Inside an office at the Hong Kong Sanatorium and Hospital in Happy Valley, a team of five prepared a checklist before setting off to inspect various departments and offices.
They were not health officials, but overseas health care professionals invited to act as 'detectives' to check if the hospital had maintained satisfactory standards.
The five 'surveyors' sent by the Trent Hospital Accreditation Scheme, developed in Britain and adopted by 12 private hospitals in Hong Kong four years ago, conducted the hospital's third audit.
Under the programme, the 'surveyors' visit private hospitals in Hong Kong every two years to audit services ranging from medical equipment and hospital management to staff training and service standards for each department. They also make recommendations for improvements.
Of the five-member team that visited the Hong Kong Sanatorium, three were British and two were from other private hospitals in Hong Kong. They came from different medical backgrounds - hospital administration, nursing, doctors and paramedics. They stayed in the hospital for five days and were free to visit any department or office they wanted and to check records and documents.
Head of the Hong Kong Sanatorium, Walton Li Wai-tat, said the accreditation exercise was a good learning process for staff of all levels. 'It's a new culture for both the top management and frontline staff,' he said. 'We know we have to improve all the time as the standards of accreditation are continually raised.'
On August 20, 1998, three patients died of formaldehyde poisoning at the hospital, after disinfectant was pumped into their bodies. Although the Coroner's Court later returned a verdict of accidental death on three kidney patients, the incident, one of the most serious medical blunders in Hong Kong, has raised public concern over the supervision of private hospitals.
Dr Li would not say whether the hospital introduced the audit because of the dialysis incident, but he offered: 'The media at the time was very critical of private hospitals and we believed that we had to do something to restore public confidence.'
He also said private hospitals wanted to attract more patients from public hospitals, which take up more than 90 per cent of all in-patients in the city.
All private hospitals are under the supervision of the Department of Health, according to the Hospitals, Nursing Homes and Maternity Homes Registration Ordinance. The department's team - comprising a doctor, a hospital administrator and a nurse - inspects each hospital at least twice a year.
The areas of inspection focus on accommodation, manpower and equipment used in the hospitals, according to statutory requirements. The registration is renewed on a yearly basis.
According to the code of practice issued by the department in 2003, private hospitals should notify the Director of Health in events of public health significance, such as radiation health incidents, serious medical incidents or sentinel events, and outbreaks of infectious diseases.
But Dr Li said the Department of Health, as the licensing authority, did not have the duty to help hospitals to improve. 'The licensing board is there to check performance and outcomes - it won't tell us how we can improve the process. We need another quality assurance scheme,' he said.
Set up in 1992 in Trent in Britain, the accreditation scheme covers 35 small- to medium-scale hospitals there. Leader of the Trent audit team Colin Clews, a private hospitals manager from Britain, said mutual learning was the spirit of the accreditation, which was done through peer reviews.
'How it operates is the manager of a hospital from one region visits another area and assesses it, using a set of standards,' he said. 'The merit of the scheme is that inspectors can also learn from the hospitals they visit, and bring home their experience.
'We come [to Hong Kong] to provide the services, knowing that we can take back details of good practice.'
He said it was a low-cost programme. Surveyors provide free services and the hospitals only have to pay for accommodation and air tickets.
Mr Clews, who used to manage seven private hospitals in Britain, has visited all 12 private hospitals in Hong Kong in the past five years, and understands that there are doubts as to whether the team members could see the real face of a hospital, as the visit was not a surprise or undercover test.
'A hospital manager can paint you a beautiful picture, but when you go out to individual departments and talk to the staff and patients there, and check their documents and patient records, you can then form your own picture.
'In five days, it's very difficult for a hospital to disguise its real face - what is actually happening, what its staff members feel and what its patients and users feel. I can assure you, we are professionals and we know the questions to ask,' Mr Clews said. 'If everything is OK, a two-year full accreditation will be granted. If there's anything that a hospital has to improve, a partial accreditation of one year will be given.'
All 12 private hospitals in Hong Kong have received full accreditations.
Mr Clews said the team made reference to legislative requirements and the views of local professional bodies in setting accreditation standards.
The standard will be set according to the best hospital. It means if the best performer is running faster, the others have to catch up.
Team member Li Tin-chiu, a Hong Kong-born gynaecologist who has practised for more than 20 years in Britain, said hospital standards had to be adjusted according to a local situation and culture. He said it would be too rigid to apply all British standards to Hong Kong institutions.
For example, it is common practice for mothers in Britain to take care of their newborn babies at their hospital bedsides. But in Hong Kong, nurses take care of babies in a neonatal room.
'Although the rooming-in practice is common in the west, in Hong Kong, babies are taken care of in nurseries because locals believe mothers should be given more time to rest.'
Professor Li, who inspected the Hong Kong Sanatorium and Hospital's maternity and neonatal department, said he looked into the quality of baby care, breastfeeding policy, infection control and also security measures.
'These are all newborn babies with very weak immune systems, so infection control is of the utmost importance for the neonatal ward. We also go through the staff training records - what kind of courses they have taken, their emergency procedures for mothers who have serious bleeding during delivery.'
When he audited the same department two years ago, Professor Li saw room for improvement and made some recommendations.
'One recommendation was to ask the hospital to make sure midwives keep up with their skills, even though the birthrate in Hong Kong is dropping. I asked a question at the time: do they attend refresher courses?
'When I came back this time, the hospital had documented that it had sent four midwives to Kwong Wah Hospital, and each stayed there for one month for a refresher course. Kwong Wah Hospital is a public hospital and one of the busiest in Hong Kong, so the midwives had a chance to top up their skills.'
Although the scheme has helped private hospitals improve themselves, patients and members of the public so far have no access to the accreditation results. Scheme director Elizabeth Brownhill said it was up to individual hospitals to publish their own results. She said some hospitals worried that the public might 'misinterpret' the reports.
Dr Walton Li said the hospital had no plans to make public its own accreditation report. 'It's like a doctor's examination - would your doctor show you his examination report? We are here to deliver good services and we do not see the necessity to make public the report.'