Interview with JCI's Karen Timmons (transcript)

David Williams: This is David Williams, CEO of MedTripInfo.com. I spoke recently with Karen Timmons, President and CEO of Joint Commission International. JCI is part of JCAHO, the leading accreditation arm for US hospitals. International hospitals seek accreditation to demonstrate quality, and JCI accreditation is considered a seal of approval by medical travelers from the US.

In our discussion, Karen shared her thoughts on medical travel and the quality of overseas hospitals. She also provided tips for would be medical travelers.

Karen, thanks very much for joining me today.

Karen Timmons: Glad to be with you.

David: Karen, what is the Joint Commission International, and what does it mean to have JCI accreditation?

Karen: We are a major division of the Joint Commission, which is the largest accreditor here in the United States. But outside of the United States, we provide technical assistance, education, publications, and accreditation services. Our mission is to improve the quality and safety of patient care to the international community.

David: As part of the Joint Commission, are the standards that you're working with for accreditation overseas, are they the same as the ones in the US, or are they different in some ways?

Karen: No, they are different. When we first started providing services internationally, many of the organizations who had already worked with us on a technical assistance consulting basis on their journey to improve their performance towards approved quality and safety, their logical next step was to seek accreditation, and many sought to do that.

Really, the desire for accreditation poses a dilemma for us, since the only standards available were those that are domestic, and we were very concerned that the standards in the domestic area contained national and cultural considerations. They were filled with American jargon and referenced US organizations, such as the National Fire Protection Association, which does not really have an international equivalent.

So we determined that the existing Joint Commission standards should not be used, and developed a set of international standards that could be applied to various health care systems and that would be sensitive to unique cultural issues.

We established an international task force comprised of 18 experts, representing all five major regions around the globe. We tested the standards to ensure their appropriateness as well as their achievability.

We convened special task forces on issues such as patient and family rights and facility management and safety, which were particularly sensitive to develop an international standard that would be applicable, in order to obtain a clearer understanding of what was a realistic expectation in these areas, and reflecting the wide disparity of practice due to cultural and regional differences.

So, we feel that our standards are comparable, but different.

David: Is there then one international standard that goes across the various regions and countries?

Karen: Yes. We developed the standards to be able to have them applied according to various health care delivery systems or according to the culture. For instance, I can give an example of patient rights. In some countries, the family is also considered to be the vehicle by which consent might be given for a procedure, whereas here in the United States, and in some other countries, it's the patient who would make that determination as to whether to share diagnosis.

But if it is really culturally acceptable that it is the family and that is how policies are written within hospitals within that country, we will defer to that and survey our standards so that our patient rights would include the family, not just the patient.

David: So there can be some variation in how things are implemented, by country, but you have an overall guideline.

Karen: Yes, yes. But there is only one set of international standards.

David: Now, when you do an accreditation, what are the categories of things that are assessed?

Karen: We really look at all of the major clinical, management, and administrative functions. Accreditation is really a risk reduction activity. It helps an organization do the right things, based on evidence, best practices. And if an organization is doing the right things, it has a better likelihood of having better outcomes.

For risk reduction activities, we look at things such as access to care, continuity of care, patient rights. It's how patients are assessed, the care of the patients, anesthesia, surgical care, medication management, education.

And then with respect to management standards, we would look at how infections are prevented and controlled, what's the role of governance, leadership, facility management, staff qualifications and education whether physicians, for instance, are appropriately credentialed and privileged. Do they have the competency to really do the procedures that they are performing?

David: When a hospital says that it's JCI accredited, does that apply to the hospital overall, or are there just specific services or departments within the hospital?

Karen: It applies to the entire hospital. Now, however, if there are four different hospitals within a system, we would survey each hospital. We do also provide certification of what we call disease specific care, where we might certify a stroke center or an asthma center, and those would apply only to that specific unit of care.

David: Once a hospital is accredited, is that something that lasts forever, or is there a follow up or renewal?

Karen: An organization is accredited for three years. And after that three-year period, there is an on site survey again, with a physician, a nurse, and an administrator conducting that survey. If we get a complaint within that three-year period and the complaints can be from a patient, a professional staff member, a member of the community or if we hear about an event through the media, we will request a response from the organization. And based on that response, we can do what we call a "for cause" survey, and we do follow up.

David: How many hospitals are accredited now?

Karen: It's about 130 accredited, but I would say probably about 100 organizations are preparing for accreditation.

David: And is there a high failure rate? Do hospitals generally get accredited once they try for it, or is it something that you have to try several times or spend an extended time period on?

Karen: If an organization is not in compliance with the standards at the time that they are surveyed, they have six months to try to bring their organization into compliance. We non accredit about one percent.

David: How good do you find the international hospitals are, compared to hospitals in the US that you know of from JCAHO work?

Karen: We've been very impressed with the organizations. And obviously, in the ones that have met our standards, we feel that very good care is being given.

David: Can you identify any things that international hospitals, either individually or as a whole, might be able to teach their US counterparts?

Karen: Some of the organizations do a very, very good job and of course, you're talking about medical tourism as part of this interview with their translation and being able to accommodate the needs of many different nationalities and ensuring that they have translators available, and the ratio of staff to patient and the customer service is very good.

David: And what about in areas like patient safety?

Karen: We've been struck by the similarities of challenges that hospitals face around the world, no matter where they are, with respect to patient safety. I would say that there are certainly many similarities in the challenges, and the opportunities, that hospitals face.

David: Do you see many differences in either the training or the mentality of hospital administrators or clinicians overseas? Do they have a different kind of training, and does that come through in their day-to-day work?

