HealthManagement, Volume 11, Issue 3 / 2009

Indicators of Quality for International Hospital Patients

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With the increased number of international patients travelling for medical care comes an increased demand for information about the quality of care provided by a hospital. This article will discuss the relevant indicators of quality for international hospital patients and how they can be communicated. International patients have become a lucrative base for some hospitals, since these patients generally pay out-of-pocket at the time that services are provided. As hospitals assess, first, whether to dive into the medical tourism market, and if so, how to attract patients to seek care at their organisation, it is critical to understand the underlying factors that motivate consumers to travel abroad for medical care rather than obtain services within their home country.

Motivations to Travel Abroad for Medical Care

Three distinct, but inter-related, factors motivate consumers to travel to other countries for medical care – cost, access and quality. Individuals have a motivation to search for lower cost alternatives outside of their home country when they bear a relatively large portion of healthcare costs outof- pocket and healthcare costs within their home country are relatively high. Cost is an important driver of medical travel in countries with a large private health insurance market, such as the United States. In countries with national health service or social insurance coverage, such as European healthcare systems, consumers are more likely to travel for improved access, waiting times for certain elective procedures may be so long within one’s home country that some consumers are willing to pay out-ofpocket and travel to another country for  treatment if the treatment can be delivered more quickly than at home.


While care is provided at home with either no or low out-of-pocket costs for consumers in countries with national health service or social insurance coverage, long wait times or specific treatments not offered in the home country may drive these consumers to search for care in other countries that have shorter wait times or that provide that treatment. Waiting times are a major concern in countries such as Canada, but also in many European countries. Within the European Union, according to European Court of Justice decisions, national health services must refund hospital treatments in another member state if patients waited longer than medically acceptable.


Finally, and most importantly for our discussion, quality of care plays a key role in any decision to travel abroad for healthcare. Travel specifically for care that is of a higher quality than available at home typically occurs by consumers in countries with developing healthcare systems who are able to pay out-of-pocket or have government- provided insurance coverage that pays for care in another country.


Quality remains an important factor in selecting a healthcare provider, even for people travelling abroad who are motivated primarily by cost savings or improved access. Consumers searching for quicker access to a healthcare service are likely to demand care that is at least equivalent to the quality they would receive at home. Likewise, those searching for lower cost care would have some quality expectations. Hospitals must ask themselves, how do consumers identify “high quality” healthcare providers abroad, and how can hospitals signal that they deliver a high quality healthcare experience?

Quality of Hospital Care

High quality hospital care consists of at least three major categories; quality of medical treatment, communication and broader logistical quality. Quality of medical treatment refers to the effectiveness of the treatment and the technical quality of the care itself. This includes, e.g., pain control while the patient is hospitalised, or the absence of mistakes or medical errors. A recent Eurobarometer report showed substantial variation in the perceptions of medical errors by citizens across European Union (EU) countries. People were asked about how important a problem they thought medical errors were in their home country and where they were worried about suffering a medical error. Overall, 78% of the respondents indicated that medical errors were a problem in their country, however, nearly all Italians (97%) thought medical errors were an important problem while only 49% of Danish citizens thought they were an important problem.


A second bundle of quality indicators is communication in the treatment process. This includes clear pathways from hospital admission to discharge, starting with patient informed consent, clear and unambiguous provider-patient communications about the treatment plan and post-discharge care coordination with the patient’s general practitioner, and patient-centred care by involving the patient in the decision makingrelated to the care provided during the patient’s hospital stay.


The third bundle of quality indicators relates to the broader service quality. This includes logistics (e.g. support in making travel plans for the prospective patient and kin travelling with the patient), language skills on the provider side, and reception in the hospital environment. Well-organised logistical processes for international patients may be the differentiating factor between hospitals with equivalent medical quality and communicationsabout the treatment.

Signalling High Quality Hospital Care

Hospitals providing treatment to patients from other countries are not a completelynovel development. With a few exceptions, however, it is only a small fraction of their entire treatment volume. Apart from acute and emergency care for non-residents staying in a country for reasons other than to obtain medical care, these exceptions include some private hospitals aimed at international patients, some specific treatments such asaesthetic surgery and hospital cooperation in border regions based on bilateral agreements. If hospitals on a larger scale attempt to move into the medical tourism market they will have to signal that they deliver a high quality healthcare experience.


Signalling includes various information tools including an on-line presence of the provider organisation, presence on websites promoting medical tourism, the provision of electronic and printed materials in multiple languages, the establishment of an international patient department within the hospital, and having providers who are proficient in multiple languages or seamless availability of interpreters that cater to the languages of the international patients.


In recent years, hospitals have also begun to use international accreditation as such a signal of high quality to international patients – as a “stamp of approval,” so to speak. Accreditation is often a voluntary process of certification to ensure a minimum level of quality in a hospital, where hospitals must meet certain specified standards of care. There are at least four organisations that accredit hospitals in multiple countries, but only one has been active across Europe. These international accrediting bodies include Joint Commission International, based in the United States; Accreditation Canada, based in Canada; the Australian Council for Healthcare Standards International (ACHSI), based in Australia; and Trent Accreditation Scheme, based in the United Kingdom. JCI has 50 accredited hospitals in the EU, and Trent Accreditation Scheme has 25 accredited hospitals (Figure 1).


Hospitals competing for international patients must not only provide an exceptional patient experience that includes high medical quality, excellent patient-provider communications and outstanding service quality, but must also market their hospital internationally. Information on medical, communication and service quality must be easily accessible to international patients via the Internet. Potential international patients often rely on a handful of signals provided by hospitals to judge their quality – international accreditation, simplicity of the logistics required to travelto the hospital, and ease of communicating with the healthcare team. In the international patient market, providing a high quality patient experience is insufficient – hospitals must also market their patient experience to the potential patients.


Tricia J. Johnson

Department of Health Systems Management

Center for Health Management

& Policy Research

Rush University Medical Center

Chicago, Illinois U.S.A

[email protected]


August Österle

Institute for Social Policy

Research Institute for Health Care

Management and Health Economics

Vienna University of Economics

and Business, Austria

[email protected]


With the increased number of international patients travelling for medical care comes an increased demand for information about the quality of care provid

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