Original Article

Clinical Risk
2014, Vol. 20(4) 8289
! The Author(s) 2014
Securing patient safety through quality Reprints and permissions:
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assurance in a mixed economy of DOI: 10.1177/1356262214542520
cri.sagepub.com
healthcare: The role of accreditation

David Cochrane

Abstract
Independent accreditation is the third component of comprehensive regulatory systems of countries with a mixed
economy of healthcare provision such as the United States and Australia. Now that the Health and Social Care Act
2013 is fueling more pluralistic provider and commissioner models in England, this article explores the case for requiring
all suppliers of publicly funded healthcare to be formally accredited. In doing so, it sets out the benefits of independent
accreditation, describes the international market including the UK-based accreditation bodies, lists some NHS providers
who have already opted to be accredited and sets out a proposed way forward based on the recent experience of
South Africa.

Keywords
Patient safety, quality assurance

Development Association highlighted the following

Introduction
The Health and Social Care (HSC) Act 2013 has estab-
lished the principle of any qualied provider giving new
momentum in England to the development of a mixed
economy in healthcare provision and assumedly com-
missioning. As new market entrants successfully com-
pete with NHS providers for large contracts, the Care
Quality Commission (CQC) has the role of scrutinizing
the tness of providers, whether NHS or private, with a
view to formal designation as qualied under the
terms of the Act. This is a function key to ensuring
quality and value for money on behalf of the public.
At the same time in the wake of the Francis and
Berwick Reports, patient safety re-emerged as a central
concern in the NHS. Key themes include movement to
a culture of transparency along with a duty of candour
which, as in the airline industry, would embrace intel-
ligence on performance deciencies in order to prevent
further future occurrences. The case for minimum
standards such as nurse stang levels and competences
is once more on the agenda.
The NHS regulatory system is still relatively young
so teething troubles may be seen as inevitable.1 Indeed,
there are evident parallels with the early days of regu-
lation in other industry sectors in other parts of the
world. For example, the United National Industrial
early learning points2:
. A lack of transparency and openness as core operat-
ing principles necessary to promote condence in the
regulatory body and the processes it follows.
. Variations in performance and levels of public
condence.
. Insucient awareness of the role of quality manage-
ment systems to drive continuous and sustained
improvement, including the need to measure and
respond to customer satisfaction and handle com-
plaints satisfactorily.
Since the Berwick Report, the CQC has done much
to improve public condence. However, as more pro-
viders enter the healthcare market in England, it is
timely to review how quality assurance, encompassing
patient safety, is managed in more mature, mixed
economies of healthcare provision such as the
Director, Conrane Consulting, London, UK
Corresponding author:
David Cochrane, Conrane Consulting 76 Corbyn Street, London,
N43BZ, UK.
Email: david@conrane.com
Cochrane
United States or Australia.3 America is seen by many
policy analysts as a model for the UK Governments
market reforms, as well as integrated care design, long-
term condition management, and payment system
reform. So it can be similarly instructive to look to
the experience of the US and other OECD countries
where independent accreditation is a central component
in the model of choice for quality assurance and
improvement.
Whole system approach to quality
assurance and improvement
Accreditation can be seen as one tier of a virtuous
trinity or whole-system approach to patient safety,
quality assurance, and improvement (Figure 1).4
The UK has an established tradition of accreditation
as described in a later section. However, in terms of this
three-tier framework, the NHS has only two of the
three elements fully in place, and consistent with inter-
national practice these two are vested with quasi-
governmental agencies.5 As the mixed economy gathers
pace, so the case becomes persuasive to incentivise
Figure 1. A virtuous trinity. Licensing is the process by which a
government authority grants permission, usually following
inspection against minimum statutory standards, to an individual
practitioner or healthcare organization to operate or to engage
in an occupation or profession. This is the role of Monitor in
England in relation to foundation trusts. Certification or formal
recognition of compliance with a set of minimum standards (e.g.
the ISO 9000 series for quality systems) validated by inspection
a function vested with the CQC. Accreditation or public con-
firmation by an internationally recognized agency of the
achievement by healthcare organizations of standards and quality
assurance procedures, demonstrated through independent,
external peer assessment.
