The government's role in hospital accountability for quality of care.

BACKGROUND: The role of the U.S. government in the accountability of hospitals for quality of care involves shaping the community of those interested in quality, developing methods and infrastructure, standardizing information, providing information and technical assistance, and enforcing standards. The federal government's role in shaping an atmosphere of trust or distrust is critical but underestimated. The research and development of methods and infrastructure is widely acknowledged and many health systems' reform proposals emphasize it. Several state governments have begun standardizing and providing quality information, and this role is also assigned to the federal government in several reform proposals. Enforcing standards, including licensure and certification, is the most widely understood governmental role; states license whereas the federal government certifies compliance with Medicare conditions of participation either directly or through accreditation by the Joint Commission. These standards are evolving rapidly. Only recently has government taken on the role of providing technical assistance for quality improvement. ISSUES: Health system reform legislation may shape hospital accountability by (a) mandating uniform quality performance measurement and disclosure, (b) replacing emphasis on minimum standards with emphasis on improvement, (c) changing the structure of certification requirements, (d) requiring participation in quality improvement activities, and (e) funding new quality improvement structures. Some support a federal role in developing and implementing measures, but there is disagreement on the feasible pace, the uses of the resulting information, and the federal role in quality improvement. There is also disagreement about the future form of Medicare-based federal quality improvement efforts.