EDITORIAL

Academic training in the certification of medical facilities in Mexico.

La formación académica en la Certificación de establecimientos medicos en México

Juan Pedro Herranz Sanmartín¹

President of the Centro de Estudios Avanzados en Administración en Salud (Center of Advanced Studies in Health Management). www.ceaah.org.

The certification of healthcare facilities in Mexico is a established government program, depending of the Presidency of the Republic, as well as global need of the North American Free Trade Agreement (NAFTA) signed by Canada, the US and Mexico, that aligns our country with the progress and development towards a better quality in medical services and with other countries that have developed the accreditation and certification of medical services as a general policy.

As compared to the experience worldwide, we see that our medical services are lagging behind in such regard, due to multiple circumstances that have led to negative results to this date. The factors that have favored this scenario include primarily the poor managerial development of the governing bodies in hospital units, together with the ignorance and lack of interest in the implementation, application, execution and control of the certification methodology by managerial leaders. Besides, there are other specific factors that negatively influence certification processes, such as the organizational structure, design, and development, the lack of interest in understanding the culture of medical facilities that is based on the principles and values provided in the organization manual of each public and private medical institution, the integration of medical resources and inputs, including medications, wound-care materials, specialized devices, and hi-tech life-sustaining medical equipment.

All of the above results in a lack of control of the internal operational processes of medical and paramedical care, and administrative support, among others, that together have led to a delay in the implementation of the certification methodology in the hospital network of our country.

The strategic changes in terms of the implementation and operation of the certification process in our country, have evolved in a very specific manner, starting from the first strategy of assigning the process to private companies in 1999, with independent auditors. Though the results in terms of number of certified hospitals, deviations occurred that led to a strategic change in the country, moving to a direct and vertical control of certification, which became the direct responsibility of the Consejo de Salubridad General (CSG) (General Health Council), within the Presidency of the Republic, in 2002. For this particular case, auditors were trained by the CSG in the certification process of hospital units.

All these efforts were taken at the start of the certification process in the period of 1999-2002, in accordance to documents based in the initial criteria of the CSG (amounting to 345). These efforts resulted in the significant number of 365 certified hospitals, a figure that remained unchanged over the period of 1999 to 2007 .

The swings in the certification process due to the lack of maintenance and follow-up of the application, operation, and improvements of medical care in health facilities, prevented that many already certified health units were recertified after the three year validity period. It was clear that the health institutions were making significant efforts that, unfortunately, were lost due to a poor culture of quality.

Comparatively, the number of certification criteria of the CSG in 2002 (345 essential, necessary and convenient criteria), was far from that of Canada with its 1,609 criteria .

It must be highlighted that the responsibility of the implementation of a certification methodology was not assumed in our country until 1992, when the PHO took the first steps in all its member countries to establish certification councils, starting with Argentina and then with Brazil, Peru, Bolivia, Trinidad and Tobago, Guatemala, Colombia, and finally Mexico in 1997. This negatively compares with Canada and the US, both countries with a cultural development of more than one Century.

Certification activities started in our country in 1999 through a mixed association concept with subrogate private companies. This process stretched from 1999 to 2002, since corruption gave rise to certification institutions that had no verifiable elements to certify, like in the case of a Hospital/ Sanatorium located next to the Secretary of Health, as well as other cases. For this reason, the CSG had to centralize its control by training its own auditors, the number of which increased from 575 in 2002 to 875 in 2008.

Historically, the number of certification criteria started increasing since 2002. The number of criteria increased and the certification process was gradually discouraged, particularly in the public institutions of the country. In 2007, the number of certified hospitals decreased from 345 to 143, less than half the hospitals (345) that were certified in 2002.

When the certification processes became standardized as a result of the Free Trade Agreement (NAFTA) in 2009, there was again a considerable decrease in the adoption of good medical, administrative, and paramedical practices based on the safety of patients, their relatives and healthcare staff, using international goals and the concept of a safe hospital in the country's hospital care services. At the same time, there was an increase in the user demand, which led to issues in terms of the installed physical capacity, with insufficient human, material, and financial resources. All these factors promoted a unique change in the strategy that the General Health Council suffered when facing the reality of our country, since there was no development in terms of modern, duly implemented and certified structures and the processes were far from being efficient, documented, and measurable by International certification standards. Consequently, by July 2012, only 70 hospitals are certified in Mexico in accordance to the new homologated certification standards and to international goals, as compared to 3,500 hospitals of varying complexity in several developed countries of the world (OECD). It should also be noted that only 7% of the GDP is devoted in our country to health, as compared to the US with almost 17% of the GDP. Besides, in terms of indicators of health resources, Mexico ranks second to last, just before Turkey. Hence, it is clear that our development is poor in regards to guaranteeing the safety of patients.

Historically, Canada (1950) and the US (1913) are one century ahead than Mexico in the implementation of accreditation and certification processes, on par with European countries such as England, Germany, France, the Netherlands, Belgium, Austria, and with several Oceania countries, such as Australia.

