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Righting the Scales

Will the modified guidelines of JCI benefit hospitals? Will it lead to the consolidation of JCI's fledgling market in India? Jayata Sharma finds out.

The Joint Commission International (JCI), the international arm of The Joint Commission, the US-based accreditation body, has modified its guidelines from January 1, 2007. The changes emphasise more on patient safety, a factor highly neglected in the Indian healthcare industry.

"Currently we are not looking at any specific target number of hospitals that must be JCI accredited" - Dr Paul vanOstenberg, Managing Director, Asia Pacific, JCI

JCI decided to include the patient safety guidelines based on the data they gathered while conducting studies on hospital functioning. "During an analysis of the causes of medical errors and the reason for hospitals making losses, we found the root cause is the system breakdown," says Dr Paul vanOstenberg, Managing Director, Asia Pacific, JCI. System breakdown includes factors like communication errors amongst hospital personnel, which can lead into a patient not being identified properly.

Here are some interesting statistics. The November 1999 report of the Institute of Medicine (IOM), USA, indicated that as many as 44,000 to 98,000 people die in hospitals each year as the result of medical errors. Even using the lower estimate, this would make medical errors the eighth leading cause of death in the country—higher than motor vehicle accidents (43,458), breast cancer (42,297), or AIDS (16,516).

Besides, medical errors carry a high financial cost. The IOM report estimates that medical errors cost the nation approximately $37.6 billion each year; and about $17 billion of those costs are associated with preventable errors.

"Patient safety is one area which cannot be taken lightly and hence we came out with the new mandatory guidelines. These guidelines only require behavioral changes, and are not at all capital-intensive," Dr vanOstenberg adds. The guidelines are soon expected to be made available in a printed format. Currently, they are available on the JCI website.

The new guidelines, called the International Patient Safety Goals, emphasise on identifying patients correctly, improving communication, safety of high alert medications, eliminating wrong-site, wrong patient, wrong procedure surgery, reducing the risk of hospital-acquired infections and reducing the risk of patient harm resulting from falls.

Meatier degree

The new addition in the guidelines will certainly increase patient safety manifold. "JCI has brought patient safety to the forefront, thus aiming for clinical risk management. The effect can only be positive, worldwide and in India," says Sheenu Jhawar, Director, ACE Vision Health Consultants (P) Ltd., Jaipur, which assists hospitals in acquiring JCI accreditation. The hospital will arrive on the global map, which will impact the branding and image of the hospitals.

The hospital set-up will have to be improved in order to follow the guidelines strictly, which will result in a more disciplined working environment. "However, most foreign patients under NHS will not look at India as a healthcare destination, as the JCI standards in our country are different from the US or other countries," opines Brig Joe Curian, CEO, SL Raheja Hospital, Mumbai.

However, India can be assured of attracting foreign patients who are outside the net of NHS, as they will find the treatment quality better and at low rates.

Also, insurance companies based abroad or handling foreign patients will be able to reap the benefits of these guidelines. The companies will prefer to divert their clients, who are paying low premium, to India. By doing this, the companies will also save on costs. Also, the rate at which insurance companies are growing in India, they might even come up with various insurance products which will be specific to JCI-accredited hospitals. "Risk management process of hospitals will get better and there will be a reduction in risk exposure," says Dr vanOstenberg. The adjoining results will be less patient falls and injuries, thus reducing the time of patients stay, and hence reduction in the hospital cost.

All these advancements will help in shaping up the organisation culture, which is one factor that will surely last for a longer time. In fact, experts opine that the modified guidelines will prove to be a good management tool, as both the hospital management and the clinical departments will have to work in sync, which will result in better joint approach.

"Our national accreditation bodies will now stress more on patient safety. The day will surely arrive when hospitals set up a department for patient safety," says Dr Lloyd Nazareth, Associate Vice President, Wockhardt Hospitals Group.

