Definitions & Purpose of
Licensure, Certification &
- Licensure is a process by which a governmental authority grants
permission to an individual practitioner or health care organization to
operate or to engage in an occupation or profession.
- Licensure regulations are generally established to ensure that an
organization or individual meets minimum standards to protect public health
and safety Licensure to individuals
- Licensure to individuals is usually granted after some form of
examination or proof of education and may be renewed periodically through
payment of a fee and/or proof of continuing education or professional
Organizational licensure is granted following an on-site inspection to
determine if minimum health and safety standards have been met. Maintenance of
licensure is an ongoing requirement for the health care organization to continue
to operate and care for patients.
Accreditation is a formal process by which a recognized body, usually a
non-governmental organization (NGO), assesses and recognizes that a health care
organization meets applicable pre-determined and published standards.
Accreditation standards are usually regarded as optimal and achievable, and
are designed to encourage continuous improvement efforts within accredited
An accreditation decision about a specific health care organization is made
following a periodic on-site evaluation by a team of peer reviewers, typically
conducted every two to three years.
Accreditation is Voluntary
Accreditation is often a voluntary process in which organizations choose to
participate, rather than one required by law and regulation.
The Major Purposes of Accreditation
- Improve the quality of health care by establishing optimal achievement
goals in meeting standards for health care organizations.
- Stimulate and improve the integration and management of health services
- Establish a comparative database of health care organizations able to
meet selected structure, process, and outcome standards or criteria
- Reduce health care costs by focusing on increased efficiency and
effectiveness of services
- Provide education and consultation to health care organizations,
managers, and health professionals on quality improvement strategies and
“best practices” in health care
- Strengthen the public’s confidence in the quality of health care, and
Reduce risks associated with injury and infections for patients and staff
Certification is a process by which an authorized body, either a governmental
or non-governmental organization, evaluates and recognizes either an individual
or an organization as meeting pre-determined requirements or criteria.
- Although the terms accreditation and certification are often used
interchangeably, accreditation usually applies only to organizations, while
certification may apply to individuals, as well as to organizations.
Individual Practitioners Certification
When applied to individual practitioners, certification usually implies that
the individual has received additional education and training, and demonstrated
competence in a specialty area beyond the minimum requirements set for
- An example of such a certification process is a physician who receives
certification by a professional specialty board in the practice of
When applied to an organization, or part of an organization, such as the
laboratory, certification usually implies that the organization has additional
services, technology, or capacity beyond those found in similar organizations.
Licensure, Certification and Accreditation; how they contribute to improving
quality in healthcare
Three Aspects of Quality
- Measurable Quality
- Appreciative Quality
- Perceptive Quality
Quality Health Care Quality Evaluation Approaches
The three primary approaches for evaluating health care quality
accreditation, licensure, and certification use standards to determine the level
of quality achieved by an individual or organization.
- Selecting the right approach or combination of approaches requires a
careful analysis and prioritization of user needs.
Use of Data from the External Quality Improvement System
- Support comparisons of performance
- Shape health care services delivery in new settings
- Demonstrate whether a predetermined rate of beneficiary coverage for
preventive services is being achieved
- Ensure efficient use and allocation of limited health care resources
- Identify and create centers of excellence
- Integrate structures and services of several organizations Licensure
- Established to protect basic public health and safety
- Licensure standards address the minimum legal requirements or
qualifications health care professionals and organizations need to operate
- They also guarantee appropriate adoption of new medical practices and
provide a framework to accommodate amendments to existing practices.
- Hospitals and health care facilities
- Governments or regulatory authorities grant licenses when facilities
meet defined levels of quality Certification
- Distinguished from accreditation by its application to both individuals
- Recognition of individuals who have demonstrated specialized knowledge
and skill and to organizations that have the ability to practice in a
certain area or specialty.
How Certification Can Affect Quality Of Care
- Most medical specialty boards require re-certification
- If an individual does not meet the standards, certification can be
- Verification of performance, however, does not include a review of
actual care processes or patient outcomes.
- The American Board of Medical Specialties (ABMS) & The American Medical
Association Council on Medical Education (AMA/CME)
- Maintain a rigorous process of review for new boards in emerging
medical specialties (e.g., the American Board of Medical Genetics). How
Certification Can Affect Quality Of Care
- The American Medical Association, through its American Medical
Accreditation Program, have started to evaluate individuals within their
- Voluntary, standards-based evaluation
- Reviewers conduct an evaluation of credentials and qualifications,
actual practice conditions, environment of care, clinical processes, and
- For organizations, lack of proper certification can affect funding
- Certification distinguishes organizations as capable of practicing or
delivering services in a specialty area
- Accreditation focuses on continuous improvement strategies, achievement
of optimal quality standards, and ongoing education and consultation.
- Effective accreditation programs have well-defined missions;
pre-determined infrastructure and authority for the program; participation
from health professionals in standards development and interpretation; and
relevant, objective, and measurable standards. A Strong Accreditation
- Encourages professionals to continuously seek to improve quality despite
- Provides sustained management of field operations
- Ensures a fair, valid, and credible process
- Establishes an accreditation database of information to determine
compliance, pinpoint problem areas, or highlight opportunities for
improvement Accreditation Standards
- Optimal and achievable
- Developed by a consensus
- Published and reviewed and revised periodically
- Provides a visible commitment
- Comprehensive review of the competencies of the organization
- Evaluation and management tool
The Accreditation Process
- Combination of self and external organizational assessments based on
- Focuses on continuous improvement strategies
- Access to Care and Continuity of Care
- Care of Patients
- Patient and Family Rights
- Patient and Family Education
- Assessment of Patients Health Care Organization Management Standards
- Quality Improvement and Patient Safety
- Facility Management and Safety
- Prevention and Control of Infections
- Staff Qualifications and Education
- Governance, Leadership, and Direction
- Management of Information
Does accreditation cause improved quality of services?
WHO found that, of twelve experiences with external quality assessments in
eight countries, the majority showed evidence of improved services quality. Does
accreditation cause improved quality of services? Well-designed and implemented
accreditation processes can result in an increase in the quality of healthcare
What is the Evidence?
“Accreditation programs, if undertaken with careful planning, strong
government support, and organizational commitment, have the potential to improve
the quality of care available in hospitals and medical laboratories in many
developing countries. Where understanding and support exist, accreditation
programs and other external quality assessment methods are desirable and
sustainable ways of improving care in developing countries”
- Montagu, D. 2003. Accreditation and Other External Quality Assessment
Systems for Healthcare. The Quality Assurance Project Study in South Africa.
The Quality Assurance Project implemented the first randomized control trial
to measure the impact of accreditation in a developing country setting.
- J. Warren Salmon et al. October 2003. “The Impact of Accreditation on
the Quality of Hospital Care: KwaZulu-Natal Province, Republic of South
Africa.” Quality Assurance Project: Operations Research Results.3232
Can Accreditation Improve Quality and Patient Outcomes?
The answer is YES IF
- Taken seriously
- Leadership is committed
- Considered a framework to improve quality
- Considered a means not an end
- Becomes the responsibility of everyone in the organization
- Clients are more satisfied Larger share of the market
- Pride of the employees in their workplace Retention of excellent human
- Safer environment Less risk less liability
- Quality culture Continuous improvement
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