The NAFTA was a visionary agreement signed by the then President of the Republic Carlos Salinas de Gortari. During his administration, he emphasized the strategic importance of the continuously improving the quality of medical services in our country, despite the limitations imposed by the lag in our cultural development, and towards greater efficiency, efficacy, and effectiveness in the first, second, and third level medical facilities.

The lack of training and integral knowledge of the certification methodology, as well as the conceptual subjects involved in the systematic training in this methodology, are critical for the healthcare providers in each facility, substantially limit the dissemination, acceptance and empowerment of the knowledge on the changes needed to improve the established systems, as well as the articulation of processes and, mainly, the individual development that promotes a change in attitudes and behaviors in healthcare providers. This last reason in particular must be given the due academic attention and represents the main challenge we must apply and develop in the 100% of the medical institutions, to facilitate the implementation and development of the certification process methodology.

The total hospital mortality is considered, in those developed countries that have a good performance in terms of the standardization of medical care processes, such as Australia, Germany, Canada etc., an acceptable indicator of no more than 10% of verifiable medical errors. In Mexico this indicator is quite high, of 40%. However, this percentage may be misleading since, due to our ingrained practice of masking evidence, and it is worrisome that it might only be the visible tip of the iceberg and that the risk index of the patients hospitalized in our non-certified medical units is even higher.

This has represented an eye opener to the existing circumstances in the health setting, reflecting the lack of a professional technical development in updated healthcare processes, with poor attitudes and behaviors by the medical, paramedical, and administrative staffs in regards to patients and their relatives, and inadequate safety in the medical facilities and use of resources, both of which should be focus instead in promoting the safety of the processes performed by the employees of medical facilities, taking into account their ability as well as the duly authorized good service practices.

The lack of adequately trained hospital managers that could manage and head each of the hospital units in the country, brings about a new academic opportunity, since it is necessary to train not only the directors, but all the members of hospital governing bodies, including assistant directors, heads of departments, coordinators, heads of office, heads of sections, etc. The methodology should permeate all the hospital management structure and, therefore, training of governing bodies plays such a significant role in the implementation and execution of the certification methodology in a medical facility.

It is necessary to propose a systematic organizational development process that integrates the acquired knowledge, provides value and promotes a change in the staff, strengthening the internal quality controls that are applied in our medical units, by means of chain of virtuosity and development in the training of managerial resources, based on the certification methodology of the General Health Council (CSG).

It is absolutely certain that able leaders would not be shaped that could assume all the changes in the certification methodology, with a permanent and integral character and, mostly, with the ability to implement, execute, integrate, and control its development within a medical organization, with simple one-week training courses. Hence, it is clear that the adequate training programs and counseling must be implemented for the healthcare professionals to be able to assume their commitments, with the appropriate hospital management knowledge, and to propitiate the basic platform for the CSG certification methodology execution and development in medical facilities.

Counseling is essential in the training of managerial leaders to ensure their integrity and systematic approach, to teach them the basic Management knowledge, the continuous quality improvement processes, as well as to promote the safety of patients, families, and healthcare providers, the safety of the medical facility infrastructure and of the life-sustaining installations, through the use and monitoring of structure, process, and results indicators that support and justify all the strategic change actions in each hospital, all of which could be achieved through the development of the hospital certification methodology.

Changes in the governing bodies of medical facilities lead to immobility and regression in the certification process of a hospital unit or health center. Therefore, 6 months are at least needed for the new manager(s) to assume control of the managerial and regulatory processes and to be able to push the certification process with a certain degree of certainty. This delay must be taken into account in the very same moment when the directors, managers, and heads of services are replaced, both at the centralized level and in each of the medical units.

The lack of management training in the high-level staff is another obstacle that delays the implementation and execution of standardization processes in each medical unit.

It must be pointed out that each medical facility differs in terms of its denomination, installed physical and problem-solving capacity, infrastructure, adequately selected human resources on the basis of their job profile diagrams, organizational structure and, particularly, diagnosis of ruling, structural, and processing requirements and needs. Hence, there are no master formulas, lists or steps to determine the time and depth of the certification methodology in each hospital or health center.

The average development time for the medical unit to achieve the necessary conditions to become certified is of approximately one year. The time varies depending on the group integration of each unit, involvement attitudes, Leadership and work carried out in regards to operational group dynamic tasks, to move forward in the implementation, execution, follow-up, and empowerment of a culture based on good practices and aware of the importance of developing the concepts of patient safety and duly standardized management development in each of the members of the governing body.

The certification of the medical units is a priority of the federal government and of our own institutions. With we assume our commitment towards quality in our services to the community, the citizens and/or the users who, in the end, are the main goal of our actions.

The change in the methodology strategy of the CSG certification process represents a specific challenge for the training of hospital human resources in order to provide certainty to the academic challenge, as well as to the implementation, execution, operation, integration and managerial and service control involved in this advanced system in the country, homologated to the existing International standards. For this reason, the current improvement program is justified, with the creation of operational training and post-degree processes that include a specialization in hospital certification capable of integrating all the required fields of theoretical and practical knowledge, giving rise to a proactive, innovative, and creative leadership that facilitates the methodological process work of medical unit certification.

