Keywords

Ambulatory Care, Medical Displacement, Case Study, Quasi-Experimental Approach, Latin America.

Introduction

The prompt access to medical procedures in various advanced nations has become an issue since overcrowded public and private health systems have increased the waiting time for medical care, including ambulatory procedures, limiting the coverage of medical insurance policies, thus jeopardizing patients' health. Voluntary travel to other nations is becoming popular to avoid long wait times. International medical displacement is a concept that indicates the consumption of medical treatment and medications in foreign countries (Pacheco et al., 2020). The two main reasons for international medical displacement are, on the one hand, individuals who seek equal attention in receiving medical procedures at lowered prices in developing nations, and on the other hand, those who move to advanced countries in search of sophisticated medical interventions not always accessible in their home country (Rico et al., 2022; Landazury et al., 2022).

According to various authors individuals included in the international health displacement concept are the ones whose primary purpose is to receive medical treatment and acquire medications. Patients' displacement also poses high risks of medical malpractices that jeopardize their physical well-being in a limited international consensus on the design, implementation, and periodic reviews of ambulatory medical care protocols to guarantee their physical safety (Dalen & Alpert, 2019; Puente et al., 2020). As a result, private clinics in developing nations have adopted complementary foreign outpatient care protocols to improve patients' and health insurers' confidence in local healthcare systems (Puente, 2017).

As a result, the Joint Commission International (a health accreditation body) has become a reference in ambulatory care standards that are followed by hospitals and insurance companies in developing nations throughout Latin America (Thorpe, 2012). Several clinics have begun to adapt ambulatory medical care protocols based on Joint Commission International standards recognized by international health insurers (particularly in the United States) to boost the number of overseas patients and diversify their revenue streams. Ambulatory care certifications by the Joint Commission International are based on three main variables: the length of an outpatient visit, follow-up attention, and a clear explanation of the medical condition identified by doctors to patients (Puente, 2015).

Foreign patients (mainly from the United States and Canada) seeking high-quality ambulatory procedures go to various Latin American JCI accredited facilities to receive medical care. However, the importance of this study stems from the scarcity of data on the influence of such certification on foreign patients' perceptions of quality, making it very difficult to understand the scope of the Latin American influx of medical displacement (Dalen & Alpert, 2019).

It is essential to identify perception disparities between individuals treated by analyzing such opinions in ambulatory procedures received in accredited and non-accredited facilities according to the three variables. This study associates the patient attraction strategy of selected Latin American Clinics in ambulatory procedures located in Bogota, Quito, and Mexico City, with 236 foreign patients quality perceptions. Descriptive-analytical research using a quasiexperimental methodology found a difference between accredited and non-accredited clinics in the three variables observed.

This study contributes to a better understanding of the effectiveness of international accreditations in outpatient services as an element of attracting foreign patients and increasing the confidence of medical insurers to send their policyholders to these destinations. The findings of this study are essential for healthcare researchers since they indicate the impact of such variables on patients' perceptions of treatment quality.

Ambulatory Care Protocols and the Quality of Medical Care

When it comes to providing high-quality outpatient medical treatment, doctors face several challenges, including protocol reporting. Using standardized protocols and case notes is essential to understanding patients' perceptions of quality. Critical care pathways and the Kingston case notes system based on standardized questionnaires have been chosen as vehicles to encourage their usage. Based on the three characteristics listed above, ambulatory treatments aim to improve patients' sense of quality.

The following research review demonstrates the role of the factors in improving patients' perceptions of ambulatory care quality. The restricted use of one variable has a detrimental impact on quality perception. Various researchers examined whether the length of a visit affects patients' perceptions of time quality (Romero, 2022; Medical Tourism in Mexico, 2022). Various authors have stated that although subjects were satisfied with their time spent with physicians (high valuation of the first variable), they reported that doctors didn't explain their medical condition in a "simpler" way, so it took much longer than they expected (low valuation of the third variable) (Lev, 2022). As a result, according to participants, longer consultation time does not imply improved patient-doctor communication. It has also been shown that doctors who are suggested by their social circles and close family members score higher on the communication component. Patients with such doctors are more tolerant of poor-quality explanations concerning their problems than patients with non-recommended doctors.

