Earlier today (November 18, 2015) I had a conversation by e-mail with a member of an accreditation body.  Because I think accreditation is an important part of excellence in healthcare organizations, in oversight and compliance functions and, in quality improvement, I shared the below.  The spirit of accreditors, which should be collegial and collaborative, is addressed, as is the value of accreditation.  If accreditation and/or oversight deteriorates into an adversarial dynamic, the positive effects of that oversight can and will be lost.  This is true for accreditation organizations and for compliance officers, whether governmental or other.

The Question:  2. You note that "The provider must be an extension of the family. This is the ultimate genius behind the concept of Medical Home, and it cannot be achieved by regulations, restrictions and rules."  Are you implying by this statement that there is no role for "regs, rules, and restrictions", or simply that they are insufficient to sustain long-term change?

The Answer:  No doubt, as our accreditation efforts suggest, we believe that there is a key place for standards and guidelines.  My point is directed at the government’s preoccupation with creating “change” with demands and dictates.  I have said to the ONC often, “if you demand that everyone must do the same thing, the same way, every time, you will eliminate creativity, generative thinking and transformation.  Tell us what you want done and let us demonstrate our unique way of doing it. Then evaluate it and find the ‘best practice or best solution’ and promote that.”

When change is driven only by external demands, it is not sustainable and will become dependent upon rewards to drive improvement.  But when change is driven by internalized values and vision, being self-sustaining and generative in nature, it is sustained not by financial or other rewards, but by the passion of the participants.  For change to be permanent, it must be driven by transformation rather than reform.  Transformation is driven by internalized value and vision.  Rules, regulations and requirements can be part of an external standard against which you can measure yourself, but they will never become a part of the energy which sustains change.

The Question:   Also, would you consider "standards" (such as those that certain accrediting bodies use ) to be equivalent to “regs, rules, and restrictions”, or do you see them as having value because they offer a blueprint that describes a desirable future state that is worth attaining/maintaining?

The Answer:  As implied above, I think standards to be important guideposts in starting us on our pilgrimage and in giving us guidance in what to do, and, often, even, in how to do it.  Remember Lincoln’s famous quote in his 1858, House Divided Address to the Republican National Convention.  He said, “If we can first know where we are and whither we are tending; we can better judge what to do and how to do it.”  A healthcare GPS must tell you where you want to go – that is often expressed in standards, evidenced-based goals and quality outcomes – but if the GPS does not also tell you where you are – how far you are from where you want to be -- you can never get to where you want to be. 

Standards are what we measure ourselves against, as we create our future.  Remember Peter Senge’s great comment in The Fifth Discipline as he addresses “creative tension,” which is the difference between your “reality” and “your vision.”  The “tension,” which cries out for resolution is created by standards which you have not yet met, but which you embrace as “the good.” 

Yes, I believe in standards; that is why we sought _____ _______ accreditation and why we will renew it.  That is why we objected to the original spirit of the surveyors as they announced in their first sentence, “If you are doing something wrong, we will find it.”  It was a threat, when in fact that is why we sought __________ ________ accreditation in the beginning – to tell us both what we are doing wrong but more importantly to tell us what we are not doing right.

We WANTED to be measured by  ________ __________standard; to discover where we needed improvement was not a threat, it was an expectation.  The worst experience in bringing in a practice consultant is that after you have paid him/her $10,000, you are told, you are doing everything perfectly and we can recommend no improvement.  You have just wasted your consultation fee.  If, however, you are told, “we can show you how to really improve.”  That has great value.

The interesting thing about  “creative tension,” as it drives you from your “reality” to your “vision,” is that as you approach your “vision,” and as your “vision” increasingly becomes your “reality,” you discover that your “vision” expands and when you “arrive” at your former “vision,” it having become your “new reality,” it is challenged by a new, larger and more comprehensive “vision.”  That should always be the goal.  

I would hope that when we are reaccredited by _________ _________ that we will have corrected the very few things which you pointed out before but that you will find more subtle and perhaps even more important things we can improve. That is not failure; that is progress and that is a dynamic for success.

James (Larry) Holly, M.D.
C.E.O. SETMA
www.jameslhollymd.com

Adjunct Professor
Family & Community Medicine
University of Texas Health Science Center
San Antonio School of Medicine 

Clinical Associate Professor
Department of Internal Medicine
School of Medicine
Texas A&M Health Science Center