{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,8]],"date-time":"2026-10-08T15:49:20Z","timestamp":1791474560268,"version":"4.3.4"},"reference-count":36,"publisher":"Pan American Health Organization","content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":[],"published-print":{"date-parts":[[2026,10,8]]},"abstract":"<title>ABSTRACT<\/title>\n                  <p>Cardiovascular diseases are the leading cause of death in the World Health Organization (WHO) Region of the Americas, with uncontrolled hypertension as the main modifiable risk factor. Their frequent coexistence with kidney and metabolic conditions creates an interconnected cardiovascular, kidney, and metabolic burden and highlights gaps in prevention, detection, continuity, integration, and quality of care. HEARTS in the Americas is one of the largest regional implementations of the WHO\u2019s Global HEARTS initiative and a central platform for strengthening primary care. Building on the HEARTS quality improvement model and HEARTS 2.0 clinical pathway, this report presents a service-oriented accreditation framework for integrated cardiovascular, kidney, and metabolic care delivered in primary care. Rather than accrediting facilities as institutions, the model focuses on the capacity of primary care services to deliver high-quality integrated cardiovascular, kidney, and metabolic care. Developed by the Pan American Health Organization\u2019s HEARTS in the Americas team, thematic experts, and country implementers, the framework conceives accreditation as an elevated stage of continuous quality improvement rather than a stand-alone inspection. It combines self-assessment, external assessment, maturity and performance appraisal, review of organizational quality processes, improvement plans, and renewable accreditation. Based on maturity and performance results, services are classified as accredited, progressing towards accreditation, or not yet accredited, with findings linked to improvement actions, technical assistance, governance, and resource allocation. The framework offers a pragmatic pathway for strengthening cardiovascular, kidney, and metabolic services in primary care and a scalable model for extending quality improvement to other priority health services.<\/p>","DOI":"10.26633\/rpsp.2026.101","type":"journal-article","created":{"date-parts":[[2026,10,8]],"date-time":"2026-10-08T14:49:46Z","timestamp":1791470986000},"page":"1","source":"Crossref","is-referenced-by-count":0,"title":["HEARTS Accreditation: institutionalizing quality improvement of integrated cardiovascular, kidney, and metabolic services in primary care"],"prefix":"10.26633","volume":"50","author":[{"given":"Esteban","family":"Londo\u00f1o","sequence":"first","affiliation":[{"name":"Department of Noncommunicable Diseases and Mental Health, Pan American Health Organization, Washington, D.C., United States of America."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Grace","family":"Ku","sequence":"additional","affiliation":[{"name":"Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Reena","family":"Gupta","sequence":"additional","affiliation":[{"name":"Resolve to Save Lives, New York, NY, United States of America."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ricardo","family":"Rodr\u00edguez-Bu\u00f1o","sequence":"additional","affiliation":[{"name":"Pan American Health Organization, San Salvador, El Salvador."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Laura","family":"Cort\u00e9s","sequence":"additional","affiliation":[{"name":"Directorate-General for Quality and Health Education, Mexico City, Mexico."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Pedro","family":"Bernal","sequence":"additional","affiliation":[{"name":"Health, Nutrition and Population Division, Inter-American Development Bank, Washington, D.C., United States of America."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Natasha","family":"Sobers","sequence":"additional","affiliation":[{"name":"Pan American Health Organization, Georgetown, Guyana."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Lila","family":"Estephan","sequence":"additional","affiliation":[{"name":"Ministry of Health and Wellness, Belmopan, Belize."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Andrew","family":"Moran","sequence":"additional","affiliation":[{"name":"Resolve to Save Lives, New York, NY, United States of America."