As the international medical travel sector expands and matures, accreditation – the internationally recognised evaluation and assessment by independent organisations of hospitals and other providers – has become an important tool for healthcare providers seeking to expand their services into international markets.
Accreditation has expanded rapidly since the 1980s. Its growth was initially driven in part by adverse media coverage of quality failings and an increased perception of the need to emphasise patient safety, and it has become a key part of the health provision strategy of more than 70 countries.

By providing independent constructive criticism, its proponents say, accreditation can in some cases be of value to a national public health service that seeks to improve its performance and the quality of healthcare it provides. Several European governments dabbled with the concept, but none except France – which subjects all public-sector and private health service providers to external review – has rolled it out at national level or made it mandatory.

The accreditation game

In part, this is because adopting state-operated accreditation is not a comfortable fit with most European health systems, which typically rely on state provision of hospital and other medical services, in partnership to a greater or lesser extent with private providers – unlike the US and many developing nations, where the private sector plays a much bigger role. “Government accreditation is somewhat of a contradiction in terms, since a third party is needed to guarantee independence. In addition, government accreditation tends toward regulation – that is, the traditional emphasis on aspirational standards gives way to an emphasis on compulsory minimum requirements,” note the authors of a report published in 2002, as the concept of international accreditation was beginning to gain traction.

So, on a global basis, accreditation is the province of non-governmental organisations like the US-based Joint Commission, a prime mover in rolling out accreditation to hospitals worldwide since launching its international wing, Joint Commission International (JCI), in 1999.

In turn, the major accreditation organisations are themselves accredited by the Dublin-based International Society for Quality in Healthcare (ISQua), which examines their organisation, standards and training, and is keen to emphasise that this provides end users with further assurance that their scrutiny of candidate hospitals is exacting and reliable. “Being accredited by ISQua means that we have been thoroughly evaluated against international standards. We have earned all three of ISQua’s accreditation awards – for our organisation, our standards, and our surveyor training programmes,” stated Accreditation Canada.

The gold standard

The non-profit JCI now conducts around 90 per cent of international accreditations and by its own estimation is considered the gold standard in global healthcare. In a rapidly expanding sector of the international healthcare industry, it rubs shoulders with a number of other accreditation organisations based in countries where private and public-sector hospitals are implicitly recognised as setting the standards that those elsewhere must meet in order to access international medical travel source markets. They include the Australian Council on Healthcare Standards, Accreditation Canada, and the UK's QHA-Trent, a successor to the Trent Accreditation Scheme.

Almost 700 hospitals in 90 countries worldwide have received JCI's seal of approval and more are being added at the rate of around 20 per cent annually. To an outsider, accreditation may seem like just another marketing tool, designed to boost an accredited hospital's reputation and inspire trust. However, accreditation organisations say its benefits are more extensive than that.

“Are standards necessary?” asks Dr Christine Dennis, CEO of the Australian Council on Healthcare Standards. “Clearly, yes. I wouldn't get on a plane unless there were standards and checklists. And I certainly would be very, very concerned if a hospital I, or someone I knew, was entering indicated they did not evaluate their performance against standards.”

The ACHS created its international offshoot, the Australian Council of Healthcare Standards International 2005. It began by signing up hospitals and clinics in Hong Kong (where it now lists 34 institutions), then expanded into Macau, China, Taiwan, Indonesia and Singapore. More recently, it has accredited hospitals in India and has moved into the Arab world, accrediting hospitals in Bahrain, Saudi Arabia, Oman, Qatar, and the UAE. It now lists a total of 81 institutions and continues to expand.

Accreditation, Dr Dennis says, provides an opportunity for health services to be reviewed by peers and to receive feedback on how they are performing against the standards. “We do not actively market, but rather respond to organisations that contact us because they have decided to seek accreditation. Their motive may be compliance with a directive from a funding body or regulator, or that the leadership team see value in having an independent perspective,” she stated.

Dr Dennis is firm that accreditation cannot be a one-time rubber stamp of approval, while at the same time, responsibility for standards must always remain with the hospital. “Accreditation should not assume a fixed or continuing status, as it is ongoing. The leadership around standards and patient safety needs to be part of the organisational culture. Accountability cannot be outsourced to an accreditation agency,” she said. Meanwhile, the proliferation of accreditation agencies “provides healthcare services with a choice and ensures providers deliver services based on the organisation’s needs.”

