Accreditation, standards of care: Necessary or nuisance?

Words like quality, accreditation and standards of care need to be part of the standard lexicon of any healthcare organisation worth its salt, writes Dr Arjun Kalyanpur.

Last month, our entire organisation gave a loud collective cheer (and simultaneously breathed a collective sigh of relief) as we reached a landmark in our evolution. We became India’s first JCAHO accredited healthcare organisation.

JCAHO (pronounced Jayco) the Joint Commission for Accreditation of Healthcare Organisations, is to healthcare what the ISO-9001 standard is for the IT industry. It is a global standard, established, as might be expected, by a US agency. I say this because to date, American medicine, despite its current travails, arguably represents the greatest healthcare delivery system that mankind has created for itself.

The journey to JCAHO accreditation was not only difficult but also stressful. We started the application process some nine months prior and at the outset were presented with the CAMAC, a forbidding 300-odd page manual that sets out in detail, the expectations or standards that the Joint Commission sets for those who aspire to meet them. We worked for months to define the policies and establish the practices that JCAHO recommends and to create the documentation that it requires as evidence of implementation of the same. We realised along the way that JCAHO is simultaneously a philosophy and a way of life for an organisation. The two JCAHO surveys several months apart, resulted in our being awarded the Gold seal of approval by the Joint Commission, a proud moment for us.

How does JCAHO establish quality in an organisation? Some of its key elements include performance improvement, management of the environment of care, organisational structure, leadership and management of information. The Joint Commission has set Patient Safety Goals for Universal Application, defined policies for infection control and disaster response/emergency management, among a myriad other concepts that translate into better healthcare management. In the hubbub and chaos that is the typical hospital, JCAHO sets a standard of practice that ensures optimal healthcare delivery to the patient. The JCAHO survey is therefore not a finite event but an ongoing process and philosophy. As the JCAHO website states: “Hospitals that participate in continuous accreditation efforts, monitor and improve their performance every day, not just in preparation for a survey. At any point in the accreditation cycle, these hospitals know if their performance efforts are working. Continuous improvement efforts help hospitals maintain the highest quality of patient care and services. In addition, hospitals can use their resources more wisely, avoiding the high cost of gearing up for a Joint Commission survey.”

The use of standards of care in medicine has been around for as long as medicine has been practiced, and has always been used to raise the quality of medical practice and improve the outcome of patient care. Among the first instances, in 1847, Dr Ignaz Semmelweiss, a physician in a Vienna hospital, discovered that fatal infections spread among patients by doctors who failed to wash their hands between examinations. Semmelweiss immediately instituted a disinfecting procedure whereby physicians were required to wash in a chloride of lime solution after autopsies and with soap and water between patient visits. Doctors also had to change into clean lab coats before examining patients. As a result of these measures, which today seem so obvious, hospital mortality rates from infectious diseases declined significantly. Similarly, Joseph Lister in 1867 recommended the use of disinfectant to reduce the incidence of wound infection in surgical wounds, which soon became the standard of care.

More contemporarily, the use of Board Certification Examinations, Medical licensure, Hospital credentialing boards, Continuing Medical Education Programmes are all a means to ensuring that the expectations and training standards which the medical fraternity sets for itself are consistently met and maintained.

Why the need for quality standards in the Indian healthcare industry? As with every other industry, and perhaps more than for any other, the need for uniform standards of practice is essential, fundamentally to protect the well being of the patient, which is at its very core, and to ensure that the contemporary standards of care are maintained.

Specifically in the Indian setting, the challenges that present themselves include:

An emphasis on quantity. By virtue of our population, our healthcare institutions tend to be swamped with numbers, and the quality of care tends to suffer. Also some centres tend to aim for larger numbers of patients in order to keep down the per capita cost of care. While a noble philosophy, this can sometimes translate into less than optimal conditions for healthcare.

A preoccupation with the feeling that “we are the best”, especially for high-tech institutions which invest heavily in the latest technologies, such overconfidence in the health care scenario is a recipe for disaster, given that every patient situation is unique. (The US is no exception to this phenomenon, as was recently tragically highlighted by an incident where a patient in an MRI scanner at a US hospital was killed by an oxygen cylinder that was sucked into the magnet’s bore).

Working on short fixes and lack of long term planning, this is exemplified by the imaging centre where the annual maintenance contract is not renewed, and temporising measures instituted that gives a short term solution rather than a more permanent one, resulting in repeated outages that cost more to fix in the long run.

A feeling that ‘quality costs money’, this is quite the opposite of the truth. As Edward Deming, the guru of quality, observed in the 60’s (although not directly in the healthcare context) an obsession with quality means that all other good things follow naturally. In the case of the healthcare organisation, quality translates into improved patient satisfaction, improved and more appropriate utilisation of services, lower costs and eventually a healthier population with a better quality of life.

However, especially with the growing interest in medical tourism, all this is rapidly changing and more Indian healthcare organisations are beginning to explore international standards organizations such as JCAHO or its International wing, JCI, in order to demonstrate to the western world that they meet their expectations of standard of care. Accreditation is therefore an important marketing strategy for the Indian healthcare industry today.

Apart from being a marketing tool, quality is really the key to optimal healthcare delivery today. It is also the key to competitive success, in the healthcare arena no less than in any other field of business. The hospital with better quality medical and nursing care, a better ambience and greater patient focus will certainly have superior occupancy than its peers.

To assess quality in the ongoing clinical practice setting is itself a challenge. Obviously, there is no single method that spans all specialties. For instance, in my field, diagnostic radiology, quality can be assessed in several ways:

1. Quality of the Radiographic Image as the specialty becomes more digital, this is of increasing importance, especially in low contrast situations such as mammography.
2. Quality of the report- This can be assessed by Accuracy of reporting – This refers to the comprehensiveness of the report in terms of describing all relevant abnormalities
3. Interpretive accuracy: This refers to the skill of being able to translate multiple findings into a composite clinical diagnosis
4. Timeliness of reporting – Equally important to ensure timely patient care
5. Quality of communication and accessibility of the radiologist – This does not necessarily mean physical presence as, with a well-run teleradiology service, the radiologist can be just as accessible from half a world away.

Besides JCAHO, other standards organisations exist as well. There are European standards such as the CEN/TC251. Canada has the CSA and the Indian Healthcare Federation is actively involved in developing a set of standards in accordance to the Indian conditions, which makes perfect sense for us.

It is however, no longer a matter of debate that today words like quality, accreditation and standards of care are, or need to be, part of the standard lexicon of any healthcare organisation that is worth its salt. The Indian IT industry has shown that it is capable of demonstrating the highest standards in the world, acquiring certifications such as SEI CMM, ISO 9001/9002 and Six Sigma along the way. Now it is up to the Indian healthcare industry to follow suit and prove its mettle on the world stage.

The writer is CEO, Teleradiology Solutions, Bangalore