4dventist i#Health tTsuen Wan Adventlst Hospltalt rE*rH

Trent and JCI hospital accreditationWhat for? And why both?

Conference Report byDr. Charles WONG Yat-cheung, MD FRCP FHAM

This article shares what I leamt from chairing a recent international Trent Accreditation Scheme* (TAS)conference, in addition to what was discovered from background reading. Merging these two sources isessential to make this article comprehensible. My views are purely personal and not representative ofAdventist Health (AH) or any of its hospitals. lt provides different perspective to the upbeat Adventist HealthJune 2007 JCI (Joint Commission Intemational.*) Newsletter "Return to the Basics".

Dr. Charles WONG, with Ms Manbo MAN of HK Sanatorium & Hospital on his left, with the TAS Team, andtwo participants from the Philipines

Limit of my personal knowledge on TAS and JCI Accreditation

In the past, my knowledge on hospital accreditation was limited to helping Tsuen Wan Adventist Hospital(TWAH) paediatrics service in its preparation and attendance at the time of accreditation surveys. Thisconference was an excellent opportunity to learn. lt was fortunate that I was its chairman therefore not

Attribute of Photo:

reqiiired to deliver any pearls of wisdom. Even so, it was only prudent for me to prepare by researching intothe subject.

The Conference . "Garing for Patients across International Borders - Doing it well and letting peopleknow you do it well" on 14th July 1007 at the Singapore Management University.

Professor Steve Green, Infectious Disease Consultant from Sheffield, England, took the lead for the TAS team.Roughly 30 participants aftended. The largest contingent was from Singapore. Others were from thePhilippiires, Thailand, Brunei and Macao. Two were from Hong Kong (HK), Ms Manbo MAN, Director ofNursing Service for the HK Sanatorium & Hospital (HKS&H), and me from lhe TWAH. Many aftendants weresenior nurses in management position. Presenled papers were mainly connected with various aspects of"medical tourism", meaning to bring in overseas visitors to receive medical treatment, "selling' local medicalservice to overseas clients.

The unique feature of AH, that its two hospitals being are the only ones certified by both TAS and JCl, mayhave been the reason that TAS invited me to chair the Conference.

Hong Kong private hospital accreditation and statutory requirement

The government Department of Health is responsible to inspect and license private hospitals, using its ownset of un-published standards. At this moment in time, Hong Kong has no legal requirement for Hong Kongprivate hospitals to undergo any form bf independent accreditation such as JCI or TAS. With no such statutoryrequirement, many have queried Adventist Health's double flagellation of TAS and JCI accreditation.

Historical background of Hong Kong private hospital accreditation ,, fe" aT{"-*'E',^&"5

According to Ms Manbo MAN, prior to 2000 around the time that the HK S{natorium & Hospital suffered theaccident-at its renal dialysis unit, local media alleged HK private hospit{b were lacking supervision andproviding care without consistent standards.. -Sir Dr. Harry FANG,bf St. Paul's Hospital introducedTAS from the UK partty as a tool to rebuff thbse criticisms. One reason f6r choosing the Trent dccrediiationScheme was its willingness to work with HK private hospitals to modify established TAS standards to suit thelocal Hong Kong situation. Furthermore, due to the large variation of affordability amongst HK private hospitals,TAS agreed to charge HK private hospitals for out of pocket expenses only. Most of the UK based surveyorscome lo HK using their own vacation time. TAS remains a non profit making body.

All 12 private hospitals were accredited in 2000 by TAS. All private hospitals shared cost of the accreditationprocess, resulting in cost containment. Conlinuing with this effort, a set of standards evolved specifically forHong Kong, adapted from established UK TAS standards. These standards continue to be reviewed andrevisld, with HK private hospitals each supplying two committee members, taking into account the TASBoard's inout..

This unprecedented m-operation of all private hospitals was the impetus that gave birth to the official HongKong Private Hospitals Association. Incidentally, I am delighted to report that international attendants at thisconference unreservedly admired the very existance of this organisation, and the solidarity and co-operationwithin.

