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An operation at the American Hospital in Dubai.
An operation at the American Hospital in Dubai.

Hospitals seek gold standard

There is big money to be made from medical tourism and increasing numbers of hospitals are waking up to the idea of a global market worth an estimated US$54.4bn.

Few outside the healthcare sector in the UAE have heard of the Joint Commission International (JCI), a US-based arbiter of medical standards whose influence is being felt throughout the world as nations go head-to-head in competition for a share of the increasingly lucrative business of medical tourism. In the UAE, however, much-sought-after "accreditation" by the JCI is linked inextricably not only with the commercial development of health care, but also with the improvement of medical standards and facilities for all residents of the Emirates.

The country has three main health bodies - the Health Authority Abu Dhabi, the newly formed Dubai Health Authority and the Ministry of Health, which has jurisdiction over the Northern Emirates. Each applies different standards and regulations and, although many are similar, there is no single set of rules. In Abu Dhabi, the Government seems to be relying on the JCI to raise standards; the Executive Council's Policy Agenda for 2007-2008 identifies a number of key initiatives to improve and standardise quality and one of these is "ranking and accrediting all healthcare facilities in Abu Dhabi through a partnership with the Joint Commission International".

JCI, a division of Joint Commission Resources, a not-for-profit affiliate of The Joint Commission, launched its accreditation programme in 1999, with the aim of "assisting international healthcare organisations, public health agencies, health ministries and others to improve the quality and safety of patient care in more than 80 countries". It is only in the past two years, however, that the UAE has woke up to the potential of JCI accreditation. Accredited in May 2000, the American Hospital Dubai was the first JCI customer in the UAE, and has been re-accredited twice, but since 2006 no fewer than 15 healthcare facilities in the UAE have followed suit and been awarded JCI accreditation. On the list are some of the biggest hospitals in the country, including Tawam Hospital, Al Rahba Hospital and Al Noor Hospital in Abu Dhabi, Al Wasl Maternity and Paediatric Hospital and Rashid Hospital in Dubai and, most recently, winning accreditation this summer, Sheikh Khalifa Medical City in Abu Dhabi.

On Nov 2, some 300 health industry delegates from around the world will congregate at Al Bustan Rotana Hotel in Dubai for the inaugural Healthcare Travel Exhibition and Congress, the first such show in the Middle East and the first official event of the Singapore-based International Medical Travel Association (IMTA), which was launched in March. One of the founding member organisations of the IMTA was the American Hospital Dubai.

There is big money to be made from medical tourism and increasing numbers of hospitals in the Emirates are waking up to the potential of a global market worth an estimated US$54.4 billion (Dh199.8bn) a year, and rising. In August, Nasser Khalifa al Budoor, in charge of international relations and health at the Ministry of Health, said money invested in accreditation was worth it if the UAE could attract medical tourists. He told The National the ministry had already set up a medical tourism department to exploit the potential of the industry.

The cost of accreditation to an average-size hospital is thought to be about $41,000. "Medical healthcare travel is one of the biggest trends in 2008, for both health providers and tourism agencies," says Sietske Meerloo, the Dubai-based marketing manager for IIR Middle East, the organiser of November's conference. "The Middle East is an ideal location for people travelling from abroad for medical tourism. In the UAE we have beautiful five-star hotels and everybody speaks English."

The company, she said, had had "a big interest from hospitals in the Middle East in general; we have hospitals participating in the exhibition from the UAE. "I think people recognise that this could be a way for a hospital to diversify its business. We are all going into difficult economic times and this may be a way of making sure the last few rooms are filled. You cannot just depend on one type of consumer."

This economic imperative will have a valuable spin-off not only for health tourists, but for nationals and residents who rely on medical services in the UAE, she believes. "They all want to ensure the best possible services," says Ms Meerloo, who is based in Dubai. "It will benefit all of us. We would all be happy if we could get the best health care in the world in our cities. "Accreditation is a very, very big topic. We have a number of people speaking about this, including a Canadian accreditation organisation."

And if local hospitals are now waking up to the potential of JCI accreditation, the JCI has also woken up to the potential of the region. Headquartered in Oakbrook, Illinois, JCI has only four offices outside the United States - two in Europe, one in Singapore and, since 2006, one in Dubai. Derick Pasternak, the managing director for the Middle East office, insists JCI accreditation is far more than a mere rubber stamp for hospitals hoping to tap into the lucrative medical tourism market.

