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Accreditation of Hospitals: Assuring Quality Health Care for Medical Tourism in India
PJAEE, 17 (7) (2020)
7195
Accreditation of Hospitals: Assuring Quality Health Care for Medical Tourism in
India
Hari Krishnan P. K1, K. S. Chandrasekhar2
1 Research Scholar, Institute of Management in Kerala, University of Kerala, & Assistant
Professor, Kerala Institute of Tourism & Travel Studies, Thiruvananthapuram
2Professor and Head, Institute of Management in Kerala,University of Kerala,
Thiruvananthapuram
Email: 1 71pkhk@gmail.com, 2kscnair@gmail.com
Hari Krishnan P. K, K. S. Chandrasekhar: Accreditation of Hospitals: Assuring Quality
Health Care for Medical Tourism in India -- Palarch’s Journal Of Archaeology Of
Egypt/Egyptology 17(7). ISSN 1567-214x
Keywords: Evidence based practice, patient centric, quality index, Standard operating
procedures, risk mitigation, stamp of approval
ABSTRACT
“Quality of patient care” is a significant axiom in the emerging medical tourism industry
and has become an essential prerequisite to subsist in the challenging and competitive industry.
Quality of patient care incorporates everything the health care institution delivers, from how
institutions care for their patients, to how they ensure effective, efficient and equitable service
delivery and conform with occupational safety. Accreditation for health care organizations
denotes third party assessment of the degree of conformity of the institutions with respect to a
set of global bench mark set by international accreditors. As the quality of patient care in
hospitals cannot be experienced prior to the availing of their treatment, international patients
often select their overseas hospitals based on the accreditations. Though premium standards of
patient care and cost effectiveness of medical treatment are the key motivators of their travel to
emerging medical tourism destinations, accreditation of the chosen hospital is the most important
factor in medical treatment destination selection. Accreditation ensures that cost effective health
care does not mean inferior health care and provides informed patient choice on the hospitals
they prefer for their overseas treatment. Through this article, a study is done about the evolution
of international accreditation of patient care institutions (hospitals) and correlation of hospital
accreditation, quality heath care delivery and medical tourism in India.
Accreditation of Hospitals: Assuring Quality Health Care for Medical Tourism in India
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1. Introduction
Increased numbers of patients are indulging in cross border travel for availing
excellent health-care facilities, which are now available in developing
countries. Better connectivity and relaxed medical visa norms have made it
simple than earlier to traverse their home country’s boundaries and obtain
superior care at hospitals around the world. An improved transnational focus
on redefining patient treatment outcomes, safety and quality care of patients
and hospital staff have led stakeholders and healthcare provider establishments
to espouse standardized processes for evaluating healthcare organizations
based on Standard Operating Procedures (SoP’s) through an accreditation
process based on global standards. Accreditation elevates the confidence level
and trust of the patients regarding their selection of hospitals for overseas
health care since accreditation ensures that the member health care institutions
follows and renders quality services and assures best benefits for the patients.
Accreditation is a quality index, which guarantees that the health care
institutions not only pursue evidence-based practices (EBP) but also has
concern for access, cost effectiveness, efficacy, and unparalleled quality
healthcare. Accreditation bridge the gulf of patient expectation- service
mismatch or eliminates the grey extents of inadequacy and insufficiency and
eventually institutes best standards, flawless service, professional
accountability and clinical excellence. Accreditation signifies a voluntary
procedure whereby healthcare institutions comply with the standards
established by an external accrediting organization and ensures standardization,
which reduces associated risks and optimization of clinical eminence and
service care. In the realm of medical tourism, this accreditation is perceived as
an instrument to assure uncompromised care and patient wellbeing by the
health care institutions especially located in the emerging medical tourism
destinations. International and national accreditation on global standards focus
on the fundamental aspects of patient care to institute a protocol for the
endurance of care, with proper processes for the patient’s hospital discharge,
procedure for reference to other institutions, if needed, follow-up and transit of
cross border patients.
