Over the last two decades, Spain has evolved towards a public National Health System (NHS), funded mainly through taxes, virtually covering the whole of the population. Expenditure in healthcare is about 7.7% of the Gross Domestic Product. This National Health System, employing the majority of healthcare professionals as salaried staff, and owning about half of the hospitals, represents about 80% of this expenditure. Private healthcare is also available, mostly through medical insurance companies, which contract with healthcare professionals (the majority of them also working in the NHS) and private hospitals. Some 6 million Spaniards, particularly in big cities and belonging to the highest socio-economic groups, carry private medical insurance, 75% of these paying twice for their healthcare coverage.

Higher education in the healthcare professions is imparted by Faculties and Schools (Medicine, Dental Surgery, Pharmacy, Nursing, Physiotherapy) throughout Spain, which are regulated by the Ministry of Education as regards numbers of students, contents of curricula and licensure requirements. The Ministry of Education awards official Specialty Diplomas after successful completion of post-graduate training. This entitles the professional to hold Specialist positions in the NHS and practice as such, both in the public and private sectors in Spain. Doctorates (e.g. Doctor in Medicine) and some other academic degrees with official recognition are awarded by Universities and the Ministry of Education. Also, Universities are entitled to award their own post-graduate degrees and a large variety of degrees (e.g. Master in Health Care Administration), some very specific, are available. These degrees, however, do not confer Specialist status and are not officially recognized for gaining access to positions requiring this. In order to practice, healthcare professionals are required to register with the appropriate local (provincial) Professional College (Physicians, Nurses, etc.). There is a National Register of Specialist Physicians and professional colleges also maintain records about the licensure, doctorate and Specialist status details of their members.

To comply with European Union mandate (EEC Directives 86/457 and 93/16), licentiates in Medicine, after a 6-year pre-graduate curriculum, are required since 1995 to complete at least a two-year training period in Family Medicine which is compulsory for practicing Primary Care. Specialty training (48 different specialties including Family and Community Medicine) for physicians (and some other allied professional, e.g. Hospital Pharmacy) in Spain is highly regulated through the Intern/Resident Physician Training National Programme ("Programma Médico Interno-Residente MIR"). This is the only approved Specialist training pathway in Spain providing high quality education . It complies with EU requirements which allow mutual recognition of specialist diplomas and practice of physicians throughout the EU. Paid training is carried out in 220 hospitals and other clinical facilities (e.g. Primary Care centers), the majority of these belonging to the NHS network, which are accredited according to specific standards (activity, structure, number of patients, etc.). The number of physicians undergoing specialist training in Spain is regulated by a fixed number of entrants (4,977 in 1997 to include 1,801 in Family Medicine). Only a proportion of them (as few as 20% in some years) gain their place through an annual public examination. The duration (3 to 5 years), contents and yearly assessment of the trainee physicians are overseen by National Council of Medical Specialties (joint body of the Education and Health Miniseries). Although there is currently no objective or external assessment of clinical competence after completion of specialty training, even if this is contemplated by existing legislation ("Certificado de Médico Especialista Diplomado"), it has been proposed with increasing insistence over the last few years.

Nursing pre-graduate education (3 years) at a primary university level (University Diploma) is undertaken by University Nursing Schools attached to hospitals which provide and coordinate practical teaching (50% of curricular time) in nursing care. A number of Nursing Specialties (Midwifery, Pediatrics, Mental Health, Community Health, Special Care, Geriatrics and Management & Administration) were officially recognized in 1987. Of these, so far, only Midwifery has specific training posts (11 units in Spain) and staff positions in the NHS.

Certification (from Latin "certus", certain: to make certain) of professionals by external bodies, other than qualification by academic institutions and credentialing by professional colleges, is a relatively new concept in Spain. However, it is starting to catch up (e.g. certified quality auditors) as the EU requirements and the need to demonstrate proficiency and quality in a more global competitive environment are becoming key issues for Spanish companies.

Given the peculiarities of the Spanish healthcare sector, including State as owner and major employer, quasi-civil servant status of employees, low job-mobility and relatively small private sector with traditionally less attractive jobs, third-party certification for any professional (physicians, nurses, etc.) is not yet a key issue in our country. This is at a variance with USA, Canada, Australia and some other countries, but the situation is likely to change over the next years. The major drivers for this change are the following:

• probable change of the healthcare structure with a larger role of private centers in the provision of care and, perhaps, extension of PMI (private medical insurance) to a larger segment of the population.
• possible EU requirements, particularly for Medical Specialist recognition outside ones own country.
• promotion within the National Health System to access top positions based on merit (which could include certification).
• continuing medical education (proof of it is not yet compulsory in Spain) to become a bonus/requirement for job promotion, professional college membership, fees for malpractice insurance, etc.
• accreditation of practitioners of "new Specialties" (e.g. Emergency Medicine) which have no official status and who have not undergone a recognized post-graduate training programme.