However, if doctors employ difficult jargon and do not devote enough time to answering their questions, patients' perceptions of communication about their medical condition will deteriorate over time. In Tabriz, Iran, similar research looked at the factors that influence the length of external consultations between professionals and their patient (Parrish et al., 2016). They discovered logistical challenges in bringing medical experts to remote locations, which harmed patients' perceptions of follow-up treatment (poor valuation of the second variable), despite participants' satisfaction with consultation time and physician explanations of their medical condition. Various authors examined the perception of medical care quality among patients in economically vulnerable situations as a preparation to the design of a social entrepreneurship program for Venezuelan immigrants in Colombia (Salisbury et al., 2013; Calvert et al., 2018; Zhao et al., 2018).

The authors found that nursing assistants working for the city of Barranquilla (Colombia) had a detrimental influence on the follow-up of ambulatory treatments due to a lack of preparedness in using a language that was easy to comprehend for the target audience (Puente et al., 2020; Rico et al., 2022). In other words, the health professionals who were monitored did not include the second variable in their quality guidelines for providing care to the poor. According to various authors, patients' perceptions of care quality are drifting away from reality. Patients are not first talked about their medical situation in a way that they can understand. Participants' impressions of ambulatory care quality improve when doctors and nurses are assertive in their communication about patients' treatments.

The average outpatient treatment duration increased by 22% in 18 months, according to research that used outpatient care procedures on 29 individuals. Participants expressed satisfaction in the third variable (Macano et al., 2017). They did, however, indicate that followup was poor (due to the low emphasis put on the second variable) and that they wished their physicians or nurses had followed them in person. Other researchers focused on patients' impressions of communication with their doctors over the course of three months. They found an association between physicians' usage of simple terms and their sense of quality (high valuation of the third variable (Omura et al., 2018; Jindal, 2018; Lee et al., 2018; Schnabel et al., 2016).

The use of intelligible terms provided a fuller picture of the participants' medical state, according to the participants. In a 2017 study, researchers looked at how the three variables were applied in ambulatory medical care in four Joint Commission International-accredited hospitals in South America. After the accreditation, the authors discovered that time spent in postambulatory care rose by 21%, and participants expressed better satisfaction with the second variable (Barghouthi & Iman, 2018). They also state that outpatient certification helped to improve clinical research methodologies and ambulatory data collection. Another research from 2017 found that using outpatient care procedures helped 34 individuals get a more accurate clinical diagnosis (Despotou et al., 2020). Such procedures not only achieve the three variables, but also aid in the improvement of certain clinical diagnoses. Outpatient methods were employed in clinical trials for 223 patients with anxiety disorders in the 2019 research (Rico et al., 2022; Jindal, 2018; Yang et al., 2022) The authors discovered that using such in data collecting improves medical risk assessment and mitigation accuracy (Avia & Hariyati, 2019). The given literature study is essential to explore the link between patients' perceptions of ambulatory care quality and the criteria listed above that contribute to the successful execution of outpatient procedures. These factors also improve hospitals' chances of getting recognized by the Joint Commission International.

The Joint Commission International (JCI) is an independent, non-profit organization that accredits and certifies health care organizations and programs. The Joint Commission's accreditation and certification program is widely regarded as a global leader in healthcare quality and patient safety (Bogaert et al., 2018; Inomata et al., 2018). By providing education, publications, advisory services, and worldwide accreditation and certification, the JCI seeks to promote patient safety and the quality of health care in the international community. It works with hospitals, clinics, and academic medical facilities, as well as health systems and agencies to promote high standards of care and provide solutions for reaching peak performance. It supports clinics to address the problems of maintaining excellent treatment as patients travel throughout the care continuum by defining and maintaining standards for health care quality and patient safety (Noree et al., 2015). The ambulatory care standards (based on the three observed variables) were created around key tasks that are shared by all accredited healthcare organizations.