2. ACCREDITATION OF HEALTH CARE INSTITUTIONS
World Health Organization (WHO) observed that safety of patients is a matter
of grave global public health concern. As per the estimates of WHO there is a
one in a million chance of a person being injured while travelling by flight;
while there is a one in 300 chance of a patient being harmed during his health
care. As per WHO estimates, there are 421 million yearly hospitalizations in
the world and nearly 42.7 million adverse events happen in patients during
these hospitalizations. Moreover WHO has stated that based on the recent
data, patient harm is the 14 th important reason for morbidity and mortality
across the globe (WHO 2019). Health care services that are safe, patient centric
and of superior quality is a prerequisite for strengthening medical care systems
and they have observed that there is an urgent requirement for the
Accreditation of Hospitals: Assuring Quality Health Care for Medical Tourism in India
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standardization of treatment care and medical procedures across the globe. The
consequence of this procedure is bestowing a grade or score to a health service
organization, which signifies the degree of conformity to the set criteria
prescribed. Accreditation is an acknowledgement and endorsement by a
accreditor regarding the attainment of accreditation criteria by a hospital or
medical care organization, confirmed through a third party peer appraisal on
the level of performance of this institution undergoing accreditation against set
standards.
International Society for Quality in Health Care Inc (ISQua) describes
accreditation of Hospitals as “a self-assessment, independent peer assessment
practiced by health care organizations to precisely gauge their degree of
performance with set standards and to introduce and initiate avenues to
constantly increase the health or social care system” (ISQua). Accreditation
was defined by Scrivens (1995) as “a process used for the appraisal of the
quality of organization’s performance which is centered on a system of
independent third party peer appraisal using standards…an asse ssment of
compliance with standards is conducted by health service personnel, on behalf
of an independent body”. According to Zahir ( 2001) concerns for the quality
and safety of the patient care provided abroad has also developed due to the
dearth of well laid out of clinical governance measures and quality guarantee
measures in provider organizations, envisioned to reassure the quality of care
delivered to tourists”. Shaw, C. D. (2004) defined accreditation as a procedure
where “competent external peer assessors assess a health care organization’s
conformity with prescribed and defined performance criteria.” According to
Pomey et al., (2004) the accreditation process encompasses “ a self-assessment,
an institution visit and compilation of a report about the assessed institution
and then award international appreciation to the assessed institution”.
Unlike licensure which is a one-time process, accreditation emphasis on
constant upgrading strategies and attainment of ideal quality criteria, rather
than observance to nominal standards envisioned to guarantee public safety.
Accreditation of health care institutions is “an official procedure to ensure
offering of safe, premium health care built on standards and processes
formulated and designed by medical professionals for medical care services
which is a acknowledgement of achievement by a healthcare organization
fulfilling the requirements of national healthcare standards (ISQua).
3. NEED OF ACCREDITATION FOR HEALTH CARE
INSTITUTIONS
Patients who wish to avail overseas health care, give paramount priority to the
quality of health care offered by health care institutions there rather than the
cost effectiveness or less waiting time for treatments compared to their home
country. This quality care is the key differentiator in the selection of overseas
health care institution, as quality may significantly fluctuate from one medical
care centre to another and from country to country. Accreditation inspire the
execution of model healthcare administration systems and practices that cater
Accreditation of Hospitals: Assuring Quality Health Care for Medical Tourism in India
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to the enhancement of the service delivery and its resultant quality,
contributing to enhanced contentment and care for inpatients.
Accreditation signifies a voluntary procedure by which accredited health care
institutions comply with the standards established by an external accrediting
body, either international or national. This process of standardization ensured
through accreditation is a risk reducing and quality optimization stratagem and
can significantly escalate quality treatment and patient experience and result in
escalation in patient volume.