At the present time it is not clear which body could become the certifying agency(ies) for healthcare professionals in Spain, although some suggestions have been advanced. A number of ongoing initiatives, however, might give clues as to which this can be.

The Spanish Association of Colleges of Physicians (a federation of provincial colleges) has set up the Professional Institute of Medical Education, an accreditation body for institutions offering continuing or permanent education in the medical field in Spain. Those physicians who attend and comply with the requirements for these education programmes will obtain personalized credentials awarded by this Institute, in accordance with the credits assigned to the various activities. Thus, the stated mission of the Institute is threefold: a guarantor of the quality of accredited training programmes, a reliable aide in covering possible gaps in the provision of CME, an effective data center where any professional can obtain information on all existing CME programmes in Spain. The emphasis on improving the competence of professionals and the quality of healthcare are attributes which could develop, in the future, into some sort of certifying body for physicians who comply with set requirements.

The Department of Health of the Catalan Government (Catalonia is one of the 17 Autonomous Communities in Spain) has established a Coordinating Council for CME, in which all four colleges of Catalan Colleges of Physicians participate, as an accreditation body. Scientific societies, teaching centers and other institutions providing medical education in Catalonia can seek voluntary accreditation by this body which will also provide education credits to participants.

Job Promotion and Post-Graduate Teaching Accreditation within the NHS:

It was recently announced that Heads of Department and Section (Chief Consultants) of public hospitals will undertake, from 1998 onwards, a 4-yearly assessment of their work by a Committee chaired by the Medical Director of the hospital. This measure is taken to provide more transparency in the designation of these posts. The criteria to be used to assess their performance are yet not adequately defined, but this procedure could make way towards a certifying process based on the NHS hospital status.

Probably the best accreditation hospital system in Spain is that of Teaching Units within public (mostly) hospitals for Specialist training. The clinical competence of the tutors is now indirectly assessed, but more direct and stringent criteria could be used in the future. Professional certification, if it becomes available in our country, could be sought by these academic physicians to preserve the teaching status of their departments with the corresponding advantages (staff, grants, etc.).

The European Union:

Several European professional bodies (European Union of Specialist Physicians, European Association of Radiology) have issued recommendations on training and CME, which could be the basis for professional certification valid in Spain. Morever, some Specialties have established Boards, for example the European Board of Surgery Qualification, which assess competence and aim at becoming the vehicle for recognition of professionals in European countries. A still small number of Spanish surgeons, have so far taken the test, but a Spanish city will be the venue of the next sitting of this Surgery Board.

Managed Care in the Private Sector:

Quality improvement programmes of public hospitals are focusing on staff training, but are not considering professional certification as an issue. The situation is different, however, in the private sector which is starting to attract well-trained physicians and nurses. Another important driver to promote professional certification are PMI companies. The most common type of insurance product in Spain is a pre-paid exclusive provider network insurance, which shares many of the features of US HMOs. Thus, some of the issues and solutions addressed and proposed by US-style managed care ("Medicina Gestionada") are very familiar in this environment. This situation calls for adequate credentialing and recredentialing of providers (professionals and centers) according to criteria of service, quality and cost. Sanitas, for example, has established procedures and methods to address its needs to ensure adequate access, use of resources and reduce exposure to litigation, while at the same time promoting an image of high quality. Third-party certification would be extremely useful for PMI companies to select proficient physicians, nurses and allied healthcare professionals. Contracting with certified professionals, particularly if this becomes a differentiating factor with competitors and the NHS, will enhance the quality added-value for the member.

While in the USA, organizations are moving beyond Board Certification towards better ways to assess physician competence to include performance and patient outcomes, healthcare professional certification in Spain is still being debated. Nevertheless, there are several initiatives which are converging towards the development of some kind of professional certification in the not so distant future. It will most likely start for specialist physicians, to be followed by primary care physicians, nurses and physiotherapists and possibly dental surgeons. Certification of other professionals working in the healthcare field will probably take more time, since functions such as Pre-Authorization Officers, Case Managers, Information Managers, etc., are not developed in Spain. However, and because of the driving factors mentioned above, managed care, obviously adapted to the Spanish environment, is likely to gain more strength. As this develops, the need for proper certification of persons performing these roles will become apparent. For the time being, the major issue to resolve is which agency could issue professional certifications which will be accepted as valid, impartial and valuable to hold by all major stake-holders in the Spanish health care arena.