The functional structure of standards is today the most utilized. The JCI relies on its Standards Advisory Panel, which is made up of experienced physicians, nurses, administrators, and public-policy professionals, to maintain best practices.

The JCI certification standards creation and updating process is guided by the panel. Latin America and the Caribbean, Asia and the Pacific Rim, the Middle East, Europe, and the United States are represented on the panel. The panel's recommendations are based on a worldwide field examination of the standards and feedback from experts and others with indepth knowledge of the subject matter. JCI accreditations guarantee that the care processes and highly complex outpatient medical follow-up are comparable to those used in the United States, the world's leading provider of high-quality medical care (Dalen & Alpert, 2019; Bogaert et al., 2018; Macano et al., 2017). This implies that health insurers who wish to secure access to highquality medical care in areas other than the United States, despite financial constraints or a lack of access to medical procedures that their policyholders want, have more reliance on certified complex medical institutions.

The Hospital Program accreditation is one of the most often applied by candidate clinics because of its importance in ensuring high-quality ambulatory treatment in certain medical procedures (as mentioned in the Methodology) (Parrish et al., 2016; Salisbury et al., 2016; Lazzari, 2018; Turner, 2007). The certification of the Hospital Program is based on the following sections: The first is the International Patients Safety Goals (IPSG), which specify how individuals should be identified before and after outpatient treatments. The second goal is to enhance patient communication by identifying early warnings of adverse outcomes in outpatient and highly complex treatments received in accredited clinics (Puente et al., 2021; Puente et al., 2020; Puente & Maury Campo, 2019).

The third goal is to use checklists to verify that the proper location, method, and patient treatment are performed, preventing procedural confusion and accidents. The second section of the Hospital Program accreditation is based on Health Care Organization Management Standards, which involves those responsible for the administrative management of accredited organizations in the planning and execution of programs for the safe care of their own and referred patients by US health insurers. The Hospital Program accreditation sections are based on the three variables to be evaluated in this study (the length of an outpatient visit, follow-up care, and a clear explanation of the medical condition identified by doctors to patients) (Puente et al., 2021; Medical Tourism in Mexico, 2022; Goldert, 2020).

The effectiveness of the three selected variables in the perception of quality in ambulatory medical care in subjects treated in accredited and non-accredited clinics (which are the basis of accreditation in the Hospital Program) is a verification route on whether the accreditation obtained is a major differentiator in medical care for international patients.

In terms of the dynamics of the international influx of patients to Latin America, according to Market Data Forecast, it increased by 18.9% in 2021, reaching a market value of US$10.3 billion, a massive increase from its total value of $4.3 billion in 2016. Medical interventions for curative and preventive ends are the most popular, followed by invasive and non-invasive cosmetic procedures, which account for a third of all interventions requested between 2018 and 2022 (Except for both 2020 and 2021, whose demand fell due to security measures because of the 2020 pandemic) (Parrish et al., 2016; Omura et al., 2018; Jindal et al., 2018).

Mexico was one of the first countries to capitalize on the burgeoning trend of international medical displacement, given its proximity to the United States. Currently, the quality of treatment in many regions of Mexico is comparable to that in the United States. Compared to the expenses of the identical procedures in the US, foreign patients can save up to 65% of the US cost per procedure. In 2016, the influx of foreign patients brought in US$4.7 billion, up 5.2% from 2015 (Yang et al., 2022; Noree et al., 2015).

In 2016, more than 1.1 million patients traveled to Mexico for medical treatment, becoming the second player in inpatient volume behind Thailand, with 1.2 million patients. Mexico's medical industry rose by 6% in 2017 and generated US 6 billion in revenue (Gibbons, 2017; Heymann, 1994). According to the Medical Tourism Corporation, dental and bariatric operations save 70%, Orthopaedics save 70%, and prescription medicine saves 30-60%. Doctors who provide treatments to international patients often do not acquire malpractice insurance. It is frequently utilized in the United States to protect doctors from legal action.

