Intended for healthcare professionals

Education And Debate

External assessment of health care

BMJ 2001; 322 doi: (Published 07 April 2001) Cite this as: BMJ 2001;322:851
  1. Charles Shaw (, programme director
  1. CASPE Research, 11–13 Cavendish Square, London W1M 0AN
  • Accepted 1 December 2000

A rash of external inspection is affecting the delivery of health care around the world. Governments, consumers, professions, managers, and insurers are hurrying to set up new schemes to ensure public accountability, transparency, self regulation, quality improvement, or value for money. But what do we know of such schemes' evidence base, the validity of their standards, the reliability of their assessments, or their ability to bring improvements for patients, staff, or the general population?

Box 1: Characteristics of effective external assessment programmes

Give clear framework of values—To describe elements of quality, and their weighting, such as the enablers and results defined by the European Foundation for Quality Management

Publish validated standards—To provide an objective basis for assessment

Focus on patients—To reflect horizontal clinical pathways rather than vertical management units

Include clinical processes and results—To reflect perceptions of patients, staff, and public

Encourage self assessment—To give time and tools to internalise assessment and development

Train the assessors—To promote reliable assessments and reports

Measure systematically—To describe and weight compliance with standards objectively

Provide incentives—To give leverage for improvement and response to recommendations

Communicate with other programmes—To promote consistency and reciprocity and to reduce duplication and burden of inspection

Quantify improvement over time—To demonstrate effectiveness of programme

Give public access to standards, assessment processes, and results—To be transparent and publicly accountable


In short, not much. The standards, measurements, and results of management systems have not been, and largely cannot be, subjected to the same rigorous scrutiny and meta-analysis as clinical practice. No one has published a controlled trial, and there are too many confounding variables to prove that inspection causes better clinical outcomes, although there is evidence that organisations increase their compliance with standards if these are made explicit. But experience and consensus are gradually being codified into guidelines to …

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