The desire to raise the performance of healthcare organizations isn't a phenomenon limited to the United States. It's going on all over the world.
When people in foreign countries want advice on how to introduce standards into their hospitals, many turn to the Joint Commission on Accreditation of Healthcare Organizations.
The U.S. agency has established an outreach division that's consulting and advising healthcare organizations in central Asia, eastern Europe, Japan Saudi Arabia, Spain and about 30 countries altogether. Even the United Kingdom, which has a variety of accreditation choices, has looked at JCAHO standards and modified them to suit the National Health Service.
K. Tina Donahue, president of Joint Commission International, a subsidiary of the Oakbrook Terrace, Illinois-based accrediting agency, says the JCAHO has had a finger in international activities, mainly education, since the 1970s. In 1990 it was approached by the U.S. Agency for International Development and asked to be prime contractor in a project in central and eastern Europe. At the same time, the U.S. Treasury Department invited the JCAHO to assess an accreditation system for Saudi Arabia's Ministry of Health. The Treasury Department had been acting as a liaison between U.S. vendors and the Saudis.
"Over the years, more on an unsolicited basis, we began to receive increasing numbers of requests for all kinds of assistance," Donahue says. "The Joint Commission is known worldwide as the quality steward in the U.S."
Tina Cleland, USAID's director for healthcare reform activities in central and eastern Europe and the former Soviet bloc countries, says there's a lot of interest in "getting the U.S. healthcare industry to go global. Until things stabilize in the health sectors, there isn't much interest by U.S. investors in going over there."
The issues in healthcare are the same the world over: patient access, equity, cost containment, quality and choice. USAID is trying to link financing to improvements in delivery. Accreditation is the lever: no accreditation, no reimbursement.
USAID tested the water in the former Soviet bloc. The Czech Republic, Hungary, Poland and Romania signed up. The agency also found interest in Kazakhstan, Kyrgyzstan, Russia and Ukraine. Of those, Kyrgyzstan has advanced the furthest and now has a fully functional accreditation system, operated through the government, Cleland says.
Paul VanOstenberg, the Joint Commission's director of standards, has journeyed to Hungary twice this year. Because Hungary doesn't have as much money or technology, "we had to adapt (standards) to best practices for Hungary, not necessarily best practices for the U.S.," VanOstenberg says. "We wanted the standards to stretch them a little bit but not make them unreachable."
Take, for example, infection control. Hungarians lacked supplies such as dispensable gloves and needle disposal systems. "So we tried to bring out the essence of the standard: to dispose of safely the contaminated product and reduce the risk of spreading infection. Then (local) surveyors would advise us on what were standard practices in Hungary at that time," VanOstenberg says.
He was astonished at how quickly the participating training hospitals adapted to the idea of meeting standards. Without prompting, they divided up the work and created teams to address specific aspects of the accreditation survey, just as a U.S. hospital would.
From Barcelona, the Avedis Donabedian Foundation has embarked on an independent accrediting system for Spain. The foundation, named for a pioneering U.S. physician who recently won the Joint Commission's Ernest A. Codman Award recognizing excellence in the use of outcomes measurement (Oct. 27, p. 30), is trying to instill quality concepts into Spanish healthcare.
After several quality-improvement initiatives for healthcare professionals, the Donabedian foundation decided to import a fully developed accreditation system and adapt it. It looked at programs in Australia, Britain and Canada before settling on the JCAHO.
"It was the oldest one and had credibility among healthcare professionals," says Lluis Bohigas, the foundation's director. Also, the Joint Commission's functional standards were preferable to structural standards, which were less adaptable.
And third, "they have developed a very formalized process," Bohigas says. "It is written down. It is easy to transfer, to copy. The others were less standardized, more dependent on the type of surveyors."
At first the foundation wanted Joint Commission International to come to Spain and accredit hospitals on contract. But they were told the JCAHO's bylaws forbid it to accredit non-U.S. hospitals. Instead, the foundation is adapting Joint Commission standards to Spain.
Bohigas created a regional accreditation program in Catalonia in 1981, but it hasn't evolved much since then and is now "a bit obsolete," he reports. "It is based on minimum standards. Minimum standards do not promote quality. They are just a type of licensure. It looks like an inspector model.
"We wanted an accreditation that promoted quality, that was an incentive for the hospitals. Not something easy-something difficult. The level of the Joint Commission is higher than our hospitals. They have to make an effort," Bohigas says.
Two Spanish hospitals participated in a trial. The full program will start next year.
Bohigas thinks an international accreditation standard is critically important for Europe as it tries to increase the exchange of patients and professionals among countries.
"Our project of not to organize our own system but try to adapt the system from another country, I think, is a good step in this process," he says.