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Marc","family":"Jaffe","sequence":"additional","affiliation":[{"name":"Department of Endocrinology, Kaiser Permanente San Francisco Medical Center, San Francisco, CA, United States of America."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Yamil\u00e9","family":"Vald\u00e9s","sequence":"additional","affiliation":[{"name":"Ministry of Public Health, Havana, Cuba."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Salvador","family":"Tamayo","sequence":"additional","affiliation":[{"name":"Ministry of Public Health, Havana, Cuba."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Marcela","family":"Rivera","sequence":"additional","affiliation":[{"name":"Ministry of Health, Santiago, Chile."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jerry","family":"Toelsie","sequence":"additional","affiliation":[{"name":"Faculty of Medical Sciences, Anton de Kom University of Suriname, Paramaribo, Suriname."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Carmen","family":"Guerrero","sequence":"additional","affiliation":[{"name":"Pan American Health Organization, Quito, Ecuador."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Mat\u00edas","family":"Villatoro","sequence":"additional","affiliation":[{"name":"Ministry of Health, San Salvador, El Salvador."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Mar\u00eda","family":"Xochil P\u00e9rez","sequence":"additional","affiliation":[{"name":"Ministry of Health, San Salvador, El Salvador."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Alied","family":"Bencomo","sequence":"additional","affiliation":[{"name":"Pan American Health Organization, Mexico City, Mexico."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Vhania","family":"Batista","sequence":"additional","affiliation":[{"name":"Pan American Health Organization, Santo Domingo, Dominican Republic."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Andr\u00e9s","family":"Rosende","sequence":"additional","affiliation":[{"name":"Department of Noncommunicable Diseases and Mental Health, Pan American Health Organization, Washington, D.C., United States of America."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Vannesa","family":"Morales","sequence":"additional","affiliation":[{"name":"Ministry of Public Health, Quito, Ecuador."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ana","family":"Guti\u00e9rrez","sequence":"additional","affiliation":[{"name":"Ministry of Public Health, Quito, Ecuador."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Pedro","family":"Ordunez","sequence":"additional","affiliation":[{"name":"Department of Noncommunicable Diseases and Mental Health, Pan American Health Organization, Washington, D.C., United States of America."},{"name":"ordunezp@paho.org"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"11167","reference":[{"key":"ref1","unstructured":"Pan American Health Organization. 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Rev Panam Salud Publica. 2022;46:e143. http:\/\/doi.org\/10.26633\/RPSP.2022.143","DOI":"10.26633\/RPSP.2022.143"},{"key":"ref4","unstructured":"Pan American Health Organization. ENLACE: data portal on noncommunicable diseases, mental health, and external causes. Overweight and obesity. Washington, DC: PAHO; 2026 [cited 2026 May 16]. Available from: https:\/\/www.paho.org\/en\/enlace\/overweight-and-obesity."},{"key":"ref5","unstructured":"Pan American Health Organization. ENLACE: data portal on noncommunicable diseases, mental health, and external causes. Burden of disease from diabetes. Washington, DC: PAHO; 2026 [cited 2026 May 16]. Available from: https:\/\/www.paho.org\/en\/enlace\/burden-disease-diabetes."},{"key":"ref6","doi-asserted-by":"crossref","unstructured":"Rosas-Valdez FU, Aguirre-V\u00e1zquez AF y Agudelo-Botero M. Cuantificaci\u00f3n de la carga de la enfermedad renal cr\u00f3nica en Am\u00e9rica Latina: una epidemia invisibilizada [Quantification of the burden of chronic kidney disease in Latin America: an invisible epidemic]. Rev Panam Salud Publica. 2024;48:e41. http:\/\/doi.org\/10.26633\/RPSP.2024.41","DOI":"10.26633\/RPSP.2024.41"},{"key":"ref7","doi-asserted-by":"crossref","unstructured":"Martinez R, Soliz P, Mujica OJ, Reveiz L, Campbell NRC, Ordunez P. The slowdown in the reduction rate of premature mortality from cardiovascular diseases puts the Americas at risk of achieving SDG 3.4: a population trend analysis of 37 countries from 1990 to 2017. J Clin Hypertens (Greenwich). 