Library, Jawaharlal Nehru University, New DelhiHealth services in many developed countries have come under severe scrutiny in recent years. Positioned against the backdrop of globalisation, there is an intense move towards accreditation of health services. Accreditation of hospitals is a voluntary process by which an authorised agency or organisation evaluates and recognises health services according to a set of standards describing the structures and processes that contribute to desirable patient outcomes.
Accreditation can be understood as an indicator of professional achievement and quality of care. Accreditation is opposed to licensing or regulation of healthcare facilities, which is usually mandatory and state-imposed. Central to accreditation are two features: the principle of external review and the use of standards.
Accreditation is not new to the health system. The first initiative towards accreditation was taken in the United States of America as early as 1910. Over a period of time after several experiments, the Joint Commission on Accreditation of Healthcare Organisation (JCAHO), a national accreditation programme, established itself as an esteemed accreditation body by 1987. JCAHO has high standards of quality assurance and rigorous process of evaluation, which makes it a much-esteemed agency for accreditation. Health services certified by JCAHO are given ‘deemed status’.
Models of AccreditationAn accreditation body has to have a restrictive relation with the State to be effective in regulating the health system
Accreditation across the globe followed three models. The first model of assessment gives priority to standards related to available facility norms, equipment requirements, human resources and space specifications. Here, the criterion of accreditation is based on the availability of basic health facilities.
The second gives importance to quality assurance and sets standards for those institutions striving to arrive or improve quality of care, hence accreditation is based on satisfying some basic indicators of quality and involves anking based on levels of quality.
The third model is based on the ground that health systems should be accessible and acceptable to health-seekers. It gives importance to the health-seeker with an emphasis on evaluating health systems from indicators such as user-friendliness, providing information to users about the services available, setting up procedures for redressing grievances, etc. In the third model, the criterion of assessment is explicitly geared towards people-centric indicators and brings accountability of the health system to the health-seekers to the table. With each model, the criteria of accreditation changes.
The accreditation process should begin with minimum or moderate level standards and, over a period of time expand to higher, “ideal” level standards and should be achievable by local public health agencies regardless of size provided that they conduct the essential services of public health.
State and local accreditation programs should coordinate with and conform in essential ways to a national accreditation program to eliminate possible duplication and conflict. To succeed in bringing about a perceptible change in the delivery services of the health system and to go beyond mere an on-site survey and awarding certificates, any accreditation programme should address all the dimensions of healthcare.
The onset of accreditation in different countriesCanadaAccreditation has had different paths and patterns of growth in different parts of the globe. In Canada, the move towards accreditation started in 1952 with the initiative from the medical profession. Presently, the Canadian Commission on Hospital Accreditation is the sole agency to accredit hospitals and enjoys complete monopoly.
AustraliaIn Australia, accreditation was introduced in 1926, with the state initiative but it was only in the early seventies that the Australian Council on Hospital Standards was set up. Though the accreditation programme has not received a very extensive coverage, it assures interested groups that health professionals consider it a responsibility to monitor their standards of performance. It has with other medical colleges, developed a set of clinical outcome indicators for accreditation.
United KingdomIn United Kingdom, there have been multiple attempts to devise and measure standards. As a result, there are many accreditation systems like the King’s Fund Organisational Audit, the Hospital Accreditation Programme, Trent Community Hospital, South Western Health Records, etc. The regional health authorities have supported some of them. Among them, The King’s Fund Organisational Audit Programme and the Hospital Accreditation Programme are significant.
ChinaDevelopment of accreditation system in China, has received the Ministry of Public Health’s support since inception in developing standards of regulation in four areas of treatment, namely, prevention, healthcare reconstruction, support and participation in disease prevention and care and healthcare activities.
Latin America and Caribbean CountriesAccreditation in Latin American and the Caribbean countries have begun in the early nineties with the release of certain set of hospital standards by the Pan American Health Organisation and the Latin American Federation of Hospitals. The ministry of health of Argentina and the Argentina Society of Medical Auditing prepared the original draft of the same with inputs from other experts.
The standards have two dimensions: compulsory minimum standards and the non-compulsory standards. Compulsory minimum standards have five areas of evaluation namely the organisation of medical care, technical and support areas, building documentation, functional physical structure and installations.
Non-compulsory standards include such things as critical care, neo-natology, nuclear medicine, etc. There are levels of standards, which have to be satisfied to attain highest grade. But the first level of standard has to be met for minimum accreditation status.