83
universal independent accreditation of publicly funded
healthcare organizations both providers and commis-
sioners. This would follow the model in more mature
mixed economies of healthcare.
Accreditation definition, approach and
standards
In looking for denitions, there is no better place to
start than United Kingdom Accreditation Service
(UKAS) itself, the sole national accreditation body
recognized by the British government.6 UKAS denes
accreditation as a formal, third party recognition of
competence to perform specic tasks. It provides a
means to identify a proven, competent evaluator so
that the selection of a (provider) becomes an informed
choice.7 For Argawal, it is A self-assessment and
external peer assessment process used by healthcare
organizations to accurately assess their level of per-
formance in relation to established (evidence-based)
standards and to implement ways to continuously
improve.8
Accreditation can be framed by the classic
Donabedian S.P.O. typology for the denition and
measurement of healthcare quality or in terms of
three parameters.
. Structure standards and processes are concerned
with the systems inputs, such as human resources,
the design of a building, the availability of and the
availability and quality of facilities, equipment and
supplies;
. Process addresses the activities or interventions car-
ried out in the care of patients or in the management
of the organization areas, such as patient assessment,
patient education, medication administration, equip-
ment maintenance, or sta supervision. Key criteria
will include compliance with clinical guidelines
based on evidence-based practice;
. Outcome focuses on the clinical eect of the inter-
ventions employed for a specic health problem.
They also span patient safety indicators such as mor-
tality rates, hospital-acquired infection rates, and
complication rates for births and surgical proced-
ures, as well as patient experience in terms of satis-
faction and involvement in care decisions all of
which need to be recorded and reported.9
In parallel with regulation, accreditation involves
regular formal surveys. However, perhaps more
importantly, organizations are required to have proced-
ures and processes in place for continual quality meas-
urement and improvement. Indeed, it is key role of
accreditation to support capacity building so these
activities are fully operational. The survey also
84
systematically gathers data on conformity to standards,
conrms that they routinely updated, made available to
clinicians and managers, and thus integral to day-to-
day service delivery, operational management, planning
and development. Formal surveys are generally unan-
nounced as an incentive to keep data and procedures
concurrent. The schedule is unpredictable; thus in the
US, the Joint Commission (see below) can arrive at any
time between 18 and 39 months after their previous
visit. Also a key outcome is the quality assurance and
improvement action plan. Implementation of this is
monitored by the agency through regular progress
reports required from the organization. The standards
are publicly available although some agencies charge a
fee, whilst the stages of the process are explained in
detail on the various agency websites.10
In 2003, the World Health Organization reviewed
quality management systems in 50 countries and then
published research evidence. Its conclusions highlight a
key distinction between regulation and the added value
of accreditation.
There is ample evidence that quality cannot be
inspected into healthcare systems and that success
requires a quality culture to be shared by managers
and sta . . . there is little evidence that regulatory sys-
tems have adopted continuous quality improvement
principles, but Australia and the United States (both
mixed economies in healthcare provision) seem to agree
that both approaches need to co-exist.11,12
Hence in these countries, accreditation has by no
means replaced statutory licensing and certication,
rather it is a voluntary, additional tier of regulation
which promotes continual quality improvement from
the bottom-up. In the US publicly funded sector, how-
ever, accreditation by an approved agency is deemed as
compliance with statutory licensing thus exempting
them from the requisite routine inspections.13
Advantages of accreditation
If regulation is always mandatory and carries the threat
of sanctions, accreditation is voluntary and oers sub-
stantial benets to all stakeholders. These include:
For consumers
. It is an independent and authoritative kite mark
informing patients about the level and quality of
healthcare services that they should receive at speci-
ed facilities and hence strengthens the publics over-
all condence in the safety and quality of the local
healthcare system.
