretically, this design will facilitate a systems view of accreditation of benefit to the partnership, international research communities, and future accreditation designers. "Accreditation of health-care organisations is a multimillion dollar industry which shapes care in many countries. Recent reviews of research show little evidence that accreditation increases safety or improves quality. It's time we knew about the cost and value of accreditation and about its future direction." [Professor John vretveit, Karolinska Institute, Sweden, 7 October 2009]. © 2011 Braithwaite et al; licensee BioMed Central Ltd.

Quality problem There is no simple tool to assess compliance with common national and European directives, guidance and professional advice on the management of healthcare institutions. Despite evidence of unacceptable variations in the protection of patient and staff safety little attention has been given to harmonizing the way services are organized and managed. Initial assessment Existing systems which define organizational standards, or assess compliance with them, are not in a position to extend this activity into or across national borders in Europe. Certification, accreditation and licensing programmes are too variable to provide a common basis for consistent assessment. Consensual standards would inevitably be minimal if they were to achieve acceptance by all or a majority of member state governments; they would not be standards for excellence or help the majority of organizations to improve performance. Proposed solution This paper proposes the development of a framework and measurement tool, initially for hospitals, which could be used for self-assessment or peer review to demonstrate compliance with European legislation, guidance and public expectations without infringing national responsibilities. A common code of management practice could be developed through a process similar to that adopted for clinical practice guidelines by the European commission-funded project on appraisal of guidelines research and evaluation. Conclusions In practice, the legal relationships between member states and intergovernmental organizations inhibit the harmonization of management practice across-borders. Faster progress to higher levels of performance would be achieved by voluntary, non-regulatory cooperation of enthusiasts to define, measure and improve the quality of healthcare in European hospitals.

Context: This study was part of the Methods of Assessing Response to Quality Improvement Strategies (MARQuIS) research project on patients crossing borders, a study to investigate quality improvement strategies in healthcare systems across the European Union (EU).Aim: To explore the association between the implementation of quality improvement strategies in hospitals and hospitals' success in meeting defined quality requirements that are considered intermediate outputs of the care process.Methods: Data regarding the implementation of seven quality improvement strategies (accreditation, organisational quality management programmes, audit and internal assessment of clinical standards, patient safety systems, clinical practice guidelines, performance indicators and systems for obtaining patients' views) and four dimensions of outputs (clinical, safety, patient-centredness and cross-border patient-centredness) were collected from 389 acute care hospitals in eight EU countries using a web-based questionnaire. In a second phase, 89 of these hospitals participated in an on-site audit by independent surveyors. Pearson correlation and linear regression models were used to explore associations and relations between quality improvement strategies and achievement of outputs.Results: Positive associations were found between six internal quality improvement strategies and hospital outputs. The quality improvement strategies could be reasonably subsumed under one latent index which explained about half of their variation. The analysis of outputs concluded that the outputs can also be considered part of a single construct. The findings indicate that the implementation of internal as well as external quality improvement strategies in hospitals has beneficial effects on the hospital outputs studied here.Conclusion: The implementation of internal quality improvement strategies as well as external assessment systems should be promoted.

This article summarises the significant lessons to be drawn from, and the policy implications of, the findings of the Methods of Assessing Response to Quality Improvement Strategies (MARQuIS) project--a part of the suite of research projects intended to support policy established by the European Commission through its Sixth Framework Programme. The article first reviews the findings of MARQuIS and their implications for healthcare providers (and particularly for hospitals), and then addresses the broader policy implications for member states of the European Union (EU) and for the commission itself. Against the background of the European Commission's Seventh Framework Programme, it then outlines a number of future areas for research to inform policy and practice in quality and safety in Europe. The article concludes that at this stage, a unique EU-wide quality improvement system for hospitals does not seem to be feasible or effective. Because of possible future community action in this field, attention should focus on the use of existing research on quality and safety strategies in healthcare, with the aim of combining soft measures to accelerate mutual learning. Concrete measures should be considered only in areas for which there is substantial evidence and effective implementation can be ensured.

