Due to the near-universal desire for safe, effective, and high quality healthcare, there is a growing interest in international healthcare accreditation.[1] Providing healthcare, especially of an adequate standard, is a complex and challenging process. Healthcare is a vital and pervasive issue; it influences all aspects of societies. It has medical, social, political, ethical, business, and financial ramifications. In any part of the world healthcare services can be provided either by the public sector or by the private sector, or by a combination of the two. Healthcare can be provided in hospitals or be accessed through practitioners working in the community, such as general medical practitioners and dental surgeons.
This occurs in most parts of the developed world— a setting in which people continue to express increasingly high expectations for the quality of care. This trend is especially strong in nations where socialised medical systems exist, primarily in the European Union.[2] The United States is a notable exception among developed Western countries in regard to its availability and affordability of healthcare. In 2007, 45.7 million US citizens (i.e. 15.3% of the national population) had no health insurance whatsoever[3] Despite this, in 2007 the USA spent nearly $2.3 trillion on healthcare, roughly 16% of the country's gross domestic product, and more than twice as much per capita as the OECD average.[4] Some US citizens unable to access adequate healthcare within the country are seeking healthcare internationally. This phenomenon is often referred to as "medical tourism", or "global healthcare".
Healthcare and hospital accreditation
Fundamentally healthcare and hospital accreditation is about improving how care is delivered to patients and the quality of the care they receive. Accreditation has been defined as "A self-assessment and external peer assessment process used by health care organisations to accurately assess their level of performance in relation to established standards and to implement ways to continuously improve"[5] Interest in hospital accreditation ascends as far as the World Health Organization (see external links). Accreditation is one important component in patient safety. However, there is limited and contested evidence supporting the effectiveness of accreditation programs.[6]
In the USA in the early 20th century, there was concern over how to best create an appropriate environment in which clinicians could work. Standards to improve the control of the hospital environment were thus generated, and these subsequently grew into accreditation schemes with the remit to facilitate and improve organisational development. Part of the process is not only about assessing quality, but also about promoting and improving quality. Similar accreditation schemes were soon developed elsewhere in the world.
In countries such as the United Kingdom, the United States, Australia, New Zealand and Canada, sophisticated accreditation groups have grown up to survey hospitals (and, in some cases, healthcare in the community). Furthermore, other accreditation groups have been set up with openly declared remits to look after just one particular area of healthcare, such as laboratory medicine or psychiatric services or sexual health.
Accreditation systems are structured so as to provide objective measures for the external evaluation of quality and quality management. Accreditation schemes should ideally focus primarily on the patient and their pathway through the healthcare system – this includes how they access care, how they are cared for after discharge from hospital, and the quality of the services provided for them. At the heart of these schemes is a list of standards which, ideally, serve to assess evaluate in a systematic and comprehensive way the standards of professional performance in a hospital. This includes not only hand-on patient care but also training and education of staff, credentials, clinical governance and audit, research activity, ethical standards etc. The standards can also be used internally by hospitals to develop and improve their quality standards and quality management. Some international accreditation schemes believe that the standards applied should be fixed and are non-negotiable, while others operate a system of negotiation over standards - however, whatever approach is taken the every aspect of the process should be evidence-based.
International standardization groups also exist, but it must be pointed out that the mere achieving of set standards is not the only factor involved in quality accreditation - there is also the significant matter of the incorporating into participating hospitals systems of self-examination, problem solving and self-improvement, and hence there is more to accreditation than following some sort of overall "standardization" process.
As governments and the general public have increasingly come to demand more and more openness about health care and its delivery, including and especially hospital quality and safety and the clinical performance of doctors, and these accreditation systems have generally adapted to fulfill this extended role.
However, accreditation should ideally be independent of governmental control, and accreditation groups should assess hospitals “holistically”, and not just some isolated facet of the hospital’s activities or services such as the laboratories, pharmacy services, infection control, financial health or information technology services (indeed, partial accreditation of this type should be publicly acknowledged as such by both the accreditation scheme and the hospital). The best accreditation schemes also assess academic and intellectual activity (such as teaching and research) within those hospitals that they survey (see later) and have a clear and declared interest in medical ethics.
In some parts of the world, accessing healthcare can be very expensive, even prohibitively so. While some countries have elected to provide comprehensive healthcare services for all of their populations, others appear to be satisfied with leaving portions of their population without access to healthcare. When it comes to who pays the bills for healthcare, it may be the government or it may be the individual (sometimes either by direct payment, and sometimes through employer-run schemes, insurance companies etc.), or a combination of both. However, healthcare can never be truly “free” – someone somewhere will always have to pay, and the payer will always want the best value for money possible. "Affordability" of healthcare can be the insurmountable hurdle for some people. Value for money is hence another factor in assessing the true quality of healthcare.
