Accreditation of Hospitals

The Situation in Germany

by Dietmar Nichterlein and Dr. Rainer Hilgenfeld

Introduction
Because of structural changes of healthcare systems the quality of healthcare plays an
increasing role in the dialogue between hospitals on one side and payors, regulating
authorities and the public on the other side. Based on this fact it is no surprise that quality
management in general and the accreditation of hospitals in particular has become more
important for German hospitals over the last years.

This development has been advanced by several factors:

• The introduction of diagnosis-related groups (DRGs) in Germany a few years ago has
led to increased transparency of hospitals and their services. In all countries where
DRGs have been introduced the quest for quality in healthcare became more
important to the public after an initial focus on cost reduction and a perceived or real
drop in the quality of healthcare.
• The development of a quality-oriented healthcare market over the last years through
improved medical technology, clinical pathways and evidence-based medicine, more
demanding behavior of patients and payors leads to increasing pressure on
healthcare providers to justify their action and demonstrate their performance;
• Article 135a of the German Social Act (Sozialgesetzbuch, SGB) specifies the
requirement of hospitals to “ensure and further develop the quality of their services”.
They are also required to “introduce and develop quality management in their
institutions”.
• Finally, hospitals are also required to deliver data on clinical outcomes in several
“performance areas” to the Federal Bureau for Quality Assurance (BQS) that
compares the clinical performance and publishes an annual report.

Coalition for Transparency and Quality in Healthcare (KTQ)

Under these circumstances, about one third of hospitals in Germany by now have undergone
organization-wide accreditation: Most of them (more than 630) have chosen the national
accreditation system KTQ, which was created with the help of several accreditation systems
from other countries and has the backing of all major stakeholders of the German healthcare
system. The KTQ catalogue, currently in its 5th version, comprises 6 main categories of
standards:
• Patient orientation
• Staff orientation
• Safety
• Management of information
• Governance
• Quality management
Before undergoing a survey by an accrediting body, hospitals are recommended to perform a
self-evaluation. KTQ puts strong emphasis on the PDCA cycle and hospitals have to provide
written comments to at least one criterion in each PDCA step. Overall, 55% compliance have
to be shown for passing the accreditation survey and as with other accreditation systems, a
certificate is valid for three years. After successfully achieving accreditation each hospital has
to publish a quality report in the internet.

Joint Commission International Accreditation (JCIA)

The Joint Commission International (JCI) is part of the US accreditation authority Joint
Commission. This independent, not for profit, private organization has accredited more than
20,000 healthcare organizations in the USA over nearly 60 years, among them the
overwhelming majority of US hospitals.
About 10 years ago, JCI created the first universal accreditation system for acute care
hospitals, that will be in its 3rd edition in 2008. As in the USA, JCI is offering international
accreditation of acute care hospitals, “care continuum” facilities, clinical laboratories, and
medical transport services. So far, JCI has accredited more than 130 healthcare facilities in
23 countries, in Europe in Austria, Denmark, Germany, Ireland, Italy, and Spain.
JCI does not require hospitals and other healthcare organizations to perform a self
assessment before accreditation. However, mock surveys by outside experts are
recommended during the preparation. The JCI standard catalogue comprises more than 300
standards with more than 1,000 “measurable elements” that serve as kind of a checklist for
the JCI surveyors. Acute care hospitals have to show compliance with 80 – 90% of the
standards to achieve accreditation and again the certificate is valid for three years.

Results of the first accreditation of Klinikum Chemnitz and other hospitals in German-
speaking Europe by JCIA were:
• Discussing and deciding on the mission and vision of the organization
• Creating a comprehensive annual quality plan
• Writing down guidelines for standardized staff development and education
• Creating a database on clinical research conducted in the various departments
• Listing patient rights
• Designing a standardized and comprehensive orientation of new staff
• Improving emergency preparedness
• Streamlining the treatment of urgent and emergent cases
• Defining the return time of test results
• Reviewing the coordination of services and improving it
• Improving communication between departments and professions
• Reorganizing the preparation, dispensing, and administration of medication

Typical problems from the preparation arose in the following areas:

• Protection of patient privacy/patient data
• Medical records/documentation
• Analysis of quality assurance data
• Assessment of staff competences
• Medical guidelines and clinical pathways
• Transfusion of blood and blood products
• Pain management

Undergoing accreditation leads to numerous advantages, among them the collective effort of
all departments and professions of the organizations to achieve this goal. Following an
accreditation changes can be seen in all areas of the hospital. One of the major advantages
of undergoing accreditation - certainly enhanced by the nature of the JCI accreditation
standards – was the development of a comprehensive, organization-wide view by hospital
employees with the patient at the focus of all processes. The standards also provided a
framework and practical guide for the systematic development of quality management.
Helpful was the reputation of JCIA also in dealing with international organizations and
cooperation partners which proves the value of a trans-national accreditation and quality
management system.

Excellence in Healthcare
Contrary to conventional wisdom a successful accreditation is not sufficient to assure a good
quality of healthcare services and prove it for the public or market it. Here complementing
tools from the field of clinical performance measurement allowing for benchmarking as well
as marketing efforts are necessary to effectively appraise the existing quality management of
an organization and to document it for the public. The increasing globalization also in
healthcare here asks for systems that enable a self assessment as well as international
benchmarking. Klinikum Chemnitz has chosen the International Quality Indicator Project
(IQIP; www.internationalqip.com) to measure the quality of its clinical performance and to
compare them to the results of healthcare organizations world-wide. Other components of
the quality management are continuous measurement of pressure ulcers as well as staff and
patient satisfaction.

Next to these activities Klinikum Chemnitz was also a founding member of the “Alliance for
Excellence in Healthcare” (allexc), a group of independent hospitals striving for creating a
brand name for excellent healthcare in an international setting and marketing it to
multinational companies, healthcare authorities world-wide, insurance companies as well as
to the general public. Membership criteria of allexc are an accreditation of the member
hospital by an internationally acclaimed accreditation system and the participation in an
outcome measurement system.