As a result, there's still a chance that in the event of medical negligence, the response time for complaints from foreign patients may be lengthy. In the case of Ecuador, although the country was formerly a source market for medical tourism, in which Ecuadorian individuals travelled to other nations for medical care and surgical operations, the country, is no longer a source market. Patients who got cosmetic procedures in Venezuela owing to the exchange benefit might be seen as a notable case between 2012 and 2015 (Zhao et al., 2018; Macano et al., 2017). The country is now a popular medical tourism destination, competing with Argentina, Brazil, and Colombia. The major reason is the low costs of dental prosthesis implants, cosmetic operations, dermatological treatments, and maxillofacial surgery. According to Poveda Burgos, ambulatory care certifications are essential to compete on an international level, so to ensure the high quality of dental medical services, the destination's health centers must have international accreditations that guarantee high levels of security, qualified personnel, and high technology to perform all types of surgeries (Romero, 2022).

In Colombia, in 2017, roughly 25,000 international patients visited Colombia for outpatient medical care, with over 3,000 opting for cosmetic operations. Approximately 70,000 patients sought wellness procedures, resulting in the provision of over 130,000 medical services (Puente, 2021; Puente, 2017). A patient who require post-operative therapies following highcomplex medical procedures and whose health insurance coverage for follow-up treatments is restricted is in high demand for outpatient medical services. Colombian authorities hope to increase the number of incoming patients by enacting Decree 3678, titled National Policy Productive Transformation and Promotion of Micro, Small and Medium Enterprises: A Public and Private Effort, which requires hospitals to be accredited for outpatient medical care and provides tax breaks to those who meet high standards (Pacheco, 2017).

In analysing ambulatory care procedures, the Colombian Institute of Technical Standards and Certification polled national medical centers to determine which international accreditation in outpatient care was the most well-known in the United States, identifying the Joint Commission International as the most important to promote alliances between medical insurers for sending their patients to the country.

The Hospital Program certification is held by five Colombian hospitals, which provide medical services to 64% of total foreign patients. The following accreditations for outpatient treatment were obtained in 2018: arthroscopy, biopsy, ambulatory surgery, and hardware removal (plates and screws), are among the procedures that can be performed (Puente et al., 2021; Puente, 2015; Fetscherin & Stephano, 2016). The Hospital Program certification is an essential element in determining future alliances between the studied clinics in the three selected countries and US medical insurance firms (Kasiri et al., 2017). Data on patients' perceptions of quality at accredited and non-accredited institutions might help researchers better comprehend the Latin American medical displacement dynamics.

Material and Methods

This research examined foreign patients' perceptions of the quality of care in five ambulatory procedures received in three certified Hospital Program clinics in Bogota, Mexico City, and Quito, as well as three non-certified ones based on the three variables on which the Hospital Program accreditation is based (the length of an outpatient visit, follow-up attention, and a clear explanation of the medical condition identified by doctors to patients).

Changes in perception were analyzed in 121 patients seen in accredited clinics in the three cities mentioned and 115 seen in non-accredited ones. A quasi-experimental approach based on a pre-test and post-test was applied to conduct a descriptive-analytical examination. Both groups were chosen using a stratified random sampling technique (patients who underwent medical procedures in accredited and non-accredited clinics). In addition, a focus group was conducted with each group of patients to determine the most widely held perspectives on the hospitals' efficacy in implementing the three variables.

An R software version 3.6.3 was used to conduct the statistical analysis. A focus group was applied to find both groups' impressions of how comparable the received ambulatory procedures were to those in not certified clinics. In addition, the accredited group was aware of their medical insurance's mobility coverage for care received overseas. The findings were also presented in a Tau-Kendall correlation coefficient. The focus groups corroborate the participants' impressions presented in the pre-test and post-test. Both groups completed a Likert pre-test questionnaire on their initial expectations for how they would be treated on a scale of 0-10, with 0 representing the lowest perception score and ten representing the highest. Participants provided written informed consent on published anonymous information. The questionnaires were completed following ethical guidelines for the use of anonymous data. Both groups retook the questionnaire (post-test) after the procedures were completed, using the same evaluation scale. Before the study, demographic data such as gender, and age were collected to see whether the two groups had similar characteristics.

