Look up a hospital website, and the best in the world will boast a stream of accreditation standards. Accreditation signifies that the service has met the gold standard determined by the industry, often exceeding those established by national or local regulations. So says Dimitrios Papapavlous, CEO of Healthwatch, an assistance company that provides assistance in Greece and the Balkans.
Accreditation happens, typically, like this: when a hospital first decides to be accredited, it conducts a baseline assessment, which compares current services and processes against standards, to identify areas for improvement. Once it has made the necessary improvements, an on-site survey is carried out by the accreditation body. The process, depending on the accreditation body, can take anything up to two years.
Among the top accreditations available to healthcare institutions are Joint Commission International (JCI), Temos International GmbH (Temos) and Global Healthcare Accreditation (GHA) – see the headings below for more information on each accreditation body.
JCI accreditation – 'a symbol of prestige'
JCI is one of the best-known accreditation standards. “Healthcare organisations that achieve JCI accreditation undergo an exacting performance assessment and meet robust qualifications … The JCI Gold Seal of Approval, a symbol of prestige in the industry, demonstrates their commitment to quality and patient care in their facilities,” explained Joel A. Roos, Vice-President of International Accreditation, Quality Improvement, and Patient Safety at JCI.
JCI’s hospital accreditation survey covers all services offered and provided by hospitals and other healthcare organisations, including academic medical centres, laboratories, ambulatory care organisations, primary care centres, long-term care facilities, medical transport organisations, and providers of home care services. JCI standards vary based on each setting type.
Temos – 'bringing German standards of healthcare to the global market'
Temos was spun out of a German university project 10 years ago, which, according to Dr Claudia Mika, CEO of Temos, sought to bring the standards used in the German healthcare system to international healthcare. In addition, it filled the gaps where other accreditation schemes were missing; key pieces of information relevant to the international patient experience. Those included guarantees that English could be spoken by a doctor within 24-hours – for emergency services, or whether fit-to-fly certification could be available.
Dr Mika explains that organisations accredited by Temos generally go ‘way beyond’ the general criteria required for accreditation, as laid out by the organisation that accredits accreditation bodies, the International Society for Quality in Health Care (ISQua). Temos accreditation schemes include around 500 criteria, including those related to the United Nation’s Sustainable Development Goals – such as health worker gender pay parity – and ethics. Importantly, hospitals may not pick and choose which parts of its scheme can be accredited. “This is unique and this is what [a hospital] can do on top,” Dr Mika said. The organisation also differs, she said, in that it does not charge thousands of dollars in consultation fees to prepare hospitals for their assessment.
GHA – 'assessing the entire international patient experience'
Similarly, GHA differs from other international bodies in that it requires hospitals or clinics to have received clinical accreditation before they apply for its specialised medical travel accreditation, said Karen Timmons, CEO of GHA.
GHA claims to differentiate itself from other accreditation bodies by assessing the entire international patient experience. Timmons explains that this really starts from the point of inquiry to a destination and provider, pre-travel assessment, information sharing and planning, travel, hotel accommodations, admission, discharge, recovery and travel back home. “That means organisations need to measure and pay a lot of attention not only to good clinical outcomes, but also good patient experience and good business practices,” she explained. Accurate and transparent pricing and risk information on the website is just as important as how medical records are managed, she said. This means home physicians will be able to read medical reports in their primary language when the patient returns home.
“GHA conducts a deep dive into the medical travel programme of a hospital or clinic,” she explained. “GHA’s focus is on patient experience, sustainable business practices and patient-focused care management impacting the medical travel patient.” GHA accreditation usually take around three to six months to prepare, and GHA surveyors include a two-person team, one with a background in international healthcare, and the other a background in medical travel.