. It thereby not only enhances the credibility and
reputation of an organization, accreditation
Clinical Risk 20(4)
supports informed consumer choice. According to
Monitor, a key function of a regulatory regime is
to enable patients to make choices about their
healthcare.14 Unfortunately, the potential for infor-
mation gaps between consumers and the healthcare
system is manifestly great. By making all data and
reports publicly available, accreditation narrows
knowledge and business intelligence disparities
between consumers and their health system.
. Not least this obviates any temptation for providers
to hide information from regulators.15 In this way,
transparency is guaranteed as quality assurance is
not just done it is seen to be done.
For the organization
. The published comparative databases enable bench-
marking of healthcare organizations which they may
use internally or in marketing their services to
consumers.
. In addition to compliance with minimum standards
and other regulatory requirements, accreditation
conrms peer-reviewable achievement of excellence
or best practice and promotes continuous learning
and improvement. The end-to-end process incorpor-
ates capacity building to secure sustainability.
. The process provides education and consultancy to
managers, and health professionals on quality
improvement strategies and current best practices
in healthcare delivery, patient involvement and busi-
ness operations.
. Accreditation also provides a market advantage
within a competitive, mixed-economy, healthcare
sector for which the HSC Act has provided both
blueprint and impetus.
For sta
. Accreditation can create a culture of excellence
where motivation is founded in pride in their service
as distinct from negatives such as avoiding blame
and fear of adverse inspection reports. For as
Sarah Wollaston, a former GP and now
Conservative MP said recently, the best way to
improve safety in the health service is to make the
sta proud of what they do16;
. It can thus enhance risk management, job satisfac-
tion, recruitment and retention.
There are also major benets for the regulators
themselves. In the US, accreditation agencies collabor-
ate closely with regulators to facilitate their role by
ensuring the information they need to support licensing
and certication is incorporated into the overall process
including their approved standard sets. Advocates
Cochrane
also claim accreditation can reduce healthcare costs by
focusing on increased eciency and eectiveness of ser-
vices although this is perhaps more controversial and
is discussed in more detail below.
Features of accreditations agencies
Key characteristics of the accreditation agencies them-
selves include:
. They are non-statutory and independent of govern-
ment in terms of governance and sources of nance.
. They generate revenue through fees charged to the
organizations they accredit and sales of other prod-
ucts such as standards, guidelines, etc.
. Their governing bodies include expertise drawn from
the healthcare professions and healthcare executives
including corporate membership from professional
colleges, medical associations and national represen-
tative bodies for healthcare organizations.
. They are typically not-for-prot.
. Their remit is international so their clients span mul-
tiple countries.
. Their processes and standards are managed by
expert advisory panels so they constitute inter-
national benchmarks for current, best and/or evi-
dence-based practice clinically, in terms of
customer or member services and in organizational
management.
Comparing healthcare accreditation in
the US and UK
The US central and local government spends more on
healthcare per head of population than the NHS in
England. In 2014, American taxpayers are funding
over 20% more federal (central) government per
capita healthcare spending than their British counter-
parts. In the US, 18% of GDP is now devoted to
healthcare; free healthcare is a universal benet for
over-65s via Medicare, and there are similar pro-
grammes for the non-working poor and chronically ill
people via Medicaid, whilst Obamacare is subsidizing
access to healthcare for uninsured working citizens and
college students.17 To secure value for this money,
public sector payers in the US encourage voluntary,
accreditation as a layer of guarantees of patient safety
through quality assurance.
Voluntary may be something of a misnomer, since it
has become eectively impossible for providers and
payers/commissioners (health plans) to qualify for
public sector contracts without being formally accredited
by an independent body.18 For adults of working age
healthcare is a corporate welfare benet, so accordingly
85
most of the large employers will entrust their employee
healthcare benets only to accredited health plans. Both
the federal healthcare funding agency Centre for
Medicare and Medicaid Services (CMMS)19 and the
state regulators maintain lists of approved accreditation
suppliers. These are independently funded, and managed
agencies mostly, though not exclusively, based in the
North America but with clients in many other countries.