Medical tourism for Hong Kong

At my introduction to the Conference, I told the audience that there is still no medical tourism of note in HK.The iunent flood of molhers from mainland China giving birth in Hong Kong is a different issue altogether. Ibelieve that as long as HK medical service cost supersedes oveBeas patient insurance co-payment, co-payment being the ahort fall that patients need to pay despite medical insurance cover, patients from wealthycountries are unlikely to come to HK for medical tourism.

Medical tourism and negligence litigation

Doctors BEWARE - Medical Protection Society (MPS) representative told the Conference lhat mostlikely litigation will start in the country where the alleged negligence occurred. Should a US orcanadian citizen sue in the courts of the usA or canada, then MPS cover does not apply.

MpS was represented by its local Singapore solicitor who answered the question of medical negligenceinsurance cover for doctors treating international patients from abroad,

Has hospital accreditation by JCI or TAS helped to promote medical tourism?

No. There is no evidence to suggest;so. Cunent HK medical mst is not competitive within the Asia region.Alihough Hong Kong's quality and standard of medical service is world class, HK is far from being "first worldservicj at thirJ world orices" - it is "first world service at first world price". Without the price competitive edge,it would be futile for l-iong Kong to attempt to grab a share of the very small international medical tourism pie,

at least for now, irrespeciive oiwhether our hospital is accredited or not by whichever intemational body. Thefew who come to Hong Kong as medical tourist have not come because of price advantage.

So why bother with accredihtion by any independent, international body?

Mr. Alex LAN, Chief Operating Officer ("COO") of TWAH puts it succinctly: "Both JCI and Trent AccreditationSchemes are tools to imprwe quality of care and patient safety. Experience and best practices fromparticipating hospitals are incorporating into the accreditation standards as ways to improve the quality of careand safety standards."

TAS continues to be useful because of its guiding principles

. TAS is a non-profit organization run on he basis of peer review by active practicing clinicians. lt isonly now beginning to "market" itself. lt remains inexpensive.

. TAS remains committed to help establish localized hospital standards and measures. There is now aset of slandards and measures that is specific to Hong Kong which is continually being reviewed anduodated.

. Localisation of hospital standards and measure is unlikely to work TAS out of its participation in HK'shospital accreditation surveys because there remains a certain level of healthy competition betweenlocal private hospitals which is-befH by the independent TAS guaranteed neutrality and faimess.

tu ̂9",*;

TAS surveyors are not paid but only reimbursed for their out of pocket expenses. Participatinghospitals are required to supply their own staff at the participating hospital's expense for training andeventual "exchange of examiners". The latter helps to standardize equivalence of different hospitals.

"Exchange of Examiners" also results in exchange of knowledge on best practice. Personalknowledge on this issue tells me that potential conflict of interests from this exchange forimprovement of patient care have not occurred because of the good common sense of HK medicaland nursing professionals.

Presence of trained surveyors all year round stationed at the surveyors' own hospitals, with continualcontact with the TAS Board, and communication between surveyors of different local hospitals havebenefited all parties, surveyors and hospitals alike,

Experience brought in by overseas surveyors introduces fresh perspective not only from the UK to HK,but also vice versa.

Why TAS as well as JCI?

Thorough study of all eight pages of the AH "Return to the Basics" JCI Newsletter of June 2007 did not revealthe reasons for embarking on JCI after having successfully achieved TAS certification. On this issue, Mr,Alex LAN, COO of TWAH, explained that the CEO of the previous administration pushed for JCI on the basisthat it demands higher standard than TAS, and also better known than TAS worldwide. The reason forundergoing both JCI and TAS certification is that the latter is an assessment system universally agreedbetween all Hong Kong private hospitals and unilateral pulling out of this agreement by any hospital mayupset this SAR-wide private hospital accreditation system.

It is probably also worth noting JCI originated from the USA whereas TAS is UK based, that AmericanAdventist missionaries founded the two Adventist Hospitals, then AH CEO had lived and worked in the US,the Director of Nursing then was ex-staff of a Joint Commission Accredited Organisation in the USA, thePerformance lmprovement Director was then American, the Church headquarter is in the USA and the listgoes 0n . . . . . .