Apart from the organisation as a whole, individual doctors will also benefit, as their success rate of treatment, surgeries and operations will rise high. JCI will be able to measure the safety procedures of the hospitals better. "Moreover, we will get an additional tool for judging the hospitals' culture, its functioning and management," says Dr vanOstenberg.

Subsidy wars

"Some hospitals do not follow the guidelines all the time" - Ashit Dalal, Lead Auditor with TUV Healthcare Specialist, OH, USA

Some hospitals may think that additional guidelines will increase costs to the hospital, as they will have to implement new methods. "Surely, we cannot ignore the increased cost, but it will be only initially," avers Brig Curian.

Dr vanOstenberg informs that the JCI has left it to the hospitals to implement the changes. For instance, the first guideline which says always identify patients by two ways to avoid medical errors. Now, to follow this guideline, one hospital might introduce wristbands or bar codes, in which there will be cost involved. Other behavioral methods of identifying patients are if the patient is conscious then ask his/her name, or check the medical records. Also, some countries have a national ID number for their citizens, which can be made use of. "However, the room number of the patient cannot be used to identify the patient," informs Dr YP Bhatia, Managing Director, ASTRON Hospital & Healthcare Consultants Pvt Ltd, New Delhi, Member Advisory Committee, JCI and Chairman, Accreditation Committee, NABH.

Another drawback is that assessors from JCI visit the JCI accredited hospitals for periodical surveys once in three years. "In such a situation, some hospitals do not follow the guidelines all the time. They just brush up with the required guidelines just before the survey is due to happen," opines US-based Ashit Dalal, who is a Lead Auditor with TUV Healthcare Specialist, OH, USA.

JCI on homeground

The new guidelines will help in increasing the market base for JCI in India as hospitals, which are into medical tourism in a big way, are mostly inclined towards JCI. With the patient being well informed, they expect quality and safety from hospitals. Another reason for healthcare organisations opting for JCI is that the medical professionals are keen on working with associations which are JCI-accredited.

"This step is a good marketing tool from JCI's side, as the guidelines will benefit the hospitals and thus more hospitals will be inclined towards JCI," says Dr Kishore Murthy, Chief Operating Officer, Healthcare Global Enterprise Ltd., Bangalore.

"In the US, almost 50 per cent of the healthcare guidelines focus on patient safety. For India too, it should be a welcome change," says Dr Nazareth.

Currently, around 105 hospitals worldwide are JCI-accredited, of which six are in India, compared to four in China/Hong Kong, two in Taiwan, one in Thailand, one in Phillipines, as many as 11 in Singapore, and 13 in Turkey. Also, right now, there are five-six Indian hospitals lined up for JCI, and experts are positive that the number will surely increase.

"The way things are moving in the Indian healthcare industry, patient safety is on the front seat. Hence, JCI guidelines will surely be welcomed," says Dr Bhatia.

Also, as JCI is the closest to The Joint Commission but a bit toned down where guidelines are concerned, JCI's market is on a rise in India, feels Dalal.

India friendly

"The way things are moving in Indian healthcare industry, patient safety is on the front seat" - Dr YP Bhatia, Chairman, NABH, and also a JCI Assessor

So, how is JCI planning to capture the Indian healthcare market?

"India is a good healthcare investment destination, but currently we are not looking at any specific target number of hospitals that must be JCI accredited. But we are working at increasing our presence here," says Dr vanOstenberg. JCI recently established offices in Dubai and Singapore for easy access to Asian countries.

"In India, more money is being pumped into healthcare, and health insurance is being introduced in a big way. Healthcare NGO's are more organised, and common people have access to health information, which makes India a preferable destination," Dr vanOstenberg avers.

To increase its market presence, JCI is planning to collaborate with National Accreditation Board for Hospitals and Healthcare Providers (NABH). "The talks are in the primary stage," says Dr vanOstenberg, who was in New Delhi last month to have talks with NABH.

