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The Teacher Learned: Improving Healthcare in the Middle East

ABSTRACT
Quality in American healthcare has become so second nature. However, there are many places in the world that need to adopt western models to improve their care. I was fortunate to secure a position to lead the improvement of patient care in two hospitals in Abu Dhabi UAE in the Middle East. Well structured plans and strategies were utilized and target dates set. Every challenge was looked at as an opportunity for improvement. The result was significant improvement in the quality of care and patient safety in these two facilities, the hallmark was full JCI Accreditation in May, 2006.

Background
It’s hard to imagine this lovely, ultramodern country was, only 35 years ago, mostly a barren dessert with few inhabitants. Oil rich Abu Dhabi, the largest of seven emirates making up the United Arab Emirates (UAE), is the capital, located on the Arabian Gulf just across from Iran. Neighboring countries are Saudi Arabia, Oman and Qatar. I arrived in August 2004, to what I described to my friends and family in Louisiana as, a climate “as hot as the heat in your face when opening the oven to check the Christmas turkey.” Except for this heat, you wouldn’t realize that you are in the desert. Palm trees, fountains and luscious well manicured flower beds (all watered daily year round) landscape all roadways. The cities are modern with contemporary sky scrapers, opulent malls and an extremely wide range of culinary choices ranging from international chains and top class restaurants to local cultural cuisine. Most of the population is expatriates or non-locals. The locals, Emiratis, are wonderful people and make you feel so welcome. Though Arabic is the primary language, just as throughout the world now, most people speak enough English to communicate effectively. Quickly I adjusted to the heat and humidity and realized that Abu Dhabi was clean safe, modern, multicultural, and friendly.

I had been recruited as an accreditation specialist by the governing health authority to prepare hospital for international accreditation by Joint Commission International (JCI), the worldwide branch of the JCAHO. The authority was requiring that all of its facilities pursue JCI accreditation. Tawam and Al Rhaba were to become the first publicly managed JCIA accredited hospitals in the UAE. Tawam Hospital, now an affiliate of Johns Hopkins International, opened in 1977, and is located in Al Ain, Abu Dhabi, a beautiful oasis city in the western region of Abu Dhabi. Tawam Hospital is a 450+ bed hospital offering comprehensive services and centers of excellence including oncology, IVF, pediatrics, and renal dialysis. Al Rahba ( Al Rah’ ha ba) Hospital is just east of Abu Dhabi. Al Rahba, a community hospital and regional trauma referral center, was opened in 2003 and currently staffs for 133 inpatient beds. The hospitals were the perfect contrasts in size, age and complexity of services. Each had many similar and yet some unique challenges in the preparation process.

The International Standards
It was evident from the beginning that, though my knowledge and experience would be useful in the project, I had to erase preconceptions and study the international standards objectively. The JCAHO standards were much more prescriptive compared to the international JCI standards. An important point is that it is almost as important what the standards don’t say as what they do say. Whereas, the JCAHO standards include American federal regulations, the international standards prescribe that you follow local federal law, thus you must become familiar with what the local government requires. For example, I knew that the surveyors would expect a thorough facility inspection (referred to as a Statement of Condition by JCAHO) and subsequent plan of correction; however, though the JCI expectation was the same, the JCI facility inspection standards seemed innocuous, and there was no Statement of Condition guiding document for the JCI survey because it would have to be based on a particular country’s civil code. However, I found the international standards in general to be well written, well explained and unambiguous in the expectation for meeting the standards.

It is important to note that much of the education on the standards to the hospital staff was explaining the intent and American terminology. Since the workforce in the hospitals was multicultural from 50 plus countries, standard terminology varied a great deal.

First Impressions
Though the hospitals were different in age and composition, I found the challenges to be similar on many issues: documentation, policy and procedure development, committee structures, quality processes, staff orientation, credentialing, interdisciplinary care, leadership structures, and teamwork. There was no federal minimum standard for hospitals thus the accreditation standards would become the minimum expectation for these facilities. There were few standards being met at either facility. This didn’t mean the care was bad; it meant that there was a great need for implementing the accreditation expectations to facilitate a consistent and sustainable pursuit of quality healthcare. Great treasures at both facilities were discoveries of pockets of excellence and strong desires to embrace the tenants of accreditation in order to improve.

