title: Quality assessment by external bodies: intended and unintended impact on healthcare delivery.
abstract: OBJECTIVE
  External quality assessment programs in the form of pay for performance, report cards and national rankings are rapidly overtaking more traditional, internal quality assessment efforts and external clinical practice guidelines. Although such initiatives are designed to improve healthcare quality by promoting competition and increasing transparency, review of their efficacy and unintended effects is just coming to the national spotlight.
  
  
  RESULTS
  Critical evaluation of external quality assessment programs remains limited despite their scope, speed and breadth of implementation. Recent publications, however, suggest that external quality assessment efforts may have major unintended consequences. These include effects on patient decision-making, the 'dynamic equilibrium' of patient care, healthcare disparities, medical innovation and practice patterns.
  
  
  CONCLUSIONS
  In their early years of implementation, external quality assessment programs have already had significant consequences in the healthcare system. As new tools become available, their full impact on care and caregivers must be thoroughly evaluated. Careful consideration of clinical practice implications and an understanding of the risks are critical before accepting and implementing new assessment paradigms. The substantial and widespread effects of these programs should prompt further evaluation from the medical community.
authors.affiliation: Duke University School of Medicine, Raleigh-Durham, North Carolina, USA.
authors.forename: Loren
authors.initials: L
authors.lastname: Riskin
authors.forename: Jason A
authors.initials: JA
authors.lastname: Campagna
mesh_terms: D001319:Authorship; D003695:Delivery of Health Care; D017408:Guidelines as Topic; D006801:Humans; D010043:Outcome and Process Assessment, Health Care; D015397:Program Evaluation / Q000379:methods* / Q000592:standards; D011785:Quality Assurance, Health Care / Q000379:methods* / Q000592:standards*; D011787:Quality of Health Care / Q000191:economics; D012308:Risk Management; D013647:Task Performance and Analysis