Of late, there is high influx of tourists who require medical care to emerging
medical tourism nations and accreditation will only be the sole differentiator in
selection of health care institution when medical tourism market will be more
competitive. In 2020 the international medical tourism market is valued at US
Dollars 54.4 billion and it is estimated to reach US Dollars 207. 9 billion by
2027, registering a CAGR of 21.1% growth (Grand View Research 2019).
Indian Medical Tourism market is also forecasted to grow significantly from its
present size of US Dollars 3 billion in 2015 to US Dollars 9 billion by the end
2020 (Ministry of Tourism).
The surge in medical tourism will make it imperative for health care
organizations to improve and distinguish their services with an evidenced-
based framework that comprises a thrust on enhanced patient experience,
superior healthcare outcomes and flawless follow up care.
4. HISTORY OF GLOBAL & NATIONAL ACCREDITATION OF
HEALTH CARE INSTITUTIONS
The initial concept of hospital accreditation dates back to 1860’s when
Florence Nightingale established a procedure for the collection and assessment
of hospital statistics which reinforced the assurance on the quality of
healthcare. The results of her study indicated that there is considerable
disparity of mortality rates from one hospital to another (Sheingold BH &
Hahn JA, 2014). Another pioneer in the concept of accreditation of health care
was Dr. Earnest Codman who in 1914 initiated 'end result system’, which
enabled health care institutions to track the patients whom they treated and to
get feedback whether their treatment had been effective. The Hospital
Standardization Programme proposed by the American College of Surgeons
(ACS) in 1919 received an awesome response from the medical fraternity
(Dastur, F. 2012). The document published by them titled “Standard of
Efficiency”, is considered an earliest prototype of hospital accreditation
standards. American College of Surgeons in 1924, published the hospital
standardization program and is the precursor of the concepts of quality and
safety (Roberts JS et.al 1987). In 1951, Joint Commission on Accreditation of
Hospitals (JCAH) was established and they retitled “Standard of Efficiency” as
“Hospital Accreditation Program” (Chuang S et al 2019).
Joint Commission on Accreditation of Hospitals (JCAH) was later renamed in
1987 into the Joint Commission on Accreditation of Healthcare Organizations
(JCAHO). The institutions accredited by JCAHO were considered as ideal for
treatment the patients as they assured quality care. In 2007, JCAHO was again
Accreditation of Hospitals: Assuring Quality Health Care for Medical Tourism in India
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renamed as Joint Commission and then to Joint Commission International
(JCI). Accreditation Canada, another accreditor, over the year, developed and
launched “Qmentum”, a novel accreditation programme in 2008 that harnessed
clinical appraisal tool with an organized assessment system (Tomasich, F et al
2020).
In India the accreditation of health care institutions dates back to 2005 with the
formation of National Accreditation Board for Hospitals, Healthcare (NABH)
to ensure quality and safety of health care services by pursuing evidence based
medical treatment, and to ensure processes and systems to guarantee patient
safety related aspects are in place (NABH).
5. INTERNATIONAL ACCREDITATION AGENCIES -
ACCREDITOR OF ACCREDITORS
The International Society for Quality in Health Care (ISQua) and the United
Kingdom Akkreditering Forum, (UKF) are the international accreditation
organizations regarded as "the accreditor of accreditors’. These organizations
endorses global accreditation organizations like Joint Commission International
(JCI), Australian Council on Healthcare Standards (ACHS), Accreditation
Canada, Trent Accreditation Scheme Malaysian Society for Quality in Health,
National Accreditation Board for Hospitals & Healthcare Providers (NABH)
and Central Board for Accreditation of Healthcare Institutions (CBAHI), Saudi
Arabia and other health care accreditation agencies. They ensure that
accreditation is not a one-time certification process but a continuous quality
enhancement program through the accrediting agencies. Both ISQua and
UKAF are international organizations, which assess the accreditation agencies
and develop benchmark in health care safety and patient care for hospitals and
other related patient care institutes.
