International Journal for Quality in Health Care 1999; Volume 11, Number 5: pp. 425–428
Report
Accreditation: the Argentine experience
in the Latin American region
HUGO E. ARCE
Technical Institute for Accreditation of Healthcare Organizations, Buenos Aires, Argentina
The development of the Latin American hospital accreditation
programmes had a heterogeneous evolution similar to that
of the region itself, despite the existence of previous assessment tools facilitated by the Pan-American Health Organization (PAHO).
As interest in quality of care spread globally – supported by
the universal dissemination of computer and communication
technologies – in Latin America the process took the form
of a ‘multifocal’ phenomenon: expanding spontaneously in
an unorganized and unplanned fashion. It should be pointed
out, however, that like the international culture encouraged
by the Internet, the trend towards quality in health care is
expanding horizontally, and not as a simple ‘top-down’
regional or national initiative.
The influences on the region were also diverse. First, there
was the significant impetus given by PAHO to promote the
preparation of a suitable assessment tool designed for the
Latin American Region, which would act as a recommendation
to start accreditation programmes in all countries. To this
end, many regional and subregional meetings were held to
exchange experiences and reach a consensus. Unfortunately,
only a few countries followed this trend.
Secondly, the international expansion of the Joint Commission on Accreditation of Healthcare Organizations
(JCAHO) in the USA, creator of the original accreditation
method, had an impact on the region. Initially, JCAHO
started its activities in both American and Canadian hospitals
[1], but later, Canada split off and created its own accrediting
body: the Canadian Council of Health Services Accreditation
(CCHSA). JCAHO continued only domestic assessments
until the early 1990s.
After an internal revision of its methodology, focused
mainly on results under the ‘Agenda for Change’ [2], JCAHO
tried to extend its experience and advice to other countries,
and especially to the Latin American region. For these tasks,
JCAHO relied on a subsidiary body: the Joint Commission
International. Today, CCHSA also performs consulting activities outside Canada.
Another influence on the region came from industry
through the International Standards Organization system.
This universal model of quality standards for processes
focused on production or service and now penetrated and
subdued health care organizations [3], though with few echoes
in this region.
Lastly, there was the influence of the regional commercial
agreements, Treaty of the North Atlantic Free Trade Area
(NAFTA) in North America and the Common Market of
the Southern Cone (MERCOSUR, in Spanish) in South
America. Although not focused specifically on health services,
these agreements will have a significant impact on the development of local trends in each signatory country.
Some Latin American initiatives
The regional process encouraged by PAHO began in 1990,
after it signed an agreement on technical co-operation with
the Latin American Federation of Hospitals (LAFH). Their
aims were to develop quality improvement programmes for
the countries of the region and an Argentine team was
entrusted with the task of studying the issues and writing an
accreditation manual, suitable for the Latin American reality.
This duty was performed successfully by a group of medical
audit experts counselled by different scientific societies. In
May 1991, in Washington DC, the draft paper was analysed
by 22 countries and approved after some formal changes.
The final version was translated into four languages, published
by PAHO [4] and a recommendation made for its application
within the region.
In December of that same year, a working plan was devised
to promote the implementation of accreditation programmes
through subregional meetings of health sector leaders. It is
important to highlight the fact that PAHO is an intergovernmental body. Consequently, the working plan and
agreement with LAFH implied an opening to local associations and non-governmental organizations. As a very
important share of the health sector is in the hands of Social
Address correspondence to H. E. Arce, Instituto Técnico para la Acreditación, de Establecimientos de Salud (ITAES),
Av. Córdoba 1827 – 8o C/D, (1120) Buenos Aires, Argentina. Tel:+54 11 4814 0615. Fax:+54 11 4814 0838. E-mail:
itaes@éxito.pccp.com.ar, [email protected]
 1999 International Society for Quality in Health Care and Oxford University Press
425
H. E. Arce
Security and private initiatives, all efforts were focused on
attracting the interest of these health care decision-makers.