About the Author:

Juan Lahuerta, M.D. FFPM, CPHQ is a neurologist training in chronic pain management both in Spain and in the UK. Dr. Lahuerta has worked for several years in the Pharmaceutical Industry, mainly in clinical research. Hence his interest in quality issues concerning the appropriate gathering and reporting of data from clinical trials.

Over the last three years he has been responsible for healthcare quality in Sanitas, a leading private medical insurance company in Spain. His main interests are accreditation of healthcare professionals and centers, introduction of quality criteria in utilization management, assessment of patient satisfaction, outcomes research and clinical practice guidelines. He is a Certified Professional in Healthcare Quality (CPHQ) by the Healthcare Quality Certification Board.

Reference

By:
Nancy Dixon, MA, CPHQ (US),
FNAHQ (US), FIQA (UK) FAQMC (UK)
onsultant in Healthcare Quality
Healthcare Quality Quest Ltd
Shelley Farm, Shelley Lane, Ower
Romsey, Hampshire, SO51 6AS,UK
Tel: 44-1703-814024 FAX: 44-1703-814020
E mail: ndixon@HQQ.co.uk

Abstract:

In the UK, healthcare professionals are awarded their qualifications by recognized professional bodies such as Royal Colleges. To work in the National Health Service (NHS), individual healthcare professionals must be registered by defined statutory bodies. The term certification is not used to refer to a qualification or recognition of current competence.

Two developments in the 1990s are placing emphasis on the current competence of healthcare professionals. First, in the mid-1990s, professional bodies began to require continuing education or continuing professional development of already qualified and registered members. Second, national occupational standards are being developed in some professions. The standards define competence in terms of work outcomes and performance criteria. A number of intangible benefits to the availability of national occupational standards have been identified, but no published research studies could be identified to support these directions.

In 1990, the immunity of NHS organizations from legal action for clinical negligence was rescinded. Since "Crown Indemnity" was instituted, the number of law suits for clinical negligence has escalated dramatically. However, the costs and the systems for payment of legal and court fees along with the lack of acceptance of contingency fees for lawyers mean that it is not feasible for the ordinary family to pursue legal action.

Background:

Qualifications for healthcare professional staff in the UK are awarded by pertinent professional bodies, e.g. Royal Colleges for doctors, the English National Board for Nursing, Health Visiting and Midwifery for nurses, etc. Professional bodies also award qualifications for specialty areas of practice, e.g., neonatal intensive care nursing. Qualifications are awarded usually on the basis of successful completion of an approved professional training course and required assessments or examinations.

The National Health Service (NHS) is the dominant provider and purchaser of healthcare services in the UK. Healthcare professional staff who work in the NHS must be registered to practice through various national mechanisms specific to each profession.

Until the 1990s, initial qualifications and registration were the only mechanisms through which the competence of professionals working in the healthcare sector was established. Now, professional bodies which award qualifications require individuals to participate in continuing education or continuing professional development and specifically to acquire a designated number of points or hours within prescribed time intervals.

Staff who could be regarded as performing a professional function in the healthcare system but who are not involved in delivering direct patient care, e.g., health service managers, medical record specialists, or accountants, receive their qualifications from pertinent professional organizations, usually following successful completion of an approved professional training course and required assessments or examinations. Not all such staff are required or even expected to hold professional qualifications. For example, there is no recognized professional qualification available in the UK for individuals in jobs such as quality improvement, clinical effectiveness, or clinical audit director or coordinator.

Staff who are not regarded as performing a professional function but who do provide direct patient care, e.g. care or therapy assistants, can receive National Vocational Qualifications (NVQs) which are awarded on the basis of successful completion of training courses which are specific to the occupational standards established for the role or function.

The term certification is not used in the UK nor is there a formal system for recognition of specialists who are determined by a designated body to be currently competent in their fields of specialty.

Regulations and Standards:

• Recognition of Qualifications and Registration Systems:

The awarding of qualifications by named professional bodies covering professions in the healthcare system and the registration of individuals as professionals are mandated in various laws. The UK government has not tended to become directly involved in mandating particular standards specifying the performance of workers in the healthcare sector. The approach in the UK has tended to be for needs to be identified and addressed from within the healthcare system. The exception has been the restructuring of the training of doctors in the UK to make British training of doctors compatible with that of other countries in the European Union.