Different levels of accreditation available
ISQua, which, through its External Evaluation Association (IEEA), is the accreditor of accreditation bodies like these, (basing its evaluation on privately developed standards, covering the most important elements of hospital care and quality, from infection control to ambulatory care) said the fundamental concepts of accreditation have not changed over time, but how it is applied and operationalised continues to evolve. Indeed, there are far more specialised accreditation schemes. Bodies may accredit specific aspects of how the service is managed and delivered such as person-centred care and green hospital accreditation schemes. There is accreditation for disease-specific services too. Temos accredits specialist departments for oncology, as well as medical travel co-ordinators, for example.
Accreditation organisations may also offer different levels of accreditation – a pre-accreditation level for hospitals that are not ready to proceed with full accreditation, a gold or platinum accreditation award. Some range from Accreditation with Excellence, Accreditation, and Accreditation Pending to Accreditation not Achieved.
JCI said it does not have levels of accreditation, although once an organisation becomes accredited, it has an opportunity to achieve a Clinical Care Program Certification (CCPC), which endorses the accomplishments of a specific clinical programme, such as a stroke centre, within a hospital or academic medical centre.
Covid-19’s impact on accreditation practices
Inevitably, Covid-19 has meant considerable changes in accreditation. There has been a rapid and almost overnight move to remote or virtual consultations between patients and healthcare providers according to Elaine O’ Connor, Head of Operations with the ISQua External Evaluation Association. Some accrediting bodies are interviewing key hospital staff remotely via videoconference. “Many have also embraced technology and have provided tablets/iPads or action cameras (e.g. GoPros) to hospital staff to undertake live virtual walk-arounds to assess clinical and other areas of the hospital,” she added. The agencies that spoke to Hospitals & Healthcare said there has been positive feedback from this approach.
Importantly, agencies have developed Covid-19-specific accreditation schemes focused on minimising the transmission of Covid-19, preventing and breaking infection chains, maximising the efficiency of personal protective equipment (PPE) utilisation, preparing for potential staff shortages and preparing for increasing patient numbers, among others. GHA’s Certification of Conformance with Covid-19 Guidelines for Medical Travel Programmes and Temos’ Certificate of Compliance: Covid-19 Safe – Minimising the Risk of Transmission are prime examples.
Temos’ Covid-specific accreditation is based on 60 standards recommended by the World Health Organization (WHO) and the US Centers for Disease Control and Prevention (CDC). It gives patients and healthcare workers more confidence, said Temos’ Dr Mika. “We worked fast and published this in May. Some governments downloaded our standards, and now we see that some governments have used our standards as part of their own guidelines,” she said. For hospitals to earn certification, however, they must provide video and photographic evidence of specific recommendations, including a single entrance, a one-way system, the use of the correct masks and PPE. “These 60 standards fill the gap between the general accreditation scheme and the new needs of hospitals,” she added. Some have since been incorporated into Temos’ overall standards though, she said.
JCI, meanwhile, said it has not created new accreditation schemes related to Covid. “In following our standards, all JCI-accredited hospitals should be prepared to address the challenges brought about by any pandemic such as Covid, Ebola, etc. or any other emergency or disaster,” said JCI’s Roos. “However, JCI does recognise there are many important lessons to be learned in terms of Emergency Preparedness and Infection Control as a result of the Covid pandemic. The organisation is actively capturing that information, with its accredited organisations, and by incorporating this information in its accreditation survey process.
Indeed, JCI’s seventh edition of Hospital Accreditation Standards, which came into force on 1 January 2021, reflects what Roos believes is the most current thinking in patient safety practices and concepts. “It helps accredited and non-accredited organisations uncover their most pressing safety risks and advance their goals for continuous quality improvement,” he said.
Public versus private accreditation
Standards may vary by region. For its part, ISQua said primary differences relate to whether accreditation is mandatory or voluntary in a country and whether one or multiple agencies deliver the accreditation schemes. But while all hospitals might be accredited in a given country, different programmes may be in place for public versus private hospital accreditation. A public hospital may have to be accredited by the national accreditation agency, whereas a private hospital might be able to decide between the national accreditation agency or an international accreditation agency.