Meanwhile, JCI has started with awareness programmes too. End of last month saw educational workshops arranged by JCI at the national capital on the occasion of International Healthcare Quality Conclave conducted by Indian Healthcare Quality Forum in association with Quality Council of India (QCI) and JCI.

This collaboration is a good step for sharing ideas and working together towards common healthcare goals of quality in hospitals and patient safety. In addition, JCI is starting training for healthcare professionals from each region of each continent to become JCI consultants. The first batch of six JCI consultants were trained last month at the Dubai establishment of JCI.

When asked if JCI is planning to reduce its prices, Dr vanOstenberg quips, "In addition to regionally based consultants and evaluators, we have started radio-conferencing, launched e-learning books, introduced e-knowledge books, and most of the JCI information is on our website. Hence, professionals looking for any information do not have to purchase our written material but can access it from the Internet," says Dr vanOstenberg.

It will be sometime until the positive effects of new JCI guidelines actually start showing on the Indian healthcare industry as a whole. In the meantime, individual hospitals, which are JCI-accredited, will keep on reaping the benefits.

New Announcements

New Requirements for Tracer Methodology and International Patient Safety Goals: The Joint Commission International (JCI) Board of Directors has refined the hospital accreditation survey process for 2007 with the approval of six International Patient Safety Goals (ISPGs) and the use of tracer methodology—an evaluation method tracing a single patient's experiences within a healthcare organisation, in the organisation's on-site surveys. The IPSGs represent proactive strategies to reduce risk of medical error and reflect good practices proposed by leading patient safety experts. JCI introduced the IPSGs in 2006 and surveyors have been evaluating compliance with these goals during accreditation surveys in 2006, but these findings have not affected the accreditation decision. Beginning 1 January 2007, hospitals accredited by JCI are required to display compliance with the following ISPGs (in addition to JCI's 368 standards in 11 chapters): Goal: Identify patients correctly. Requirement 1: Use at least two (2) ways to identify a patient when giving medicines, blood or blood products; taking blood samples and other specimens for clinical testing, or providing any other treatments or procedures. The patient's room number cannot be used to identify the patient. Goal: Improve effective communication. Requirement 2: Implement a process/procedure for taking verbal or telephone orders, or for the reporting of critical test results that requires a verification 'read-back' of the complete order or test result by the person receiving the information. Note: Not all countries permit verbal or telephone orders. Goal: Improve the safety of high-alert medications. Requirement 3: Remove concentrated electrolytes (including, but not limited to, potassium chloride, potassium phosphate, sodium chloride >0.9%) from patient care units. Goal: Eliminate wrong-site, wrong-patient, wrong-procedure surgery. Requirement 4: Use a checklist, including a 'time-out' just before starting a surgical procedure, to ensure the correct patient, procedure and body part. Requirement 5: Develop a process or checklist to verify that all documents and equipment needed for surgery are on hand and correct and functioning properly before surgery begins. Requirement 6: Mark the precise site where the surgery will be performed. Use a clearly understood mark and involve the patient in doing this. Goal: Reduce the Risk of Healthcare-acquired Infections. Requirement 7: Comply with current published and generally accepted hand hygiene guidelines. Note: This should recognise that not all countries have a CDC (Centers for Disease Control and Prevention) or may not recognise the US CDC. Goal: Reduce the risk of patient harm resulting from falls. Requirement 8: Assess and periodically reassess each patient's risk for falling, including the potential risk associated with the patient's medication regimen, and take action to decrease or eliminate any identified risks. JCI has been testing tracer methodology as an enhanced patient-focused survey process during accreditation surveys in 2006. During accreditation surveys, the JCI surveyors will follow the experience of individual patients through the healthcare system, visiting multiple care units, departments, and/or areas to 'trace' the care, treatment, and services rendered to an individual. The JCI survey process will focus on validating compliance with the standards, evaluating that structures and processes are in place to sustain quality improvement and safety, and result in continuous quality improvement and better outcomes for the patients, organisation and staff. Source: JCI

jayata.sharma@expressindia.com