• Restructuring of the Training of Doctors:

As of 1996, a new regulatory body, the Specialist Training Authority (STA) of the Medical Royal Colleges, was designated as the UK "competent authority" for higher medical specialist training. The Authority is legally responsible for safeguarding the standards of postgraduate medical training in hospital practice in the UK. Individual Colleges and Faculties will continue to be responsible for syllabuses, handbooks, testing assessments, and examinations. In addition, previous Registrar grades are being replaced by the designation Specialist Registrars. Upon completion of defined college specialist training programs, doctors can apply to the STA for award of a Certificate of Completion of Specialist Training (CCST). This system replaces the current system of accreditation of individual doctors by individual Colleges. As a consequence of these changes, training and assessment programs for doctors are being redesigned to be "competency based".

• National Occupational Standards:

The UK Department for Education and Employment has invested heavily in supporting the development and implementation of national occupational standards in all sectors of the economy, including the healthcare sector. The justification for this development was the realization that all British organizations need, but currently don’t have, a flexible, adaptable workforce.

Occupational standards are a precise description of what employees are expected to be able to do and the outcomes they are expected to achieve. The standards are developed in accordance with a formal structure which involves defining all of the following: key purpose of the job; key roles within the job which contribute to the purpose; units of competence, i.e. expected outcomes of the roles; elements of competence, i.e., sub-outcomes; performance criteria; and range statements of the applications and contexts over which the units of competence are intended to apply.

Initially, occupational standards were used to define the roles of new support workers in the healthcare sector, to define training requirements for individuals assuming these roles, and to serve as the basis of awarding National Vocational Qualifications to individuals who successfully completed the required training. Recently, however, occupational standards are being developed for certain professional functions. e.g., therapies, doctors in training, and oral healthcare provisions, as a basis for professional training and for enabling joint approaches to defining and reaching national consensus on new areas of professional work.

If these attempts at defining occupational standards for the healthcare professions meet the objectives of the work and develop independent value to the health sector, it is possible that further developments in occupational standards will be encouraged.

Impact on Quality:

Formal measurement of the quality of care or service provided by healthcare workers is at a relatively early stage of development in the UK in comparison to the US. We do not know of any studies of quality of care which involve specifically assessing the effects of qualifications or types of qualifications of staff.

In the UK, the availability of national occupational standards is seen as contributing to improving the quality of care.

In the care sector, the overall purpose for developing standards has been seen as increasing the quality of service for all who receive care, by specifying the quality of performance required by those who provide care.⁸

At a recent UK meeting of individuals working in quality improvement-related roles, a number of benefits were foreseen of having defined national occupational standards and obtaining professional qualifications based on such standards.⁹ The benefits included the following: increase the acceptability of new roles to other established professions; increase productivity by increasing the speed at which credibility is developed in the local work situation; enable recruitment to be more efficient, e.g., employers have a qualification to expect of candidates; enhance employee retention; increase consistency in practice among individuals in the jobs; increase the potential for personal and career development; have a defined, respected body of knowledge to refer to, particularly with professional staff; and change the current perceptions of the skill level of the staff involved.

Legal Implications:

Up to 1990, the principle of Crown Immunity applied to NHS organizations, i.e., as public institutions, the board or managers of NHS hospitals or clinics could not be held legally accountable for acts of clinical negligence. Doctors could be sued individually and most carried liability insurance for this purpose and to cover their clinical work in privately-owned hospitals and clinics. As a consequence of this history and the problems of access to the legal system, British people are not accustomed to seeking legal remedies for medical negligence.

In 1990, Crown Immunity was replaced by the concept of Crown Indemnity and NHS provider organizations became legally responsible for clinical negligence. The number of claims filed against NHS organizations has slowly but dramatically increased since. Under the provisions for the restructuring of the NHS, originally, individual NHS organizations were responsible for meeting the financial responsibilities of settling or defending claims. As the number and cost of claims increased, it became clear that individual NHS organizations could not support the cost of claims out of operational or reserve budgets, particularly in a cash-limited system, and the purchase of insurance for this purpose was not accepted. Therefore, a Clinical Negligence Scheme for NHS Trusts (CNST), which is essentially a risk pooling program for NHS providers, was created in 1995.

The CNST has issued a manual of standards for risk management which NHS provider organizations are expected to meet. Apart from standards requiring organizations to have an orientation program for all newly-appointed clinical staff and for doctors and nurses to attend CPR training at least annually, there is no reference to an expectation that a provider organization will act to ensure that staff providing direct patient care are currently competent.¹⁰

A number of factors in the UK act to deter patients and their families from taking legal action over medical treatment. Legal and court costs are very high. Patients or their representatives have to "pay as you go" with legal and court fees, and if the case is lost in court, may be responsible for the defendant’s legal and court costs as well. The income threshold for obtaining legal aid is so low that most people, even those who suffer a legitimate permanent injury, do not qualify. In addition, traditionally, settlements paid by courts are related solely to out-of-pocket costs or actual financial losses, and thus the amounts of money awards are often judged as not worth the risk of paying to go to court.