Other countries have looked towards accessing the services of the major international healthcare accreditation groups based in other countries to assess their healthcare services. There are many reasons for this, including cost, a desire to improve healthcare quality for one’s own citizens (good governance is at the basis of all high-quality healthcare), or a desire to market one’s healthcare services to “medical tourists”. Some hospitals pursue international healthcare accreditation as a de facto form of advertising.
In response to this marketing opportunity, some national accreditation groups have expanded internationally, and gone on to survey and accredit hospitals outside of their own national borders, providing "international healthcare accreditation".
This process of accreditation has been made increasingly complicated by the fact that in many parts of the world, people are choosing to cross international borders to access healthcare, a phenomenon known as “medical tourism” or "Global Healthcare". Medical tourism/Global Healthcare is key issue in international healthcare accreditation. It is becoming increasingly important as millions of (especially) Europeans and Americans seek healthcare overseas outside of their own countries for a variety of reasons, including and especially affordability. It represents a growing multibillion-euro/dollar/pound business of increasing importance to the economies of many countries, such as Singapore, Thailand, India, Hong Kong, Malaysia and the Philippines. The importance of medical tourism/Global Healthcare to the economy of developing countries is increasingly the subject of academic study. , and this synergy has a clear "knock-on" effect for those organizations based within the developed world who are seeking to develop the medical tourism/Global Healthcare market.
(c) patients wish to access treatments not available at home (e.g. stem cell therapy, termination of pregnancy, unlicensed medications, gender re-assignment surgery)
(d) patients wish for greater confidentiality than may be feasible at home (e.g. HIV/AIDS treatment, infertility treatment, gender re-assignment surgery, face lifts)
Other new challenges include new medical developments which are not universally accessible, the emergence of the so-called “superbugs” (e.g. MRSA, VRSA, VRE>Clostridium difficile, ESBL-producing E. coli), problems with the blood transfusion supply (e.g. Chaga's disease in the USA, HIV, HTLV-1 etc.), and the social imponderables such as war, political change and natural disasters. Any of these factors may lead to a loss of public confidence in healthcare services, and a desire to seek out healthcare overseas. The environmental and political situation will constantly vary throughout the world, and this will need to be factored into the equations.
The following quote, from the website of Partners Harvard Medical International, crystallizes the increasing relevance of international health care accreditation and its growing commercial importance, particularly in relation to medical tourism/global healthcare. "In competitive health care markets where patients have an increasing array of choices, quality is the most important differentiator for organizations striving for sustainability and both national and regional leadership. International accreditation has become a powerful indicator of a health care organization’s commitment to high-quality care and patient safety.[7]" Reflecting this, much of the discussion on medical tourism blog sites reflects the increasing importance of international healthcare and hospital accreditation to this industry Recent News and blogs | MedTripInfo
Consumers
How does an individual contemplating becoming a medical tourist ensure that the overseas healthcare they are planning to access is as safe as possible and is of adequate quality? For sure, it is not simply a matter of looking at hospital buildings and at mattresses, and it is certainly not just an issue of looking only at the prices charged. While architecturally pleasing rooms and easier access to satellite television and the internet may improve personal comfort, and a bargain basement price may help the wallet, what is often more important may include such issues as:
the standards of governance in the hospital or clinic
the healthcare providing establishment’s commitment to self-improvement, and to learn positively from errors
the overall medical ethical standards operating within the organization
the clinical staff’s ethical standards and their personal and collective commitment to caring for patients and the wider community
the quality of the clinical staff, including their background educational attainment and training, and evidence of continuing professional development by those staff
the quality and ethical standards of the management and their personal and collective commitment to caring for patients and the wider community
the clinical track record of the hospital or clinic
the infection control track record of the hospital or clinic
the hospital may be located in a country where the environment and climate may bring a patient into contact with infectious and/or tropical diseases that are unfamiliar to them
evidence of a robust, just and fair system to deal with complaints made by patients when things go wrong, as they inevitably will from time to time, and where appropriate to compensate the injured party in a fair and reasonable way
The above list is not exhaustive, but it represents a good start. Also, the intending medical tourist should check whether or not a hospital is wholly accredited by an international accreditation group, or if it is only partly accredited (e.g. for infection control), the latter being less inclined to create confidence in a potential consumer.