2020;22(8):1296\u2013309. http:\/\/doi.org\/10.1111\/jch.13922","DOI":"10.1111\/jch.13922"},{"key":"ref8","unstructured":"World Health Organization. Rajan D, Rouleau K, Winkelmann J, Kringos D, Jakab M, Khalid F, editors. Implementing the primary health care approach: a primer. 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Washington DC: PAHO; 2023 [cited 2026 May 18]. Available from: https:\/\/www.paho.org\/sites\/default\/files\/2023-09\/integration-initiative-ncds-v2.pdf"},{"key":"ref12","doi-asserted-by":"crossref","unstructured":"Souza KM, Giron N, Vallini J, Hallar K, Ordunez P, Rosende A, et al. Barriers to access to antihypertensive medicines: insights from the HEARTS initiative in Latin American and Caribbean region. J Pharm Policy Pract. 2024;17(1): 2379045. http:\/\/doi.org\/10.1080\/20523211.2024.2379045","DOI":"10.1080\/20523211.2024.2379045"},{"key":"ref13","doi-asserted-by":"crossref","unstructured":"Whelton PK, Picone DS, Padwal R, Campbell NRC, Drawz P, Rakotz MK, et al. Global proliferation and clinical consequences of non-validated automated BP devices. J Hum Hypertens. 2023;37(2):115\u201319. http:\/\/doi.org\/10.1038\/s41371-022-00667-z","DOI":"10.1038\/s41371-022-00667-z"},{"key":"ref14","doi-asserted-by":"crossref","unstructured":"Londo\u00f1o E, Gupta R, Stuyft PV, Heine M, Giraldo G, Ku GM, et al. HEARTS quality: a policy framework to strengthen hypertension and cardiovascular risk management in primary healthcare: insights from HEARTS in the Americas. Lancet Reg Health Am. 2026;53:101311. http:\/\/doi.org\/10.1016\/j.lana.2025.101311","DOI":"10.1016\/j.lana.2025.101311"},{"key":"ref15","unstructured":"Pan American Health Organization. Integrated health service delivery networks: updated conceptual and operational framework for the Region of the Americas. Washington, DC: PAHO; 2025 [cited 2026 July 15]. Available from: https:\/\/iris.paho.org\/handle\/10665.2\/69276"},{"key":"ref16","doi-asserted-by":"crossref","unstructured":"Rosende A, Romero C, Dipette DJ, Brettler J, van der Stuyft P, Satheesh G, et al. Candidate interventions for integrating hypertension and cardiovascular-kidney-metabolic care in primary health settings: HEARTS 2.0 Phase 1. Glob Heart. 2025;20(1):45. http:\/\/doi.org\/10.5334\/gh.1428","DOI":"10.5334\/gh.1428"},{"key":"ref17","doi-asserted-by":"crossref","unstructured":"Ordunez P, Rosende A, Brettler J, Londo\u00f1o E, Van der Stuyft P, Martinez-Piedra R, et al. Readiness to deliver integrated cardiovascular, kidney and metabolic care in primary healthcare: phase II of HEARTS 2.0 in 26 countries in the Americas. BMJ Glob Health. 2026;11(1):e021298. http:\/\/doi.org\/10.1136\/bmjgh-2025-021298","DOI":"10.1136\/bmjgh-2025-021298"},{"key":"ref18","doi-asserted-by":"crossref","unstructured":"Ordunez P, Rosende A, Ratti MFG, DiPette DJ, Torres AM, Londo\u00f1o E, et al. Evidence-informed prioritization of interventions for integrating hypertension management into cardiovascular-kidney-metabolic care in primary health care: HEARTS 2.0 Phase 3. Am J Hypertens. 2026;39(8):956\u201365. http:\/\/doi.org\/10.1093\/ajh\/hpag033","DOI":"10.1093\/ajh\/hpag033"},{"key":"ref19","doi-asserted-by":"crossref","unstructured":"Ordunez P, Rosende A, Angell SY, Londo\u00f1o E, Whelton PK, Ratti MFG, et al. HEARTS 2.0: an implementation-oriented clinical pathway for integrated care of hypertension and cardiovascular\u2013kidney\u2013metabolic conditions in primary health care in the Americas. Lancet Prim Care. 2026;2(5):100161. http:\/\/doi.org\/10.1016\/j.lanprc.2026.100161","DOI":"10.1016\/j.lanprc.2026.100161"},{"key":"ref20","unstructured":"World Health Organization. Health care accreditation and quality of care: exploring the role of accreditation and external evaluation of health care facilities and organizations. Geneva: WHO; 2022 [cited 2026 May 16]. Available from: https:\/\/iris.who.int\/handle\/10665\/363528"},{"key":"ref21","doi-asserted-by":"crossref","unstructured":"Russell TA, Ko C. History and role of quality accreditation. Clin Colon Rectal Surg. 2023;36(4):279\u201384. http:\/\/doi.org\/10.1055\/s-0043-176159","DOI":"10.1055\/s-0043-1761592"},{"key":"ref22","doi-asserted-by":"crossref","unstructured":"Novaes HM, Neuhauser D. Hospital accreditation in Latin America. Rev Panam Salud Publica. 