The growth of accreditation programs in low- and middle-income countries (LMICs) provides important examples of innovations in leadership, governance and mission which could be adopted in developed countries. While these accreditation programs in LMICs follow the basic structure and process of accreditation systems in the developed world, with written standards and an evaluation by independent surveyors, they differ in important ways. Their focus is primarily on improving overall care country-wide while supporting the weakest facilities. In the developed world accreditation efforts tend to focus on identifying the best institutions as those are typically the only ones who can meet stringent and difficult evaluative criteria.The Joint Learning Network for Universal Health Coverage (JLN), is an initiative launched in 2010 that enables policymakers aiming for UHC to learn from each other’s successes and failures. The JLN is primarily comprised of countries in the midst of implementing complex health financing reforms that involve an independent purchasing agency that buys care from a mix of public and private providers [Lancet 380: 933-943, 2012]. One of the concerns for participating countries has been how to preserve or improve quality during rapid expansion in coverage. Accreditation is one important mechanism available to countries to preserve or improve quality that is in common use in many LMICs today.This paper describes the results of a meeting of the JLN countries held in Bangkok in April of 2013, at which the current state of accreditation programs was discussed. During that meeting, a number of innovative approaches to accreditation in LMICs were identified, many of which, if adopted more broadly, might enhance health care quality and patient safety in the developed world.Electronic supplementary materialThe online version of this article (doi:10.1186/s12992-014-0065-9) contains supplementary material, which is available to authorized users.

A simple technique, precipitation with acetone, was described to separate the surface-active lecithin fraction from the nonsurface-active fraction. Surface activity in lung phospholipids was found in the acetone-precipitated fractions of lecithin, sphingomyelin, phosphatidyl dimethylethanolamine and phosphatidyl inositol. Normal surface activity of saline extract of pooled fetal rabbit lung was observed from 28 days of gestation. It was possible to isolate surface-active lecithin from lung parenchyma long before the 29th day of gestation when surface-active lecithin first is found in the alveolar wash. During the nonbreathing fetal state, even at term, only 11 % of lecithin from alveolar wash is surface-active increasing after one hour's breathing to approximately 50 % of the total lecithin. The rabbits delivered prematurely after 28 full days of gestation clinically had respiratory distress and their percentage of surface-active lecithin in alveolar wash increased at a slow rate compared to full-term animals. Good temporal correlation was seen between intracellular storage of surface-active lecithin during the fetal state and the findings with electron microscopy of increasing numbers of osmiophilic inclusion bodies as gestation progresses. SpeculationSurface activity is shared by several phospholipids in lung but is related principally to lecithin. During fetal development there is production of intracellular surface-active lecithin with storage possibly in osmiophilic lamellar inclusion bodies until near term when some (11%) begins to appear in alveolar wash. After breathing, a great release of surface-active lecithin into alveolar wash occurs, with 50% of alveolar lecithin being surface active throughout the life of the animal. Prematurely delivered rabbits take much longer to increase their surface-active alveolar lecithin.

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The Medicare prospective payment system represents a fundamental change in hospital payment. The diagnosis-related group (DRG) patient classification scheme serves as the modifier of payment for this system. The DRG definitions are, in turn, based on the International Classification of Disease, 9th Revision, Clinical Modification (ICD-9-CM). Deficiencies in the ICD-9-CM coding system directly affect the equity of the Medicare payment system. A review of the ICD-9-CM system identifies three principal problems: the inability of the system to reflect clinically important patient attributes adequately; the use of outcome, rather than approach, to code surgical procedures; and the blurring of clinical specificity by the adoption of certain coding rules. If these deficits in coding specificity are not corrected, it is unlikely that DRGs will adequately distinguish clinically unique types of patients. This inability to differentiate among patients threatens to undermine the equity of Medicare payments. Physicians must become more aware of disease coding and more involved in its development and implementation.