Though the distinctions would be lost on the layperson, the Hospital General de Catalunya in suburban Barcelona, Spain, differs profoundly from the run-of-the-mill Spanish hospital.
Some of the differences are:
* Every patient signs a consent form before a procedure.
* Every employee wears a badge with his or her name on it.
* Every patient has an individualized care plan filed on a computer.
* If a controlled medication is not totally consumed, two nurses document that they have accounted for the remainder.
* Refrigeration temperatures for drugs are monitored closely.
* Oxygen tanks are secured to a wall.
"The Joint Commission (on Accreditation of Healthcare Organizations) has a standard that oxygen must be secured," explains Cynthia Shughrue, D.O., an American visiting the hospital. "If it falls over and the valve breaks off, it's like a bomb, a torpedo. It's a safety issue."
To hospital personnel in the U.S., these safety precautions are all standard stuff. But four years ago, when the Catalonians decided to try to make their hospital the best in Spain, every one of these practices was new to them. Their efforts paid off last year.
Indeed, what truly distinguishes this hospital is the little certificate hanging in the lobby next to the reception desk. It says that this hospital has been accredited by the JCAHO and the Foundation of Avedis Donabedian, a Spanish quality organization (Nov. 2, 1998, p. 38).
It was the first non-American hospital outside the U.S. or its worldwide military outposts to claim the Joint Commission's seal of approval. And this hospital wants the world to know it.
Never mind that it had to clean up 23 Type I recommendations it received at its first survey last year. Never mind that it cost a bundle. Never mind that preparing for the first survey took three years. Never mind that the standards had to be translated into Spanish, and even after that nobody could understand them.
The process, though difficult, was rewarding, if you ask hospital employees, 76% of whom say they are proud to have achieved accreditation.
The hospital's drive to become the quality leader in Europe began from bankruptcy and was accelerated by tragedy. The facility was founded in 1973 by public subscription. Some 77,000 Catalonians purchased shares, at least partly in the hope that a hospital of such excellence would demonstrate the superiority of their province to the rest of Spain.
The hospital opened its doors in 1983 as a private not-for-profit facility with 750 single rooms.
Yet the patients did not show up in the anticipated numbers. When the hospital was being planned, in the era of Generalissimo Francisco Franco, a quarter of Catalonia's population lacked access to healthcare. But a year before the hospital opened, the Socialists came to power and extended health insurance to everyone. The project's backers assumed its anticipated reputation for excellence would entice patients regardless of cost, which was considerably higher than the costs at public hospitals.
That proved to be a miscalculation. Hospital General lost money every year until 1992, when it entered the Spanish version of bankruptcy reorganization. It laid off personnel and raised more cash from its shareholders.
The hospital wrote a five-year strategic plan identifying specialties in which it could make money: cardiology, neurology and invasive procedures. It realized it could compete only on quality, not cost.
For that reason, Ignasi Arbusa, M.D., the medical director (who also has diplomas in hospital management and quality administration), looked into various seals of approval. The European Foundation for Quality Management offered a self-evaluation tool something like the Malcolm Baldrige award in the U.S., without a prize. But the EFQM offered no basis for comparison with other hospitals. The King's Fund healthcare quality organization in London sent a manual but could not provide the expertise Arbusa was seeking.
From tragedy comes progress. Then in 1994 a motor coach carrying Americans on a pilgrimage to nearby Montserrat overturned. Four died, and 20 were badly injured. Of those, 10 were brought to Hospital General, and the rest went to other hospitals.
When the U.S. consul saw the level of care being given, he ordered the rest of the Americans transferred to Hospital General. Through this experience, Arbusa learned a little about U.S. healthcare quality standards and decided that Joint Commission accreditation, the most widely recognized standard in the world, would attract more tourist business. He set in motion the plan that led to Joint Commission accreditation.
But things have not worked according to plan. The accreditation did not bring in more patients. But it did improve quality, Arbusa said.