If a healthcare organisation is formally accredited by one
of these approved suppliers, CMMS will deem it compli-
ant with its conditions of participation and coverage or
its formal, mandatory licensing procedures.
In the US, the market for provider accreditation has
been steadily diversifying from a largely single provider
model based on the Joint Commission (see below) 20
years ago. This trend has created healthy competition
and the emergence of specialist agencies for specic ser-
vices and new healthcare priorities. CMMS approves
seven agencies20 having in 2008 added the rst non-
American body, Norways Det Norske Veritas (DNV
Healthcare) which now boasts 1300 clients across 100
countries and a busy oce in Milford, Ohio.21 The
Joint Commission International (JCI) remains the lar-
gest and evaluates and accredits more than 15,000
healthcare organizations and programs in the United
States alone. It is not-for-prot and governed by a
Board of Commissioners that includes physicians,
administrators, nurses, employers, a labour/union rep-
resentative, health plan leaders, quality experts, ethi-
cists, a consumer advocate and educators. Corporate
members include the American College of Physicians,
the American College of Surgeons, the American
Dental Association, the American Hospital
Association, and the American Medical Association.
It provides accreditation services for basically all
types of healthcare providers, physician practices, nur-
sing homes, and other long-term care facilities. It also
awards Disease Specic Care Certication to health
plans, disease management and chronic care services
a role shared with NCQA (see below). The JCI also has
a Health Care Stang Services Certication Program.
There are specialist agencies for ambulatory, com-
munity and primary care. Across the world, rehabilita-
tion services, including Stoke Mandeville in the UK,
look to the Council for the Accreditation of
Rehabilitation Facilities (CARF) to dene and imple-
ment standards. Furthermore, new agencies are emer-
ging for the case management and care coordination
services central to the new Medical Homes or
Accountable Care Organizations focusing on patients
with complex needs and chronic co-morbidities. The
aim here is to proselytize and standardize best practice
aligned to the missions of these new structures to rede-
sign delivery systems thereby to improve quality of
care, patient experience and to reduce costs.
86
US health plans or commissioners look to the
National Council for Quality Assurance (NCQA).
This body was originally founded to generate relevant
quality data to counter accusations leveled by the fee-
for-service sector that managed care plans such as
Kaiser Permanente sacriced quality and choice to
save money. NCQA later became the administrators
of the H.E.D.I.S22 standards originally commissioned
by the larger health employers. Healthcare is in the top
three cost categories for both public and private sector
enterprises in the US (alongside salaries and raw mater-
ials) so employers sought objective evidence that their
increasingly expensive investments were oering their
sta quality and value for money. NCQA accreditation
is all-but essential if a health plan is to market its ser-
vices to beneciaries of Medicare and Medicaid and/or
employers of signicant size. Its reports, league tables
and awards for best practice are publicly available and,
unsurprisingly, highly rated plans employ these jeal-
ously to dierentiate their services to consumers on
quality. NCQA also accredits Accountable Care
Organizations, case management and disease manage-
ment programmes.23
The market in the UK is less well developed and
focused mainly on providers. UKAS is an independent,
non-prot-distributing private company, operating in
the public interest as a company limited by guarantee.