Political and professional attitudes in the United Kingdom are now increasingly supportive of systematic quality assurance, particularly in the acute sector. This paper describes general progress towards organisational audit or accreditation of hospitals and outlines the structure, process and findings of two developing programmes--one based at the King's Fund Centre in London, the other in the South Western Region in Bristol.

The concept of avoidable death is increasingly used both epidemiologically and clinically as an indicator of the quality of health services. This paper examines practical experience, particularly in Britain and Europe, of the organisation and impact of collaborative mortality studies in improving patient care in surgery and perinatal services. It suggests that the technical inadequacies of such studies are small compared with their benefits—as long as their message is translated into local practice. It offers some key ingredients for effective collaborative mortality studies.

Article-at-a-Glance Background In the past 15 years many countries, with widely differing health systems, have established national accreditation programs. A European survey report on accreditation, which includes data and updates from 2003 that were submitted between January and October 2004, is summarized. Methods A one-page questionnaire was circulated, with the summary of the 2002 survey, in February 2004 to known contacts in 44 of the larger states in the European Region of the World Health Organization. Combining the surveys of 2000, 2002, and 2004, responses were received from 36 of the 44 larger countries of the European Region from which information was sought. Findings The number of national accreditation programs for health services has continued to grow since the mid-1990s. By 2004, 26 programs were active or in development in 18 countries. The "English-speaking" model of North America remains the leading influence; however, newer programs are increasingly influenced by other models. Governmental programs are more likely to publish findings of accreditation assessments, and more recent programs are more likely to make results public. Discussion Accreditation programs are being set up more frequently in Europe than anywhere else; the trend is from voluntary, confidential, and self-financed organizational development toward benign but transparent regulation of stakeholders, governmental support, and public funding. Programs vary widely, yet patient and staff mobility, cross-border purchasing, freedom of trade, and protection of public safety and patients' rights imply the need for a common approach to definition, assessment, and improvement of standards in health care.

No: it's not clear what they are based on and the timescale is too short T he Healthcare Commission is about to consult on measures for assessing the performance of healthcare providers in England. The standards against which it will be making these assessments were laid down in July by the Department of Health in Standards for Better Health. 1 Despite their potential impact on service development, and on the ability of the commission to make valid and reliable assessments, the standards have received little attention. Yet they deserve to—for they provide a weak basis for assessment and improvement. The standards' main aims are to assure safe and acceptable services through compliance with minimal “core” standards; promote development by continuous improvement against optimal standards; reduce the burden of unhelpful standards and guidance; and underpin fair, responsive, and effective services. They consist of both core standards, which are assumed to be met already by all provider organisations, and developmental standards, which are to provide goals for service improvement. The standards are presented in seven domains designed to cover the full range …

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 …

Purpose. To gather data on how accreditors manage surveyors, to compare these data and to offer them to the accreditors for improvement and to the scientific community for knowledge of the accreditation process and reinforcement of the credibility of these processes. Data source. The data were gathered with the aid of a questionnaire sent to all accreditors participating in the study. Results. An important finding in this comparative study is the different contractual relationships that exist between the accreditors and their surveyors. Conclusion. Surveyors around the world share many common features in terms of careers, training, work history and expectations. These similarities probably arise from the objectives of the accreditors who try to provide a developmental process to their clients rather than an ‘inspection’.

In his letter, Auger argues that the new Care Quality Commission inspection regime is under-resourced.1 Apart from their demands on clinical specialist time, and competing with peer review by the royal colleges and associations, inspection teams of 20-25 may be unsustainable. They may have worked better for the pinpoint investigation of the Keogh reviews of 14 hospitals than they would for programmed review of …