National organisations can apply to ISQua to become an accreditation body, using the same basic criteria used by international bodies. However, in some countries, one organisation will both develop the national standards and undertake the assessment of services. In others, the national standards may be developed by a national organisation, such as the Brazilian national accreditation body, Organização Nacional de Acreditação (ONA), or Ministry of Health. However, ONA outsources assessments to credentialed accreditation agencies, known as IAC – Instituição Acreditadora Credenciada/Credentialed Accreditation Institution – who then evaluate services.
the fundamental concepts of accreditation have not changed over time, but how it is applied and operationalised continues to evolve
The pivotal role of surveyors with regional knowledge
“Standards naturally need to reflect the local context and may focus on areas of concern or risk in the particular jurisdiction,” said O’Connor from ISQua. “Organisations who work internationally may use the one set of standards internationally but may have specific implementation guidance to guide hospitals or other health and social care providers and their surveyors to understand what compliance would look like in the context of the health or social care system in place in a specific country.”
The JCI Gold Seal of Approval and standards do not vary by region, but JCI’s Roos says its surveyors are trained on regional differences and take that into account when conducting surveys. “JCI surveyors speak 21 different languages and hail from six continents, which helps to tailor the experience for our clients,” he added.
GHA said its accreditation supports standardised international best practices based on the likes of WHO and the CDC for infection disease and patient safety best practices. But surveyors must be knowledgeable about certain other issues that vary from region to region. For example, in some cultures, it is more common for a patient’s family or spouse to provide consent for a procedure rather than the patient themselves. “GHA would acknowledge this practice and accept this form of consent,” said Timmons. And Temos’ Dr Mika said: “For some non-clinical standards, we can be flexible.” For example, there is a question asked of hospitals – do they provide patients and their families access to spiritual or religious respite in hospital? The answer might mean one thing in Catholic Latin America (a Bible in every room and access to a chapel). But elsewhere, it might mean the Q’uran and prayer rooms separated by gender. “The answer would be completely different in Jordan or in Thailand,” she added.
Avoiding malpractice in accreditation operations
One assistance company said that even when clinics and hospitals have high-level accreditation, it is still very careful about assessing doctors and their experience. That is because regional variety is one of the biggest issues it comes across, said Papapavlous of Healthwatch. “Some companies rely on local people to do the checks and prepare the evaluation process,” he said. “In some countries, we know that the people who are doing the evaluation on behalf of the accreditation company are people from the market, assistance companies, and even doctors.”
organisations need to measure and pay a lot of attention not only to good clinical outcomes, but also good patient experience and good business practices
International bodies say their surveyors are independent. “Furthermore, surveyors who conduct the accreditation survey cannot have any affiliation with the organisation they are surveying,” said JCI’s Roos. “JCI Surveyors are just that, they only focus on surveying the organisations against the JCI evidence-based standards.” Indeed, JCI has a strict ‘firewall’ policy between JCI consultants – who help hospitals get ready for their surveys – and JCI surveyors that prohibits any sharing of information, he said. He added that JCI accreditation does not require a baseline assessment be conducted by the JCI Advisory Services team to obtain a Joint Commission International Accreditation award, nor does it influence the granting of such awards.
Reputation isn’t based on accreditation alone
Assistance companies very often have good knowledge of the market and are well versed with the local hospitals and the reputations of doctors, including whether or not they have been accredited by national or international bodies. “So, accreditations give us part of the picture. Local knowledge is maybe the most important factor to direct patients to the most appropriate facility with or without accreditations,” Papapavlous said. “We know local ‘gossip’ about clinics, statistics on outcome of cases, doctors who work in this clinic.”
That said, accreditation is valued by patients, especially those interested in medical travel but do not know a country well. “Partnering with accredited hospitals is an add-on to our network reputation mainly as customers who look for these accreditations can find clinics and hospitals in the network,” he concluded.
Trust, then, is perhaps the most important commodity accreditation bodies help to provide. In the current climate, for the global healthcare marketplace, including insurance and assistance companies alike, choosing and maintaining the most trusted accreditation methods is increasingly demanded, as patients look for good-quality healthcare the world over. ■