There was great commitment of all levels of staff to the project, but most pleasantly surprising was the commitment of the physicians. Many of the physicians at both hospitals had western training and experience and realized the benefit of accreditation and were committed to the project which was paramount to the success. The true journey was about improving patient care and safety; accreditation would be merely a hallmark of excellence in the accomplishment of the ongoing sustained process for achieving those goals.

Challenges
As with any major project, change is hard for many people. Why change? The current systems were “good enough”. Communication barriers were indeed a significant challenge at first as each department worked independent of other departments for the most part. Most important was the need to convince some staff that the time for giving quality patient care was now, not at some future point in time. Particularly in regards to meeting standards, we could not wait for some future innovation to solve a challenge. Safe, high quality patient care was existent a long time before Western hospitals were automated and completely computerized. Thinking outside the box was an important part of the preparation process.

The concept of the expectation of governance of the hospital at a local level took some planning. All decisions for the organizations had always been made globally at the government level. The standards require strategic planning based on a particular organizations mission, vision and values. Even the term ‘governing’ and ‘board’ seemed particularly intimidating; however, after education on the expectation and the realization by the hospital leadership that these processes were essential to the pursuit of quality healthcare of the facility, the roles fell into place quite comfortably. They realized the benefit and accepted the responsibility quite seriously.

Many key hospital employees enjoy extended vacations during the summer months. Expatriates return to their country of origin or go on exotic vacations, and the locals flee the intense summer heat traveling to all corners of the earth. I determined that the accreditations would have to be completed during a January to June window in order to have all the key players in place at the same time.
Each challenge resolution brought more strength to the project. It Though the work was quite hard, the motivation stayed extremely high during the entire preparation process.The culture of change and the change of culture were great hurdles, yet essential to the successes of the project.

Resources
A most important resource is having an adequate number of copies of the actual standards. JCI also publishes a nice survey preparation tool which gives lists of the required polices and plans. Internet surfing provided a great resource of examples of policies and plans. Many of the required policies are unique to the international standards or quite different than the JCAHO standard. Examples for most required policies were located; however, some had to be developed from scratch based on the standard, the intent of the standard, and the measurable elements alone. JCI also offers an online databank of policy and plan examples.
There are many consultation companies that offer onsite advice. JCI offers customized consultation and onsite mock surveys and other resources which can be of great benefit. To get the full benefit, mock surveys should not be scheduled until all the required monitors, policies and procedures, committees and plans have been developed and implemented. The role of the survey consultation team is not to develop policies and procedures, plans and monitors, but to assess the quality of what is in place and to provide expertise on if the intent of the standard is met. Though I was proficient in my knowledge of the intent of the standards and did not need onsite visits; they were utilized and were beneficial in preparing the staff to interact with an actual survey experience. JCI also offers annual International conferences which include lectures on the standards and expectations, and visits to hospitals for mock surveys. It is a very enlightening experience for key staff that will be involved in the preparation process and provides a valuable tool for networking with other institutions which are preparing for accreditation and some that have completed the process.

A strong quality educator is needed as the expectation is that all staff is educated on the organization’s quality plan. Though this training can be outsourced, it is essential that there is an efficient in-house process to oversee the quality structures.

Support staff is essential. Proficient typists and educators are absolutely necessary in the development and implementation of policy and procedures. It is very likely that additional support staff will be needed for the human resources department because of the documentation requirements for physicians and nurses which require primary source verification for education, licensure, training and experience. It is unlikely that this information had been primary source verified in organizations that have not previously undergone accreditation preparation. This process should start early in order to give adequate time to meet this expectation.