From 1992 to 1995, there were four subregional meetings:
(i) the English-speaking Caribbean countries; (ii) the Andean
countries; (iii) the Spanish-speaking countries of Central
America, Mexico and the Caribbean; and (iv) the Southern
Cone. Finally, in October 1995, in a final Latin American
regional conference, it became clear that not all countries
were able to develop their own programmes by adapting
tools previously approved by consensus, because other key
stakeholders wanted a stake in programme development too.
Some countries such as Bolivia, Peru, Cuba, Guatemala
and the Dominican Republic adopted a modified version of
the PAHO-manual. Venezuela and Trinidad & Tobago [5]
instead adopted models based on the JCAHO manual. The
Ministry of Health of Bolivia enforced the programme only
for public hospitals [6], whereas the Chilean Ministry of
Health developed a continuous improvement programme for
public hospitals, methodologically based on the JCAHO
model [7].
Brazil is a rather complex case due to its federal structure.
Here, the Ministry of Health devised an adapted version of
the PAHO manual for general enforcement. The programme
is being applied in the states of Rio Grande do Sul, Parana,
Santa Catarina, Sao Pablo and Rio de Janeiro [8], although
Rio de Janeiro later signed a direct agreement with JCAHO.
Mexico, pioneer among the Latin American countries in
encouraging the quality of care movement and in developing
accreditation standards through the National Institute of
Public Health, deserves special attention. Located in North
America, it is included in NAFTA and is focused on compatibility with its regional neighbours. A prestigious consulting
group is now establishing technical co-operation links with
CCHSA.
Finally, Argentina – perhaps because it played a leading
role in the development of the PAHO manual – follows this
manual strictly, making adjustments and updating it. The
manual of the Technical Institute for Accreditation of Healthcare Organization (ITAES, in Spanish) stems from the PAHO
manual. Here the key stakeholders in the health sector are
developing an accreditation programme without any government support.
This overview based on available information, while not
exhaustive, aims to explain the multiple factors – such as
the organizational characteristics of each health system, the
domestic and foreign factors and the predominant political
organization – involved in a country’s decision regarding the
development and the implementation of an accreditation
programme. The USA and Canada, for instance, began their
accreditation programmes together in spite of the different
organizational structure of their health systems, but implemented them separately to fit their respective environments.
The Argentine experience
The Accreditation Project has followed a long and sinuous
pathway in Argentina. From the late 1970s to 1990, a so-
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called ‘preliminary’ stage was developed. Basically, several
bibliographic revisions were published and different trials of
quality standards were developed. Formal tests and ‘pilot’
experiences aimed at assessing different types of services and
hospitals.
In 1990, the joint PAHO and LAFH agreement provided
a special incentive that promoted the accreditation method,
and a draft paper was outlined, as explained previously [4].
Simultaneously, another agreement was signed by the main
providers and financing associations of the Social Security
System. As a result, the Joint Commission for Quality in
Health Care (COMCAM, in Spanish) was organized and a
draft paper developed within COMCAM’s framework. By
the end of 1991, as the health authorities changed, COMCAM
lost support and collapsed before starting its accreditation
programme [9].
The challenge to continue the project originated from a
wide group of private health care institutions. In this opportunity, their aim was not another political agreement
among a few great institutions, but to cluster many individual
hospitals, health providers, financial entities and various scientific societies. Consequently, in December 1993, ITAES
was constituted as a non-governmental, non-profit civil organization.
To review the existing tools (the PAHO/LAFH and COMCAM manuals) ITAES relied on the most experienced experts
in health care quality throughout the country. Their task was
accomplished with the support of several scientific societies,
i.e., surgery, pediatrics, intensive care, infectology, hospital
architecture and engineering, biochemistry, radiology, haemotherapy and immunohaemathology, anesthesiology and medical audit.
The accreditation standards include around 40 services and
activities. They avoided detailed and troublesome descriptions
(i.e. long event descriptions or extensive structure guides).
