For personal use. Only reproduce with permission from The Lancet. RESEARCH INTO PRACTICE III 1404 THE LANCET • Vol 362 • October 25, 2003 • www.thelancet.com Over the past several decades, concerns about the quality of health care and the performance of health-care professionals have arisen in most developed countries. These concerns have led to development of programmes for measurement of quality and improvement of doctors’ performance. Early strategies targeted the individual doctor, and included such interventions as clinical audits, peer review, and continuing professional education. These traditional methods, when used alone, are now known to have limited value, 1 and associated performance improvements seem to be sustainable over time only if changes in systems that lend support to practice are also instituted. 2 Comprehensive systematic strategies are presently being developed internationally, which include public and private supervision and regulation of medical practice, national systems of practice guidelines and standards, effective use of clinical information systems, intensive involvement of professional groups in continuous quality- improvement activities, and systematic use of financial and other incentives. Without respect to national borders, professional performance improvement is increasingly being seen in view of growing demands for greater public accountability, which has been called the third revolution in medical care. 3 In this report, we present an international view of efforts to measure and improve doctors’ performance from the perspective of the UK, the USA, and the Netherlands. We look at strategies being used in these countries, the extent to which these initiatives are known to be successful, the challenges faced in undertaking these efforts, and the potential effect of greater public accountability on the approach used by every country. Lancet 2003; 362: 1404–08 Agency for Healthcare Research and Quality, Rockville, MD, USA (D C Lanier MD, H Burstin MD); National Primary Care Research and Development Centre, Manchester, UK (Prof M Roland DM); and Netherlands School of Primary Care Research, Maastricht, Netherlands (Prof J A Knottnerus DM) Correspondence to: Dr David C Lanier, Center for Primary Care, Prevention and Clinical Partnerships, Agency for Healthcare Research and Quality, 540 Gaither Road, Rockville, MD 20850, USA (e-mail: dlanier@ahrq.gov) National leadership and accountability Leadership in responding to public concerns about health-care quality has emerged differently in these three countries, largely as a result of the relative influence of government, doctors’ groups, and the private sector over the health system. In the UK, a strong government leadership role in quality regulation has been established by virtue of the fact that the UK National Health Service (NHS) funds all publicly owned hospitals and is the source of most doctors’ income. Since 1998, the UK government has implemented an overarching national strategy of quality improvement, which includes funding for quality-improvement activities and monitoring via regular inspection of hospitals and NHS trusts. Furthermore, systems have been introduced to identify poorly performing doctors (National Patient Safety Agency, http://www.npsa.nhs.uk; National Clinical Assessment Authority, http://www.ncaa.nhs.uk) and for yearly appraisal of all doctors working in the NHS (http://www.revalidationuk.info). Such an ambitious centrally driven quality-improvement strategy has been made politically possible only because of a substantial number of high profile cases in the UK, in which quality of care has been a serious problem. Although associated with a substantial loss of autonomy among doctors, this initiative includes a central role for local doctors’ groups in performance improvement activities. Despite similar public concerns about the quality of health care in the USA, the US government has, to date, played a secondary part in quality supervision, with doctors’ groups mainly self-regulating under the aegis of professionalism. Delegation of authority for quality supervision has largely been assigned to quasi-private accrediting organisations, such as the Joint Commission on the Accreditation of Healthcare Organisations and the National Committee for Quality Assurance. Most health- care insurers and health plans (both public and private) have also set up processes for assessment of the performance of doctors’ practices that provide care for their enrolled membership. While peer review and performance-improvement programmes in the USA continue to be doctor-led, the government’s role in quality supervision has been enhanced through development of state-based quality-improvement organisations. Doctors continue to exert strong influence Doctor performance and public accountability David C Lanier, Martin Roland, Helen Burstin, J André Knottnerus Research into practice III Public concern about the quality of health care has motivated governments, health-care funders, and clinicians to expand efforts to improve professional performance. In this paper, we illustrate such efforts from the perspective of three countries, the UK, the USA, and the Netherlands. The earliest strategies, which included continuing professional education, clinical audits, and peer review, were aimed at the individual doctor, and produced only modest effects. Other efforts, such as national implementation of practice guidelines, effective use of information technologies, and intensive involvement by doctors in continuous quality-improvement activities, are aimed more broadly at health-care systems. Much is yet unknown about whether these or other strategies—such as centralised supervision or regulation of quality improvement, or use of financial incentives—are effective. As demands for greater public accountability rise, continuing performance improvement efforts of each of our countries offer us opportunities to learn from one another.