Policy and Procedure Development and Implementation
Neither facility had any consistent policies and procedures nor did they have a policy and procedure standardization guideline for format and indexing of policies. These were major concerns. Not all people are good at writing policies. It is important to learn which skills each person helping has and utilize them in the areas they are most useful. Another lesson learned was that it’s much better to have a concisely written policy rather than a lengthy one. Joint Commission expects, and it makes sense, that a collaborative approach should be utilized for developing policies that are cross-departmental such as pharmacy policies, patient documentation policies, safety policies, etc. Most importantly it does absolutely no good to have a policy in place if the staff is not aware of the policy. Policies and procedures are not developed to meet standards; they are developed to guide employees in the provision of safe and effective patient care. The policy and procedure development stage will take at least a full six months and should begin early in the preparation.
It is important that if professional practice guidelines are to be used for procedure guidelines, all staff involved should be oriented to the reference guide. I found the indexing to some supplemental policy guides to be insufficient, so collateral indexes were developed for easier and efficient access.

Committee Structures
Both facilities had some committees established. Though some were excellent, most were not producing trended data suitable for performance improvement activities. I designed committee structures, terms of references and tentative standardized agendas for the basic hospital committees I was familiar with from my previous experience. The number and complexity of the committees certainly were different between the two facilities. Al Rhaba provided more general and basic services while Tawam offered comprehensive and specialized services in addition.
Coaching for efficiency in committee meetings was done. Tools such as timed agendas, documentation templates, and efficient preparation were utilized. I believe it is important after a meeting to either email or send memos to people who were assigned responsibility in a meeting reiterating their responsibility to the committee. It has been my experience that this facilitates a more efficient outcome and accomplishment without which topics can be inefficiently carried over meeting after meeting.
It became evident early on that culturally people enjoyed attending the meetings, were quite dedicated, and meetings rarely ended early. This was a pleasant finding as I had gotten used to years of rushed meetings in the West. The challenge was to make sure that regardless of how long the meeting lasted, that the time was utilized efficiently.

Required Track Records
The JCIA requires a four month track record for required monitors and processes for an initial survey and a twelve month track record for reaccreditation surveys. Failure to significantly meet this expectation could result in non-accreditation or an expensive follow-up visit. It is careful to be mindful of those expectations and to implement the required processes on a well defined time frame. A good rule of thumb is to plan for six months worth of data for an initial survey. In regards to reaccreditations, make sure the processes you have put into place continue to function according to the accreditation expectation. This track record includes policies and procedures, required quality monitors, consents, documentation elements, and required plans.

Project Management Tools
Before I had arrived at Tawam an accreditation steering committee had been developed and subsequent subcommittees, one for each chapter in the standards. We mirrored this at Al Rahba. They were assigned the role of interpretation and facilitation of meeting the requirements. This was a bit overwhelming at first for those who had never been exposed to an accreditation experience. I had arrived just in time to give them the direction and resources they needed to accomplish their tasks.

Quality management staff was in place at both facilities by the time the project gained momentum. I was very fortunate to work with some excellent staff that wanted to learn and had the leadership abilities to accomplish the goals of accreditation. The quality manager at Tawam was a local lady who had completed her healthcare management studied in the US. When I met her she had already completed half her masters study in quality management and by the time of the survey, she had completed the masters. She had excellent management skills and would work tirelessly to accomplish anything that was needed. Since she was local, I knew it was my role to develop her professionally so that in the future she could lead accreditations for the UAE. She believed in the value of the project and was a role model and great example to her peers.

Each week we would make a punch list of things that needed to be accomplished. Also, we kept a global list and timelines for milestones such as publishing and distributing the plans and policies and procedures, establishing the quality council, facilitating an effective governing board, assuring documentation was up to the standard, etc. No stone was left unturned.

With Tawam ahead in the preparation process, as much information as possible was shared with Al Rahba to assist them in their preparation process. However, deeper into the process each project took on a life of its own. The hospitals were different; even shared information had to be modified to meet specific needs.
Individualized meetings were scheduled regularly with committee chairs, department directors, and other key hospital staff to assure that there were no delays in preparation. Support from the Quality Department was consistent and well planned. Hospital leadership gave full support for the project and assisted as needed in any area.

