Is accreditation a journey or a destination?

Dr J Sivakumaran

Customer satisfaction is the cornerstone of success in any industry. Business cannot function in an ivory tower and needs to constantly stay attuned to the pulse of the customer. The same analogy is true for every industry including healthcare. A satisfied patient will act as an ambassador for the hospital, propagating its goodwill in social circles and choose to visit the same hospital for future healthcare needs. A disgruntled patient on the other hand can mar the reputation of the hospital. Patients being customers in the healthcare space have become very conscious, selective and particular about their rights as a patient and are demanding quality healthcare. Due to technological advancements and heavy competition among the service providers, the patients have a wider choice to select from. Patients have become spoilt for choice given the plethora of options at their disposal. Dissatisfied patients find it easier and convenient to switch loyalties.

Quality of service could often be the sole differentiating factor between good and bad hospitals as far as patients are concerned. Presently, comparable facilities and infrastructure are available with competing hospitals but with a difference in service delivery, which discerning patients will never fail to notice. For providing better quality care many hospitals go for accreditation programmes. It is believed that hospitals with accreditation offer better quality services to patients. Accreditation brings standardisation of procedures, protocols, correct and timely documentation of events apart from safety of patients and improved medical outcomes. If hospitals follow the processes and pathways, clinical outcomes are bound to be better. The intent of accreditation is to set a minimum standard so that it could be assessed and evaluated. It will set the framework under which the organisational clinical and other processes are formulated. One important point to be noted here is that accreditation will not guarantee quality service delivery but only will enable the hospitals to follow protocols and systems to deliver service quality. The hospitals need to make sure that execution of laid down protocols are carried out. Accreditation leads to improved quality protocols which can stop adverse events like morbidity, patient falls or hospital acquired infections. Only if the processes and protocols are understood and implemented with true spirit, corrective actions and preventive measures could be initiated to thwart adverse events.

Accreditation is a voluntary exercise in India, in which trained external peer reviewers assess and evaluate the level of compliance of a hospital with pre-established performance standards. These standards are important elements in an accreditation system. These standards are for comparison and for measuring the degree of excellence. There are several accrediting agencies available for healthcare organisations. National Accreditation Board for Hospitals & Healthcare Providers (NABH) based in India, Joint Commission International (JCI) based in US, Trend accreditation scheme and The United Kingdom Accreditation Forum (UKAF) based in the UK, Australian Council for Healthcare Standards International (ACHSI) based in Australia, Canadian Council on Health Services Regulation (CCHSA) based in Canada are few of the renowned and reputed accrediting agencies. In India 191 hospitals have been accredited by NABH and 544 hospitals are in the pipe line for getting accreditation. While around 700 healthcare organisations were accredited by JCI worldwide covering 90 countries, in India there are 22 hospitals accredited by JCI. It is encouraging that more and more Indian hospitals are opting for accreditation for improving their processes and protocols. These accrediting organisations focus on optimal care with patient safety ranking among the foremost parameter. Accreditation sets certain standards to be followed by hospitals at all times and hospitals need to maintain those standards to remain accredited. These accrediting firms formulate systems driven processes which are independent of individuals or designations, so that every time an activity is carried out, uniformity could be maintained, irrespective of the service provider. There are few opportunities and challenges in opting for an accreditation in any hospital.

Opportunities: While preparing for accreditation, a lot of internal process overhauls take place. Hospital employees who have gone through the paces of an accreditation process often report a paradigm shift in their perception regarding certain quality control processes earlier viewed by them as redundant or frivolous. An accreditation exercise exposes the chinks in the existing processes and helps strengthen processes for better patient safety and outcomes. In a normal course, the fire fighting equipment in a non-accredited hospital would not be checked for its pressure level or functioning at frequent intervals, unless it’s usage is warranted. However, if it does not work at the time of need due to long storage, it may lead to disaster. An accreditation guide line stresses the need for such checking at frequent intervals with proper documentation. Blood spillage in a hospital ward is common. But if it is not properly neutralised, chances of nosocomial infections are high. Accreditation guide line insists on neutralisation, in case of blood spillage. These small protocols could save patients, service providers and the hospital. Similar guidelines for needle stick injury, hand washing practices, physician order system, medication error etc. are available in the guidelines and strict adherence to such compliances can thwart disastrous consequences. The awareness measures and prevention protocols followed for these sentinel events will be high in accredited hospitals than others. This is primarily because of the long hours of training spent on obtaining accreditation and retaining the same. The tracer methodology followed by accrediting agencies ensures that the patient files are documented and completed in all aspects. In the process of accreditation, all the bio-medical equipment right from weighing scale is re-calibrated and hence the patients get accurate readings. A complete credentialing of all medical and paramedical professionals involved in patient care is carried out revalidating aspects like their qualification and experience, to ensure that nothing is left to chance as far as patient safety is concerned. Accreditation ensures that patients’ rights are respected and protected. Accreditation fosters confidence within the patient-community and also provides a boost to marketing efforts as far as the medical tourism market is concerned. It prepares hospitals for any disaster or epidemic like events. An accreditation exercise warrants hospital staff to work in close co-ordination with one another where everyone works for a common purpose transcending individual and department level differences. Apart from fostering the spirit of team work, collective efforts result in overall synergy.

Challenges: While accreditation brings in a lot of accolades apart from pride and prestige, it cannot be denied that the work load of the staff including doctors increases. This is due to the stringent documentation requirements. On the flip side compliance is often at the cost of patient care. At times there is a trade off as regards the ideal time to be spent on patient care with the time spent in completing the file. Further, due to overemphasis on training, an upsurge in attrition rate is quite common. Many healthcare professionals view this exercise as bureaucratic, cumbersome and uneconomical. Substantial resources are expended on accreditation, making it unviable for many hospitals. Perhaps the time has come to analyse the cost of accreditation vis-a-vis its benefits as many healthcare professionals are voicing their concerns on this. In India, healthcare is already becoming unaffordable due to high costs at every stage of the value proposition and service delivery chain. If cost of accreditation is also added to the cost, the affordability is further reduced. Valuable time and resources are spent, whenever any standards are changed. Accreditation is only a tool and not a solution in itself. Recently a study conducted in overseas on 36777 patients at 73 hospitals concluded that there is no significant association between accreditation and patient satisfaction. As per this study, accreditation is not linked with better quality care (C.Sake and others, 2011). While it is prestigious to get accreditation, there is always a risk of a marred reputation, if accreditation is not renewed, or withdrawn due to issues. Withdrawal of accreditation can dent the reputation of a hospital significantly with a direct impact on its fortunes and sustainability. The expectation level of patients goes up in accredited hospitals as they start evaluating the standards of service vis-a-vis the service levels in a non-accredited hospital. Hence, healthcare professionals in accredited hospitals are always under pressure to ensure that the expectations of patients are met.

Accreditation is an on-going, dynamic quality improvement programme. The activities don’t stop, once certification is received. Accreditation brings along a responsibility of always maintaining the standards and safety which lead to the accreditation in the first place. Every survey is a litmus test for accredited hospitals and the pressure to maintain and improve the quality of service never ceases. Paradoxically, successful accreditation can mean reaching the destination as well as commencement of a new journey for the next round of accreditation.

Reference:
“Is there an association between hospital accreditation and patient satisfaction with hospital care?” A survey by C.SACK,A.SCHERAG, P.LU¨TKES,W.GU¨NTHER , K.-H. JO¨CKEL AND G. HOLTMANN.International Journal for Quality in Health Care 2011; Volume 23, Number 3: pp. 278–2.