It encompasses major health sector expertise and
experience and foresees this sector as a major growth
area. In 2010, UKAS acquired the CPA (Clinical
Pathology Accreditation) from the Royal Colleges
including ISAS (Imaging Services Accreditation
Scheme) from the Royal College of Radiologists and
the College of Radiographers. Indeed, UKAS is recog-
nized and frequently commissioned as a leading inter-
national agency in the elds of laboratories and
radiology. The largest assurance and accreditation ser-
vice devoted to healthcare is CHKS in turn accredited
by UKAS. CHKS has been in operation for almost 20
years and includes its own Accreditation Council and
Awards Panel comprising independent volunteers with
a breadth of healthcare expertise. CHKS programmes
cover UK and international hospitals, care homes, and
include specialist services such as maternity and neo-
natal care, mental health, addiction and oncology.24
The recently formed QHA Trent Accreditation service
is advising hospitals bidding for health tourism to
engage its services to enhance their market proles.25,26
Value for money
Accreditation requires investment so a key question in a
resource-constrained healthcare sector is does it oer
value for money? In some respects this seems a curious
question since it is has long been axiomatic and
Clinical Risk 20(4)
demonstrable in the manufacturing and commercial
service sectors that the eective implementation and
certication of quality management systems bring
major economic benets.27 Certainly, no one to-date
has proven healthcare to be immune from this general
truism. That said and as Sack et al.28 point out, while
cost containment in hospitals is an issue in many coun-
tries, there is an obvious need properly to establish
costs and benets of accreditation. They report that
the process of accreditation requires resources and
time illustrating the process of an ISO accreditation
of a small Swiss hospital. For this accreditation three
years work of three full time sta members was requir-
ed . . . the implementation also requires substantial
input from physicians and nursing sta. Similarly,
the cost to a moderately-sized health plan in the US
of achieving accreditation by NCQA was over $2 mil-
lion ten years ago.29
Frustratingly, recent research ndings on the value
of accreditation can be inconclusive. Sack et al.30 found
that although accreditation was a market advantage in
terms of perceived reputation and access to certain con-
tracts, there was no signicant variation in levels of
customer satisfaction or recommendation rates for
accredited hospitals versus non-accredited institutions
in the US. Like all such meta-analyses the conclusions
can only be as good as the component studies and Sack
acknowledges these are limited. In addition, the study
did not explore whether competition led to all hospitals
meeting higher standards, with those accredited driving
up performance in the others. Hinchcli et al.31 also
identify a lack of peer reviewable evidence and are seek-
ing to redress this in relation to the impact of accredit-
ation in Australia which hopefully should add to our
knowledge base.
Since the costs of poor-quality healthcare are con-
siderable to both the individual and society, there is
scope for improved quality management to deliver eco-
nomic benets. Such costs in England can arise from
preventable and avoidable acute hospital admissions,
high rates of re-admissions, and extended lengths of
stay particularly for people in later life. For vulnerable
older people in particular, avoidable hospital admis-
sions can lead to premature physical and cognitive
impairment32 bringing forward the need for NHS nur-
sing or residential home placement funded either pub-
licly or via the individuals personal means. Not least
the damage inicted by reports of performance failure
can be considerable to both institutional reputations,
and sta morale, whilst communities need to trust the
safety and quality of the services upon which they are
reliant at times of urgent need. Since parts of the NHS
hospital sector in England have attracted adverse pub-
licity in 2013, the value of addressing collateral public
concerns should not be underestimated.
Cochrane
Going forward
Whatever the external evidence, a growing group of
NHS providers is convinced of the benets to their
patients sta and reputations. Accordingly, and at
their own initiative and costs, these providers are pur-
suing and attaining independent accreditation. Recent
examples include:
. Stoke Mandeville achieving C.A.R.F. accreditation
for its spinal injury services.33
. Kings College Hospital services for patients with
Parkinsons disease which recently became one of
one of 11 international Centres of Excellence follow-
ing accreditation by the (US based) National
Parkinson Foundation.34
. Aintree University Hospital which recently achieved
Royal College of Physicians and UKAS accredit-
ation under the Improving Quality in Physiological
diagnostic Services (IQIPS) programme.35
. Calderdale and Hudderseld NHS Foundation
Trust has become one of six diagnostic imaging ser-
vice providers to be accredited by the United
Kingdom Accreditation Service (UKAS) to the
Imaging Service Accreditation Scheme (ISAS) stand-
ard guaranteeing the quality of imaging across two
hospitals serving 436,000 people.36
In the private sector, the international competition
for health tourism can be a powerful motivator. For
example, the King Edward VIIs Hospital in London
was recently accredited by DNV Healthcare, and is
therefore able to reassure prospective overseas patients
that its services comply with international best
practice.37
Those who consider UK healthcare to be unduly
inuenced by the US may have misgivings; however,
they can be reassured that accreditation is also in
place in France, Canada, Australia and is under devel-
opment in South Africa. It is also a primary activity for
health system development and modernization pro-
grammes in other countries supported by international
donor agencies.38 Arguably therefore the NHS lags
behind in this important eld of healthcare reform.
