The challenges of being a Center of Excellence
“This accreditation process has allowed us to self-evaluate, measure ourselves in the care processes we carry out, and in a broad sense, has allowed us to improve the clinical outcomes and the health conditions of our patients; on the other hand, it greatly fosters a culture of quality and its own research processes. Finally, creating a management model for chronic diseases like these, requires an organizational culture, with a good capacity for innovation and a commitment on quality and the best clinical outcomes, overall, it provides great opportunities for personal and group development,” In the words of Dr. Pedro Santos-Moreno, project coordinator for the Centers of Excellence and the Real-Panlar Special Group.
He is talking about the Centers of Excellence. Not an easy process, whose objective is to certify those institutions that comply with the standards defined by PANLAR in the care of patients with rheumatoid arthritis.
"What is expected is that the quality of life of the patients with arthritis improves with an adequate diagnosis, correct and timely management under the highest standards of quality in health," says Paula Beltran, a professional nurse with a master's degree in public health who works with Cencisalud, the institution in charge of the certification, and is accompanying PANLAR in the Centers of Excellence accreditation project. This final message, perhaps, is what gives the patients with autoimmune diseases more hope, more confidence in their doctors and, in one way or another, having doctors, institutions and well-informed and trained patients, creates a different bond.
"In 2020 we closed the first year of certifications after three years of defining the process and the certification of the first five centers last August," says Beltrán giving an overview of what these processes cover, and the path traveled.
“It is an initiative that has generated special interest among specialist doctors. It is a strategy that challenges the institutions and that gradually introduces them to the culture of continuous improvement, there are many opportunities, especially in health quality,” she says.
She ensures that PANLAR seeks to promote this culture among institutions that care for patients with rheumatoid arthritis in the region. "From the initial steps all the way up to the final accreditation, it enables a self-critical behavior, an improvement culture in care, administrative and clinical processes, in order to achieve the best clinical indicators in patients with RA."
“The first thing that the centers must comply with in order to be able to start the process is that the executives of the institution must have the political will and that the leaders have a desire to improve the quality of care," states Beltrán.
“Teamwork is crucial to achieve this. The success of the strategy is the synergy between administrative, executive and specialists’ areas. They cannot work as separate islands, but rather as an institutional project, which enables adherence to new processes and changes in culture if investment, infrastructure adjustments or increase in budget is needed. However, this is not a requirement, some initiatives for the accreditation have been successfully promoted by the leaders of care processes in AR.”
"You can start from a self-critical view of the processes, being objective, setting achievable improvement goals and thus, starting the processes firmly," she assures.
The accreditation standards were outlined by a consensus of experts (1) in order to define what the minimum requirements were, based on evidence, experience and the context of the different countries, members of PANLAR.
“Three accreditation levels were set (2). These depend on the robustness of the institution, the size, the number of patients and the required specialists: standard, optimal and model, not meaning that one is better than the other,” she says. All three have different levels of development and depend on the experience of the institution, time, indicators, among other things.
The levels were defined based on the idea that all types of institutions, taking into account the different contexts, have different dynamics and could be identified with a certain number of standards in some of the types of Centers of Excellence. Once the scientific evidence and contexts where defined, the three levels were set, and the strategy was launched.
“It is an innovative, multidisciplinary and interdisciplinary health care model based on ten key concepts,” says Dr. Santos:
1. Patient screening process for a more assertive diagnosis
2. Comprehensive multi and interdisciplinary care model
3. Well established treatment protocol adapted to local realities
4. Treatment focused on the achievement of individual and group clinical outcomes
5. Pharmacovigilance and pharmaceutical care process
6. Proper use of management indicators
7. Health personnel and patient education
8. The use of electronic medical charts in daily care
9. Data mining for local research and decision-making
10. Cost-effectiveness to ensure the economic sustainability of healthcare providers and healthcare systems.
To obtain accreditation as a Center of Excellence, the following steps must be followed: Officially state your intention (3,4), explain how the center is composed and start the advisory process to find out what type you could apply to. "They make an inventory as an institution, of all the people involved, different disciplines, therapeutic support, specialists, what teams they have," she says.
In this regard, PANLAR provided a free virtual platform training consisting of eight modules on health quality issues. This makes it possible to align the basic knowledge in health quality and engage the professionals of the center.
Being this a voluntary process, the objective was to provide information on the reality of the institution with what is available and adhere to the real care processes. "In order to take the inputs and design the improvement plan for the next step in the accreditation."
"The Real-Panlar project seeks to implement and certify Centers of Excellence in rheumatoid arthritis (RA) throughout Latin America, together with the support of the PANLAR Accreditation Center," says Dr. Santos. This project has had unrestricted support from PANLAR since its inception to guarantee its permanence and continuity, since its long-term objectives are:
• Creation of a network of Centers of Excellence in rheumatoid arthritis in Latin America.
• Generation of minimum standards of care in RA.
• Generation of clinical care guidelines adapted for our continent.
• Generation of management indicators appropriate to each country.
• Creation of an accreditation center.