They focused on selecting the most representative tracer
criteria: representativity, simplicity and practicality. At present,
these standards are designed for use only by general acute
care hospitals [10].
The major methodological difference between the new
instrument and its predecessors was the omission of different
levels of satisfaction (three or four) for each standard, because
this contradicted the concept that quality in health care is
independent from the kind, size and complexity of the
organization. On the other hand, it fed a common Argentine
confusion between categorization and accreditation. As a
result of their different objectives, these two evaluation
modalities are complementary to each other. Whereas accreditation establishes integral quality criteria, categorization
stratifies the organizations depending on their complexity or
vital risk.
For the final accreditation decision, the individual weight
of each standard is equivalent. All standards corresponding
to the present services within the organization should be
accomplished. The standards have two parts: the first is for
evaluation and requires obligatory fulfillment, and the second
– applicable only once the first is fulfilled – is a number of
‘suggestions for improvement’. The obligatory part is divided
Accreditation in Argentina
into three columns: (i) the phrasing of the standard; (ii)
explanations of the text; and (iii) documents and data to be
provided by the organization.
When selecting the methodology and designing the evaluation instruments, the operative costs were considered versus
the reliability of results. The different steps in the assessment
procedure are:
• once the Requirement of Accreditation form has been
received and it has been verified that the hospital
satisfies the preliminary requirements, the surveyors’
visit follows;
• during the survey, the surveyors verify the requirements
for the respective standards using an instrument called
the operative form, which includes results and observations;
• finally, the information is processed by a computer
system into an evaluation form that enables the surveyors to reach the final survey decision.
The evaluation form adheres to the structure given in the
manual. Standards appear in consecutive order from 1 to 40.
All questions (675 items) are closed and binary (yes/no type).
The unique design of the operative form is embodied in 22
‘orderings of information’. An ‘ordering’ represents an area
and/or an individual in the organization where all the information required for evaluating the criteria used in more
than one standard is concentrated. The purpose of this is to
complete everything in a single visit. Both instruments are
linked by a common system of codes [11]. Hence, qualitative
data are used to evaluate all the methodological steps, unlike
the quantitative indicators, figures or percentages, as used by
JCAHO [12].
Training of surveyors in the accreditation methodology
requires a 16-hour intensive course. Participants do practical
work in groups (up to 20). A university degree in health care
or related disciplines is a prerequisite for the training. To
date, over 200 surveyors have been trained. A Code of Ethics
has established that the hospital is able to reject one or more
of the assigned surveyors given an adequate reason. Surveyors
must come from a different city or province from that in
which the hospital is located. The code also comments on
the confidentiality of results and field forms.
Possible evaluation results are Not Accredited, Temporary
Accreditation (1 year), Full Accreditation (2 years the first
time, 3 years henceforth) and Accreditation with Merit.
Once the surveyors conclude the field tasks, the Decision
Committee controls the reports and recommends that the
Board issue a decision.
Several ITAES’ Board Members participate in conferences,
academic activities and scientific events to explain the relevance of accreditation. A significant part of this effort has
been dedicated to distinguishing between hospital accreditation and the evaluation of providers performed by
financial institutions. ITAES states that accreditation is a
voluntary, periodic and confidential method based on known
standards and on objective accreditation bodies. Financial
institutions on the other hand, are linked to providers by a
work contract, and therefore, may be biased. The ITAES
magazine which includes quality in health care articles, ITAES
news and ISQua activities is another information tool.
ITAES is also developing an accreditation manual that
focuses on different types of ambulatory services, i.e. imaging
diagnosis, laboratory, ambulatory surgery, non-invasive
methods and rehabilitation. Manuals for behavioural health
care and dental care are in the developmental stages. The
review of standards for the Accreditation Manual for Hospitals is under way. This review of standards is done periodically. It will incorporate the core principles stated by the
ISQua in its ‘International Principles Panel’ and approved at
the ISQua Accreditation Symposium held in Budapest in
1998.