5.1 The International Society for Quality in Health Care (ISQua)
ISQua is an independent global umbrella healthcare organization providing
accreditation to organizations. It is responsible for assessing and evaluating the
standards of international, national and regional assessing agencies to
constantly enhance quality and safe patient care, who in turn accredit hospitals
and other healthcare institutions. ISQua neither survey nor accredit individual
hospitals or clinics by themselves.
5.2 The United Kingdom Akkreditering Forum, (UKAF)
UK Akkreditering Forum Limited is an independent accreditation authority for
organizations who accredit healthcare. UK Akkreditering Forum Limited is
autonomous, impartial and a pioneer in the field of accreditation and similar to
ISQua, UKAF never survey nor accredit hospitals by themselves.
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6. ACCREDITATION OF HEALTH CARE INSTITUTIONS – AN
INDIAN CONTEXT
To position India as the most preferred medical tourism destination,
competitiveness of treatment cost may alone be not enough. As it is the quality
of care which is the key differentiator, we require more accredited hospitals to
further enhance in the global medical tourism arena. Higher the number of
global accredited hospitals a destination has, the better will be its standing in
the international medical tourism map. It assists in positioning India as the
provider of quality, standard and safe high-end medical care and augments the
confidence of global medical travellers about our safe and quality patient care.
6.1Joint Commission International (JCI)
Currently there are 958 health care institutions in the globe with have JCI
Accreditation, which is considered as the premium standard in global patient
care and benchmark of global standards on quality, patient confidence and
security. JCI is the major, oldest standards-setter and accreditation organization
in global health care. It assesses and appraises health care institutions to be
world class in delivering safe, efficient and effective patient care. The time line
for JCI accreditation is likely to take 12 to 24 months. This includes setting an
attainable time frame and communicate the significance of taking a steady,
comprehensive approach to accreditation. Organizations undergoing
accreditation have to conduct a baseline assessment, gauge the gap between
their performance and JCI standards, and refine their policies and procedures to
ensure compliance with JCI standards
Fig 1. JCI’s accreditation time line for hospitals
Source: JCI website
International patients, especially medical tourists, perceive JCI Accreditation as
the best ranking in international patient care and as a hallmark of global
standards on patient confidence and security. Medical insurance companies
across the world rate JCI accreditation as a mandate for its patient cover for
treatments abroad. Among the key medical tourist destinations located in Asia,
India has the second highest Joint Commission International accredited health
institutions.
Accreditation of Hospitals: Assuring Quality Health Care for Medical Tourism in India
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Table 1. Hospitals with JCI accreditation in the major Asian medical tourism
destinations
JCI Accredited hospitals in major Asian medical tourism
destinations
Sl.
No.
Medical tourism
Destination
No. of JCI accredited
hospitals
1
Thailand
60
2
India
35
3
Indonesia
30
4
Malaysia
16
5
South Korea
11
6
Singapore
4
8
Total JCI accredited
hospitals worldwide
958
Source : Compiled from Joint Commission International (JCI) website
6.2Australian Council on Healthcare Standards (ACHS)
ACHS is an independent, non-profit institution committed for augmenting
health care quality and is an approved accreditor to Australian and overseas
healthcare providers. ACHS is recognized by the International Society for
Quality in Health Care (ISQua) for their institutional structure, accreditation
procedures and assessor training. Currently 1450 health institutions are
globally accredited by ACHS
6.3 Temos International Healthcare Accreditation (TIHA)
Temos Quality Systems and Temos Quality Criteria, developed in 2006, were
intended to optimize international patient management in the healthcare
facilities across the globe. Their standards of quality are centered on broad
research and feedback from multiple sources which comprise of healthcare
institutions and global insurance companies. While adopting with accreditation
requirements and quality management for international and internal patients,
Temos “Excellence in Medical Tourism” accredited organizations are able to
cater to the demands of international patients.