South Africa is an interesting comparator since it has
launched a ve-year national but phased programme at
the end of which all providers should be formally
accredited.
A similar progressive approach could be adopted for
NHS-funded commissioners and providers. To begin
with, where the regulators nd performance inadequa-
cies these providers could be encouraged to embark on
accreditation. Performance is rarely uniform and even
so-called failing organizations will have some higher
quality services, which could instigate the process.
87
Figure 2. Home run of accreditation.
This would establish a culture of safety management
through performance improvement which could
spread to other services, and not least mitigate any
negative reputation accruing to the organization as a
whole. More generally, nancial incentives could be
oered as a quality component within the NHS pay-
ment system which is currently under review. For
commercial companies winning NHS contracts,
accreditation would allay any public fears that since
extracting prot ostensibly reduce nances available
for front-line services quality could be compromised.
More positively, those companies with experience of
other business operations where safety and quality man-
agement are paramount from day one (such as airlines)
should be bringing this knowledge and experience to bear
as they expand their healthcare operations.
Finally, the above list of accredited NHS services is
only snap-shot. Hence, as a rst step, a register of all
NHS accredited services and the agencies they have
engaged would be a useful addition to our intelli-
gence-base on patient safety and quality assurance
within the NHS. The participating organizations
could then be exempted from any general reputational
damage to services which reports of adverse events may
cause. Accredited services could also act as beacons to
share their learning, discuss the costs and benets and
thus inspire parallel quality improvement in other simi-
lar services and organizations. At the very least this
would be a welcome contribution to the current
debate on promoting quality assurance and sustaining
public condence in our healthcare system.
88
At a summit in 2009, involving Kings Fund and the
NHS Chief Executive the then UKAS Chairman struck
a positive note:
Everyone is in agreement that we need to deliver the
highest possible levels of patient care, and it is encoura-
ging that people from every side of the debate agree
that there is a vital role that accreditation can play in
enabling this.39
At its best, accreditation oers additional safe-
guards on patient safety as a part of a comprehensive
framework which includes best practice and continual
quality improvement. Hence, to borrow an American
sporting analogy, patient safety is the rst base in the
home-run that is independent accreditation
(Figure 2).
Acknowledgement
I would like to thank Rita Lewis for her support in my deci-
sion to write this piece, and helpful comments on the rst,
pre-review draft.
Conflict of interest
The author declares that there is no conict of interest.
Funding
This research received no specic grant from any funding
agency in the public, commercial, or not-for-prot sectors.
References and notes
1. So called regulators have been of singular irrelevance . . .
Quote attributed to Dr. William Pickering, in Private Eye,
number 1345, page 12.
2. United Nations Industrial Development Association. ISO
9001 its relevance and impact in Asian Developing
Economies. Vienna: Author, 2012.
3. In Australia most working age adults are required to take
out private health insurance to cover elective care, emer-
gency and primary care being publicly funded.
4. Drawn from Accreditation of healthcare providers:
Econex, Health Reform Note 2, RSA, July 2010, www.
econex.co.za/images/stories/ECONEX_Health%20
Reform%20Note_2.pdf (2010, accessed 23 June 2014).
5. The Care Quality Commission (CQC) is a non-
departmental public body of the United Kingdom
government.
6. www.ukas.com (accessed 23 June 2014).
7. www.ukas.com/aboutaccreditation/What_is_Accreditation/
What_is_Accreditation.asp (accessed 23 June 2014).
