Raising the standard

The clock is ticking for Dubai’s doctors. In a move that has sent shockwaves through the medical community, the Department of Health and Medical Services announced last month that private polyclinics and small hospitals have less than three years to win international accreditation. Those that don’t, face closure.

Schemes such as the Joint Commission International (JCI) and the Canadian Council on Health Services Accreditation are hotly sought after by hospitals fighting to position themselves favourably to potential patients.

On a global scale, however, healthcare facilities that boast these stamps of approval are the exception rather than the rule. Thus DoHMS’ decision to demand widespread accreditation, admits Dr Derick Pasternak, managing director of Joint Commission International (JCI), Middle East, certainly raises the bar.

“These systems are aimed at seeking out those hospitals that are leaders, organisations that are better than average,” he explains. “What DoHMS is saying is that we want every one of our hospitals to be better than average on a world scale.

This community doesn’t wish to be an average community: it wants to be an outstanding community.”

In the short term, however, the first casualties of this community will be practices that don’t make the grade. Those that fail either to meet the clinical standards, or lack the budget to make the operational and structural changes required, can expect to lose their licence.

Dr Khaldoun Sabbagh, deputy CEO of the International Modern Hospital (IMH), is certain the legislation will spark a spate of closures.

“A lot of facilities will close, I’m sure,” he says, bluntly. “It’s not easy to be accredited. I know so many hospitals that failed the first time they attempted it, or it took them three years to be prepared for it.”

Even if an organisation’s procedures are up to scratch, potential costs can literally lurk around every corner. Sabbagh, who is pushing IMH towards accreditation, outlines the cost of meeting building regulations as a case in point.

“I have a small problem with my building and it will take quite a long time to solve, and a lot of money. There is an area of the hospital which does not have a proper firewall…a simple problem, but it will take me one month to solve it and something like AED150,000.”

Select your survey

For practices that plan to bite the bullet of benchmarking, the first step is selecting an auditor. While there are variations between the schemes, each body primarily aims to ensure medical facilities have procedures in place that regulate its clinical practice, its business matters and its staff. For hospitals, as with any large company, say accreditors, auditing breeds accountability.

For many physicians wary of being pulled under the microscope, the spectre of external examination can be threatening. This attitude is the first matter that must be addressed by clinics serious about staying in business, argues Rosemary Hood, director of clinical services at Interhealth Canada.

“I think people can get very scared about accreditation,” she explains. “You have to understand what accreditation actually is…an assessment tool that is designed to improve quality. If you improve quality, you’re improving safety and that is the whole essence of accreditation.”

The process can be laborious, Hood admits, and can take at least two to three years to obtain, but she insists this is a reflection of the changing demands in healthcare provision throughout the world.

“The consumer demands more, the profession demands more and you have to be accountable to your public,” she explains bluntly.

P is for preparation

The timescale of accreditation – polyclinics and hospitals must have completed the process by 1st August, 2010 – may have left physicians with barely enough time to catch their breath, but experts are urging them to up the pace of their preparation.

The main obstacle to winning approval by 2010, warns Mark Bradford of Team Healthcare Consulting, is delaying groundwork for too long. Equally as important, he adds, is ensuring all employees are on side and committed to the process. Enlisting outside help from a consultancy firm can help smooth the path.

“Accreditation preparation has to be a team effort involving all levels of staff from the top all the way down to the housekeepers,” he explains. “I advise setting up a team of core leadership to study (the chosen) accreditation model and assign responsibility to the different elements.”
Bradford’s advice may be sound for those with the budget for a specific management team, but for independent hospitals and polyclinics may struggle to find funding. When a polyclinic with as few as five specialists is being asked to obtain international accreditation, the strain on their resources, both in terms of personnel and capital, is palpable.

As James Hildebrand, a senior consultant with Interhealth Canada, points out, “JCIA and these other processes are really not meant for the smaller organisations, like the polyclinics. They are meant for hospitals or large organisations like a complex.”

Certainly, some physicians have argued that demanding polyclinics obtain international accreditation is unnecessary. Dr Moopen, chairman of The Moopen Group believes local auditing would provide a better middle ground.

“For the small clinics, which is the large number of providers in Dubai and the UAE, a local accreditation body that can take the good points from all of these accreditation bodies can look after this,” he suggests. As well as avoiding the logistical nightmare of putting all of theseclinics through international accreditation, Moopen argues, this approach could be beneficial to the local economy.

“If you look at the financial aspect, why do you want this money to go out of the country?” he asks. “Why can’t this be utilised here? They have the people and they have the knowledge.”

Bottom line benefits

Ironically, one of the dangers of bringing in an external accreditation system is that providers lapse into bad habits between audits. You only have to travel down Sheikh Zayed road to realise that people drive differently in real life than in their driving test. Disturbingly, this same trait can be found among healthcare providers, says Pasternak.

“I think that some organisations are going to try and go the cheapest route and try to get this done the quickest way possible,” he explains. “That is regrettable but I know it will happen. I’ve had worldwide experience before I came to Dubai, working for JCI, where I have gone back to organisations after they have been accredited and there has been significant backsliding.

“There is minimal compliance when organisations ramp up to comply, but stop these practices the day after.”

Despite his fears, Dr Pasternak believes in the prospect of blanket accreditation for Dubai’s private sector as “it is an area where the community as a whole has aspirations to being a world leader in every respect.” Pasternak cites Singapore as an example of another small community that has won the battle to internationally benchmark its facilities.

“We had the same sort of situation there, skepticism at first, dismay at having to do this, but now hospitals are going through the second round of accreditation. Those that have done it really felt they have benefited from the process.”

More importantly, for practices facing a sizeable outlay on bringing their premises up to scratch, achieving accreditation should impact favourably on an organisation’s bottom line.

“Most hospitals in this community are half empty,” says Pasternak, frankly. “The American Hospital, which has been accredited two or three times, is not half empty, even though they charge more than many other hospitals do.”

As in any industry, an investment in the quality of the service provided should pay dividends in the long run. If accreditation is considered as a means of improving your business, rather than red-tape that needs to be waded through, the likelihood is that it will be of positive benefit to your facility.

A common trait among accredited organisations is that staff buy fully into the concept, rather than methodically ticking boxes and stiffly implementing procedures. But what are the first steps private healthcare facilities should be looking to take?

Start with self-appraisal, recommends Hood.”You should be looking at what you have, what is your baseline. You should decide where you fit in, which accreditation you want to hang your hat on and you should be looking at their standards,” she advises physicians.

Whichever audit practices choose, the path to accreditation is a long one. The JCI accreditation alone has 1032 requirements. Organisations must be meticulous and, above all, motivated to meet them.

“You must foster an ethos of quality within your organisation. It is your whole organisation that is actually accredited, its systems, its processes, its manpower and its budgets,” Hood explains. “From the moment you come through the door, from the way you do sign-posting, disability access. From things as simple as that right through to your clinical outcomes, that is what accreditation requires.”

If the majority of the private providers currently operating in Dubai achieve international accreditation by August 2010, it will be a considerable feat. The reality is that many will not.

What remains to be seen, however, is whether or not DoHMS will keep to its own ambitious targets and shut down those that do not meet the standards. It would be a radical measure for any authority to enforce, but all indications suggest that Dubai healthcare is ready to stop taking small steps and start making giant leaps.