We know that clinical guidelines are not self-executing. But the Leeds University Maternity Audit Project [1] has thrown new light on the complexity of change—light that deserves to shine not just on maternity or on the UK; the messages could apply equally in many specialities and in many settings. The project identified four accessible markers of compliance with available evidence-based guidelines and applied them to existing records in 20 maternity units in 1988 (before the evidence was widely published) and again in 1996 to show how practice had changed. Staff interviews collected further background on attitudes and access to guidelines and information. The good news was that, overall, there was a massive and appropriate shift in clinical practice; the bad news was that there were notable pockets of resistance. This resistance was not associated with aversion to the published guidelines (most respondents thought they were a ‘good thing’), nor did it prevent maternity units from developing their own consistent policies (many had adopted them locally), nor was non-compliance with one guideline correlated with non-compliance with others in the same unit. The composite scores of individual units were not provided, nor were all other non-correlations given. The improvements were ‘despite the fact that …

In short, quality assurance in UK healthcare has developed since the mid-1980s driven by a series of national policy initiatives in the NHS, by increasing determination of the clinical professions to maintain standards, and by a general consumer movement to know more about public and professional services. Much has been achieved but there remains substantial debate about quality assurance leadership, coordination, funding and evaluation--or even what to call it.

Principles for Best Practice in Clinical Audit National Institute for Clinical Excellence Published in 2002 by Radcliffe Medical Press Ltd, Abingdon, UK 208 pp. ISBN 1 85775 976 1 (paper) Price £29.95. This book (and the CD which comes with it) is aimed at leaders of local clinical audit in the UK National Health Service (NHS). The principal authors have contributed experience from three established national authorities (Royal College of Nursing, Department of General Practice at University of Leicester, and the National Institute for Clinical Excellence); they have also drawn together a wealth of supporting evidence and sources from bibliography and the internet. The main body of the text traces five stages of the clinical audit …

Background Quality problems in medical care are not a new finding. Variations in medical practice as well as actual medical errors have been pointed out for many decades. The current movement to write practice guidelines to attempt to correct these deviations from recommended medical practice has not solved the problem. Objective In order to gain greater acceptance of these guidelines and to change the behavior of health care providers, the science of guideline implementation must be understood better. Research design A group of experts who have studied the problem of implementation in Europe and the United States was convened. This meeting summary enumerates the implementation methods studied to date, reviews the theories of behavioral change, and makes recommendation for effecting better implementation guidelines. Results A research agenda was proposed to further our knowledge of effective evidence-based implementation.

This paper is the report on the technical discussions on "Quality assurance of health services" at the 38th session of the WHO Regional Committee for Europe, one of the activities aiming at achieving WHO's regional health for all target 31, which requests WHO's Member States to establish a quality assurance mechanism. Attended by national health authorities and experts in quality assurance, the technical discussions identified the European context for developing quality assurance and looked at national initiatives. Having agreed that the question is no more, "Is there a need for quality assurance of health services?" but, "How can it best be carried out?", the participants identified a range of quality assurance activities at national and international levels, including national strategies and financial incentives, criteria for clinical practice, information systems and coordination and management mechanisms. The report concludes with recommendations for Member States on, for example, inclusion of quality assurance in national health policies, dissemination of information, research on quality assurance, information systems and role of professional organizations.

Public, political and professional pressure for formal medical audit is mounting in Britain, as in other countries. Within the National Health Service, the government has proposed that audit should be established by 1991 in hospitals and by 1992 in general practice. Prior to this proposal considerable progress had already been made by individual doctors and by national professional bodies. If this medical initiative is to be retained, doctors must be able to demonstrate that audit is universal, systematic and effective.

The perinatal mortality rate (PNMR) was calculated for each rural parish in Gloucestershire for the years 1968–79. The characteristics of high- and low-rate parishes (each set comprising about 10% of all births) were contrasted according to routinely recorded fetal, maternal and environmental variables. The overall PNMR in the high-rate set was six times higher than in the low-rate set; congenital malformations and low birth weight distribution could explain about one-third of this difference but the residue wás not attributable to fetal gestation, maternal age or parity or social class as may have been expected. However, there was a strong association with population and housing density. It is suggested that comparisons within districts may provide more sensitive associations with PNMR than comparisons between districts, regions and countries.