• Creation of a center for continuous quality improvement.
• Generate regional research by countries and Latin America.
The next step was to define a timeframe for the execution of what was lacking, "we did not want to impose how things should be done, but rather suggest for example, the standards of each type of center," says Beltrán, taking into account context, population, health policy in each country in order to make the adjustments, which she calls "an orienting process fostering the culture of continuous improvement."
The next step was the compliance review. “A pre-visit is scheduled by local verifiers, that is, rheumatologists involved in the processes and who know the standards. They visited the institution to review compliance and do a prior check so that the final visit, the last step, would be positive, " she explained.
From that point on, a second improvement plan was generated, a timeframe for the execution of the checklist and so it was ready to receive the certification visit. “We did two in person in Argentina, the Hospital Italiano in Buenos Aires and the Italiano in La Plata. The pandemic forced the following to go virtually, making adaptations to the process,” says Beltrán.
The visit reviews how the processes are carried out to comply with each standard, with the intention of registering good practices, what is being done correctly and what can be improved. "The health issue is dynamic, it evolves every day and opportunities for improvement may arise," says Beltrán, stating that after this last step, the certification is carried out.
SEAL OF EXCELLENCE
Since it is a voluntary process, it highly requires the commitment of the leaders because it is the driver that mobilizes the rest of the processes so that the proposed goals are achieved, in addition to engaging the patients.
“Having a seal of excellence gives the patients confidence, a clear knowledge of the institution and a brand where people are going to be treated. Knowing that it had to go through a process to obtain the accreditation and is continuously improving with the objective of doing things right,” said Beltrán. The fact of measuring and comparing with existing standards, gives the reassurance that it wants to evolve and improve," she adds.
Currently there are four institutions in process in Colombia, Chile and the Dominican Republic in different stages. One in self-assessment, in the pre-visit improvement plan and in execution process in another three.
Among the most common aspects in which the institutions that enter this process have agreed upon, is the evidence and documentation of what is being done. “We are used to doing many things, but not documenting them and saying that it was done this way, and in the end noticing that it was better in another way. This, for example, is an undocumented improvement process,” she indicated.
“Many things are defined by the standards and the institutions are already doing them, but there is no documented evidence, so we must get used to saying why and how I did it. We know that the standard is met, but there is no way to support it, and this is why it is important to start rebuilding, "she said.
Institutions from 7 countries have applied, Colombia (5) being the country with the highest number of institutions that applied, followed by Chile (4), Argentina (2), followed by Peru (1), Dominican Republic (1), Ecuador (1) and Mexico (1).
To date, five institutions have been certified:
• Hospital Italiano de Buenos Aires, Argentina. (Model)
• Hospital Italiano de La Plata, Argentina. (Model)
• Biomab IPS, Bogotá, Colombia. (Model)
• Hospital Nacional Guillermo Almenara Irigoyen, Lima, Peru. (Model)
• Clinica Ciudad del Mar, Viña del Mar, Chile. (Optimum)
According to Beltrán, it reassures the patients that it is an institution that is interested in the continuous improvement in the quality of its care processes. “If I am inclined to continuously improve, I must always know the best clinical practices for the management of the disease and should have permanent training processes for all my staff. Additionally, the vision of the PANLAR Centers of Excellence is patient-centered care, which is the central axis of the entire process.”
This means that the patient participate actively in his/her treatment, participates in the decisions shared between him/her and the doctor, “it’s a leap in the evolution of care that we knew by making the patient participate and more likely adhere to the therapies, thus Improving the quality of life".
“Being connected to one of our centers means that the patient will have the resources available such as education programs and interdisciplinary management. Denotes an institution interested in having a model of care, not simply a stand-alone care, but responding to a designed model that has therapeutic objectives,” she added.
CENTERS OF EXCELLENCE
Each Center of Excellence spoke to us about the process and what it means to their job as a service to the patients:
Hospital Nacional Guillermo Almenara Irigoyen EsSalud, Lima, Peru
Rocío Gamboa Cárdenas, Coordinator of the Rheumatoid Arthritis Functional Department of the Institution's Rheumatology Service.
The certification process was a unique 2-year experience, first with training in quality improvement issues, which among other things helped us to “put the house in order.” The indicators proposed by REAL-PANLAR made it possible to organize various points of improvement in our processes, but above all, helped us believe in our teamwork, since the task was shared due to the characteristics of the requirements that cover multiple aspects.
We realized that we were doing several things that the certification required, but we began to systematically document them. It was also an opportunity to implement other, for example, the early arthritis onset tool and the clinimetric assessment tool for our patients which changed a lot thanks to the guidelines they presented us, even though it was a challenge to implement, we managed to make our directors understand that it was worth it.
An important aspect was related to sustainability and thanks to REAL PANLAR we realized that with our own guideline we could support the care model, this led us to be part of the current management guideline in RA, led by the Social Security in the country.
Picture 1: Appointment in Hospital Almenara: Lima, Peru
Hospital Italiano de la Plata, Argentina
Rodrigo García Salinas, director of the Rheumatology Department, Hospital Italiano de la Plata.