IndiaIn India, accreditation of the health services has never been a serious issue though some feeble attempts have been made to evolve a voluntary accreditation system in the late eighties and early nineties interestingly coinciding with the LPG (Liberalisation, Privatisation, and Globalisation) reforms. The attempts made by the Indian Hospital Association (IHA) at both Mumbai and Delhi is worth mentioning. Their efforts were not well received as the initiative did not involve the various stakeholders and had moved with predetermined standards of evaluation, membership fees and assessment mechanisms.
In India, the initial premises of introducing accreditation were based on the overall objective to ensure the quality of care. The Bureau of Indian Standards (BIS) had laid down standards for hospitals having 30, 100 and 250 beds. The National Institute of Health and Family Welfare (NIFHFW) had such rules laid for more than 50-bed hospitals and only for equipment. Most of the standards laid down by both BIS and NIFHFW were criticized for having an urban bias. There have been attempts in some states to institutionalize uniform standards for hospitals. In Maharashtra, the government hospitals follow the Hospital Administration Manual. The Andhra Pradesh Vaidya Vidhana Parisad has laid down standards for secondary-level hospitals in the government sector, which comes under it. Apart from this some efforts have been made by consumer bodies, groups of health professionals, hospital organisations and non-governmental organisations to evolve standards for accreditation. But what was lacking was a unity of various such attempts to monitor the functioning of hospitals in India and the stringency of compliance to established standards.
At the threshold of globalization and increasingly opening-up of the Indian health sector, attempts are being made at various quarters to draft systems of accreditation. There are certain points, which cannot be missed. What does accreditation mean for India? The answer to this question would help us to know which model can be adopted for accreditation of hospitals in India. If it follows the ranking-model based on quality of services provided, accreditation will have very little to contribute to the improvement of the overall health system in India. In contrast, the facility-survey model can be partially pertinent in putting in place the basic facilities required for providing care.
The most relevant model of accreditation for the Indian health system is the people-centric model, which would ensure the presence of 4 A’s, namely Acceptability, Accessibility, Accountability and Allocative efficiency. Ensuring the presence of the above would monitor utility of the available services and orient the health system towards performance management.
The emerging system of accreditation in India has to consider the uniformity of the standards used for the purpose, the nature of the relation of accreditation bodies with the State and the role they would play in the health sector. An accreditation body has to have a restrictive relation with the State to be effective in regulating the health system. It can have observers from the government but largely it has to be an autonomous body constituted of health professionals, experts and various stakeholders.
The nature of relationship of the accreditation bodies with the to-be accredited institutions would also determine its relevance for the health systems in India. Effective regulation and monitoring will depend on whether the relationship is evaluative, educational, consultative or inspectorial and judgmental with punitive powers.
In the backdrop of the opening-up of the Indian health system to foreign patients and the increased pressure from the insurance sector seeking grading of the hospitals, there would certainly be an exceeded emphasis on quality of hospitals and other health institutions providing health care. Under such circumstances, the role of accreditation systems may be expected to be more stringent than mere consultative.
Accreditation systems over a period of time have shifted from a single system focusing on entire hospital to a more complex pattern with specialized agencies regulating and certifying parts of several compartments of the health delivery system. The structure of the agencies and methodology adopted for evaluation and monitoring/regulation also varies. In the 1980s, the accreditation systems began to consider ways of revising standards to make them more patient-focused rather than professionally focused. In the 1990s, they have revised their standards to reflect the changing functions of hospitals, seeking to move away from departments towards patient experience of hospital systems. They have all moved towards trying to find standards, which would reflect the integration of hospital services rather than examining them in isolation. Finally, they have all begun to examine outcome measures instead of simple process standards for good practice. The context in which accreditation of health services have started in India generates fear that it may only endorse inequality rather than institutionalize quality.
The rising demand for quality care, the limited healthcare investment, the growing number of private players in healthcare and insurance sector, the opening-up of the health-sector to global patients makes the search for quality an imminent reality. But a sound system of accreditation would require to take into consideration the important performance measures that affect community health status, gives due weightage to the content and outcome of the public health agency’s community contribution than to its structure and resources, should result in the strengthening of the public health infrastructure and contribute to ongoing quality improvement. It should add value to the public health process in communities.
The costs of the accreditation process should provide no economic barriers to local public health agencies wishing to participate.
Other countries that have accreditation system and some that is in the process of setting up one are Malaysia, Spain, France, Pakistan, South Africa, Italy, Taiwan, Netherlands, and Israel among others. Over a period of time accreditation systems have moved away from single system focusing on entire hospitals to more complex patterns.
Dr Chandrima B Chatterjee