The following were the working hypotheses:

H1: There is a link between outpatients treatments obtained in JCI Hospital Program accredited clinics and the high perception of the three variables observed.

H2: Patients who receive ambulatory procedures in JCI Hospital Program accredited clinics were sent by their health insurance provider to the cities chosen due to the similarities in outpatient care standards.

The cities indicated above were chosen due to the availability of resources for the study's preparation. For each case, information was collected in different years (2015 in the case of Mexico City, 2019 in Quito, and 2022 in Bogota). H. Medica Sur (Mexico City), Hospital Pablo Tobón Uribe (Bogotá), and H. Metropolitano S.A.S. (Quito) were the JCI Hospital Program certified clinics where the first set of patients received one of the five selected ambulatory procedures (biopsy, arthroscopy, endoscopy, removal of hardware (plates and screws), and other ambulatory surgery). These procedures were identified as the most demanded by individuals treated medically in accredited and non-accredited clinics.

It was decided to keep the second set of clinics unidentified due to the absence of a formal response to the request for the mention of non-accredited clinics to which the second group of patients underwent medical procedures. The Education For All Online organization provided the pre-test, post-test data, and the most shared ideas in the focus groups analysed in this study within the framework of the research project "The impact of ambulatory care accreditation in promoting foreign patients' medical displacement to Latin America: A quasiexperimental approach" under grant 2021-01-1.

Results

The T-test does not show statistically significant differences between the average age and the genre (Table 1).

Table 1 Average Patients’ Ages who Attended the two Groups of Clinics
Clinic	N (%)	Mean (SD)	Median	Min-Max	Statistics (P-value).
Accredited	121 (51.27)	51.80 (14.59)	53	19-95	0.1632
Not accredited	115 (48.73)	52.23 (14.14)	53	22-88	-
Total	236 (100)	52.02 (14.37)	53	19-95	-

Likewise, the number of subjects who attended an accredited and non-accredited hospital remains close.

College was the highest educational level (49.58) while the non-accredited hospital received the most patients with 48.72% of whole participants. The Chi-square test did not show significant differences in the gender variable; however, if a 90% confidence interval is used, the Chi-square test would show significant differences (Roos, 2022). Participants’ educational level and their city of origin did not show statistically significant differences between groups (Table 2).

Table 2 Distribution of Sample Variables in Accredited and Non-Accredited Clinics (Chi-Square Test)
			Clinic
	Total		Accredited	Not Accredited
Variables	n=236 (%)		n=121 (%)	n =115 (%)	Statistics (p-value)
Gender	Male	126(53.4)	57(47.10)	69(60)	3.4373 (0.06374)
	Female	110(46.6)	64(52.90)	46(40)
Educational level	College level Undergraduate level	117(49.58)	55(45.46)	62(53.91)	5.3458 (0.2536)
	Graduate level	90(38.13)	48(39.67)	42(36.53)
		29(12.29)	18(14.87)	11(9.57)
Country of Origin	Colombia	93(39.40)	50(41.32)	43(37.40)	2.6154 (0.2704)
	Ecuador	90(38.14)	49(40.50)	41(35.65)
	México	53(22.46)	22(18.18)	31(26.95)

In Table 3, the association between being referred by health insurance and being in an accredited clinic is close, as is the relationship between not being referred by insurance company and attending a non-accredited clinic, thus complying with H2. There is a high connection between the types of clinical procedures and the type of hospital (accredited and non-accredited), as in the case of ambulatory surgery (Table 3).

Table 3 Distribution of Sample Variables in Accredited and Non-Accredited Hospitals
			Clinic
		Total	Accredited	Not Accredited
Variables		n=236 (%)	n=121 (%)	n=115 (%)	p-value
Referred by his/her medical insurance	Yes	121(51.27)	121(100)	0(0.0)	2.2x
	No	115(48.73)	0(0.0)	115(100)
Outpatient medical procedure	Biopsy	12(5.08)	3(2.47)	9(7.83)	0.001156
	Arthroscopy	77(32.62)	53(43.80)	24(20.87)
	Endoscopy	99(41.94)	48(39.66)	51(44.35)
	Removal of Hardware (Plates and Screws)	44 (18.64)	16 (13.22)	28 (24.35)
	Ambulatory surgery
		4 (1.69)	1 (0.82)	3 (2.60)

Figure 1 shows the number of patients who received ambulatory medical procedures in accredited and non-accredited clinics. Arthroscopy was the most demanded procedure in accredited hospitals (53), while endoscopy was the most consumed one in non-accredited clinics (51).

