Annex A > Chapter 18 - Medical and Clinical Audit > Audit: the national perspective > International comparisons
<< previous | next >>
International comparisons
109 Dr Walshe described the state of audit in the United States as at 1989. He said:
`... the United States has had systems for the external accreditation or inspection of hospitals in some form or other since the 1980s, in fairly vigorous form certainly since the 1960s and it first mandated quality assurance, introduced federal legislation that required it effectively in I think 1973. So we would have found a very long history of this kind of work, and lots of efforts with different approaches to attempting to measure quality, different kinds of measures and different ways of structuring and doing this, so a great deal of experience ... Every hospital we visited then and indeed now, would have had a well-developed internal quality assurance programme with staff, structures, processors and things like that in place. They would also have had programmes for risk management and utilisation review, looking at the use of resources, and then we would have also found a number of external programmes, payers for healthcare, examining the quality of healthcare provided by hospitals and healthcare providers. I think it would be right to say you would also have found far from a consensus about how useful that very substantial investment had been in bringing about quality improvement and in fact from the late 1980s, the US healthcare system began to move away from its traditional approaches to quality assurance and to embrace what is sometimes called "whole system" approaches to continuous quality improvement and TQM, and that movement in the US has continued.' [132]
110 Dr Walshe said that it would not necessarily be possible to implement the USA model in the UK. First, the system of quality assurance or audit within the USA was largely imposed externally or was required by regulatory systems, and secondly, there was a lack of consensus as to the benefits that had been produced by those approaches. [133]
111 The other difference noted by Dr Walshe was that, in the USA, audit had been required by federal legislation and by payers of healthcare. There were also cultural differences between the way that the US healthcare organisations had traditionally been run compared with British NHS trusts or healthcare organisations. Dr Walshe pointed to the
`... big differences in the employment status of doctors and the degree of medical involvement in the management of those organisations, and big cultural differences that effect the transference of an organisational approach to quality improvement from their context to ours.' [134]
112 Dr Walshe was asked whether the legal position in the UK, whereby audit data does not attract public interest immunity or any other form of confidentiality within civil litigation, differed from the stance taken in other countries. He told the Inquiry that it did:
`In the United States, something like 47 or 48 of the states have legislation which gives some kind of qualified immunity or privilege to information that health care providers collect for quality assurance purposes. Not all states have that, but the great majority do. Some people pointed to that as an example and said clearly that is needed to allow audit or quality improvement to be established. That has to be seen in the light of levels of litigation for medical negligence which are an order of magnitude higher at least in the US, so a very different situation.
`Interestingly, more recently, I think I am right, Australia has introduced some legislation which gives some qualified privilege to information that providers there collect for the purposes of quality improvement.' [135]
He was further asked whether it was possible to assess whether the provision of such immunity made any difference to the effectiveness of the audit process, and replied:
`I do not think we can really answer that question. You could argue in practical terms. It clearly has not been necessary in Canada, it has not been necessary in other European countries and it does not seem to have been necessary here, but we cannot prove the counterfactual, had we had that legislation, things would be different today.' [136]
<< previous | next >> | back to top
Footnotes