6.4 National Accreditation Board for Hospitals and Healthcare Providers
(NABH)
National Accreditation Board for Hospitals and Healthcare Providers (NABH)
was established to launch and activate accreditation programme for Indian
healthcare institutions and it is a vital member of Quality Council of India
(QCI). It was set up with the purpose of strengthening health care system &
maintaining constant quality enhancement, patient care and safety of patients
against set standards. NABH provides necessary framework for assurance of
quality and improvement for healthcare institutions. These standards
necessitate continuous monitoring of sentinel events and suggest
comprehensive corrective action plan leading to quality consciousness across
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the areas of patient care. Presently there are 716 NABH accredited hospitals in
India (NABH 2020)
Fig 2: Approval process of health care institutions by NABH
Source : Current Medical Issues Journal, Christian Medial College , Vellore
7. ADVANTAGES OF ACCREDITATION IN MEDICAL TOURISM
In medical tourism, the concept of accreditation assures health care
organizations a testimony of independent third party quality assessment against
prescribed standards or healthcare criteria, which confirms that international
medical tourists are assured of consistent healthcare treatment practices
regardless of geographical location of the health care institution where they
avail treatment. Majority of medical tourists are risk-averse and accreditation
of the health care institutions is perceived as a risk mitigation factor in their
cross border treatment decision making.
The process of accreditation envisages surveys and reviews conducted by
trained professional peers who use various measures through which concerns,
if any, can be diagnosed prospectively, rectified and ensure incessant
enhancement. Based on the recommendations that arise from the survey,
accreditation process suggests follow-up action for the problems identified and
ensure continuous quality. The assessment process is repeated typically
between two to four years.
Accreditation envisions several advantages to the health care institutions and
to the medical tourists and few of them are highlighted below:
(a) accreditation persistently improves the quality of the patient care and
espouses modern treatment facilities based on the findings and endorsements of
the accreditation organizations
(b) minimizes the risks and inaccuracies related to the treatment and
recognizes gaps through appropriate monitoring at different stages
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(c) continuously promotes patient centric policies and standards to augment
paramount patient care and satisfaction
(d) provides a systematic approach towards the working environment of the
hospital involving clinical and support staff
(e) ensures that the patient care and service delivery are designed to deliver
better treatment results
(f) harnesses global standards of excellence in patient centric services to
augment the quality and effects of treatment for medical tourists
(g) guarantees the patient profile privacy and confidentiality of treatment
records and
(h) accreditation can also be used for marketing by health care institutions,
medical travel facilitators (MTF) and even by governments of the emerging
medical tourism destinations to lure the lucrative medical tourism business and
thereby increase international patient inflow.
8. CONCLUSION
Maximization of quality and minimization of associated risks are the twin key
constituents for building improved, safer and healthier health care facilities,
which could only be accomplished through the accreditation of health care
institutions, which necessitates suitable forms of organizational framework
designed to quantify the patient care quality, analyze and isolate risks, and
mitigate entire concomitant patient care concerns. Global medical tourists
perceive accreditation as an attestation of quality or “endorsement of
excellence” for ascertaining the genuineness and service excellence offered by
the health care institutions catering to medical tourism. Accreditation on global
standards ensures that health care institution ascertain rational, prudent
standards of practice. Accreditation does not imply that flaws will never ever
occur, but it minimizes the chance of occurrence of errors and promotes
willingness to learn continuously from them. Accreditation safeguards
international patients from the dearth of oversight and guidelines or
international laws associated with medical tourism industry, which could
otherwise surge the risks associated with overseas treatment.
Globally, accreditation has been perceived as a risk alleviating strategy, a tool
for performance judgement, an organization instrument for analyzing strengths
and domains for improvement and provides important stakeholders an
impartial, unprejudiced external assessment and review. Mounting ageing
population, rising treatment costs, increasing pressure for quality assurance and
long waiting time for availing treatment in international healthcare landscape
will make medical tourism a better option for its important stakeholder - the
patient - and accreditation ensures the patient, quality healthcare across the
world.
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