Formal complaints procedures exist in all NHS organizations, and these may include provisions for awarding cash settlements to patients who are injured or suffer gross inconvenience or expense. Thus, the controls acting within the legal system tend to limit the number of cases in which practitioners’ abilities or current competence becomes a legal issue.

Managed Care Issues:

Access to specialist care in the UK is reasonably strictly controlled through the system of general practitioners (GPs). Patients can be seen by a specialist only upon referral of a GP. Thus, primary care doctors automatically serve as the authorizer for services which cannot be provided on a primary care basis. As the doctor making a referral for specialist care is the patient’s doctor, the doctor brings all he or she knows about the patient to bear upon making the referral for more complex care. Under the present structure, GPs may hold their own publicly-funded budgets so they may purchase and directly manage specialist care for their patients.

Access to very expensive care such as infertility treatment is also controlled through "purchasing" NHS health authorities that decide the range of treatments to be made available (or not available) to a local population and the number of patients for whom treatment will be paid via publicly-funded contracts with NHS "providers". In a cash limited system, the conflicts which emerge are that there may be more patients clinically eligible for referral than there are funds allocated to treat. In such circumstances, the most "needy" patients are selected by specialists for treatment either using risk-adjusted data on probable outcomes and/or in consultation with the patient’s GP.

The part of the managed care concept which applies in the UK is managing care across organizational and jurisdictional boundaries. Examples are enabling consistency between the GP’s and the specialist’s management of the same patient in the face of financial disincentives to do so, or managing continuity of care between the health and social services sectors or between the private healthcare sector and the NHS.

Techniques from managed care in the US such as case management and care pathways are being adapted for use in the UK to improve the efficiency and effectiveness of healthcare services, particularly across professional and organizational lines, and to improve continuity of health and social services in the community.

Conclusion:

Trends concerning the qualification of individuals working in the healthcare sector could include the following:

• Review and restructuring of basic professional training courses to enable as much non-duplicative, generic training of various professions as feasible.
• Qualification and registration of more categories of healthcare workers, including support workers who provide direct care services and those manufacturing medical or related devices used directly by patients.
• Development of more competence-based occupational standards, particularly because of their emphasis on work outcomes.
• Further expectations for continuing professional development.
• Research and other evidence of good practice being used as a lever to raise the levels of competence among the health sector workforce.

About the Author:

Nancy Dixon holds qualifications in the field of quality and quality in healthcare from both the US and the UK. She is a member of the British Medical Association’s Clinical Audit Committee, a member of the Board of the Healthcare Quality Foundation in the US, a member of the Board of the International Society for Quality in Health Care, and the immediate Past Chairman of the Association for Quality in Healthcare in the UK. She is the author of numerous books, reviews, and articles on healthcare quality topics which have been published in the UK, USA, and the Middle East. In the US, she had several years of experience working for the Joint Commission on Accreditation of Healthcare Organizations, and in the Kingdom of Saudi Arabia, she was Principal Consultant and Director of the Quality Assurance Department for the Medical Services Division of the Saudi Arabian Armed Forces. She currently works in the UK as a consultant for Healthcare Quality Quest Ltd.

References

Written and Presented by:
Janet L. Maronde, RN, BS, CPHQ
Executive Director
Healthcare Quality Certification Board
P. O. Box 1880, San Gabriel, CA 91778
USA
626-286-8074 FAX 626-286-9415
www.cphq.org                 e-mail: janmaronde@compuserve.com

Abstract:

Certification for healthcare professionals in the United States is pervasive in the United States. Both employers and the public have come to expect that their care will be provided by individuals who have achieved voluntary certification in their particular area of service beyond the minimum required by state licensing laws. In a recent verbal survey of health facilities, 199 individual occupational licenses and/or specialty certifications were identified.

No mandatory standards govern the various organizations that grant voluntary certification credentials. Only one accreditation group, the National Commission for Certifying Agencies (NCCA) of the National Organization for Competency Assurance, evaluates certifying organizations and their programs and grants accreditation to those that meet its standards. The accreditation process, however, is completely voluntary. With no mandated standards, the quality of non-accredited programs can vary widely. Employers have a legal obligation to inquire about the quality of certification programs if they are used for employment decisions. Accreditation by NCCA has been used successfully as a demonstration of the credibility of an individual credential in legal challenges. However, no substantial studies have been performed to objectively evaluate whether certified professionals provide better care than their non-certified colleagues.