Health care networks accreditation: a
new trend
The accreditation of health care networks must be considered
a quality trend for the future. Health care quality pivots on
the hospital’s internal proceedings for the care of patients,
as well as the protection of health and prevention of disease
for the whole population through communal health care
facilities. For JCAHO in the USA, it simply meant a widening
of hospital methodology by starting a specific programme in
this way. To accredit a health care network, the hospitals
should be accredited first [13].
However, another accreditation organization emerged as a
competitor, the National Committee for Quality Assurance
(NCQA). NCQA developed the Health-Plan Employer Data
and Information Set (HEDIS), a set of quality indicators that
Health Maintenance Organizations (HMO) were to record
and process. The HMOs who chose to join this project can
be assessed by comparing their respective quality indicators
[14].
In 1997, the Institute for Technical Cooperation in Health
(INTECH; a Washington DC-based private consulting organization) selected some Argentine experts to develop an
accreditation manual, suitable for the continuous quality
improvement of certain health care networks which the W.K.
Kellogg Foundation had supported in some Latin American
cities. The Kellogg Foundation Project, called ‘A New Initiative’ (ANI), includes a strong participation of community
organizations, academic institutions and basic level care facilities.
The working group designed a completely new tool using
different criteria from those used in health care organizations.
Their target was to improve ANI as implemented by the
organizations’ leaders themselves, and not that it should be
used as a means of competition among different networks.
The standards designed by the group provide an ideal model
of a network that can be used as a reference. Another goal
was to provide programmes of disease prevention and health
promotion for the patient population. The entire project was
set out in two volumes: (I) Quality Conditions and (II)
Manual for Surveyors.
This manual is now being applied to test and review some
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H. E. Arce
ANI Projects: in Londrina and Marilia in Brazil, and in Cali
and Barranquilla in Colombia. Naturally, the final outcomes
of these experiences will modify the original papers, adapting
them to local conditions. Presumably, none will envisage a
regional Latin American scope. Nevertheless, this brief review
of different initiatives allows us to infer that the quality trend
is gradually extending its target from organizations to entire
networks.
Acknowledgements
The author thanks C. Marracino who guided the initial stages,
and R. Otero, who collaborated throughout the Argentine
accreditation process, as described in this paper. Thanks are
also due to G. Yaury for her valuable assistance, and V. Ques
who reviewed the final version of this report.
References
Conclusions
As it was mentioned at the beginning of this paper, the
international quality movement is proving itself to be a
‘multifocal’ phenomenon. Regional processes had, and still
have, a major influence, but in each case their scope is limited.
Many factors have affected their respective developments.
The regional quality leaders should try to stick to regionwide agreements based on principles, standards, assessment
tools and policies, regardless of their neatness. Yet, the
complex reality usually overflows all plans.
Furthermore, within each Latin American country, they
should strive for the adherence of these agreements by the
different institutions. The organizational model of the Latin
American health systems is generally pluralist, i.e. health care
services either are public, private or supported by Social
Security. Consequently, the decision power of the national
health authorities is usually conditional. It is thus reasonable
to expect that proven methods of quality assessment would
be fundamental for the regulation of their future health
policies. Hospital Accreditation is the most extended of these
methods.
In this process, ISQua has a significant role to play. The
plan accomplished by its accreditation subcommittee can be
considered auspicious because it is trying to address the
international ‘convergence’ on accreditation, not as a ‘topdown’ process, but as a natural agreement on criteria and
policies among participating bodies [15]. Nevertheless, bearing
in mind the inherent characteristics of the Latin American
region, this specific ‘convergence’ would represent a regional
contribution to the worldwide ‘convergence’.
Author’s note
In the case of (i) the Manual for Accreditation of Hospitals
in Latin America and the Caribbean, (ii) the Implementation
Project of Hospital Accreditation Bodies in Latin America
and the Caribbean, and (iii) the Accreditation Manual for
Health care Networks, the author of this paper was entrusted
with the task of wording the draft versions of these papers.
428
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Accepted for publication 21 May 1999