Mr. LAN stressed that the reason to gain TAS or JCI accreditation is not the certification. The process ofachieving accreditation is acknowledged to be the mechanism to improve the hospitals' services and patientsafety. He reasoned that since JCI is more stringent than TAS, preparation for JCI is likely to have coveredTAS requirements, therefore the question of redundant certification does not arise. AH administrationintended that such improved standards will be applicable to the impending expansion planned for bothhospitals. In practice, and not surprisingly, as with any serious inward examination of processes andprocedures, the outcome is indeed improved clinical service and patient safety.

In contrast to TAS, JCI is well known amongst US hospital negligence insurers. One reason for choosing JCIis that it provides very clear and measurable standards, Some outcomes of the JCI accreditation are knownto me by hearsay. These include the following:

' The assumption that there will be an automatic 25% discount on hospital negligence insurancepremium, applicable to JACO (Hospital Commission) accredited hospitals in the USA, did not turn outto be automatic for HK.

. Hospital negligence insurance premium cost did eventually g0 down after insurers came to inspectthe hospitals first hand for themselves after the hospitals passed their JCI accreditation.

Despite extensive education of telling staff that the process of improvement to achieve accreditationwas the aim, staff was stressed out by the JCI survey preparation because no one wants to be culpritfor failing an assessment for accreditation. This is analogous to the futility of telling a student that it is

not the examination score that counts; the value of the examination is in the learning and the selfimprovement process that took place before hand.

Cost of JCI accreditation inevitably remains far greater that of TAS.

O(her relevant, current local HK development include

. Hospilal Authority, operating Hong Kong's massive public hospital service, is using its own standardsand measures, cbupbd with JCI standards and measurements. There is no immediate plan to go forformal, independent, full accreditation (hearsay).

. The HK Baptist Hospital is also aftempting JCI.

. HKS&H is contemplating double accreditation, continuing with TAS, but adding an Australian scheme

. Both Matilda and Union Hospital have acquired ISO 9000 standard in addition to TAS certification.

FUTURE - Hospital accreditation is here to stay. As Hong Kong becomes more knowledgeable on thisissue, coshbenefit and in particular duplicated accreditation, wanants continual re'evaluation.Breaiing away from TAS is unthinkable as this will ruin the hard earned solidarity of the Hong KongAssociation of Private Hospitals,

Declaration: TWAH financially suppofted the authols trip to Singapore to chair this C'onference.

Overview summary of JCI/ TAS:

JCI - http://www.jointcommissioninternational.com/Taken from JCI website 23.08.2008 -"The mission of Joint Commiss:on International is to continuously improve the safety and quality ofcare in the international community through the provision of education and consultation services andintemational accreditation ......Today the largest accreditor of health care organizations in the Unitedstates, the Joint commission surveys nearly 20,000 health care programs through a voluntaryaccreditation process. The Joint Commission and its subsidiary are both not-for-profit corporations."

Author's note: For different departments of the healthcare institution, JCI states its specific scope forthat department, and then divide the accreditation process into two sections, Intent and Measureable

.. Elements.

TAS - http://www.trentaccreditationscheme.org/Taken from TAS website 23.08.2008 -The Trent Accreditation Scheme has been developed by practitioners and managers from within theTrent Region ensuring capability, credibility and ownership by its users and is continuing to evolveand develoo.

Scheme Benefits

o assures the quality of service to patients, staff, commissioners and providerso provides a benchmark of standardso provides quality monitoring information

n facilitates the development of people and organisationso creates a dynamic environment for changeo provides networking opportunitiesB overseas contacts.

Core Elements

o peer reviewo accreditation awards by an independent Boardtr newslettertr training events for participants and surveyors in the scheme and networking opportunitiestr pre-survey visitstr mentoring for the organisation if desireda continuous process of developmentAuthor's note : Healthcare institutions of Hong Kong are inherently different from those of the UnitedKingdom, the scheme's originator country. TAS' built in flexibility in its Core Elements enables theTAS, with continual consultation with its Hong Kong partners, to adapt then evolve a specific set ofstandards applicable to Hong Kong.