International travel in an increasingly globalised world means a growing number of international patients are travelling for medical care in a bid to find the highest-quality, most affordable care. In turn, information about the quality of care a hospital provides is in high demand from patients and insurers alike. Accreditation is a reputable tool for evaluating and enhancing healthcare quality. It initially began as a voluntary programme but, today, many countries have government mandated programmes. Indeed, according to a 2020 article, there are more than 120 healthcare accreditation programmes in over 80 countries. “Since JCI entered the international market 20 plus years ago, the role of accreditation in general has changed,” reflected Joel Roos, MD, Vice President of International Accreditation, Quality Improvement and Patient Safety for Joint Commission International (JCI). “Government healthcare regulators and hospital leadership have come to realise the value of accreditation as a tool for establishing quality and patient safety practices within a healthcare organisation. What was once seen as a lofty goal to obtain, via an optional process, has become a baseline standard in many countries to serve as a foundation for quality and patient safety.”
Indeed, accreditation procedures are recognised as an effective way to ensure adherence to optimal standards and there is a strong body of evidence indicating that accreditation programmes improve clinical outcomes. For example, a 2021 research study found that ‘introducing hospital accreditation schemes stimulates performance improvement and patient safety’. International accreditation represents adherence to global standards but, in some countries, national accreditation has been established, borrowing from international accreditation’s established tools and expertise and making adjustments according to a country’s peculiarities.
In this context, is it important for insurers to look for national as well as international accreditation? Roos said that national accreditation standards tend to serve a slightly different role from international standards. “The goal for national accreditation is to set a foundational level of quality and patient safety across an entire country and may be tailored to achieve specific aims of a Ministry of Health,” he stated. “International standards are generally written on a higher level based on evidence of global best practices and processes.
Accreditation is a reputable tool for evaluating and enhancing healthcare quality
As such, international goals are designed to achieve a higher level of quality and patient safety as healthcare organisations advance their quality agendas,” he stated. Dr Claudia Mika, Founder and CEO, Temos International, agreed that there are fundamental differences between national and international accreditation, mainly in terms of reputation: “We see that some national standards do not have the same reputation as international accreditation bodies’ standards, although they might have accreditation by the International Society for Quality in Health Care's External Evaluation Association (ISQua/IEEA). It seems that in some countries people trust international accreditation bodies more than national ones,” she told ITIJ.
Increasing international patient numbers
One motivation behind national organisations developing their own accreditation standards is a desire to boost international patient numbers. “A number of national healthcare organisations with which JCI partners and accredits do indeed seek to boost their international patient numbers by complying with JCI’s international standards, because they are more comprehensive than national standards,” said Roos. “When a national healthcare organisation creates its own national accreditation standards, those standards tend to only be applicable within that organisation’s local region and not outside of the country. So, international standards are more beneficial for patients who seek to travel outside of that country.” Given the specificity of national standards they can be considered less universal and widely applicable than international standards.
ITIJ also spoke with Cathie Abrahamsen, Chief Standards and Program Development Officer, North America at DNV Healthcare, who agreed that national accreditation standards borrow from their international counterparts and confirmed that amplifying international visitors can be an incentive for the development of national standards within a region or country. “There are several national organisations around the world that have developed their own accreditation organisations and standards. They are usually based on well-established and accepted standards of practice,” she said. “The national organisations have realised that to attract international travellers they need to explore outside of what may be the traditional therapies in that country and to adopt and adapt to more worldwide acceptable treatments.” Ultimately, by adhering to recognised international accreditation standards, organisations and hospitals can be considered, across the board by universally agreed metrics, to deliver high-quality care.
Juan Felipe Santos is the coordinator of a medical tourism project at ANDI (Asociación Nacional de Empresarios de Colombia) in order to represent the Colombian Health Sector in national and international scenarios. He lent his perspective on accreditation in Colombia where the Health and Social Protection Minister has defined a local health accreditation to guarantee that health services are safe and demonstrate gradual compliance with quality levels above the mandatory minimum requirements for healthcare. “The process is voluntary, and hospitals must renew it every four years to maintain the accreditation,” he explained. “The accreditation is concentrated on local services. Locally, the Colombian health accreditation is an advantage when offering health services to insurers, and some foreign insurers recognise this accreditation. International accreditations are recognised, but these are focused more on attracting international patients and generating trust in international insurers.”
When looking to develop their own standards, it appears that national health authorities are approaching international accreditation organisations for guidance on developing their own. Roos confirmed that JCI has been involved in such relationships. “On occasion, JCI is invited to collaborate and help shape national programmes,” he told ITIJ. “JCI has established relationships with national healthcare organisations, ministries of health and other organisations to better understand healthcare worldwide and how to best help with developing national standards.”