Karen: I would say that one of the impacts of accreditation that some organizations have said has come about as a result of accreditation has been the emphasis on teamwork and how they actually manage the organization. I think, here in the United States and in some other more developed countries, the concept of teamwork is how we're taught in some cases. But in some organizations, and some countries, they're very, very separate, and various disciplines have never worked together to solve a problem, until it's been part of the accreditation process.

David: Do you find that some of the leading hospitals are seeking accreditation from JCI, but also from other international accreditation bodies?

Karen: Certainly. I think when an organization is holding itself out to be a leading organization, it seeks validation from as many different organizations or standards setting bodies Malcolm Baldridge, the ESQM award in Europe. Many organizations will seek those out.

David: For example, the Trent Group out of the UK, when they talk about their approach, and they say that they sit and they discuss and negotiate the standards, based on local needs and sensitivities and traditions and perceptions of quality which sounds a little bit different from what you do is that compatible?

Karen: No, we do not negotiate the standards. As I said in fact, we're just coming out with our third edition of the standards this month they are developed. And I think one thing that very much differentiates JCI is that we have three members of the international community on our board of directors.

We have a standards committee that is comprised almost entirely by international members, and we have regional advisory councils in the Middle East, the Asia Pacific Rim, as well as in Europe.

And we really use these various stakeholder groups to help us develop consensus standards as they are being developed. What is the best practice? As I explained earlier, what might be attainable, applicable, to various health care settings, various cultures? But once that standard is set, it is not negotiated.

David: What is the interaction between accreditation and medical travel or medical tourism?

Karen: Some organizations are positioning themselves as a site for medical travel, and because of that, they are seeking validation regarding their quality. And accreditation is one means to do that.

David: When a patient is looking at different hospitals, what should they think of when they see a hospital as being JCI accredited?

Karen: One, they should know that every three years, the physicians within that organization's staff have to be reviewed, as far as their credentials and their privileges. That's assuring that the staff who are providing the services are competent and have the qualifications and training to do so. It's a very important aspect, the credentialing and privileging of services.

Infection control is another major area, as far as the MDROs, the multiple drug resistant organisms that organizations are facing worldwide. And we do have infection control standards. And I think that accreditation really is a commitment and a demonstration by an organization to have an external, valid, objective third party review.

David: So if a patient is planning a trip abroad for medical care, I'm wondering whether you would advise them to set up service by themselves, by working with a JCI accredited facility, or whether it makes sense to go through a medical travel agency, or if it just depends on the individual's circumstances.

Karen: The Internet makes some information available, but I would certainly review the quality aspects of an organization that they're seeking. There are also issues such as translation. Will they be able to translate? Here in the United States, or wherever the country is that they are currently residing in, will that physician be able to provide information to the facility? What about discharge planning and follow on care afterwards when the patient gets home? What about the portability of medical records? It's very important that they be able to carry their medical records to the site as well, you know, as back to the site. What about an emergency? Is the patient bringing an advocate with them? Do they have an emergency back up plan?

David: And are there specific services that JCI provides to patients?

Karen: We are... we do have on our website some information with respect to what I just mentioned, those are issues that need to be very paramount and important and we certainly have a quality monitoring system that if a patient has an issue or concern about an organization that is accredited and they would like to bring it to our attention, we certainly would welcome that and would follow up with the organization.

David: What kind of changes are you expecting to see in medical travel over the next few years? Is it something that you expect to continue to grow and become more significant and what sort of role do you expect JCI to play?

Karen: Well, as I mentioned earlier our mission is to improve quality and safety. Our predecessor organization here in the United States was established in the late 1980s and we began doing international work in the mid 1990s for improving quality and safety. We would not anticipate that we would change because of medical travel.

The issues with respect to patient care and continuity of care, portability of medical records, those are probably issues that we will examine if an organization is treating patients from outside the country, you know, what are they doing to ensure proper care. But we already require an organization to ensure that staff have translators and are able to accommodate the needs of language for the patient population that they serve.

David: Do you expect the number of countries that have JCI accredited facilities to increase? It seems to me that some countries, like the Philippines for example, or Malaysia, are trying to get more into the medical tourism business and I'm wondering if there's any impact from that?

Karen: Yes, I do. Although I don't think the increase in accreditation is only due to medical travel and medical tourism. The World Health Organization and the World Bank have really over the past five to seven years endorsed accreditation as a way to enhance the quality and safety of care for patients and the reason is because accreditation is one of the few frameworks that really embraces the quality improvement methodology and the World Bank, for instance, has done studies showing that a healthy nation is a more wealthy nation and therefore really embraces accreditation as a means to improve the quality and safety of healthcare for that country and obviously then, hopefully, over time, it would have an economic impact also on the nation.

David: If a hospital wanted to become JCI accredited, what should they think about in terms of budgeting for that purpose in terms of their own time and resources and then any fees that they need to pay?

Karen: Well, our average survey fee is between $25,000 30,000, again that's once every three years. It really would be up to the organization and managing how they would comply with the standards. Usually, in our experience, it takes an organization about 18 months to 24 months to fully prepare for a survey for the first time and to be in compliance with the standard and many organizations do this themselves without any help.

David: I'm wondering Karen, have you seen the movie "SiCKO"?

Karen: No, I have not.

David: Are you planning to?

Karen: I probably would. Obviously it's about an industry that I work in, so it would be interesting, but I've not seen it.

David: I know, I haven't seen it yet either but I know that one of the things there is Michael Moore taking people to Cuba for care, which sounds like an interesting choice. Are there any JCI accredited hospitals there?

Karen: No, there are not that I am aware of.

David: I've been speaking today with Karen Timmons, President and CEO of Joint Commission International. Karen, thanks for speaking with me.

Karen: Oh, enjoyed it very much, David. Thank you for the opportunity.