Developing national accreditation systems: Needs, challenges & future directions

Jyoti Gupta and Dr Bidhan Das

Health systems currently operate within an environment of rapid social, economic and technological change. Such changes are expected to continue for the foreseeable future as a result of restructured economic and social policies, globalisation of markets and enhanced worldwide communication. New insurance mechanisms, restructuring and health reform initiatives, privatisation within the health sector, redistribution of human and other resources, reduced public funding, new technology, and many other factors may raise concern for the quality of healthcare. As a result of these health sector reforms, national health systems are coming under increasing scrutiny with a view to cost containment and quality improvement.

Accreditation can be the single most important approach for improving the quality of healthcare structures. In an accreditation system, institutional resources are evaluated periodically to ensure quality of services. Standards may be minimal, defining the bottom level or base, or more detailed and demanding. Accreditation standards are usually regarded as optimal and achievable, and are designed to encourage continuous improvement efforts within accredited organisations.

In all developed and developing countries, accreditation helps the hospital enhance patient care through continuous quality improvement process. It also strengthens community confidence by highlighting hospital’s commitment to provide safe and quality care to the community. An accreditation decision about a specific healthcare organisation is made following a periodic on-site evaluation by a team of peer reviewers, typically conducted every two to three years. Accreditation is often a voluntary process in which organisations choose to participate, rather than one required by law and regulation.

Hospitals are an integral part of health systems; by harmonising standards in hospitals in line with other institutions and levels of care, continuity of care is improved and the healthcare network strengthened. Hospital accreditation is gaining prominence due to globalisation efforts and especially trading in health services. Hospital accreditation is a system of ongoing consensus, rationalisation and hospital organisation. National ownership is crucial, both to lay the foundation and to maintain, from the beginning, a high degree of integrity and accountability of the national accreditation system.

While making use of accreditation as an incentive to improve capacity of national hospitals to provide quality care, countries need to work together to ensure that accreditation is protecting the national health system. Establishing national accreditation systems will help to ensure that hospitals, whether public or private, national or expatriate, play their expected roles in national health systems.

In most developing nations, private healthcare industry, though responsible for more than 80 per cent of healthcare delivery, is not very organised. There is no standardisation of processes and quality of delivery. Private healthcare players want to evolve accreditation norms that will enable them to compete globally and get a major share of the medical tourism market.

National accreditation ensures that accreditation systems are developed in a way that upholds the principles of health for all. Such strategies include encouraging national debate to reach consensus on accreditation, developing guidelines at country level and establishing an advisory group to guide countries in addressing accreditation issues. Specific goals of hospital accreditation are usually determined by the type of national health system and its policies.

The most important objectives include enhancing health systems, promoting continuous quality improvement, informing decision-making and ensuring accountability to national health policies. Country and culture-specific accreditation systems not only safeguard the country’s primary healthcare, but they also involve fewer costs and are better accepted as compared to external international accreditation systems.

A fundamental tenet of all approaches to health services quality evaluation and management is that every system and process in an organisation produces information that when collected and analysed, can lead to improvement in the system or process. Depending on the scope and philosophy of the individual accreditation programme, accreditation standards may take a “systems” approach that is organised around key patient and organisational unctions and processes, such as patient assessment, infection control, quality assurance, and information management.

There are specific features in any accreditation model which differ from other accreditation approaches and that are intended to help make the hospital accountable to the national health system. One of the areas of focus is to make an accreditation model that is comprehensive including promotive, preventive and curative standards wherever relevant. The model should entail a stepwise approach to accreditation, starting with a basic level, to be required for all hospitals, to a more sophisticated level.

A number of government, semi-private and private health institutions in the countries of the Mediterranean region are currently seeking recognised accreditation systems in order to cope with heightened demands for quality in health care service delivery. Many countries, including Jordan, Kuwait, Oman and Saudi Arabia, have established national committees to study requirements for accreditation; others, such as Egypt and Morocco, are piloting national accreditation programmes. The US, the UK, Japan and Thailand have accreditation programmes initiated and controlled by their respective health ministries.

Institutionalising improved quality of care through accreditation requires more than a technical approach. Sustained improvements often require a change in attitude and acquisition of a sense of ownership with regard to the quality of services provided by an organisation.

The challenges in setting and measuring against standards are mostly technical; the challenges in making appropriate change are social and managerial. Accreditation is not an end in itself, but rather a means to improve quality. When implemented appropriately, accreditation can strengthen the fundamental leadership and steering role of national health authorities.

Dr Bidhan Das is Director, Operations, Rockland Hospital and a member of Technical Committee, National accreditation Board for Hospitals and Healthcare Organisations, QCI. Jyoti Gupta is Head, Training, Communications and Corporate Affairs of the same hospital