Clearly, Hospital General's achievement has been noted. Two other healthcare organizations in Spain- Hospital Costa Del Sol, and Instituto Oftalmologico de Alicante, an ambulatory eye surgery center-attained accreditation last summer. And a team from Albert Einstein Hospital in Sao Paolo, Brazil, toured the Barcelona hospital in July, looking for tips on Joint Commission accreditation.
The Joint Commission has not been in the international accreditation business very long. Only in 1998 did the Board of Commissioners alter its charter to allow accreditation of hospitals outside the U.S. At that time it created Joint Commission Resources, a consulting arm, to advise foreign organizations about accrediting standards.
Arbusa said he doesn't know exactly how much the hospital spent to achieve the standards, but accreditation has not raised operating costs.
In accrediting these three organizations, the Joint Commission worked with the Foundation of Avedis Donabedian, an independent healthcare quality agency established by Lluis Bohigas and others to improve healthcare in Spain. Taking its cue from the Joint Commission, the Donabedian foundation has advised more than 100 Spanish healthcare operators about quality improvement and translated the Joint Commission's standards into Spanish.
A model of efficiency. Hospital General de Catalunya is its star pupil, not just because it ultimately won accreditation but because it is big, bold and ambitious. Hospital General is a tertiary institution with revenues of 6.2 billion pesetas a year, roughly $410 million, and has 630 employees.
The hospital handles 150,000 outpatient visits per year, 32,000 emergency visits and 10,500 surgeries. The average length of stay is 6.4 days. "This hospital is more efficient than the average Spanish hospital," Arbusa said.
But efficiency alone does not a business strategy make. The average Spanish hospital is operated by the government and doesn't have to recruit patients or worry about lengths of stay. Healthcare is considered a social good that doesn't have to meet financial performance standards. For that reason, Spain is thinking seriously about how to separate healthcare finance from delivery, expand patient choice and introduce more autonomy for providers and hospitals.
"We believe the introduction of accreditation will be a very good tool to improve quality directly," said an official from the Spanish health ministry.
But that doesn't mean the Joint Commission-Donabedian model of independent accreditation is universally endorsed. The government already has its own accreditation mechanism. Lluisa Lopez i Vinas, M.D., works for the regional health department and accredits 130 hospitals in Catalonia. At an accreditation conference in Barcelona, she was asked her opinion of the Donabedian project. She glanced at a colleague from the Basque region and said, "We'd rather hold our opinion."
In another context, Bohigas comments, "Public health officials know about this effort. It is not yet clear how they will respond."
Switching from a Spanish mode of thought to American-style quality assurance didn't come easily to the hospital. It took three years and a lot of sweat equity.
Hospital General formed a quality-assurance commission of 35 people to take the lead. Two subgroups-one composed of quality tutors, the second of quality promoters-maintained the momentum. Cross-departmental problem-solving groups were formed to propose and carry out solutions to major issues. Many fundamental processes for delivering care had to be changed.
Staff nurse Montserrat Comellas I. Oliva, for one, took a 15-day training course from the Joint Commission in October 1997 to become a "simulation surveyor." She and her teammates spent months surveying and interviewing staff members before the actual survey in July 1998.
Along the way, the hospital faced some serious obstacles:
* The manual was hard to comprehend.
* It was impossible to reconcile Spanish and Catalonian regulations for the physical plant with U.S. regulations. For instance, the building contains a lot of wood, which wouldn't be permitted in a U.S. hospital.
* There was no consideration of other important aspects of quality management, such as waiting lists and waiting times, and there were no absolute standards for measuring results.
By the time the surveyors came to look over the hospital, the staff was gripped by great curiosity. "A line of employees waited outside the conference room door during the concluding summary meeting with executives and surveyors," Arbusa recalls. When the surveyors let it be known informally that the hospital would be accredited, "a hysterical explosion of joy broke out in the hospital."