As managed care continues to grow as the major model for healthcare in the United States, requirements for specialty certification of providers within individual plans will intensify as one way to demonstrate a commitment to quality. Technological advances and information exchange, particularly through the Internet, will increase awareness and global expectations for the "best" treatment by the most "specialized" provider. As the public becomes more informed, the market for specialty certification will expand globally. With the widespread public acceptance that "certification" has a direct correlation to "quality", certifying organizations have an ethical obligation to insure their programs are fair, valid and reliable measures of competency.

To obtain some sense of the prevalence of certifications today, four quality management colleagues participated in research for this paper by conducting informal surveys at their institutions. They collected listings all of the possible certifications employees could cite, without the use of outside resources. Within this small but geographically and facility-size diverse group, 15 state-controlled licenses and 184 occupational and/or specialty certifications could be identified. Of these, 19 licenses and certifications were mandatory for practice and 180 were voluntary. In nursing alone, 14 generalist and 13 advanced practice specialty certifications were cited. Within the hospital laboratory, laboratory technicians can become certified in 8 individual specialties. The American Board of Medical Specialties recognizes 37 generalist and 74 sub-specialty medical board certifications for physicians. There are currently over 500,000 board certified physicians practicing in the United States.²

Regulations and Standards:

There are no mandatory standards that govern the development and administration of voluntary certification boards in the United States. Voluntary certification programs are usually guided from within the community or association that serves members engaged in the specialty.⁹ The "Certified Professional in Healthcare Quality" (CPHQ) program administered by the Healthcare Quality Certification Board (HQCB) was founded in 1984 as a voluntary certification program for the healthcare quality field. HQCB’s parent association, the National Association for Healthcare Quality (NAHQ), serves the educational and support needs of members engaged in that field. Regular surveys determine the knowledge, skills and abilities needed for competent practice and provide data to guide program development. The HQCB and the CPHQ program are accredited by the National Commission for Certifying Agencies (NCCA), the accrediting arm of the National Organization for Competency Assurance (NOCA) based in Washington, D.C. The NCCA is the only standard setting body for professional and occupational tests.¹⁷ Application by certification boards to NCCA for national accreditation is voluntary.

Other organizations that have jointly developed standards are the American Educational Research Association (AERA), The American Psychological Association (APA) and the National Council on Measurement in Education (NCME). NOCA and the Council on Licensure Enforcement and Regulation (CLEAR) have developed Principles of Fairness: An Examining Guide for Credentialing Boards. The principles and standards advocated by these organizations are important as certification boards strive to administer quality programs.

NCCA-accredited certification programs have demonstrated the required level of quality in the development and administration of their programs which reflects positively on professionals certified through accredited organizations. Evaluating non-accredited programs requires employers and the public to ask more detailed questions about the structure and processes used to evaluate potential certificants. Issues such as role delineation studies, exam development procedures, and validity and reliability measures of the testing instrument are some of the major components that the public should inquire about to judge the quality of a non-accredited program.

Recently identified quality issues regarding voluntary certifications required for some government contracts are expected to generate legislative hearings next year. This process will make legislators at the federal level more aware of the myriad of voluntary certifications in healthcare and other industries. Also apparent will be the absence of legislated standards or criteria by which the quality of the programs can be evaluated. In response, a large number of voluntary certification boards have joined together to form the Coalition for Professional Certification (CPC). This coalition will provide a forum for certification programs committed to quality in voluntary certification to share their combined experience and knowledge, provide education, and have a positive influence on future federal policy and legislation. Consistent with its commitment to foster quality and ethical certification practices, the HQCB, joined the coalition as a charter member and expects to maintain active participation in this effort.

Impact on Quality:

Objective data evaluating the impact of certification at the entry, specialty or advanced level on actual patient care or quality of service are not available. The author was able to locate only two studies on specialty certification, both in the nursing profession.

The first study, published in 1997, addressed the efficacy of nursing certifications that require education, experience and a demonstration of special knowledge and skill beyond the criteria required for licensure as a Registered Nurse.¹⁹ Supervisors and the certified and non-certified staff nurses were each asked to rate their performance on a number of dimensions. While the survey population was small and the evaluation tool subjective, results suggest that certified nurses perform better, particularly in the areas of teaching, collaboration, planning and evaluation. Certified nurses also indicated an overall higher level of self-esteem than their non-certified colleagues.