How does the person in the street access this type of quality information? This can be very difficult. Accreditation schemes well-recognised as providing services in the international healthcare accreditation field include:
Trent Accreditation Scheme (based in UK-Europe) The former Trent Scheme (which ended in 2010) was the first scheme to accredit a hospital in Asia, in Hong Kong in 2000
The different accreditation schemes vary in approach, quality, size, intent, sourcing of surveyors and the skill of their marketing. They also vary in terms of how much they charge hospitals and healthcare institutions for their services. They all have web sites.
Umbrella organizations
The International Society for Quality in Health Care (ISQua) is an umbrella organisation for such organisations providing international healthcare accreditation.[8] Its offices are based in the Republic of Ireland. ISQua is a small non-profit limited company with members in over 70 countries. ISQua works to provide services to guide health professionals, providers, researchers, agencies, policy makers and consumers, to achieve excellence in healthcare delivery to all people, and to continuously improve the quality and safety of care. ISQua does not actually survey or accredit hospitals or clinics itself.
The United Kingdom Accreditation Forum, or UKAF, is a UK-based umbrella organisation for organisations providing healthcare accreditation.[9] Its offices are based in London. Like ISQua, UKAF does not actually survey and accredit hospitals itself. India becomes 12th nation to join ISQua.
Accreditation services
If a hospital or clinic simply wishes to improve its services to patients wherever those patients come from (locally or from further afield), or wishes to attract medical tourists, how do they choose whom to go to when contemplating accessing external peer review by an accreditation group such as those listed above. No one healthcare system has a monopoly of excellence and no one provider country or scheme can claim to be the total arbiter of quality. The same is true of healthcare accreditation schemes.
For example, some countries, such as the USA, perform very poorly when it comes to providing anything close to universal access to healthcare of adequate quality to the population living within their own borders. Others, such as the United Kingdom and Australia, have created state-funded systems which provide everything without the assistance of the private sector.
Different holistic accreditation schemes are sourced out of different parts of the world, for example in hospitals there is (see map):
ACSA International out of Spain: partnership with IBES - Brazilian Healthcare Excellence Institute.
Joint Commission International (JCI) out of the USA[10]
Australian Council on Health Care Standards International in Australia[13]
No single international accreditation scheme enjoys exclusive rights to be seen as an overall worldwide-relevant scheme. Some hospitals seek multiple accreditations to increase their credibility in different parts of the world.
Locations of geographical bases of four of the world's leading international hospital accreditation schemes
Other fields of accreditation pertain to general medical practices ("GP" or Family Medicine) is some westernized countries. GP accreditation services, such as the Royal College of General Practitioners (RGCP)[14] in the United Kingdom, and Australian General Practice Accreditation Limited (AGPAL)[15] in Australia provide accreditation services for these practices. The cost of such accreditation varies enormously[16] and precise data are scarce; in the case of the Joint Commission International, JCI, costs can be substantial. Variance in cost is based on the country, size and operations of an organization.[17][18]
Health care, or healthcare, is the improvement of health via the prevention, diagnosis, treatment, amelioration or cure of disease, illness, injury, and other physical and mental impairments in people. Health care is delivered by health professionals and allied health fields. Medicine, dentistry, pharmacy, midwifery, nursing, optometry, audiology, psychology, occupational therapy, physical therapy, athletic training, and other health professions all constitute health care. The term includes work done in providing primary care, secondary care, tertiary care, and public health.
Medical tourism is the practice of traveling abroad to obtain medical treatment. In the past, this usually referred to those who traveled from less-developed countries to major medical centers in highly developed countries for treatment unavailable at home. However, in recent years it may equally refer to those from developed countries who travel to developing countries for lower-priced medical treatments. With differences between the medical agencies, such as the Food and Drug Administration (FDA) or the European Medicines Agency (EMA), etc., which decide whether a drug is approved in their country or region, or not, the motivation may be also for medical services unavailable or non-licensed in the home country.
Clinical governance is a systematic approach to maintaining and improving the quality of patient care within the National Health Service (NHS) and private sector health care. Clinical governance became important in health care after the Bristol heart scandal in 1995, during which an anaesthetist, Dr Stephen Bolsin, exposed the high mortality rate for paediatric cardiac surgery at the Bristol Royal Infirmary. It was originally elaborated within the United Kingdom National Health Service (NHS), and its most widely cited formal definition describes it as:
A framework through which NHS organisations are accountable for continually improving the quality of their services and safeguarding high standards of care by creating an environment in which excellence in clinical care will flourish.
The Joint Commission is a United States-based nonprofit tax-exempt 501(c) organization that accredits more than 22,000 US health care organizations and programs. The international branch accredits medical services from around the world.
