Hospitals that undertake high volumes of relevant procedures are likely to be stronger candidates for accreditation, as studies have shown that surgical complications and mortality rates are inversely related to the volume of procedures (see, e.g., Birkmeyer et al., 2002 and Katz et al., 2002). JCI accredited hospitals are responsible for renewing their accreditation every three years, and have to collect and report outcomes data on services rendered as well as quality indicators. Studies have found a positive association between hospital performance reporting and hospital quality improvement efforts (see, e.g., Hibbard et al., 2003).<sup>31</sup> The receipt of JCI accreditation by foreign hospitals could be used as the basis for selection to join the provider network of an industrial country insurer.<sup>32</sup> Foreign hospitals could also signal quality by establishing affiliations with reputed hospitals in industrial countries and mirroring their procedural standards, guidelines and clinical pathways. Foreign investment in the health care sector, sometimes inhibited by developing country restrictions, could also be a powerful vehicle for improvements in technology, managements and overall standards.

# _7.2 Accreditation of foreign medical professionals_

The second proposal is for doctors and nurses in export-oriented health care organizations to credibly signal quality by passing, respectively, the United States Medical Licensing Exam (USMLE) and the US National Council Licensure Examination for Registered Nurses (NCLEX-RN).<sup>33</sup> Since foreign medical graduates that practice medicine in the US are obliged to pass these examinations, a natural extension from a trade in health care perspective would be to institute a similar requirement for foreign physicians in exportoriented health care organizations abroad. It is also possible that as part of the residency program for physicians, foreign medical boards could form partnerships with medical centers in developed countries involving an exchange of medical experts, for example, as in the partnership between the Methodist Health care System of San Antonio and Mexico (see Albro and Norton, 1997).

Doctors that have passed the USMLE written and clinical skills exam, and have a sufficient number of training credits could be included in the overseas provider network

> 31 Hibbard et al. (2003) evaluate the impact of private versus public reporting on hospital performance on quality improvement.  They found that hospitals that received low scores in cardiac surgery and obstetrics initiated a higher level of quality improvement activities.  Also, quality improvement efforts in hospitals whose reports were made public appeared to be significantly greater than in hospitals given only private reports.

> 32 For example, companies such as WGA, Frontera and SMI have successfully maintained provider networks across the US-Mexico border for almost 15 years.

33 The first stage of the USMLE involves a test of medical science concepts, the second stage involves a test of clinical knowledge and skills, while the third stage assesses whether the candidate can apply medical knowledge and understanding of biomedical and clinical science essential for the unsupervised practice of medicine, with emphasis on patient management in ambulatory settings.

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