Hospital systems and services around the world are broadly similar and therefore the application of quality standards, whether QHA Trent or another, must be consistent to have international credibility.

Wherever one goes in the world, a country’s culture may be different from another, but patients in both countries have broadly the same illnesses, expectations, and fears. The distribution of illnesses may be a little different from country to country but the application of healthcare quality standards should have the same core principles.

Nevertheless, one should beware of applying one country’s values on another.

Standards and accreditation

The work of international hospital accreditation is similar to that of a skilled tradesman. Just as the tradesman needs the best quality tools, experience and expert skill to do a professional job, the accreditation surveyor needs the tools of his work – the standards.

Standards must be precise

The success or failure of accreditation is highly dependent on the wording of the standards. Doctors and other healthcare professionals are often less attentive than others to the meaning of words. The precise wording of the standard is therefore critical to how it is interpreted and applied in different cultural environments. Getting this right is the best possible start for a survey.

Respect sensitive cultural issues

Knowing the nature of national and local cultural considerations is of great value. A pre-survey visit is a mutual learning opportunity for both hospital and the survey team. Very valuable information can be gathered to ensure the smooth progress of a future survey.

Know local customs and expectation

The next step is to ensure that surveyors are appropriately briefed. Knowing customs and expectations helps otherwise sensitive issues to be dealt with without problem. Local laws and regulations are very important. It is unrealistic to expect standards to be at odds with local laws for obvious reasons. A pre-survey visit and dialogue ensure that any possible conflict with local law and regulatory authorities can be dealt with before the survey.

It is tempting to think that local laws are inevitably more relaxed regarding healthcare standards. In fact, in some cases these laws may be more stringent than those surveyors and standards are familiar with. An example is the stringent restrictions placed on opiate medication administration in some countries, and tightly regulated by its ministry of health.

Standard ‘not applicable’

It is rare that a standard or aspect of hospital practice is too difficult to apply or assess. The hospital should always have the opportunity to consider an aspect of the service as ‘not applicable’. Whilst this may seem a convenient way out of the problem, this should always be regarded as a last resort and one which is explicit in any conferral of accreditation. The judgement of an experienced lead surveyor is invaluable in negotiating this difficult course. Surveyors being in active clinical practice is of crucial importance, in my opinion, in ensuring a pragmatic approach.

Culturally sensitive

Examples range from the relatively simple accommodation of excluding male surveyors from sensitive areas (one needs to ensure there is a female surveyor before travel) to assessing a locally provided charitable function in a developing country to an impoverished population that is impossible to upgrade to western hospital standards.

Specific local standard

Excellent service could be accommodated by applying a locally specific standard consistent with other providers of a similar service in the country, and providing a narrative explanation in the accreditation if it is conferred.

Narrative verdict

Finally, the Accreditation Award Panel must have sufficient information, experience, and wisdom to make an informed recommendation about accreditation. In the circumstances, a ‘success or failure’ verdict is less helpful than a narrative verdict regarding those aspects of service that are subject to difficult cultural considerations.

Experienced surveyors

Most international hospital accreditation systems have some safeguards to ensuring cultural concerns are accommodated. My own experience with QHA Trent, as lead surveyor, is entirely positive in these matters and I strongly believe that the depth of experience of varied cultural and social environments that our surveyors are familiar with, is the reason our approach and standards are transferable throughout the world.

Dr. Alan Fletcher is Director, QHA Trent Accreditation, UK