Accreditation is widely viewed as one of the most reliable tools for evaluating and enhancing healthcare quality. According to a landmark report published in 1999 by the Institute of Medicine, ‘quality assessment is one of the driving forces to establish performance improvement’. Since then, various approaches have been used around the world to regulate healthcare quality, with accreditation being the oldest and most common tool for this purpose.
Process of quality measurement
Hospital accreditation programmes are thriving, and are now viewed as an integral part of healthcare quality systems globally. The process of accreditation refers to an external ‘peer review’ by trained reviewers to evaluate compliance against pre-established performance standards.
Various governmental and non-governmental groups oversee the process, using different voluntary or mandatory approaches. Among the international healthcare accrediting groups are the Joint Commission International (JCI) developed by the US Joint Commission, Temos, Accreditation Canada, and Global Healthcare Accreditation (GHA).
Each is unique in their mission, activities, process and standards, hence certain accrediting organisations are better suited than others for specific areas. With the rise of self-pay patients seeking cross-border care, and insurers adding the ability to travel for treatment as a benefit in their policies, combined with the Covid-19 pandemic, international healthcare accreditation is more important than ever before.
Overall, there is a good body of evidence to show that accreditation programmes significantly improve quality of care and clinical outcomes for a wide spectrum of conditions. Evidence from several studies supports the positive impact accreditation programmes can have on different specific clinical outcomes, including the management of heart attack, trauma, surgical care, infection control and pain management.
Cost of accreditation
The cost for a hospital to go through the process of assessment for accreditation varies depending on many factors, including the number of beds and level of care provided, but may start at around GB£8,000 for a small clinic, rising to around £40,000.
One major organisation working to promote cooperation and communication in global health is the International Hospital Federation (IHF), based in Geneva, Switzerland. This ‘global voice of hospitals and health systems’ brings together a community of members that act together to assist healthcare services in improving their performance.
Joel Roos MD, Vice President International Accreditation, Quality Improvement, and Patient Safety at JCI, is also a member of the IHF Governing Council. He spoke to ITIJ about JCI’s activities and aims: “JCI has worked with well over 1,000 healthcare organisations around the globe, providing them insight and expertise into the safe delivery of high-quality healthcare. JCI’s goal is to improve the quality of care and patient safety while assisting healthcare organisations with public health concerns and challenges.”
Roos explained that JCI accreditation means that a healthcare provider can ensure they are offering a safe environment that reduces risks to both patients and caregivers, consistent clinical and operational processes across facilities, and an organisational commitment to continuous and sustained improvement. In addition, he points out that hospitals gain experience from assessors with knowledge of international standards and best practices.
A collaborative process
Accreditation is a key milestone in the establishment of new hospitals, so the JCI collaborates with all healthcare organisations, including those just beginning their quality and safety journey. Roos pointed out: “Accreditation provides healthcare organisations with an objective assessment of their practices and risk assessments while providing tools to drive continuous improvement.”
The path toward JCI accreditation ‘requires a foundational quality infrastructure, with skilled staff and resources that maintain standards of care, policies, and procedures to track performance’, he added.
There may be overlap between national or international accreditation standards and local standards, as national standards are often based on local country regulations. For example, US national standards are based on Centers for Medicare & Medicaid Services requirements.
Temos International Healthcare Accreditation
Another important international accrediting group is Temos International Healthcare Accreditation, established in 2010. With regional offices around the world, Germany-based Temos International serves providers and patients on six continents.
Temos publishes a directory of accredited hospitals on their website
Claudia Mika, Founder and CEO, explained the role of accreditation in attracting holidaymakers and international patients to healthcare facilities. She told ITIJ: “Emergency patients and their families might not have time to do their own research, they just need help, and in this case, they may ask for a nearby hospital at their hotel reception. But if they have more time, it is possible they can select hospitals based on third party accreditation. We know that they sometimes do research hospitals and select one depending how much the focus is on quality.” However, she added that for patients, it can be hard to differentiate between different accrediting organisations.
To assist patients, Temos publishes a directory of accredited hospitals on their website. It also has a partnership with The Diplomatic Council, an international diplomacy organisation that publishes the ‘Preferred Partner Hospitals’ directory, distributed to consulates and embassies in many countries.
“We have heard from hospitals that word of mouth is important,” Mika said. “Once a patient has a good experience they share the message by social media, family recommendations, etc. Then they have first-hand information from someone who’s had that experience. Patients also go back themselves for more treatment if they’re satisfied.”
Accreditation Canada (AC) is a not-for-proﬁt organisation dedicated to working with patients, healthcare organisations, policymakers, and the public to improve the quality of health and social services. Founded more than 60 years ago in Canada, AC has since worked in more than 35 countries and is accredited by ISQUA at all three levels (Standards, Organisation and Surveyor Training Program).
Qmentum International™, Accreditation Canada’s flagship accreditation programme, is designed to support healthcare organisations improve and maintain the quality and safety of their services. The programme uses evidence-informed standards developed by the Health Standards Organization (HSO), which provide requirements, criteria and guidelines to ensure that processes are designed to meet the highest achievable level of quality. With over 100 standards covering the entire health ecosystem, Qmentum International™ is a programme for all types of providers around the world, from acute care settings to home care. People-centred care criteria are weaved throughout all standards, so that each organisation is empowered to give patients the tools they need to take charge of their own health.
