Accreditation as a Tool for Quality Enhancement

Healthcare facilities and healthcare providers in emerging economies like Bangladesh operate with impunity. Besides some minimal licensing requirements, these facilities and providers operate largely unregulated. There are no benchmarks, no peer review and simply no accountability. The government licensing bureaus in most emerging countries do not have the resources or even the minimum education to monitor the quality of care.

This paper is intended to offer accreditation of healthcare facilities as an alternative and complement to the current licensing requirements.  The first part of the paper is intended to illustrate the distinction between licensing and accreditation followed by description of the principal features of accreditation and how the process of accreditation is put into practice. Finally a preliminary road map for Bangladesh and other emerging countries to follow is presented.

Accreditation and Licensing

Licensing serves as the minimum required standards dictated by a governmental agency in order to ensure public safety is not endangered. Without the proper licensure, an organization is not legally recognized in the United States. There are both state and federal requirements for licensure, and requirements can vary slightly depending on the state. Licenses must be renewed on an annual or biennial basis, and the facility must be prepared for unannounced survey visits.  “Facility licensing inspectors generally focus strictly on the organization’s compliance with the minimum regulation required, and unlike accreditation surveyors, do not see their role as one of consultation and education.”  As long as there are no safety hazards and the facility is compliant, licensing officials are satisfied.

(Rooney, Anne L. and Paul R. van Ostenberg, Quality. Quality Assurance Project, Center for Human Services. April 1999.) As a voluntary process, accreditation goes beyond basic licensing requirements and seeks to achieve the highest standards of safety, quality, and self-improvement. “Unlike licensure, accreditation focuses on continuous improvement strategies and achievement of optimal quality standards rather than adherence to minimal standards intended to assure public safety.” (Rooney, Anne L. and Paul R. van Ostenberg, (bid).  Due to the fact that every organization is required to be licensed, accreditation is a way of distinguishing a facility as being of a higher caliber. Through accreditation, organizations use self-assessment in addition to third party observance in order to achieve the highest standards. Not content with passing the bare minimum requirements, organizations challenge themselves to earn accreditation status.

Accreditation in Health Care

The history of accreditation in healthcare began in 1917 when the American College of Surgeons established a set of hospital standards to improve surgical safety. “This developed into a multidisciplinary program of standardization and led to the formation in 1951 of the independent Joint Commission on Hospital Accreditation, now the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), from which all subsequent national programs have been directly or indirectly derived.” (World Health Organization. Quality and accreditation in health care services: A global review. Geneva: WHO, 2003.) Quality of care in American hospitals rose as a result of the voluntary application of the accreditation standards. “The accomplishments of voluntary accreditation in improving conditions in services in the health care delivery system have been considerable, far-reaching, and lasting.” (Affeldt, John E. Voluntary Accreditation. Proceedings of the Academy of Political Science. 1980.) Accreditation has fostered a healthcare culture that continues to seek quality improvement; non-accredited institutions do not hold the same level of esteem as their accredited peers.

The most common accreditation organizations in healthcare today include The Joint Commission (Formerly the Joint Commission on Accreditation of Healthcare Organizations, JCAHO), Healthcare Facilities Accreditation Program (HFAP), National Committee on Quality Assurance (NCQA), Det Norske Vertas Healthcare, Inc. (DNV), and International Organization for Standardization (ISO). The Joint Commission is the largest accrediting body in the United States, with around 15,000 accredited healthcare organizations, including 5,000 hospitals. By comparison, HFAP has accredited around 200 hospitals. (NAMSS Industry & Government Relations Committee. The Big Three: A Side by Side Matrix Comparing Hospital Accrediting Agencies. Synergy. National Association Medical Staff Services. January/February 2009.) The Joint Commission remains the most well-known accreditation organization.

Accreditation has been embraced by the United States government. Medicare (Medicare is a United States government-run health insurance program for citizens aged 65 and older.) Conditions of Participation required by Centers for Medicare & Medicaid Services (CMS) (Centers for Medicare and Medicaid Services is a division of the United States Department of Health and Human Services) are federal requirements for all American hospitals. However, they can be fulfilled by approved accreditation organizations that have been designated by CMS as organizations that have “deemed” status. Because accreditation standards meet or exceed those required by CMS, a healthcare organization that has earned “deemed” status from an approved accreditation body is accepted as having fulfilled the Medicare Conditions of Participation. CMS retains the right to perform unannounced surveys and inspections of a healthcare facility. The acceptance of accreditation as a fulfillment of federal requirements validates these accreditation organizations and gives healthcare facilities more incentive to work towards accreditation.

Principle Features of Accreditation

Accreditation standards vary depending on the individual organization, but the basic process is similar. A healthcare organization must volunteer for the accreditation process, and must be prepared for an in-depth look at their policies, procedures, and practices. With hard work (and payment), a facility can attain accreditation status.

The process for obtaining Joint Commission Accreditation begins with an Application for Accreditation and the initial deposit fee.  The initial survey that Joint Commission performs must occur within six months of the submission of the application. Surveyors visit the healthcare facility and evaluate its day-to-day operations. On-site surveys are very important for accreditation, and for Joint Commission all surveyors are certified and employees of the organization. They are the only organization that requires certification of surveyors; for HFAP the surveyors are paid volunteers. The Joint Commission surveyors trace a patient through each step of their time at the healthcare organizations. Even if an organization has flawless policies and written procedures, the execution of the policies while the facility is running can reveal weaknesses.