8. Argawal R. A guideline for quality accreditation in hos-
pitals. Inside Health Care, www.qualitydigest.com/inside/
twitter-ed/guideline-quality-accreditation-hospitals.html
(2010, accessed 19 May 2010).
Clinical Risk 20(4)
9. Accreditation of healthcare providers: Econex, Health
Reform Note 2, RSA, July 2010, www.econex.co.za/
images/stories/ECONEX_Health%20Reform%20Note_
2.pdf (2010, accessed 23 June 2014).
10. See for example, www.carf.org/Accreditation/
AccreditationProcess/StepstoAccreditation and
www.jointcommission.org/ (accessed 23 June 2014).
11. World Health Organisation. Quality and accreditation in
health services: a global review. Geneva: WHO, 2003, p.41.
12. In their review of the literature on accreditation,
Tabrizi et al. concord with WHO that the US predomin-
antly and Australia and Canada lead the OECD in the
implementation of accreditation in the healthcare area.
(Tabrizi RS, et al. Advantages and disadvantages of
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2011; 1: 131.
13. Centre for Medicare and Medicaid Services, Section
1865 (a) exemption from otherwise mandatory state
inspections and surveys, www.cms.gov/medicare/provi-
der-enrollment-and-certification/surveycertificationte-
ninfo/accreditation.html (accessed 23 June 2014).
14. www.monitor-nhsft.gov.uk/home/news-events-publica-
tions/our-publications/browse-category/about-monitor/
what-we-do/-introduction (accessed 23 June 2014).
15. Sharing of information, lack of transparency and the
temptation for providers to withhold information from
regulators being key issues identified in the Grant
Thorton Report: The Care Quality Commission re:
Project Ambrose, dated 14 June 2013 p.7 para 1.21.
16. www.telegraph.co.uk/news/politics/10228052/Why-a-cul-
ture-of-fear-and-blame-wont-fix-the-NHS.html (accessed
23 June 2014).
17. The projected US federal government healthcare expend-
iture alone for 2014 is $1012 bn for a population of 314
million, equivalent to a per capita spend of 2,300 per
year compared to around 105 bn for 56m population or
1875 per head in England. State funding of health care is
additional so that total public spending equates to 45%
of all health care expenditure now approaching $3 tril-
lion. Congressional Budget Office, The Budget and
Economic Outlook: Fiscal Years 2010 to 2020;
www.cbo.gov/publication/41880 (accessed 23 June 2014).
18. Centre for Medicare and Medicaid Services op.cit.
Section 1865(a)(1) of the Social Security Act (the Act)
permits providers and suppliers accredited by an
approved national accreditation organization (AO) to
be exempt from routine surveys by State survey agencies
to determine compliance with Medicare conditions.
19. The Centre for Medicare and Medicaid Services.
20. www.cms.gov/Medicare/Provider-Enrollment-and-
Certification/SurveyCertificationGenInfo/Downloads/
AOContactInformation.pdf (accessed 23 June 2014).
21. www.dnv.com/binaries/DNV%20brochure%20%20
Final%20%2023%20Aug%202012_tcm4-535588.pdf
(accessed 23 June 2014).
22. Healthcare Effectiveness Data and Information Set,
www.ncqa.org/HEDISQualityMeasurement.aspx
(accessed 23 June 2014).
Cochrane
23. www.ncqa.org/Programs/Accreditation.aspx (accessed 23
June 2014).
24. www.chks.co.uk/Assurance-and-Accreditation (accessed
23 June 2014).
25. www.qha-trent.co.uk/#!medical-tourism-and-accredita-
tion/c1xj6 (accessed 23 June 2014).
26. Not everyone on the private provider side sees the need to
go beyond the current system. For example, the website
of UK Treatment which promotes health tourism in the
UK to the United States claims that the CQC:
is the equivalent of the Joint Commission which
accredits hospitals and clinics in the USA and inter-
nationally. In the UK, there are no JCI accredited
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UKs Care Quality Commission either match or
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