Organisations also get access to their client portal and dedicated support from Accreditation Canada’s experts throughout the cycle
At the beginning of the three-year accreditation cycle, applicable standards are selected for each organisation, based on the type of services provided. Organisations also get access to their client portal and dedicated support from Accreditation Canada’s experts throughout the cycle. After receiving in-depth knowledge on the accreditation process during the orientation sessions in the initial months of the programme, organisations begin working in multidisciplinary teams. Thanks to the self-assessment tool, each organisation is also able to engage all staff in the quality improvement process and identify priority areas in preparation for the survey. The actual accreditation survey, conducted as a peer-review, is planned in the middle of the cycle, which allows organisations to work on improvements and implement recommendations afterwards.
“Implementing an accreditation programme helps mitigate and decrease risks and improve patient outcomes, while also working on identifying any gaps in existing processes,” said Yuliya Shcherbina, European Development Lead at Accreditation Canada. “Organisations also demonstrate accountability and credibility to external stakeholders, foster an internal culture of quality and safety and improve collaboration among staff,” she added.
Working with assistance companies
A further valuable resource for insurers is a database maintained by the International Assistance Group (IAG) in collaboration with Temos. Under this agreement with IAG, Temos-accredited partners receive appropriate referrals from the IAG partner assistance companies for travellers who need medical care.
Mika noted that while some insurers check the hospitals in a country themselves, the thoroughness of the visits can vary. An insurer or assistance company representative may visit a facility, ‘but for two or three hours and only with one or two people, whereas Temos spends four days and up to four people for an inspection’. Commonly, the insurer’s experience with a hospital is in line with Temos’s assessment, so ‘they trust us and go to our website to check the database for the Temos reference letter’.
Some of the Temos accreditation standards were developed together with international assistance companies to assure that their needs regarding the management of international patients are met by the standards. This includes the processing and case management of international patients, as well as the billing and accounting departments, and respective contacts within the organisation, but also the language skills of hospital staff, as well as legal and ethical aspects of care provision.
Transparency and accountability in healthcare provision
Temos has recently launched a project in Egypt, a country with a national accredited body that accredits the local hospitals and clinics. The standards there are accredited by ISQua – The International Society for Quality in Health Care, as is Temos. “ISQua gives minimum standards, though more can be added,” Mika said. “We mapped Egypt’s accrediting standards, and found several gaps versus Temos standards. Working together with the national body, if a hospital wants to attract international patients, they also can get Temos accreditation, so they benefit from both.”
Accreditation is even more important for smaller hospitals, clinics, dental or IVF groups
Accreditation is even more important for smaller hospitals, clinics, dental or IVF groups, Mika believes, as they may not have clearly assigned staffing roles. “Accreditation forces you to clearly assign structures and accountability,” she explained. New clinics can start to prepare for accreditation as soon as they open, working with the existing standards.
Furthermore, standards are adjusted to the type of setting being assessed. “As an example,” Mika explained, “one Turkish dental clinic with 150 staff, as part of the preparation for a recent accreditation process, brought in a human resources manager. They knew from patient feedback that their patients were happy, but this doesn’t measure complications or other outcomes.”
Impact of Covid-19 on accreditation services
While some accrediting bodies moved to virtual assessment due to the Covid-19 pandemic, others chose not to use this method. Mika told ITIJ: “I decided not to do virtual assessments; we had an internal discussion and decided that on-site assessors are crucial. I don’t think you can have the same quality and in-depth assessment virtually. Virtual visits are not the same quality, in my personal opinion, supported by the team here. We found solutions with all our clients.”
Temos now has a separate certification programme only for Covid
The group had an eight-month break from March to December 2020 with no visits, then restarted, aiming to catch up with outstanding assessments. New standards have now been introduced, Mika said: “We were the first organisation worldwide who published Covid standards – we created 60 standards by May 2020 specifically on Covid and how to minimise transmission. These were published free of charge, available for download.”
Temos now has a separate certification programme only for Covid, and after an upcoming review, they will decide which of these should become part of the general medical standards to include in the future. These include telemedicine and crisis communication, such as how to report Covid cases to the government.
Hospitals have their say about the value of accreditation
Accreditation can be earned by many types of healthcare organisations including hospitals, academic medical centres, laboratories, primary care centres, long-term care facilities and providers of home care services. Standards vary based on each setting type, but every setting can benefit from accreditation regardless of size, as long as it meets the requirements.
Joseph DeLeon, President of Texas Health Harris Methodist Hospital, Fort Worth, says that gaining accreditation demonstrates his organisation’s commitment to quality and patient-centred care for the community they serve. He told ITIJ: “We are proud to have achieved the Advanced Comprehensive Stroke and the Neurotrauma certifications from The Joint Commission. Achieving these designations, considered the ‘gold seal’ in quality patient care, is a differentiator for Texas Health Fort Worth. We are very proud to be the first Neurotrauma program in the US and the first Advanced Comprehensive Stroke Center in Tarrant County certified by The Joint Commission.”
One of the largest healthcare organisations in the US state of Florida is Orlando Health. Thibaut van Marke, President of the Orlando Health Dr P. Phillips Hospital and Sr Vice President Orlando Health Southeast Region, explains why certification is so important: “Healthcare accreditation ensures that hospitals like ours meet the highest standards of quality and patient safety,” he told ITIJ. “Patients should rest assured that an accredited hospital goes through a rigorous process to ensure that all standards are met at all times.”
Van Marke explained that the accreditation process is rigorous, but he added it was not ‘burdensome’ – reassuring to healthcare providers that are wary of taking on the accreditation task.
Research studies indicate that hospital accreditation results in a consistently positive effect of on patient safety, process-related performance measures, efficiency and length of stay. Evidence highlights multiple benefits of compliance with accreditation standards. Many employment positions and even departments within healthcare systems exist as a direct consequence of accreditation compliance.
Together with other health policies, accreditation is widely recommended as a desirable process to establish and integrate high standards into everyday hospital activities.