It may surprise U.S. hospital executives, who grind their teeth at the thought of a visit by the Joint Commission on Accreditation of Healthcare Organizations, that a yen for independent accreditation is sweeping the globe.
The quality cachet is gaining currency in countries as diverse as Brazil, Finland, Germany, Saudi Arabia and South Africa. In the abstract, accreditation offers strategic applications that may not occur to Americans, who don't know of life without it. For instance, it can be used:
* To neutralize doctors who are blocking needed reforms.
* To embarrass the government, especially if it owns, operates and finances a country's dilapidated healthcare system.
* To recover a hospital's reputation and attract more patients, for instance, if the facility has filed for bankruptcy (See related story, this page).
* To persuade American tourists that they should pay up to four times more to use a private hospital instead of a government clinic.
* To improve quality, assuming a hospital knows how to define and measure it.
Something for everyone. In July, 250 healthcare experts-physicians, government officials, regulators, hospital executives and free-lance consultants from more than three dozen countries-gathered in Barcelona, Spain, for three days in a meeting convened by America's own Joint Commission, which is trying to extend its international reach.
The international healthcare community warmly applauded the leaders of the Joint Commission, which is often vilified at home. "I didn't meet anybody who hasn't been impressed by the conference," said attendee Rolf Hildebrand, a consultant in Berlin. "We are able to learn a lot from them."
In Spain, especially, the accreditation idea seems to be picking up steam. Carmen Aleranz Pardo, a pharmacist, is the quality-assurance expert at the Clinica Quirurgica Adria (Hadrian's Surgical Clinic) in Barcelona. The clinic's president sent her to the conference to learn about surgical outcomes measurement and investigate the possibility of accrediting her clinic. "I don't know if a small hospital with 20 beds is big enough to (be accredited)," she said.
Antonio Perez Rielo, chief executive officer of Hospital Costa del Sol in southern Spain, wanted "una cultura diferente in el hospital," and he wanted someone from outside to certify this. Self-evaluation wasn't credible; hospital leaders thought an organization that had been evaluating quality for 50 years was the place to go, so they called on the Joint Commission. The hospital was awarded its stripes at the conference.
Foreigners, too, came to Barcelona to see how they could apply accreditation to their own projects. Marcus Engelman, M.D., an American who's president of AmeriMED Hospitals, is looking into accreditation as a way to differentiate the hospital he is building in Mexico from the local government hospitals. The insurance companies don't see why they should pay his hospital $200 per day when they could pay $50 to the state clinic. He needs external proof that his hospital provides better-quality care.
Ross Duncan, an Australian who works at King Faisal Hospital in Saudi Arabia, said he believes accreditation is vitally important to health systems everywhere, including developing countries. "The key problem is teaching people the methodology to improve. Without this, most programs will fail," he said.
Josiane Vankerckhoven, director of nursing at the American Hospital of Paris, came to Barcelona with two colleagues. "The fact that there are so many hospitals represented means that there is a move. That is very clear." Her hospital attained Joint Commission accreditation two years ago.
Some other options. Although it has international momentum, the Joint Commission model is far from the only vision of quality improvement. Attendees heard about two quality programs-ISO 9000 and EFQM-which are not specific to healthcare and are firmly rooted in Europe.
ISO 9000, explained Paul Hardman of Underwriters Laboratories in the United Kingdom, was published in 1987 by the International Organization for Standards. A model for quality assurance in design, development, production, installation and servicing, it has been adopted by 250,000 organizations in the world. The big multinational companies have viewed ISO 9000 as a certificate of consistent quality control across national boundaries.
Although widely used in manufacturing, the model can be easily adapted to service industries. Hardman most recently read the ISO 9000 standards on the ceiling above his dentist's chair.
Four U.S. hospitals have been accredited under ISO 9000, and more are looking into it.
EFQM stands for the European Foundation for Quality Management. It dates from the late 1980s and represents a method of self-scoring for quality. It doesn't allow cross-comparisons. RENFE, the Spanish high-speed train system, won the EFQM award in 1998.
In addition, countries are creating their own models of healthcare-specific accreditation. Healthcare, unlike agricultural regulation and foreign-exchange markets, has not been "harmonized" in Europe, nor is it likely to be very soon.
In January of this year, the Netherlands Institute for Accreditation of Hospitals was launched. Like the Joint Commission, it is sponsored by the national hospital association and an organization of medical specialists. It will undertake its first two accreditations by year-end.
In France, the government has developed its own mandatory accreditation process, known as ANAES.
In Germany, the Bundesaertzekammer, the professional union of physicians, is creating a voluntary accreditation procedure for hospitals. Still in its infancy, the program is scheduled to be field-tested by Aug. 31, 2001, but even that is uncertain.
However the European countries choose to respond, all face the same problems. Their healthcare spending is increasing faster than the gross domestic product. Their populations are aging; technology is becoming more expensive; and patient expectations are rising. There are more doctors per capita to give people what they want but no more marks, pesetas or florins to pay for it.
