In our ongoing discussions on standards and regulations in health care, in today’s column, we will examine the roles of professional councils and associations, market forces, and legal frameworks that ensure transparent, uniform, equitable and consistent application of standards and enforcement of compliance.

Professional councils and associations

In many countries, the regulation of health-care professionals takes place outside of the formal government structure. In Jamaica, as with many Commonwealth countries, the regulation of physicians is done through the Medical Council of Jamaica. This body is composed chiefly of physicians with some layperson representation. They act to register physicians and regulate their conduct but only if there is a formal complaint made in writing to the medical council. Failure of a particular physician to meet acceptable standards in patient care may be reported to the medical council, which has the power to investigate and apply sanctions. Sanctions may include being struck from the medical register and losing the ability to practise medicine. An essential component of the work of the medical council is ensuring that physicians are pursuing continuing medical education and ethics training. Similar councils exist for nursing, pharmacy, and other health professions. Several arguments have been proffered about the need to amend the acts governing these councils to allow them to independently initiate investigations if complaints are in the public domain without necessarily being mandated to await a specific written complaint to the council. In the USA, for example, states have local medical licensing boards which are tasked with periodic licensing of health-care workers.

There is an independent licensing board for every professional class. Most state medical boards in the USA require biannual licensing that requires full compliance with strict licensing guidelines and disclosures. Proper documentation of required continuing medical education credits and hours must be submitted and verified independently. Failure to disclose significant adverse events would result in either denial of licensure or withdrawal of existing license. The boards operate independently and outside of external or political interference, and this ensures a fair and just application of rules to ensure that standards are uniformly maintained. Different from professional councils are also various professional associations that function like traditional trade unions but with varying negotiating power or clout. Examples would include the American College of Physicians in the USA, the British Medical Association in UK, the European College of Cardiology in Europe and the Nursing Association of Jamaica, the Medical Association of Jamaica, and the Pharmacy Association of Jamaica. These professional associations also have committees on standards, professional conduct, ethics, etc, that hold members accountable to minimum acceptable standards and can often respond when appropriate to ensure adherence to those standards.

Market forces/reputation

Reputation is an important way of maintaining standards. From the level of the organisation to the individual physician or health-care worker, a reputation for excellence often requires years of hard work and investment. The Massachusetts General Hospital and the Mayo Clinic are known as places of excellence in all aspects of medical care. Probably the most critical part of the worth of their brand is the clinical reputation. It allows them to attract patients worldwide, charge premium prices from insurers, and attract health-care workers who believe strongly in the pursuit of clinical excellence and patients are willing to acknowledge that value by paying for it. Places such as these have a strong incentive to deliver care that exceeds minimum standards in all regards.

In developed economies with more enlightened health-care consumers, employers and insurers are becoming increasingly interested in choosing facilities that can deliver high-quality care and will often steer patients towards these institutions where the long-term outcomes are better. Among enlightened patients themselves, reputation matters enormously, and employers respond to pressure from these patients to align with the best quality health-care providers. This factors in the selection of insurance service providers. In less developed countries, some insurers are more focused on profit rather than quality and may often default to the lowest cost possible, irrespective of the quality of care. Because the patient pool is not as well informed, Insurers are not under pressure to align with the best providers. Unfortunately, “any care” is not the same as quality care. When standards are not met, patients suffer in the long run, even if immediate adverse impact is not readily apparent. Our heart institute and heart hospital have become beacons for heart care in Jamaica. Patients travel from all over the island to be seen at “UWI” and If you, unfortunately, happen to get shot, the Kingston Public Hospital (KPH) is seen as the hospital of choice. These are decisions driven by patients’ perception and recognition of the reputation of facilities.

Law

The law can serve to promote standards in several ways. It can serve as a vehicle for a government to establish standards that require relatively little regulatory oversight outside of the court system. An excellent example of this is the HIPAA (Health Insurance Portability and Accountability Act) laws in the United States. This act serves to set standards for protecting patient privacy and medical information. HIPAA includes measures that should be used to protect patient identity, how medical records are stored, and how and to whom they can be released. These laws cover health plans, health-care providers, and other institutions dealing with health care records. If patient health care data is not handled according to law or is compromised, the patient can report the breach to the Office of Civil rights. Federal prosecution with fines starting at 50,000 US dollars or one year in prison is also possible. Given this risk, there are strong incentives to handle patient data and privacy with the strictest of confidentiality. The new Data Protection Act being implemented in Jamaica promises some similar protections.

A second area in which the law can serve to maintain standards is malpractice suits in which health care providers and health-care organisations can be held responsible for breaches in standards of care. Malpractice can occur when a negligent act or omission results in injury to a patient. In most jurisdictions, the legal process of malpractice is lengthy and often financially and emotionally draining for those involved. Ideally, malpractice litigation should be less and less needed if we can maintain standards in other ways.

Looking at the Jamaican context, we have opportunities in all the above methods of evaluating and maintaining standards in health care. We believe it would be worthwhile if the Jamaican State takes into consideration the aforementioned observations and how they may apply to our reality in improving the health of our people

Dr Ernest Madu, MD, FACC and Dr Paul Edwards, MD, FACC are consultant cardiologists for Heart Institute of the Caribbean (HIC) and HIC Heart Hospital. HIC is the regional centre of excellence for cardiovascular care in the English-speaking Caribbean and has pioneered a transformation in the way cardiovascular care is delivered in the region. HIC Heart Hospital is registered by the Ministry of Health and Wellness and is the only heart hospital in Jamaica. Correspondence to info@caribbeanheart.com or call 876-906-2107