The CSG decided in 2009 to strengthen certification and to improve its contents and general structure. This has meant to restart practically from zero, to look for new strategies for training certification auditors that assume the control and analysis of the new certification standards and that can manage the new Trucking and marking methodology based on the medical record. Hence, there is a need to review and to face changes in paradigms that should be addressed, both politically and technically, with gradual modifications assumed as a need for reforming medical care and hospital systems. This will be a gradual improvement process in the medical care and hospital systems of the country, both at the public and private level.

The search for new strategies in staff training involves a familiarity with the new certification methodology which also brings about new academic strategies that provide direction, orientation, planning, integration and control to continuously and permanently strengthen and provide the required certainty to this reforming methodology of the medical care and hospital systems.

The lack of adequately trained professionals that could manage and direct the particular needs of each of the country's medical units, brings about a new academic opportunity, since it is necessary to train not only the directors, but all the members of hospital governing bodies, including assistant directors, heads of departments, coordinators, heads of office, heads of sections, etc. The methodology should permeate all the hospital management structure.

It is necessary to propose a systematic organizational development process that integrates the acquired knowledge, provides value and promotes a change in the staff, strengthening the internal quality controls that are carried in our medical units, by means of chain of development and training of managerial resources, based on the certification methodology of the General Health Council.

The costs to establish a vertical and centralized academic line for the management staff to train leaders in the knowledge of hospital certification homologated standards are considerable, not to say anti-pedagogical, in most cases, since these students will spend more than eight hours in a classroom or auditorium, for a period of four days, in order to generate or shape in them the personality of an internal auditor aware of his executive role as planner, implementer, supervisor and evaluator of the certification process in each state of the country.

It must be considered that a formal academic project of this nature represents a global institutional effort that involves a change of paradigms, including major changes in the organizational culture of an institution and requiring a minimum training and educational period.

It is absolutely certain that able leaders would not be shaped that could assume all the changes in the certification methodology, with a permanent and integral character and, mostly, with the ability to implement, execute, integrate, and control its development within a medical organization, with simple one-week training courses. Hence, it is clear that the adequate training programs and counseling must be created for the healthcare professionals to be able to assume their commitments, with the appropriate hospital management knowledge, as well as the basic platform of hospital certification methodology of the General Health Council.

The training of managerial leaders must be really integral, capable of instructing them in the basic knowledge of management processes, the continuous improvement processes of quality, of patient, family and healthcare providers safety, of facility safety, of analysis and monitoring of structure, process, and result indicators, with the adequate organizational structure that supports and justifies all the strategic change action in each hospital by means of the development of the hospital certification methodology.

This scenario makes of hospital certification a priority in the agenda of the country's health institutions, both public and private. For this reason, we are giving a response to the needs of the medical care systems that must be addressed in the immediate present.

For all of the above, the Diploma Program in Management for the Certification of Medical Facilities was created that represents a creative and innovative academic effort and is supported its development and endorsed by the Scranton de University of Pennsylvania in association with the University of Veracruz. This new program was implemented after the Forum of Health System Reforms of 2015 in which the General Health Council participated through its Secretary, Dr. Leobardo Rui'z Pérez. Since then, the Diploma Program in Hospital Management that had been in force for more than 6 years and was endorsed by the Westhill University, experienced a clear innovative reform in its academic program with the inclusion of the methodological process of medical facility certification to train the certification instructors or qualified specialists that are supporting currently the progress of health institutions.

The Diploma Program for the Certification of Medical Facilities has already trained 4 generations of students. The implementation methodology of certification standards has been optimized and comprised 12 development phases and a specific academic program for the internal development of an organizational culture that must be established in parallel to the certification execution process with good practices, evidences, records, licensing, charts, analysis, and essential documents such as the health diagnosis for the outer setting, the situational diagnosis of the infrastructure for internal organizational knowledge, and the substantiation of the organization manuals of each medical facility, to achieve the essence and respect of those behaviors and attitudes that will lead to ethical and safety actions for patients, families, and healthcare providers, as well as the delimitation of processes and the development of operative groups.

The creation of documentary control systems on the intranet or internal networks of the medical facilities is an innovation that has currently strengthened the certification process through information access and documentary standardization. Likewise, the creation of a state control chart of the entire country to verify by state the status of public and private certified units, identify institutions, and have a signalized reikin of each state. Thanks to all these, we know that there are 111 certified medical and hospital facilities out of a total of 4500, that 98% of the certified units are private, and the Secretary of Health has no first-level certified health center in the country. Unfortunately, these figures only convey the weakness of our health system.

Only the firm support to creative and innovative academic strategies and to the control and training process of adequately trained auditors in this matter would make it possible to modify the current reality that prevails today in our great nation.