A growing market

Like Dr Dennis, Dr Paul Chang, JCI's vice president, accreditation, standards and measurement, maintains that the spread of accreditation by international organisations is driven by demand from the hospitals themselves. He points out that while accreditation and quality control at national level may meet the requirements of hospital users domestically, hospitals and other treatment providers that want to forge relationships with international users need a seal of approval that is quickly recognisable to potential clients such as health insurance companies.  

I wouldn't get on a plane unless there were standards and checklists. And I certainly would be very, very concerned if a hospital I, or someone I knew, was entering indicated they did not evaluate their performance against standards

He believes it’s not a question of national programmes being unable to provide adequate quality control but more of recognition. “National schemes need to cater to up to 100 per cent of their local market, so depending on how homogeneous your local market is that may not be something that can easily be met by a national system.” Some providers, Chang says, feel that their national system does not provide enough recognition outside their country. “We have had operators who tell us that they know that that they provide high standards and a high level of care but that they find it difficult to initiate a conversation, for example with major international insurers, without the higher level of credibility that certification by an organisation like JCI gives.”

Chang also concurs with Dr Dennis that a greater number of accreditors operating globally can be a positive influence. “What we have seen is that there are more operators that want to enter the international accreditation market. Some have looked at the success of JCI and hope to emulate that and we are perfectly fine with competition. The market is big enough to accommodate the current players or even more players,” he said. “I do think that having more providers is better than having fewer – with the caveat that that the providers coming into the market are not fly-by-night operations who see easy money but are sustainable and long term, not proving certification or accreditation too easily.”

An ongoing process

Liz Brownhill, chief operating officer of QHA-Trent, a UK-based for-profit accreditor, agrees that to be effective accreditation should be ongoing. She too says that the spread of international accreditation is driven by demand from hospitals. “The whole process briefly is that usually a hospital or clinic expresses interest in accreditation. Some want to attract medical tourists, others want to show [the domestic market] that they provide the highest level of care by being externally evaluated,” she stated. “All the hospitals have found that the way we have worked with them has been developmental and helpful. It is encouraging to the staff to see the praise the surveyors include in the reports and it gives them motivation. Accreditation also provides reassurance to government, the public and patients about the level of care.”

QHA Trent was launched in the UK in 1993 to meet a perceived need to monitor quality of care in smaller community hospitals in central England. Initially, it was an independent scheme under which hospital staff were trained to survey other hospitals against set standards. In 1999, the scheme expanded to include twelve private hospitals in Hong Kong. "It was clear that the method worked very well with large hospitals outside the UK," commented Brownhill. "Eventually all the work was overseas so in 2010, it was agreed it was no longer appropriate for it to continue within the [UK] National Health Service. Accordingly clinicians who had been surveyors established QHA-Trent as a commercial company. Full accreditation is for two years but recommendations are always given to enable the hospital to develop further. There are options for shorter times if there appears to be any risk to the organisation, staff or patients. The philosophy of developing organisations and people remains one of the crucial parts of QHA accreditation. Our standards are all based on UK guidelines, Royal Colleges advice and professional guidelines as well as international ones."

However, Brownhill points out, accreditation organisations should be sensitive, within limits, when dealing with different cultural expectations. “We do not impose ways of working,” she said.  “It is possible to meet the standards in the way which best suits the hospital or clinic. We can also amend the standards to meet local cultural practice where this does not impose a risk to the organisation. For example, in Hong Kong, care of new born babies is very different from that of UK and we took account of that and accommodated it in how we assessed them. The standards are rigorous.” 

Benefits aplenty

According to Accreditation Canada, another organisation that has added a growing number of hospitals in Asia, Latin America and the Caribbean, the Middle East and Europe, (where it is particularly strongly represented in Italy and Slovenia) the process of accreditation “demonstrates credibility and a commitment to quality and accountability,” ensures an acceptable level of quality and “improves an organisation's reputation among end-users and enhances their awareness and perception of quality care”.

Other benefits, according to Wendy Nicklin, Accreditation Canada's president and CEO, include providing a framework that improves and sustains operational effectiveness and advances positive health outcomes, better internal and external communication, stronger interdisciplinary team effectiveness, efficient and effective use of resources, enables on-going self-analysis of performance in relation to standards, provides healthcare organizations with a well-defined vision for sustainable quality, stimulates sustainable quality improvement efforts and increases healthcare organisations’ compliance with quality and safety standards.

So the case for hospital accreditation is convincing, and it is clear that hospitals worldwide perceive a need for it. Expect more institutions to acquire such credentials in future.