Cultural barriers and Hospital Accreditation

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When a company decides to work on quality and in the pursuit of excellence, once it starts down that road there is no turning back. Since its origins, CHRISTUS Muguerza Alta Especialidad accepted the commitment of spreading within its staff the culture to imprint in their daily activities both elements of quality and excellence. With its vision to be leaders in the private medical attention field in Mexico by exceeding the expectations of medical quality and increasing the communitarian aid to the needy, the goal became something real… tangible. Now, who had the greatest knowledge in order to assess if we really excel in the quality of medicine?

Under the premise “that which is not written down and is not done does not exist, and that which is done but is not written down is not known,” in 2001 we commenced with the task of obtaining the Hospital Certification bestowed by Mexico’s general Health Authority (Consejo de Salubridad General). The challenge back then was to document, document, and again document.


The struggles of dealing with people’s resistance towards writing down their activities, in starting to gauge their performance by indicators, as well as added words to their vocabulary such as “process”, “procedure” and “plan”, where rewarded when the hospital received the recertification by this organism in 2005.

The foundation laid out during preparations for the national certification gave the collaborators at CHRISTUS Muguerza Alta Especialidad the confidence and certainty that, working as a team, the maximum international recognition could be achieved: being accredited by Joint Commission International, an organism whose certificate guarantees that health care organizations meet the rigorous standards designed to better quality and safety in patient care. The goal was not only to obtain this accreditation, but to be the first Mexican hospital to do so.

New challenges appeared along the road Quality management for Healthcare organizations has a new foundation today: patient safety. This must be an active process and so policies had to be created. We were forced to set in place processes and procedures that would more clearly guide the role of each staff member to reach this new goal.

Physicians were not used to working under the guide of specific hospital protocols. Getting them to understand how important it is for their patients – and for themselves – to document their findings and recommendations in the clinical record, to dictate the surgical procedure and participate in the implementation of processes like operating room verification of “Right Patient, Right Procedure, Right Site” before the start of a surgery, was our fundamental task. In due time and by continuously sharing the reasons of these procedures we managed to change their attitude concerning “Patient Safety” and “Medical Quality”.

Staff’s sensitization in quality and safety, transmitting confidence in their being knowledgeable in their own departments, free and peaceful talking about procedures of their departments during an interview, as well as appreciating each individual’s effort as “process expert” in the hospital, were the tools that allowed successful acquisition of Joint Commission International’s Golden Seal of Approval.

Clinical excellence has always been a passion and concern to CHRISTUS Muguerza Alta Especialidad. The achievement of this accreditation reflects our commitment to achieve and maintain these high standards.

LISSETTE CHAVARRÍA MARTÍNEZ MD is part of CHRISTUS Muguerza’s Internal Survey Accreditation Team