Post-survey, the surveyors release an initial report and indicate the standards that need improvement or were not compliant. The organization must then send a plan of corrections, and afterwards The Joint Commission gives the final accreditation decision. Even if a healthcare organization earns the gold seal of Joint Commission approval, the process does not end there. Follow-up surveys, assessments, and proof of continued efforts to improve the facility are necessary to retain accreditation status. Updates to accreditation standards need to be noted and followed by the healthcare facility; above all, accreditation is not a static position but rather a dynamic process towards continued improvement.

On the Healthcare Facilities Accreditation Program website, they clearly outline the steps required for their accreditation: Application, Survey, Deficiency report, Plan of corrections, Accreditation action.  As already described in The Joint Commission example, the on-site survey is essential to accreditation. A healthcare facility can have deficiencies exposed during a survey, but a proper plan of correction can bring the facility up to the necessary level for accreditation. Hospitals are not expected to be perfect in an initial survey yet should be prepared for correcting any standards that they did not fulfill.

As third party organizations, accrediting bodies have the advantage of focusing solely on constant improvements on their process. Governments can get weighed down by bureaucracy, politics, funding, and other issues that make change a slow process. Accreditation organizations can devote their resources to constantly streamline processes and outline new goals, from infection control to patient safety and medication management. This will allow for medications like Modalert and Waklert to be more easily managed for narcolepsy patients. Updates to accreditation standards are common and The Joint Commission offers classes to encourage continued education on the most up-to-date standards and policies.

The United States is not the only country with accreditation in healthcare. “In 1999, Joint Commission International Accreditation, a subsidiary of the Joint Commission of Healthcare Organizations in the USA, developed and published a core set of international accreditation standards that can be adapted for use in an individual country.”  Joint Commission International has published International Essentials of Health Care Quality and Patient Safety that revolves around five Focus Areas: Leadership Process and Accountability, Competent and Capable Workforce, Safe Environment for Staff and Patients, Clinical Care of Patients, and Improvement of Quality and Safety  Each of the five Focus Areas has ten different criteria that the healthcare facility is measured on. For example, the first criterion for Clinical Care of Patients is correct patient identification. These essentials are not as thorough as their accreditation process, but are designed to aid health authorities around the world start with a solid framework for improving patient safety and quality care.  The full accreditation requires a more in-depth process with fourteen different Standards Chapters; starting with the essentials could serve as a stepping-stone towards fulfilling those standards.

The focus of the Joint Commission International Standards can be grouped under two broad categories: Patient-Centered Standards and Health Care Organization Management Standards. The former emphasizes:

The latter category incorporates:

As Joint Commission International summarizes, the benefits of accreditation are numerous and includes improving public trust, establishing a safe work environment, encouraging data collection to help negotiate with payers, increasing communication with patients, and promoting a culture that learns from reported safety and quality issues. Perhaps most importantly of all, organizations pursuing accreditation must emphasize collaborative leadership that understands that the patient experience and safety need to be the greatest priority.  These are all goals that healthcare facilities around the world should try to achieve.

Road Map for Emerging Countries, including less developed South Asian countries

While licensing is required for a healthcare provider to practice or a healthcare facility to operate, accreditation is a voluntary process in most developed countries. It is unlikely that the current healthcare providers and facilities will automatically or voluntarily embrace accreditation.  Therefore, the government initially has to have a role as a sponsor/organizer/facilitator of the accreditation body. As private healthcare insurance becomes common, the insurance companies could become a stakeholder in the process.

As a starting point, a task force consisting of physicians, hospital operators, senior executives from insurance companies and senior bureaucrats should be brought together ideally under the leadership of an international healthcare consultant with the specific charge of developing the standards and process of accreditation for healthcare facilities. This could be done expeditiously as the launching point could be the international standards of The Joint Commission. The task force should customize the process of implementation because each country has its unique characteristics and governance structure. There should be very little variation of quality standards because every emerging country should embrace the highest standards as the ultimate goal even though some intermediate benchmarks could be set as reachable interim goals.

The initial cost of the task force should be met by government and is likely to be supported by a variety of international agencies. The cost of implementation initially should also come from the same source but eventually all accreditation bodies are self-funded and self-sustaining. The budgetary needs of accreditation bodies are met through annual dues and special fees to cover the costs of the team which comes for onsite review. There is no reason why that formula would not work for emerging countries like Bangladesh.

What is the incentive for the current operators of healthcare facilities to embrace accreditation? Accreditation will help them to identify areas of improvement and improve quality. In addition accreditation bodies can provide benchmarks in areas of clinical quality and management efficiency. Accreditation bodies also provide continuing education and keep members abreast of latest developments in patient care and operational efficiency. The other incentive could come from insurance companies who may dictate that they will only pay for services provided at accredited facilities. Government could also save money by putting in the “deemed status” provision which will eliminate the need for separate licensure for fully accredited facilities. Finally if all the international standards of The Joint Commission are met, the healthcare facility operators can contract with foreign governments (as some Indian hospitals have done) to provide services with superior outcome and lower costs. Medical tourists could also potentially bring in hundreds of millions dollars as they do for Thailand, Singapore, and India.

Governments in emerging countries should be a facilitator in raising the standards of quality in all areas but particularly healthcare.  Accreditation provides a powerful policy tool which makes the healthcare providers accountable and potentially a “win win” situation for all parties — particularly patients. An accredited healthcare facility guarantees a certain level of quality care which evokes confidence on the part of the sick and their families all over the world.  This alone is reason enough to consider accreditation for healthcare facilities in Bangladesh and other emerging economies. ■

Dr. Faisal M. Rahman is the Founding Dean and Professor at the Graham School of Management of St. Xavier University, Chicago, Illinois, USA. Dr. Rahman is also CEO of the APAC group of healthcare companies.

Dr. Meghan Jankovich is the Research and Administrative Support Associate at APAC Partners, LLC.