Quality on the march, not on the run

Quality is synonymous with affordability, accessibility, less medication errors and many more benefits. Surprisingly, many Indian players are reluctant to formally set up a department of quality, observes Nayantara Som.

The Indian healthcare system, though unaffordable to many, can be truly described as being state-of-the-art. There are more hospitals now within accessible distance, and some that are cost-friendly. But are these the basis criteria with which hospitals are judged? If not then what's missing in the link? A quick survey will tell you: Quality. While the first two factors are dictated by external forces of physical feasibility, market economy and competition, quality is controllable and can be moulded internally.

The most desired hospital may impress you with their infrastructure, but if the staff is impolite you can be assured that the hospital has lost all credibility.

The Institute of Medicine (IOM) defines quality as the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.

"Quality in healthcare involves people right from the ward boy and to the CEO" - Somnath Das, VP Quality & Compliance, MEMG International India Pvt Ltd, Bangalore

Says Dr Hari Prasad, CEO, Apollo Hospitals, Hyderabad, "Quality in healthcare means quick access to care, good outcomes, meeting the patient's needs and avoiding medical errors." It is based on the principle as emphasised by Walter A Shewhart way back in 1931, that errors could be predicted and prevented even before a product was produced. Therefore, a defective product was never produced. To produce a quality product, training and educating employees about the importance of quality was a pre-requisite since they were the only medium for making the wheels of inputs and production moving. This was in the post World War II era when the world economy was in doldrums. This concept is now adopted by healthcare experts where an ongoing process of quality control and improvement is in operation right from the input to the processing and ending in the outcome.

"If your hospital is providing high quality services, you are providing acceptable services to yourpatients at an optimum cost" - Dr Aninda Chatterjee, Medical Superintendent, BM Birla Heart Research Centre, Kolkata

Says Somnath Das, VP Quality & Compliance, MEMG International India Pvt Ltd, Bangalore, "Quality in healthcare includes the involvement of people right from the ward boy and the ambulance driver to the CEO and the Chairman. If an ambulance driver believes that it is his responsibility to drive to the emergency spot on time and bring in the patients on time to the hospital, he is in a way contributing to the quality of the hospital."

The concept is measurable, and is intricately related to cost. In India for instance, with the tertiary healthcare being taken over by the private sector, the relationship between quality and cost has become all the more apparent. "Value for money is measured as a product of quality and cost. Due to the competitive economy, cost is dictated by external forces such as balancing your prices according to those of your competitors. This in turn will attract more patients," says Dr Aninda Chatterjee, Medical Superintendent, BM Birla Heart Research Centre, Kolkata.

But quality is not to be mistaken with luxury or high incurring expenses. "If your hospital is providing high quality services, it only means that you are providing acceptable services to your patients at an optimum cost," adds Dr Chatterjee.

Seeing new horizons

Though lying dormant, the concept of quality in India has been in vogue since the last two decades starting with bodies like ISO, NABL, and the recent entrants like JCI and newly constituted NABH. Some form of quality indicators (for instance, success rates after surgery) have been documented for a very long time.

Over the years, with healthcare entering the service sector, providers have realised that quality can be the determining factor for hospitals fighting out the corporate race for the numero uno position.

Recalls Dr Lloyd Nazareth, Associate Vice-President, Wockhardt Hospitals Group, "The first serious moves to establish formal healthcare quality systems in India started in the early 1990s. Several healthcare management schools started teaching quality management as part of their course curriculum and a number of hospitals opted for ISO certification. Though ISO was not healthcare-specific, it was good to streamline processes at the institutes, which adopted it. Initially, the focus was on Quality Assurance (QA), but gradually over the years it is shifting to Continuous Quality Improvement and Quality Planning."

Moreover, it was a report on medical errors brought out by The Institute of Medicines in 1997 that triggered the need for quality among Indian health providers. According to the report, between 44,000-98,000 Americans die from medical errors annually and medication-related errors for hospitalised patients cost roughly $2 billion annually for the hospital.

Points out Dr Krishna Seshadari, VP, Sri Ramachandra Health International, SRMC, Chennai, "This was a wake up call to healthcare providers who then began stressing on medical safety to enhance the quality of services in their institutions." Quality has evolved with advances in healthcare and today it has achieved the status of a critical component of any healthcare institution. Echoes Dr Nazareth, "We are also seeing a shift from a suppliers market to a buyers market. In a competitive scenario, the only differentiator will be quality."