In the second study, nurse managers rated the performance of certified and non-certified perioperative nurses under their supervision. 90% of the nurse managers were themselves certified, so an argument of bias could be made. Ratings, however, did not favour certified nurses on all skills and competencies which would be expected if bias was a significant factor. Nurse managers perceived the certified operating room nurses performed better than non-certified nurses. Again, while subjective, the evidence of this study suggests that certification is at least associated with higher levels of performance.¹⁸

The lack of data to support the efficacy of professional healthcare certification presents a clear and urgent opportunity for certifying organizations. Certification programs need to prove their worth in today’s market. Credibility depends on it, as does the opportunity to claim the scarce resources that are still available to employees for professional education and development.

Legal Implications:

In the United States, employers, whether they are aware of it or not, have a responsibility to determine the credibility of any certification that influences employment decisions.⁵ The Uniform Guidelines on Employee Selection Procedures requires employers to determine the credibility of organizations that award certification credentials based on tests when they are either required or preferred for employment, promotion or salary increases.⁵ Standards and principles established by NCCA and others referred to previously have been used successfully in legal challenges.⁹ Relying on accredited programs that meet these standards provides important evidence employers can present to document that they have fulfilled their due diligence in investigating the credentials it requires or recognizes for its care givers.

Managed Healthcare Trends:

As of March 1997, the U.S. Census Bureau reports that 84.4% of U.S. citizens are covered by some type of health insurance and 15.6% or 41,716 thousand people are not covered. Of those with insurance, 61.2% or 163,222 thousand are covered by employment-based plans.²⁰ A National Survey of Employer-Sponsored Health Plans in 1996 found that greater than 75% of all active American employees were enrolled in managed care plans. Health maintenance organization (HMO) costs dropped 2.2% in 1996 to $3,185 per active employee while costs for all other health insurance employee plans rose to an average $3,500 per employee.¹⁰ Predictions are that HMO rates will begin rising in 1997 in response to low profit margins and managed care backlash from the federal government. Concerned that cost containment strategies are adversely impacting quality of care, the government has and will continue to enact prescriptive legislation about access to services. A most recent example is the passage of legislation requiring providers to guarantee new mothers the option of at least 48 hours of hospital care.

Some experts predict that 100% of insured workers in the United States will be under the managed care system by 1999. This shift with its emphasis on reduction of inpatient admissions and lengths of stay, is expected to have the combined effect of reducing total inpatient days by 34% by 1999 from the 1994 figure of 199.5 million inpatient days. Average length of hospital stay is expected to drop from 6.1 days in 1994 to 5.5 days by 1999.⁴ Forecast hospital bed needs for 1999 are 424,000 contrasted with the 1994 supply of 1,200,000 available beds, a drastic shift in the type of healthcare facilities needed to serve patients. The only exception predicted is in the field of psychiatry where inpatient stays are expected to lengthen by 27%.⁶

A recent CNN survey on patient satisfaction found that in general, most Americans are pleased with their personal medical coverage. Those, however, who belong to HMOs tend to believe the HMO cares more about money than it does about providing care. Of those participating in managed care plans, 59% complained it was harder to obtain care from a specialist, 51% worry that their quality of care has deteriorated, and 55% say price governs decisions made by the HMO rather than quality.¹³

One way the managed care industry is responding is through increased attention to specialty certification. Many require board certification before they will contract with a physician specialist or add them to their panel. The same reliance on certification in advanced specialties is true of nursing and many other healthcare providers including case managers and healthcare quality professionals. Increased preference for employees with specialty certification can serve to demonstrate a commitment to quality to the public, protect the HMO in legal challenges to standards of care, and help assure they get the best service for the HMO’s contracting dollars.

One outcome that has personally impacted this author has been the increased need for and reliance on skilled healthcare quality professionals who collect and analyse patient satisfaction and quality of care data. The managed care model also relies heavily on case managers to coordinate care. Considered as part of the healthcare quality field, case managers evaluate patient needs, provide prior authorization for services, and/or act as the central coordination point. Their job frequently includes identifying the most appropriate and economical mode of care delivery from among the various options proposed by the medical team involved in treating the patient. This has resulted in greater employment opportunities in managed care for healthcare quality professionals.

Influence of Technology:

The managed care industry is being increasingly challenged to prove to the public that the system provides high quality care and that patient outcomes are the same or better than other types of insurance plans. As the managed care model spreads globally and large managed care networks develop, bench marking for clinical outcomes and resource utilization will become commonplace within and among countries. Movements are already underway around the world to standardize computerized information systems to facilitate aggregation and analysis. The United Kingdom is moving now to standardized information technology systems among its general practitioners.¹¹ Best practices will be identified globally and many countries will begin to benefit from innovations implemented outside their own boarders.