2000;7(6):425\u201330. http:\/\/doi.org\/10.1590\/s1020-49892000000600019","DOI":"10.1590\/S1020-49892000000600019"},{"key":"ref23","unstructured":"Pan American Health Organization. Strategy and plan of action to improve quality of care in health service delivery 2020\u20132025. Washington, DC: PAHO; 2019 [cited 2026 Sep 14]. Available from: https:\/\/iris.paho.org\/handle\/10665.2\/55861"},{"key":"ref24","doi-asserted-by":"crossref","unstructured":"Greenfield D, Braithwaite J. Developing the evidence base for accreditation of healthcare organisations: a call for transparency and innovation. Qual Saf Health Care. 2009;18(3):162\u20133. http:\/\/doi.org\/10.1136\/qshc.2009.032359","DOI":"10.1136\/qshc.2009.032359"},{"key":"ref25","doi-asserted-by":"crossref","unstructured":"Shaw CD. Evaluating accreditation. Int J Qual Health Care. 2003;15(6):455\u20136. http:\/\/doi.org\/10.1093\/intqhc\/mzg092","DOI":"10.1093\/intqhc\/mzg092"},{"key":"ref26","doi-asserted-by":"crossref","unstructured":"Rastegarimehr B, Teymourlouy AA, Abolghasem Gorji H. Accreditation of primary health care services: a systematic review. J Educ Health Promot. 2025;14:15. http:\/\/doi.org\/10.4103\/jehp.jehp_1649_23","DOI":"10.4103\/jehp.jehp_1649_23"},{"key":"ref27","doi-asserted-by":"crossref","unstructured":"Tabrizi JS, As\u2019habi A, Nazari M, Tavani ME, Haghi M, Gharibi F. Impacts of accreditation on the performance of primary health care centres: a systematic review. Malays Fam Physician. 2023;18:63. http:\/\/doi.org\/10.51866\/rv.274","DOI":"10.51866\/rv.274"},{"key":"ref28","doi-asserted-by":"crossref","unstructured":"Nouwens E, Van Lieshout J, Bouma M, Braspenning J, Wensing M. Effectiveness of improvement plans in primary care practice accreditation: a clustered randomized trial. PLoS One. 2014;9(12):e114045. http:\/\/doi.org\/10.1371\/journal.pone.0114045","DOI":"10.1371\/journal.pone.0114045"},{"key":"ref29","unstructured":"Pan American Health Organization. HEARTS in the Americas: evaluation framework for continuous quality improvement in primary care centers. Washington, DC: PAHO; 2025 [cited 2026 Jun 21]. Available from: https:\/\/iris.paho.org\/handle\/10665.2\/64210"},{"key":"ref30","doi-asserted-by":"crossref","unstructured":"Moran AE, Gupta R; Global Hearts Initiative Collaborators. Implementation of global hearts hypertension control programs in 32 low- and middle-income countries: JACC International. J Am Coll Cardiol. 2023;82(19):1868\u201384. http:\/\/doi.org\/10.1016\/j.jacc.2023.08.043","DOI":"10.1016\/j.jacc.2023.08.043"},{"key":"ref31","doi-asserted-by":"crossref","unstructured":"Prado P, Gamarra A, Rodriguez L, Brettler J, Farrell M, Girola ME, et al. Monitoring and evaluation platform for HEARTS in the Americas: improving population-based hypertension control program in primary health care. Rev Panam Salud Publica. 2022;46:e161. http:\/\/doi.org\/10.26633\/RPSP.2022.161","DOI":"10.26633\/RPSP.2022.161"},{"key":"#cr-split#-ref32.1","unstructured":"World Health Organization and the United Nations Children's Fund. Primary health care : report of the International Conference on Primary Health Care, Alma-Ata, USSR, 6-12 September 1978. Geneva: WHO"},{"key":"#cr-split#-ref32.2","unstructured":"1978 [cited 2026 Jun 21]. Available from: https:\/\/iris.who.int\/handle\/10665\/39228"},{"key":"ref33","unstructured":"World Health Organization Regional Office for Europe. From Alma-Ata to Astana: primary health care: reflecting on the past, transforming for the future: interim report from the WHO European Region. Copenhagen: WHO Regional Office for Europe; 2018 [cited 2026 Jul 17]. Available from: https:\/\/www.who.int\/docs\/default-source\/primary-health-careconference\/phc-regional-report-europe.pdf"},{"key":"ref34","doi-asserted-by":"crossref","unstructured":"Brettler JW, Arcila GPG, Aumala T, Best A, Campbell NR, Cyr S, et al. Drivers and scorecards to improve hypertension control in primary care practice: recommendations from the HEARTS in the Americas Innovation Group. Lancet Reg Health Am. 2022;9:100223. http:\/\/doi.org\/10.1016\/j.lana.2022.100223","DOI":"10.1016\/j.lana.2022.100223"},{"key":"ref35","unstructured":"Pan American Health Organization. HEARTS in the Americas. quality improvement for primary health care centers. Washington DC: PAHO; 2024 [cited 2026 Jul 17]. 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