On the one hand, the length of a medical visit has no relevance to a clinic´s accreditation. Being an authorized clinic does not ensure that the consultation time will be sufficient to demonstrate the patient's current state of health (The Editors Ecuador, 2022).

On the other hand, there is a link between a clinic's classification and the likelihood that a doctor will be aware of its condition of health once the treatment is completed. The expectation that patients would obtain intelligible information regarding their health state has nothing to do with the type of clinic (Table 4).

Table 4 Comparison of the Variables in The Pre-Test
Pre-test variables	Clinics	Average	Median	Min-Max	Statistics (P-value)
Length of an outpatient visit	Accredited	4.69	5	3-6	0.2303
	Not accredited	4.56	5	3-7
Follow-up attention	Accredited	4.41	4	3-6	0.000124
	Not accredited	4.90	5	3-8
Clear explanation of the medical condition identified by doctors to patients	Accredited	4.57	5	2-7	0.5354
	Not accredited	4.42	5	2-6

Patients' perceptions improved in accredited clinics, whereas impressions in nonaccredited clinics remained constant. The lowest and highest values at non-accredited clinics remained consistent. Table 5 demonstrates that, based on the p-value, the variables under study have a close relationship with the type of clinic, showing that patients' opinions of the quality of a certified facility are mirrored in their perceptions of the type of clinic, thus complying with H1 (Table 5).

Table 5 Comparison of the Variables in The Post-Test
Post-Test Variables	Clinic	Average	Median	Min-Max	P-value
Length of an outpatient visit	Accredited	8.69	9	8-10	2.2
	Not accredited	5.40	6	3-7
Follow-up attention	Accredited	8.48	9	7-9
	Not accredited	4.34	4	3-5
Clear explanation of the medical condition identified by doctors to patients	Accredited	8.92	9	8-10
	Not accredited	4.14	4	3-5

Graphically, in the post-test, accredited clinics continue to have greater levels of satisfaction, whereas non-accredited clinics have lower levels (Figure 2). It might have to do with how satisfied patients were following the selected ambulatory procedure.

According to the p-value, there is an association between the cost-saving factor and the length of an outpatient visit (0.01). The cost-saving factor is not related to the follow-up attention variable. It was found that the cost-saving factor is associated with a clear explanation of the medical condition identified by doctors to patients (Table 6). There is a relationship between the fact that a user considers that it received detailed information about its health status and that the arrival to the selected destinations was due to the similarity in the ambulatory protocols (P-Value 0.09), again complying with H1. The last question is not related to any of the post-test variables. In other words, there is no consensus on how long a medical visit should last and whether the patient receives detailed medical information.

Table 6 Correlation between Complementary Questionnaire and the three Observed Variables (Non-Accredited Clinics)
		Post-test
Questions	Length of an Outpatient Visit	Follow-Up Attention	Clear Explanation of the Medical Condition Identified by Doctors to Patients
	P-value	P-value	P-value
From 0 to 10, where 0 is the lowest perception and 10 the highest, indicate the extent to which your transfer to the selected city was due to cost savings in your medical care.	0.01	0.29	0.07
From 0 to 10, where 0 is the lowest perception and 10 the highest, indicate the degree to which your arrival to Colombia was due to health centers applying similar care protocols.	0.48	0.81	0.09
From 0 to 10 where 0 is the lowest perception and 10 the highest, indicate the estimated of time you consider medical consultation should last.	0.65	0.97	0.90

In two one-hour sessions, each group engaged in a focus group technique to express their thoughts on patients' perceptions of quality. The most notable thoughts are listed below.