Patient safety is a discipline that emphasizes safety in health care through the prevention, reduction, reporting and analysis of error and other types of unnecessary harm that often lead to adverse patient events. The frequency and magnitude of avoidable adverse events, often known as patient safety incidents, experienced by patients was not well known until the 1990s, when multiple countries reported significant numbers of patients harmed and killed by medical errors. Recognizing that healthcare errors impact 1 in every 10 patients around the world, the World Health Organization (WHO) calls patient safety an endemic concern. Indeed, patient safety has emerged as a distinct healthcare discipline supported by an immature yet developing scientific framework. There is a significant transdisciplinary body of theoretical and research literature that informs the science of patient safety with mobile health apps being a growing area of research.
A patient safety organization (PSO) is a group, institution, or association that improves medical care by reducing medical errors. Common functions of patient safety organizations are data collection, analysis, reporting, education, funding, and advocacy. A PSO differs from a Federally designed Patient Safety Organization (PSO), which provides health care providers in the U.S. privilege and confidentiality protections for efforts to improve patient safety and the quality of patient care delivery
Health information management (HIM) is information management applied to health and health care. It is the practice of analyzing and protecting digital and traditional medical information vital to providing quality patient care. With the widespread computerization of health records, traditional (paper-based) records are being replaced with electronic health records (EHRs). The tools of health informatics and health information technology are continually improving to bring greater efficiency to information management in the health care sector.
Bumrungrad International Hospital is a private hospital founded in 1980 in Bangkok, Thailand. More frequently referred to as Bumrungrad Hospital or simply Bumrungrad, its name, Bumrungrad means 'to care for the populace' or 'to nurture the people'.
The Trent Accreditation Scheme (TAS), now replaced de facto by a number of independent accreditation schemes, such as the QHA Trent Accreditation, was a British accreditation scheme formed with a mission to maintain and continually evaluate standards of quality, especially in health care delivery, through the surveying and accreditation of health care organisations, especially hospitals and clinics, both in the UK and elsewhere in the world.
Hospital accreditation has been defined as “A self-assessment and external peer assessment process used by health care organizations to accurately assess their level of performance in relation to established standards and to implement ways to continuously improve”. Critically, accreditation is not just about standard-setting: there are analytical, counseling and self-improvement dimensions to the process. There are parallel issues in evidence-based medicine, quality assurance and medical ethics, and the reduction of medical error is a key role of the accreditation process. Hospital accreditation is therefore one component in the maintenance of patient safety. However, there is limited and contested evidence supporting the effectiveness of accreditation programs.
National Accreditation Board for Hospitals & Healthcare Providers, abbreviated as NABH, is a constituent board of Quality Council of India (QCI), set up to establish and operate accreditation programme for healthcare organizations. Formed in 2005, it is the principal accreditation for hospitals in India.
Hamad Medical Corporation (HMC) is Qatar’s main not-for-profit health care provider, and is based in Doha. It was established by Emiri Decree No. 35 in 1979. HMC manages several hospitals, as well as emergency, specialized, and ambulatory care centers, and operates both the national ambulance service and a home healthcare service.
A medical tourism agent is an organisation or a company which seeks to bring together a prospective patient with a service provider, usually a hospital or a clinic. These organisations are generally facilitators and developers of medical tourism, which brings into play a number of issues that do not apply when a patient stays within their own country of origin.
Fee splitting is the practice of sharing fees with professional colleagues, such as physicians or lawyers, in return for being sent referrals.
Partners HealthCare International (PHI) provides advisory services and professional consulting to organizations outside the United States. PHI is a subsidiary of Partners HealthCare System, a non-profit health care system based in Boston, Massachusetts.
Bellevue Medical Center founded in July 2009, is a community hospital is located in Mansourieh, Lebanon. It offers healthcare services in many specialties. It has a capacity of 130 beds within its eight floors. Bellevue Medical Center is a Joint Commission International (JCI) accredited and Planetree Gold designated hospital.
Jordan University Hospital (JUH) (Arabic: مستشفى الجامعة الأردنية) is a teaching hospital located on the University of Jordan campus, Amman, Jordan.
Health care quality is a level of value provided by any health care resource, as determined by some measurement. As with quality in other fields, it is an assessment of whether something is good enough and whether it is suitable for its purpose. The goal of health care is to provide medical resources of high quality to all who need them; that is, to ensure good quality of life, cure illnesses when possible, to extend life expectancy, and so on. Researchers use a variety of quality measures to attempt to determine health care quality, including counts of a therapy's reduction or lessening of diseases identified by medical diagnosis, a decrease in the number of risk factors which people have following preventive care, or a survey of health indicators in a population who are accessing certain kinds of care.
The International Patient Safety Goals (IPSG) were developed in 2006 by the Joint Commission International (JCI). The goals were adapted from the JCAHO's National Patient Safety Goals.
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