These governments are trying to introduce more market-driven private initiatives into healthcare delivery in social welfare states that are suspicious of private enterprise in the public sphere. For those countries, it doesn't come naturally to separate quality oversight from the regulatory apparatus.
In Germany, said Christoph Straub, M.D., "People always say, `You must show that it's cost-effective first.' I say no. You are doing 80% of your work without knowing whether it's cost-effective. We have to start doing quality management and accreditation without first proving that they are cost-effective. We have to be given this chance."
Some benefits can't be measured in money, said Straub, a policy director at the German association of health insurers. "If you have something that proves to the public that you are doing quality care, this has value in itself." The German accreditation initiative, called KTQ, is going nowhere fast, Hildebrand said. "We are planning to invent the wheel once more. It's expensive, and we don't have the money. Therefore, it will take time."
The Germans could have modeled their accreditation on the U.S. version but chose not to. The Joint Commission has been contaminated by its involvement in what many Europeans regard as the socially immoral American healthcare system, Hildebrand said. Germans do not want to borrow from any delivery system that leaves so many millions of people uninsured.
The other reason is "pride," Straub said. "The German Medical Association wanted something developed in Germany. `We are smart enough to do it ourselves. We aren't going to buy it off the shelf.' " Quality programs won't fly without emotional buy-in from the locals and respect for domestic concerns.
Still, Straub added, the Germans are headed the wrong way down the Autobahn. Their fledgling program is based on departments-surgery, OB/GYN, ophthalmology-instead of crossing departmental boundaries. "To be honest, I'm promoting international exchange and harmonization with the Joint Commission. I believe it will take us 10 years, and we will be at the Joint Commission level."
American style. Adapting the Joint Commission's structural framework to the foreign institution does, in fact, improve quality, say those who've tried it, but it also changes the culture of the institution. The climate of the hospital will be de facto Americanized.
The American Hospital of Paris, for example, portrays itself in its marketing materials as a sort of QE2 among French hospitals, a place where the elite meet for tea and surgery. To publicly ratify its superior quality and special status, the hospital's board of governors decided to apply for Joint Commission accreditation in 1996.
"Historically, a strong hierarchy exists in French institutions; this was especially true at the American Hospital," wrote Daniel Richard, M.D., and Alexandra Wooster, leaders of the quality team at the hospital. "Departments and the administration were vertically structured and functioned almost independently. The concepts of multidisciplinary teamwork and interdepartmental communication barely existed."
To prepare for the survey, the hospital formed multidisciplinary-care teams. "People's habitual methods of working changed, communication between team members increased, and existing vertical barriers began to break down," they wrote.
In other words, it's now a little less French and a little more American.
At Albert Einstein Jewish Hospital in Sao Paolo, Brazil, the quality-improvement team tried several quality-improvement programs before deciding to pursue the Joint Commission model. The team set the accreditation process in motion only after conducting an inventory of potential cultural conflicts: "laws; regulations; religious and/or philosophical ideals; patient and physician expectations and attitudes; initiation of behaviors that required substantial deviation from comfortable norms or rituals."
Cynthia Shughrue, D.O., and Jairo Hidal, M.D., reported that Einstein must overcome many obstacles-physical, structural and mental-before it's prepared to receive any surveyors.
To that end, Joint Commission International, a consulting arm of the JCAHO, has created a principles and standards task force comprising 14 representatives from various countries. The task force is trying to make the standards culturally sensitive on issues such as patient rights by placing the standards in the history and context of the patient's life. The basic thrust has been to orient accreditation around the patient's experience of care, not around departments and structures.
Outside opinions. Yet a lingering question is, Why do some developed countries embrace this path so readily while others do not? "Accreditation is a nongovernmental function. That makes the government people nervous," replied William Jessee, M.D., who served as president of the International Society for Quality in Health Care from 1990 to 1991, when he was working for the Joint Commission.
Most healthcare in the West is government-operated, which creates a conflict of interest when governments start accrediting their own hospitals. Therefore health professionals see independent standards as a means to gain leverage in improving hospital quality.
"If I run the hospitals and provide the financing, I don't have incentives for quality performance," Jessee said. "External standards could show I'm not putting in enough resources" or setting high-enough internal quality goals, he said.
Among Europeans, the independent accreditation model seems to hold the strongest appeal in Spain, where the private Foundation of Avedis Donabedian has largely duplicated the Joint Commission's role.
The foundation has translated the Joint Commission's standards into Spanish. The standards are now in their third edition, and 3,000 copies have been sold or given away. "The standards have become something known in Spain," said Lluis Bohigas, the foundation's founder.
But why Spain and not some other European country? Representatives of the Joint Commission and other institutions were circumspect, but Bohigas came right to the point: "To improve quality, you have be very humble. You have to recognize there is a lot of room to improve." Without naming names, he continued: "Sometimes some countries or doctors or hospitals are not humble enough. They don't acknowledge that they are not very good."