One hundred and twenty-seven patients from the United States, sixty-seven from Canada, twenty-six from Puerto Rico, two from the Dominican Republic, and five from other countries were treated at the observed accredited and non-accredited clinics. Twelve participants underwent a biopsy, 77 arthroscopy, 99 endoscopy, 43 hardware removed (plates and screws), and 4 had other ambulatory surgeries. Medical insurance companies sent all patients treated at accredited clinics to the designated locations. Eighty-two patients were from the United States, twenty-eight from Canada, seven from Puerto Rico, three from the Dominican Republic, and one from another nation in the accredited group.

Three individuals had a biopsy, 53 had arthroscopy, and 48 had an endoscopy, 16 had hardware (plates and screws) removed and 1 had other ambulatory surgery. Its health insurance company referred all participants to the study. In the non-accredited group, forty-five patients are US nationals, thirty-nine Canadians, nineteen Puerto Ricans, eight Dominicans, and four other nationalities. Nine underwent biopsies, twenty-four arthroscopy, and fifty-one endoscopy, twenty-eight removals of hardware (plates and screws, and three other types of outpatient surgery). All patients in the non-accredited group declare that they travel to the locations on their own, that is, without the support of a medical insurer.

In the second section, participants discussed their experiences with patient-doctor communication and consultation time. All participants treated at certified clinics expressed satisfaction with the care they received, noting that the data collected on their medical record and follow-up care methods were like those in their own country (especially for the U.S and Canadian patients). "Doctors took their time to visit without rushing," "physicians and nurses spoke good English, and they tried so we could comprehend our medical problem with simple terms" were the most often expressed sentiments. Participants who had arthroscopy, biopsy, or endoscopy agreed that their medical insurance company sent them to the selected locations to receive a similar quality of ambulatory care.

They also mentioned that hospitals performed well with inpatient identification and communication. Sixty-two patients treated at a non-accredited clinic reported problems with information flow, despite their partial satisfaction with their medical care. They also stated that doctors' descriptions of the medical procedures to be conducted were insufficient, causing them to stay longer than they would have liked. According to participants, a lengthier outpatient visit does not mean that physicians provide patients with an intelligible description of their health situation. Considering that quality perception is not exclusively based on treatment duration, it is necessary to strengthen assertive communication between physicians and nurses to improve medical care quality. This widespread belief corresponds to the findings of the literature review, which show that a balanced application of the three variables leads to a successful implementation of ambulatory medical care practices. Participants who attended accredited clinics were more satisfied with the information flow process, indicating that accredited hospitals performed than non-accredited clinics.

The final section of the focus group asked participants for their thoughts on the follow-up process before and after ambulatory medical procedures. Patients in the United States who received care at accredited clinics were pleased with the follow-up.

There was a physical follow-up just after the procedures, according to everyone. Thirtynine individuals indicated dissatisfaction with the help provided by hospitals in bureaucratic procedures to enter selected locations (visa requirements, economic proof of short duration stays). Fifty-two individuals at non-accredited clinics indicated that their follow-up was done remotely, which they felt was insufficient. Both groups' opinions support H1 (patients treated in accredited clinics had a higher perception of ambulatory care quality) and H2 (patients who receive ambulatory procedures in JCI Hospital Program accredited clinics were sent by their health insurance provider to the cities chosen due to the similarities in outpatient care standards).

Discussion

The pre-test and post-test results revealed a significant difference in patients' perceptions of quality. The research results corroborated the findings in the literature review, indicating that the equitable application of the three variables has a positive impact on quality perception, as protocols play an important role in influencing consumer service evaluations and destination selection beyond cost-cutting considerations, particularly for patients from developed countries who are undergoing foreign medical procedures for the first time.

Quality perception is not solely determined by one of the three variables observed in the present study. To reach a high-quality medical treatment, each must be applied equitably. The findings and focus groups show that accredited clinics emphasize the application of the three variables. When this study is compared to similar case studies in the literature review, it is found that clear communication between doctors, nurses, and patients improves the perception of quality in outpatient care while also avoiding more time for consultation than is typically required in ambulatory care. This study adds to the literature review's findings that the third variable is perceived as being applied less strictly in the non-accredited group.