Two mock surveys were conducted at each hospital, the first early in the process and the second five months before the actual surveys. The first surveys were too soon. Neither hospital had completed the policy and procedure development phase, nor, though timelines had been established for all expectations, only about 50% were met. The second survey was much more useful. It motivated the staff and gave confidence to the projects. It also exposed staff to the true survey process which would be found beneficial in the actual survey. My feelings of adequate preparation were confirmed with the second consultation.

Health Information Documentation
The JCIA standards have little to say about documentation; however, they have much to say about what should be assessed and reassessed and planned. There are no prescriptive directions from the standards for any of the documentation forms in the chart; however, documentation templates (forms) are the most efficient way to meet the intent of many standards. The considerations for the forms designs are the elements that should be assessed and reassessed and how to facilitate a team approach to care, inter-disciplinary care. At Tawam and Al Rahba, we broke tradition. No longer was there a nursing assessment and care plan form but an interdisciplinary assessment and care plan. Progress notes, also, were no longer the property of physicians only; all disciplines documented their care notes on the same form. At first, no one wanted to give up their traditional documentation system. Every discipline wanted to keep ownership of their own notes; however, through persistence and education, interdisciplinary documentation was accomplished. The system was designed with criteria for triggers for such assessment concerns as nutrition, pain, functional ability, social needs, etc. If certain areas were ticked, the appropriate discipline was notified to do a more thorough assessment on the patient. Documentation redundancy was reduced, the process facilitated a team approach to treatment, and with one month there was great satisfaction among care givers on the new documentation system.

Early in the survey process, comprehensive chart review for the important elements of documentation was begun. Findings were published and appropriate disciplines were educated on how to improve their documentation. By the time of the surveys, we were able to show track records of improvement along with the action plans that had facilitated the improvements.
A lesson learned was that it is very important to review charts for redundancy in documentation. Redundancy leads to staff frustration and inconsistency such as the physician identifying past medical problems and nursing finding different ones and the two never being reconciled. Design documentation forms based on standards and efficiency and with a process to facilitate a team approach to care.

It’s important that the forms design is a multidisciplinary process and by all means, use a professional to give ideas for layouts of the forms. For example, it’s much easier to review a vertical list for ticking of elements than a horizontal one. Make documentation count. A form should not be filled out to meet a standard; a form should be filled out to assist in patient care. A good rule of thumb is that you should not spend more time should be spent with the patient than with the form. Don’t be afraid to challenge each documentation element to make sure it is useful and necessary.

Feeling the Change
The greatest personal satisfaction was learning from the staff that there was an improvement in patient care. Patients also were more satisfied. Staff was more satisfied, and was empowered to make a difference if an opportunity for improvement was identified. Systems were improved, processes for procuring needed supplies and equipment were more efficient, and the facility was made safer for patients, visitors and employees. There was a general feeling of pride and accomplishment throughout the organizations. These hospitals now have a sustainable process to continue to improve. The greatest achievement was the facilitation of a team concept of safe patient outcome oriented care. These accomplishments were not something one person accomplished; it was the hard work of teams who wanted to make a difference.

The Reward
The true goal of the project was never only accreditation; it was improving patient care quality, safety and outcome. The accreditations as we say in Louisiana were lagniappe. The JCIA surveys were successful at both facilities. I came to this desert to teach and lead; I ended up learning and walking along side.

Conclusion
We are all so fortunate to have professions that make things better. These projects were of such great benefit to the patients. Implementing the accreditation guidelines added a consistency and stability in the absence of federal healthcare guidelines.
Though a task may seem impossible at first with well structured plans and goals and support from leadership, the impossible becomes possible. With proper utilization of our professional quality skills, we can make a much needed difference in the quality of healthcare services throughout the world.

BIOGRAPHICAL SKETCH

Mark L. Bradford, CPHQ, RHIT, was recruited to work in the Middle East as an accreditation specialist for the local healthcare governing agency. He arrived in Abu Dhabi, United Arab Emirates in August 2004, after a 22 year healthcare career in the USA spanning from Health Information Management and Quality Management to Healthcare Administration. Mark has an associates degree and bachelors degree from Louisiana Tech University in Ruston, Louisiana.

KEY WORDS

International Accreditation
JCIA
Documentation
Track Records
Policy and Procedure Development
Committee Structures