Expansion of healthcare information on the worldwide web, spearheaded by large pharmaceutical corporations, will place clinical and best practice information within the reach of the consumer. More and more, the public will become more homogeneous in expectations for the same standard of care worldwide. Likewise, they will be more aware of board specialty certifications. As we learn more about each other and evolve into healthcare roles that become more similar than dissimilar, key cultural concepts will play an important role in the evolution process. Issues of language, sex and role socialization, perceptions of time and work, whether one relates individually to a situation or as part of a collective, and how one views their own place in the universe will all influence globalization of certification.⁷ The evolution of a global marketplace, expanding knowledge bases and new technology will contribute to globalization of the healthcare professions, making the market for specialty certification more attractive.⁸

Conclusions:

Voluntary certification in non-licensed fields and voluntary specialty certification in healthcare is a well established and expected reality in the United States. It has the advantage of assuring, to the extent possible, a pre-defined level of competency among those who achieve certification. If the credential is granted by an accredited certifying body, legal challenges can be defended on the grounds that national standards for evaluating competency were followed. In some cases, this can provide valid arguments during legal proceedings and thus, some protection from liability may be gained.

Pressure on managed care organizations to provide evidence of the quality of care they provide will continue to increase. Technological advances, standardized computer and data collection systems and public access to a vast amount of healthcare information on the worldwide web will both facilitate and generate its own demand for bench marking and public reporting and comparison of provider-specific healthcare outcomes. Globally, countries will benefit and healthcare improve as easy access to information on best practices becomes commonplace. The specific impact on certification will be an increased awareness and greater expectation globally for the "best" and "latest" treatment by the most specialized provider. Managed care will look to specialty certification among its contracted providers as one more way to demonstrate a commitment to quality to the public.

Finally, research is needed to establish the efficacy of board certification. The author was unable to identify any statistically valid surveys which establish objectively whether certified professionals provide better care or produce better patient outcomes than non-certified professionals. With the widespread public acceptance of the notion that healthcare providers who are certified provide the latest and best quality care, certifying bodies have an ethical obligation to initiate studies to verify that perception. This should be viewed as an opportunity, particularly for the more well-established and financially well-endowed organizations. The author predicts more research in this area will emerge as public expectations for certifying organizations to "prove their worth" increase.

Janet L. Maronde, RN, BS, CPHQ, is the Executive Director of the Healthcare Quality Certification Board. Founded in 1984, the HQCB certifies professionals engaged in the practice of healthcare quality, case, utilization and risk management, known collectively as quality management. The HQCB certifies over 1,000 candidates annually through a national board eligibility and examination process. There are currently over 6,000 active CPHQs in the United States and overseas. The Board is presently conducting research to define the role of the healthcare quality professional internationally with results of that role delineation study expected next summer. Prior to accepting this position, she directed the quality management program at a large teaching hospital. She has served as a Commissioner on the National Commission for Certifying Agencies (NCCA) for three years and as Chair in 1995. Having completed both the initial accreditation process and one renewal cycle for the Healthcare Quality Certification Board, she has practical knowledge of NCCA’s accreditation standards and process. Ms. Maronde was recently elected to the position of President of the National Organization for Competency Assurance (NOCA) and will complete that responsibility at the end of 1997. Currently serving in the volunteer elected position as Treasurer of the California Association for Healthcare Quality, she maintains close ties to the practice of healthcare quality management and the managed care model, a long-established and broadly accepted system within the state of California.

• Health maintenance organization (HMO):

An organized system that includes both a medical care organization and an insurance plan which collectively is responsible for providing comprehensive care to a voluntarily enrolled population for a fixed, prepaid fee. HMOs contract with or directly employ healthcare providers (i.e., hospitals, physicians, allied health professionals). Enrolled participants choose from among those providers for all healthcare services. HMO physicians control referrals to outside physicians who are not a part of the organization. HMOs accept both the risk and the responsibility for financing and delivering care to their enrolled population and can be organized as either a for-profit or nonprofit entity.

• Preferred provider organization (PPO):

A specific type of MCO through which providers of medical care contract with payers. Providers usually agree to accept lower fees in order to have access to a larger pool of patients who are members of the preferred plan. Patients who choose to receive their care from preferred providers receive more services at less personal expense than if they use providers who are not members of the preferred provider organization.

• Physician hospital organization (PHO):

A legal entity through which physicians partner with a hospital to negotiate for managed care contracts. Rates for the menu of services included in the contract include both the hospital and physician fees. Both parties share the risk of delivering quality care within the defined cost structure of the contract.