By Elizabeth Ziemba
President, Medical Tourism Training and Temos representative
Leveraging her background in business, public health, and law, Elizabeth Ziemba, President of Medical Tourism Training, delivers practical yet innovative, patient-centric solutions to complex issues for governments, healthcare providers, hospitality businesses, facilitators, non-profit and non-governmental organizations. Ms. Ziemba provides consulting and training services to a diverse client base including the governments of the Philippines, Poland, Costa Rica, Colombia, and others as well as to wellness, health, and medical providers around the world. She is the Temos representative for the US, Caribbean, Mexico, Central & South America focused on access to quality healthcare. Contact Elizabeth at
Hospitals and clinics are increasingly interested in being accredited by international, independent bodies like Temos International. As a basic requirement for engaging in the accreditation process, Temos, like other accreditation organizations, expects the hospital or clinic to have a Continuous Quality Improvement (CQI) system in place. This article offers an overview of the role CQI plays in the accreditation process.
https://www.healthit.gov/sites/default/files/tools/nlc_continuousqualityimprovementprimer.pdf. Accessed 18 Feb. 2019
Continuous Quality Improvement (CQI) is a business philosophy. It does not follow the adage of ‘If it isn’t broken, don’t fix it’. Instead, CQI team members proactively search for improvements to efficiency and outcomes. The focus is on prevention of business or system errors before they happen, rather than reactively fixing them after they occur
CQI is also referred to as Total Quality Management, Quality Improvement, Six Sigma, Kaizen and a variety of other labels. At its core, it is a scientific management method designed to identify wrinkles or gaps in business operations and to prevent problems in the delivery of healthcare services.
Here are some essential CQI principles:
• Processes, not people. CQI examines the organisation’s system and its processes to maximize its business operations with the focus on outcomes. International accreditation organizations expect hospitals and clinics to be able to measure clinical outcomes for procedures, factors impacting patient safety, risk management, and other key aspects of the patient experience. CQI systems view ‘problems’ as variations resulting from issues with the processes, not people. It looks at the root causes of these variations and/or errors, and seeks system-wide solutions, rather than blaming individuals
• Scientific method. CQI and accreditation are joined together through the data-driven processes involved with the collection, analysis, monitoring, reviewing, and adjusting to information obtained about processes and systems. CQI uses a statistical process to identify and detail variations and errors in service delivery. It employs the scientific method approach (also called “serial experimentation” – similar to “trial and error”) to measure business systems and processes. Teams of practitioners observe, measure, and then experiment with changing different variables to see which combinations produce the best results
• Inclusive. Cross-functional teams are drawn from various stakeholders including employees, management, volunteers, board members, and customers. Quality improvement is the responsibility of the whole team, not just management, so a holistic approach is used to gather input from all interested parties.
• Empowering. All stakeholders are empowered to identify variations and/or errors as well as opportunities for improvement. Individuals are encouraged to develop and present solutions.
• Understanding customers. ‘Customers’ are both internal and external to the organisation – i.e. employees, patients, patients’ families, and others. Understanding who these customers are and fulfilling their requirements is of paramount importance
A commonly recognised or observed ‘problem’ in any process is an unwanted variation, in that a variation in process causes a variation in outcome. CQI and all quality management approaches seek to define the limits of variation in processes and, through experimentation, render those processes more reliable – that is, more consistent. When output is consistent, processes improve.
CQI Evaluation Process
Improvement should be part of the culture of the organisation and a natural part of how people perform their jobs. Improvement does not only mean success in a particular project; rather, it is an ongoing way of approaching one’s regular duties. Regular interventions also test improvements, as they happen without waiting for a formal evaluation.
Relationship Between CQI and Accreditation
International accreditation organizations (IAO) offer clients an independent third-party review of an organization’s systems and processes to verify that those systems and processes deliver a quality of clinical care at levels consistent with best practices.
Different IAO’s have developed proprietary standards against which providers’ systems and processes are measured. For example, while most healthcare IAOs measure some aspect of clinical outcomes, other IAOs fail to measure the international patient experience. Selecting the IAO that best meets the needs of the providers and the patients they serve requires research and careful selection.
By its very nature, healthcare is dynamic and ever changing. That reality requires healthcare providers to ensure that their systems and processes evolve to meet the challenging landscape of healthcare. By incorporation CQI principles, systems, and processes into every aspect of clinical and nonclinical services, patients can be assured that providers are delivering the best possible healthcare to them. IAOs can ensure that the hospitals and clinics that complete the accreditation process that those providers do indeed meet established international standards.
What Is Needed to Implement Continuous Quality Improvement and/or Accreditation?
There are several essential elements required for successful CQI implementation:
•Substantial and strong leadership support, involvement, consistent commitment to CQI, and visibility are important in making significant changes
•Substantial commitment from hospital boards is highly correlated to success
•The inevitability of process changes and resource demands require senior leadership to:
• Ensure adequate financial resources by identifying sources of funds for training, purchasing and testing innovative technologies and equipment
• Facilitate and enable key players to have the needed time to be actively involved in the change processes
• Provide administrative support
• Grant enough time for CQI-generated process changes to work
• Emphasise safety as an organisational priority and support this, especially when the CQI process is delayed or results are periodically not realised
Senior leaders also need to understand the potentially high-level impact of CQI decisions on work processes and staff time, especially when there is a change in practice to allow quality improvement to be incorporated into system wide leadership development.
Leadership needs to make patient safety a key aspect of all meetings and strategies to create a formal process for identifying regular patient safety goals, and to hold themselves accountable for patient safety outcomes.
With CQI systems firmly in place, healthcare providers opt to pursue international accreditation for several reasons including: improved clinical and nonclinical outcomes; increased patient and third-party confidence in services; better operational efficiency that may include costs savings, revenue generation, and staff satisfaction; competitive advantage; and more.
Which IAO is right for my organization?
The accreditation process does require an investment of time, energy, and money. Before embarking on the road to accreditation, it is important to understand the reasons why accreditation is important to each particular provider and the goals that it should attain once the process is completed. Because different IAOs review different aspects of the providers’ systems and processes and utilize different proprietary accreditation standards, it is important to select the IAO that is the best match for the organization.
Here are some questions to consider, research, and then ask potential IAO organizations:
• Is the IAO itself accredited?
• Does the IAO have a good reputation? How long has it been in business?
• Does the IAO accredit the entire organization or just a specific program?
• Are the accreditation standards relevant to your organization, your patients, and your culture?
• What are the qualifications of its assessors?
• What are the steps in the accreditation cycle?
• How long does accreditation take to complete?
• What are the costs associated with accreditation?
• What value does the accreditation provide to the organization and its patients?
• What benefits are unique to different IAOs?
The answers to these and other questions can help you to select the international accreditation organization that is best for you. With the principles of CQI in place and those principles, systems, and processes evaluated by a respected, independent third-party accreditation organization, the success of your hospital or clinic should be positioned well for the future.