Our institution has a quality policy that is based on continuously improving our care, to meet the needs of our patients and their families. To meet the requirements of regulatory bodies and other interested parties, promoting the definition of quality and safety objectives, process-based management, use of indicators for monitoring and assessing the objectives and processes, participation and training of human resources, joining efforts in the definition and implementation of preventive and corrective measures and opportunities for improvement, and the use of technologies, that simplify the daily tasks and favor the integration of the hospital with the community.
The process carried out was very useful for us in order to reassure what we had been doing well, improve what we did wrong, and commit ourselves to the challenge of continuous improvement. We have no doubt that the PANLAR CoE accreditation will not only have an impact on our patients but on the entire community and is a paradigm shift in managing chronic non-communicable pathologies. This process confirms what our mission says: “place the patient and the family at the center.”
Picture 2: Rheumatology Department Team, Hospital Italiano de la Plata
Hospital Italiano de Buenos Aires, Argentina
Johana Zacariaz H, attending rheumatologist in the Rheumatology Department, Medical Clinic,
Hospital Italiano de Buenos Aires (HIBA)
It was an arduous task that required prior training provided by PANLAR, and this makes it even more gratifying to have received this recognition. The training helped us to learn to better organize the tasks that we had already been carrying out in the department according to the standards of good clinical practice, and to highlight those areas in which we needed to improve. The challenge of being evaluated by REAL PANLAR, and achieving the objectives, was also motivating.
We obtained a greater connection among the members of the rheumatology department and other specialists of the center, keeping a record of the virtual meetings with the participation of the aforementioned professionals.
Virtuality helped us to gather a higher number of professionals from different areas during the discussions of the clinical cases of the patients. Guaranteeing continuous education, interdisciplinary work, and alignment of a medical approach on case analysis. At the same time, most academic activities were virtual, which allowed a greater participation of rheumatologists and physicians in training to national and international congresses, and the participation of colleagues and specialists from different areas and geographic regions.
Clínica Ciudad del Mar
Alejandra Rojas de Reyna, nurse, Programas de Salud y Ley Ricarte Soto
The process was a joint collaboration of our team from the Rheumatoid Arthritis Center of Excellence and Karla Benz, clinical deputy director.
As a group, we were able to view the strengths that we have to maintain and improve over time, it also allowed us to see the deficiencies that must be addressed in favor of our certification, professional growth and the well-being of our patients.
The main differential factor lies in the methodology that we have in our Center of Excellence for Rheumatoid Arthritis that guides out interdisciplinary work. On the other hand, it is a recognition of collaborative work, highlighting the importance of our center at the local and national level.
Picture 3: Virtual verification visit with the Clinica del Mar team, Viña del Mar, Chile
Biomab IPS, Derly Duarte Hurtado, Auditor and Quality
By mid-2020, the final visit to verify the requirements was carried out in a virtual setting given the conditions of the covid-19 pandemic, where REAL PANLAR determined the progress and the actions implemented, the strengths and opportunities to improve processes, evidencing compliance with the 81 requirements contemplated in the pre-visit.
As a result of this visit, Biomab IPS obtained the certification as a Center of Excellence type Model in Rheumatoid Arthritis. The certifying body said that the strengths of the IPS was the will of the directives to continuously improve the center's processes, the quality of health established, the coherence between the processes, procedures and measurement of health outcomes with the RA patient Model of care and all its components, highlighting the adequate management of processes in the IPS, integrating the essential concepts of the REAL-PANLAR standards, among others.
- Santos-Moreno P, Galarza-Maldonado C, Caballero-Uribe CV, Cardiel MH, Massardo L, et al. REAL-PANLAR Project for the Implementation and Accreditation of Centers of Excellence in Rheumatoid Arthritis Throughout Latin America: A Consensus Position Paper From REAL-PANLAR Group on Improvement of Rheumatoid Arthritis Care in Latin America Establishing Centers of Excellence. J Clin Rheumatol. 2015 Jun;21(4):175-80. doi: 10.1097/RHU.0000000000000247.
- Santos-Moreno P, Caballero-Uribe CV, Cardiel MH, Galarza-Maldonado C, Massardo L, et al. A Consensus Position Paper From REAL-PANLAR Group About the Methodological Approach for the Accreditation Process of Centers of Excellence in Rheumatoid Arthritis in Latin America. J Clin Rheumatol. 2019 Jan;25(1):54-58. doi: 10.1097/RHU.0000000000000773.
- Santos-Moreno P, Caballero-Uribe CV, Massardo ML, Maldonado CG, Soriano ER, et al. Systematic and progressive implementation of the Centers of Excellence for rheumatoid arthritis: a methodological proposal. Clin Rheumatol. 2017;36 (12):2855-58.
- PANLAR. Accreditation Process of Centers of Excellence in Rheumatoid Arthritis – especial group Real-PANLAR. 2020. 6. Available in: https://www.panlar.org/sites/default/files/documento_tecnico_espanol_0.pdf