International accreditations are recognised, but these are focused more on attracting international patients and generating trust in international insurers
Abrahamsen has experienced that the relationship also works in reverse. “International accreditation organisations are approaching the national health authorities in most cases,” she stated. “The national health authorities are often not in favour of changing what they have in place and do not always want to give up what might be perceived as their own control of accreditation. There are some national authorities that will make a decision to seek organisations out to enhance or improve care to their own patients and by that become recognised as enlightened and wanting to bring the best and newest care to their patients and then to attract international travel for care as well.”
Indeed, there are various opportunities for collaboration between international accreditors and national health authorities in building standards for healthcare systems to adhere to, as Mika confirmed. “There are different opportunities for cooperation. For example, Temos cooperates with the national accreditation body in Egypt, the General Authority for Healthcare Accreditation and Regulation (GAHAR), to support Egyptian hospitals and clinics to qualify for international patients. Organisations can apply for Temos accreditation after they have received accreditation from GAHAR.”
Mika shared with ITIJ how Temos worked with GAHAR to align standards: “Together with GAHAR we did a ‘matching exercise’ in which Temos and GAHAR experts went through both organisations’ standards and identified those that were similar, overlapping, and not covered by the other organisation. Then, we compared our results and identified the standards that will be assessed by Temos to ‘fill the gap’ between GAHAR standards as a national accreditation body and Temos as an international accreditation body with its Excellence in Medical Tourism programme.” Mika explained that the result of this was the creation of the ‘Temos Excellence in Medical Tourism – GAHAR version' accreditation programme with a limited number of standards and a reduced accreditation fee for GAHAR-accredited organisations.
“This is a great benefit for Egyptian organisations, GAHAR, and Temos. The cooperation with GAHAR has been great and very transparent and could start the process with the first GAHAR-accredited organisations,” she enthused. This is a great example of how, by working together, international and national organisations have the potential to further enhance healthcare quality on a global scale and such partnerships are laying the foundation for change. Indeed, a 2020 study confirmed that ‘there is a need to provide a roadmap for the successful development and implementation of accreditation programmes in low-resource settings’. One way to do this could be by high-income countries sharing their established knowledge and expertise with low- and middle-income countries.
A question of quality
Of course, hospital quality and health provision differ around the world, with Western medical standards representing higher quality care due to factors such as better access to resources. “International health accreditations must be adapted to local realities and the medical facilities, because a hospital in Europe for example, is not the same as one in Latin America,” said Santos. “The capabilities and financial resources are limited in most countries and healthcare provision is related to this budget.”
Mika provided an insight into Temos’ assessment process and how it might differ in different countries. “Quality is measured by indicators. Accreditation programmes and respective standards provide guidance and help to define and identify relevant indicators based on international best practices and respective evidence and to build a robust quality management system including quality control and continuous quality improvement in all departments and units,” she said. “Temos considers differing national regulations and healthcare systems when assessing a hospital or clinic. An example would be that our standards ask to have a clinical pharmacist. There are countries where there is no specialisation available and in this case, the hospital cannot comply with our standard and we work together with the organisation to find the best possible solution. However, we never compromise and we are not flexible regarding standards that refer to infection control, patient and staff safety, clinical governance and others. This means that organisations in some countries where national regulations are lower than our international standards may need more guidance, training and education on the standards and may need more time for their preparation to achieve international accreditation.”
So, should insurers be looking for national, as well as international, accreditation of hospitals? Roos believes insurers and other consumers of healthcare should be seeking out healthcare organisations that are JCI accredited. “JCI accreditation represents the highest levels of quality and patient safety. Anyone interested in receiving quality healthcare should be looking into whether the healthcare organisation they visit is JCI-accredited.” Mika agreed that insurers should look for accreditation based on standards that are accredited by ISQua/IEEA. “This can be national or international accreditation bodies’ standards,” she said. “From our perspective insurers should also look for accreditation standards that include international patient management, cultural differences and the respective needs of patients and relatives to assure that their clients are served in the best possible and effective way.”
International health accreditations must be adapted to local realities and the medical facilities
Abrahamsen told ITIJ that there are several important factors that insurers should keep in mind to inform their coverage decisions. “As more consumers (and businesses and insurers) are looking for more cost-effective treatment offerings, some insurers should look into the various accreditations that a hospital may have,” she stated. “There are also a number of certain disease-specific certifications that healthcare organisations could apply for such as orthopaedic or cardiac treatments. An insurance company could make coverage decisions based not only on the hospital accreditation status, but could also include certification for specific programmes, such as, hip replacement or other procedures.”
The bottom line is that international accreditation represents the highest quality standards, confirming a hospital’s adherence to processes that ensure the best care possible. For insurers and other stakeholders, international accreditation is one of the most important things to look for. National accreditation is a way for countries to strive towards higher quality care and with the influence of established international accreditation programmes and processes, these countries can develop their own guidelines to promote high-quality care, patient safety and improved outcomes. Ultimately though, these are not guaranteed to be applicable outside of the country in question and international accreditation, specifically by ISQua/IEEA, is regarded as the gold standard and, for insurers, this is a secure way of knowing which hospitals can guarantee the highest standard of care possible.