"The JCI process is all about improving the quality of care and services for a patient," he says, sitting in his office in Dubai Health Care City. "We are here because the hospitals have asked us to be, they want improvement." The JCI in the Middle East does not apply the same standards as its sister organisation does in the US and the organisation's international standards have been created by a panel of around 15 experts from Europe, the Middle East and Asia.

"In some parts of the world, American standards do not necessarily apply," says Mr Pasternak. "They do not have the same legal and regulatory specifications. For example, the American standards are very specific when it comes to complying with safety regulations, such as the fire regulations. International standards are much more international." Because of cultural and legal differences, he says, a country such as the UAE could not, and should not, apply American standards to its healthcare sector, but this is no reason to assume international standards are set any lower.

"There are cultural differences that simply have to be taken into account," he says. "Some may be difficult for a western person to accept. For example, the consent process for a married woman in some Middle Eastern societies is sometimes different to that of a man. You may think that is inappropriate but they follow the law of their country." In some countries, he says, "some things about patient rights are simply not yet achievable". JCI standards "are about the maximum achievable standards. This is subjective. They may not pretend to be best practice in each and every incidence."

To achieve accreditation, a hospital's performance is assessed in 14 categories, including assessment of patients, patient and family education, quality improvement and patient safety, infection control and prevention, staff qualifications and education, and management and communication of information. Hospitals undergo a period of consultation and inspection, conducted by a team of two or three JCI employees, who are not necessarily from the Middle East.

There are no graded levels within the accreditation process, but it is recognised that it is easier to gain an accreditation first time around than it is in subsequent assessments. As a facility is accredited over the years, the margins for error become smaller. "If a hospital does not meet the standards the first time, they get a second chance to remedy the problem," says Mr Pasternak. "It has six months to do so on the first accreditation. On the second it is only 60 days."

If an institution falls short on some of the 320-odd standards, they are given a grace period in which to get things right. One thorny issue for any country relying on JCI accreditation to raise national standards is that of transparency. Mr Pasternak admits the JCI in the Middle East has not accredited every hospital that has applied, but while a list of those that have been successful is online, there is no published information on the hospitals that have come up short.

This is a far cry from some other countries. In the UK, published "league tables" show exactly how institutions perform in every area of medical practice. In cardiac surgery, for example, even the survival rates of individual heart surgeons are available online, allowing patients to choose their doctor. "There is a balance between transparency and encouraging more hospitals to go for this using confidentiality," says Mr Pasternak. "Here, it is overwhelmingly on the confidentiality side. We do not publicise who has had consultations or any recommendations given to make some things different."

It is, he says, "valid to say that the public want to know more. But we should not be punishing people for trying to do better in what they are doing." Patients' right to know more "is, I think, a nice idea and we would certainly strive to get to a point where we could share more information. But at the moment we think if we were to say to the hospital, 'do this or we will tell the public you failed', it would not be productive."

Keith Pollard, the founder of treatmentabroad.com, a medical tourism website which carries advertising from hospitals around the world, is due to speak about accreditation at next month's Healthcare Travel Exhibition and Congress in Dubai and says accreditation is playing an increasingly important role in the medical tourism business. "Hospitals abroad are applying for either JCI, a UK accreditation called Trent, or an Australian version," he says. "These three are actively marketing themselves to hospitals around the world. One of the reasons is medical tourists are being more selective about asking about accreditation levels.

"One of the other factors is the growing numbers of self-paid medical tourists paying out their own pocket." As well as the patients themselves, he says, there is also an increasing number of insurance companies, especially in the US, who are seeking cheaper treatment for patients overseas and are selecting groups of accredited provider hospitals around the world. For the American Hospital Dubai, the UAE's first JCI-approved institution, accreditation is all about raising standards. Richard Larison, the chief executive of the hospital, says it "adds an extra dimension of discipline. There are a lot of things you know that need to be done but you can get a little lazy, but when you know someone is going to come and inspect, you do not leave anything out."

However, he acknowledges that the growing trend of accreditation in the UAE is partly linked to the demands of the health insurance market. "There is a mad rush for accreditation now because it shows that a facility has reached some minimum standards," he says. "I think we will see many more." munderwood@thenational.ae

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