Another report cited in the literature review supports the non-accredited group members' viewpoints. Participants acknowledged satisfaction with the third variable in both studies but questioned the efficiency of the second variable due to the lack of in-person follow-up. Although certification in outpatient care does not guarantee that recognized institutions would perform more physical follow-ups, it does contribute to a better patient sense of personal medical attention. The selected accredited clinics in JCI Hospital Program enhance alliances with foreign insurance companies, as evidenced by data collection and focus groups. Patients stated that they were sent to such locations for the guarantee that similar care protocols would be applied.

Participants who had ambulatory procedures in accredited hospitals clinics shared the idea that, while accreditation encourages best practices in ambulatory care, many hospitals see it to attract American patients, dismissing other accrediting organizations during the post-test application.

Data collection and focus group ideas indicate that ambulatory care accreditation adds to international patients' arrival in Latin America, implying that foreign insurers, not just from the United States, rely on Joint Commission International accreditations as a medical displacement factor. According to the findings of the study referenced in the literature review, accreditation by the Joint Commission International implies that the patients polled express higher levels of satisfaction in the second variable. Unlike the previous study, which stated that accreditation in outpatient care has a positive influence on the evaluation of the second variable, this study verifies that accreditation in outpatient care has a positive impact on the evaluation of the second variable (Barghouthi & Imam, 2018; Fetscherin & Stephano, 2016).

The data obtained in the questionnaires and the shared thoughts in the focus group confirm the results cited in the literature review's second section. Achieving an International Joint Commission certification results in more international patients being recommended by their health insurance companies, which participants verified during the questionnaires. Nonetheless, various studies criticize the priority that government organizations place on gaining Joint Commission International certification to fulfil the standards of US insurers, claiming that it might have a detrimental impact on other private healthcare market sectors ( et al., 2020; Rico et al., 2022). Due to medical insurers' lack of familiarity with US ambulatory care protocols, Puente argue that patient attraction strategies based on obtaining JCI accreditations limit the scope of the medical offer from Latin American countries to other destinations such as the European Union or the Middle East (Landazury et al., 2022).

The notion floated in the focus group that Joint Commission International accreditation benefits American patients referred by their insurers more than other nationalities is consistent with the study mentioned above, suggesting that the Latin American medical offer focuses on a single country.

Medical insurance portability for patients from advanced countries in developing nations with public insurance is restricted. The major impediment to providing international health services is the lack of mobility for medical treatment. One of the reasons why more individuals do not engage in Latin American medical displacement is because insurance schemes in the US limit treatment overseas. If portable insurance includes foreign medical procedures and medicines, patients from developed nations may profit from the international medical offer.

However, the impact of insurance portability on home nations is unknown. While there is still more research to be done on this subject, there are compelling arguments for expanding insurance coverage globally. It's crucial to think about gaining comparable accreditations in outpatient medical treatment from other healthcare accreditation organizations to help broaden Latin American medical offers.

Conclusion

The findings support the notion that certification in ambulatory medical interventions is a tool that might help enhance the Latin American medical offer by improving foreign patients' perceptions of quality. It was found that the complementary relationship between the length of outpatient consultations and a comprehensible description from doctors to patients about their health situation based on assertive communication favoured the quality perception of selected ambulatory procedures in the three cities studied.

The International Joint Commission's certification in ambulatory medical care is a tool that promotes foreign patients' and insurers' trust in the selected medical procedures. This exploratory case study demonstrates that the strategic framework to boost foreign patient arrivals based on international accreditations has a favourable influence on the study population.

Acknowledgement

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Research was supported by Education for all Online Organization under grant 2021-01-1.

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Received: 18-Apr-2022, Manuscript No. JLERI-22-11794; Editor assigned: 21-Apr-2022, PreQC No. JLERI-22-11794(PQ); Reviewed: 05- May-2022, QC No. JLERI-22-11794; Revised: 28-Jul-2022, Manuscript No. JLERI-22-11794(R); Published: 04-Aug-2022