System of health 2017-06-12, Kantipur

Accreditation is not easy but it does raise the bar for patient safety through continuous improvement.

Choosing the right doctor, hospital or diagnostic facility for the diagnosis and treatment of one’s illness is difficult. Rather than making an objective decision, we often end up being influenced by our friends and relatives. Will I meet the right doctor? Will I be correctly diagnosed? Will I get the right treatment? These are a few questions that come to our minds. Are having glossy websites, big buildings and renowned doctors sufficient for us to believe in the services of a health care provider? Given so many choices over the internet these days, patients struggle to find the right hospital, lab or diagnostic center offering quality care in a low risk setting and one focused on patient care.

Currently, whether you get to the right place is a matter of sheer luck. In a developing country like Nepal, with little or no medical insurance, the financial burden during an illness can be tremendous. Having to visit two or three hospitals for proper diagnosis, two or three pathology laboratories and radio diagnostic centers for a proper report has greatly increased the cost of health care. Don’t we have a solution for this problem? How have other countries tackled it?

Government regulations are based on minimum standards, inspection, enforcement and public accountability. On the other hand, when it comes to increasing the quality of customer care, accreditation is the answer. It relies on establishing technical competence of health care organizations in terms of accreditation standards or norms to be followed for continual excellence. The quality of patient care is essentially determined by the quality of infrastructure, quality of training, competence of personnel and efficiency of operational systems. Accreditation establishes the competency, authority or credibility of an organization. The competency is certified by a third party. With accreditation comes quality in health care.

Health care providers are also looking for accreditation to reassure patients about the care they can expect. At the same time consumers are also more aware and look for accreditation by an accepted international body. Pathology laboratories have taken the pioneering step to ensure quality in laboratory tests in our country. Accreditation with ISO 15189:2012 (which assesses both technical and management competency) was first granted to pathology labs in Nepal in 2015. Was this customer driven? Yes, one hundred percent.

Patients complained of varied results in different laboratories for the same test. Treating physicians were also having difficulties deciding which laboratory results to rely on and base their treatment. As a result, the process of laboratory accreditation was started. Gone are the days when the best pathology laboratories were assessed based on gray hair, big machines and big building. We are in an era of evidence based medicine, not opinion based medicine. In a short span of three years, four stand-alone pathology laboratories and one hospital-based laboratory have been accredited in Kathmandu. The foundation for quality patient care has been laid down.

But what about the quality of care that a patient receives at a hospital or diagnostic imaging center? Are they not to be accredited? How sure am I as a patient that I shall receive international standard service at a given hospital? How sure am I of the radio diagnostic reports that I receive for a plain radiography, angiography, mammography, ultrasound, MRI, CT Scan, PET scan, nuclear medicine techniques, etc? In modern times, the concept of quality was introduced into health care by a team of surgeons with a concept of “end result idea”. Uniformity in patient care was sought for and as a result “Hospital Standardization Committee” was formed by the American College of Surgeons in 1910. Subsequently, Joint Commission on Accreditation of Hospitals was formed in 1951.

The term accreditation means systematic assessment of hospitals against accepted standards. Generally, accreditation has developed for hospitals, but it has also moved to primary care, laboratory services and other healthcare services. Unfortunately, till date, we do not have any accredited hospitals or radio imaging facilities in the country. A few hospitals in Kathmandu have strived for ISO 9001 certification for quality management, which is a good step, but it does not include a holistic management of both technical and nontechnical areas.
Regulation is mandated by the law of the land, whereas accreditation is driven by market forces and is voluntary. The government cannot enforce health care facilities to be accredited. Neither can the government act as an accreditation body, due to the possible conflict of interest. Almost all the accrediting bodies around the world are either private or semi-government, so as to prevent undue interferences.

So what can the government do to improve health care facilities? It can form a body which creates awareness among citizens regarding accreditation, recognize institutions which have been accredited, and provide minimal incentives in the form of reduced tax in purchase of machines or reagents for accredited hospitals, labs and radio imaging centers. The government, health care facilities and patients, all have important roles to play in promoting accredited health care in Nepal.

Accreditation is not easy, but it does raise the bar for patient safety through continuous improvement. Health care should be safe, effective, patient centered, timely, efficient and equitable. Regular assessment of both medical and nonmedical staffs is an important aspect of patient care.

In conclusion, quality is customers driven. Unless we as customers don’t demand quality care, hospitals and clinics will still remain as they have always been.