Think local

Quality has evermore been stressed on with the growing stiff competition among corporate hospitals and the boom in medical tourism. In fact, the concept is even spreading to semi-urban cities, making this the topmost priority for hospital administrators. Establishing a brand image in the market is the reason experts say why hospitals should embrace the concept quickly. Moreover, quality is as perceived through the eyes of the patient. Quality helps to achieve that by catering to the three 'A's' which are the cornerstones for quality healthcare services—accessibility, affordability and acceptability. Says Vikram Anand, General Manger, Operations, HOSMAC India Pvt Ltd, "Corporates when setting up hospital chains seek to create a presentable image of their services. If they imbibe the concept of quality, they will be successful in setting up a sustainable model, attract good clinicians and a team of experts on board."

"With increasing choices, patients and clinicians and surgeons know that if quality standards are not met in one hospital, they can always shift to another hospital," adds Anand.

Quality is an interlinked process. "If a department does well because it has been following certain benchmarks, and reviewing, documenting and improving on its processes, it will be an initiative for other departments to follow this lead," says an expert.

Lastly, flourishing medical tourism over the years has been an impetus for hospitals adopting new strategies in bringing about quality services Says Anupam Verma, Director-Administration, PD Hinduja Hospital, Mumbai, "Prospect of medical tourism has created a platform of comparison on the quality front. It has precipitated a hidden business opportunity of vast dimension for a ‘Quality’ product where the differentiator is price and skills." Agrees Dr Kishore Murthy, Chief Operating Officer, Healthcare Global Enterprise Ltd, Bangalore, "Medical tourism is setting up quality standards in the country. This because most surgeons here have been trained or worked in some of the best medical institutions in the US or Europe."

Braced for impact

While stressing on quality is one thing, the question is continuous management of quality systems. It helps having a dedicated team of experts aiding the management of the hospital - both clinical and non-clinical aspects. If implemented efficiently, quality can elicit insurance companies, travel agencies and hotel chains to promote their brand, leading to an influx of domestic and international patients to their hospital.

The concept also brings in monetary benefits. Maintenance, documentation and reviewing on a regular basis can cut down operational costs drastically. "If an X-Ray machine is callibrated, then there will be no wastage of films. Similarly, regular reviewing can bring down wastage of resources from laboratories, infection levels and medical errors.," adds Anand. |Top quality services can reduce stay of patients thus making room for other patients and increasing the profit margins for the hospital.

HOSMAC of Mumbai, in its report observed that regular documentation and reviewing can bring down, patient admission time from one hour to 15 minutes! In the same project, an error detected (suspected to be the vendor's fault) in a machine could be traced and eradicated with continuous documentation and reviewing by the lab technicians.

Quality is futile if it is left only to ideation. Once an organisation commits itself to providing quality services, it must chalk out ways to execute them. Standards help to achieve that. "They are an important benchmark for an organisation to achieve its desired goals," says Dr Praneet Kumar, Director Quality Assurance, Fortis Hospitals, New Delhi. Standards are broadly divided into two categories - clinical and non-clinical. "Unfortunately in India there are no set regulations or guidelines set by the government for healthcare. Setting standards help to bring about that regulation. However, hospitals in India should not go for very high standards because they will be difficult to implement," adds Dr Kumar.

Clinical and Non-Clinical Protocols

Clinical: Some of the important clinical standards include infection control standards, air control management, laboratory services, use of antibiotics, ensuring that the exact protocol and methodology of tests are conducted, blood samples used, testing waste management, and standards for operational theatres. Clinical standards, may vary, but the final result is the patient safety and satisfaction and staff productivity.

Hospitals also concentrate on patient environmental safety where patient is the first program-for the prevention of patient falls prescription audit, infection control, clinical audit, credentialing and privileging of healthcare professionals, fire safety measures, control on use of hazardous material, codes for various situations like external disaster and child abduction, equipment management, water safety and safety rounds.

Many hospitals even have an air handling committee to review and set standards for keeping the indoor air circulation infection free. Says Dr Anil Parakh, Consulatant Anaesthesiologist, Bombay Hospital and Medical Research Centre, Mumbai, "In our operation theatres we have a laminal flow of air where a 10/10 feet of microfilters are installed just above the operating table to prevent stagnation of air and thus prevent breeding of bacteria. These laminar air filters are a must for joint replacement surgeries."

Non Clinical: Consolidating non clinical or service quality care is an important component. If a hospital is doing well, it is only because its patients have gone back to spread the good word. Training programmes for employees, tracking star performers, devising soft-skill techniques, identifying personal interests of employees, putting up a pleasant approach to customer clients and in-house programmes and outsourcing trainers and employees should all come under the avenue of standardisation.

Service quality is commonly attributed with two dimensions: technical and functional quality. "Technical quality refers to the quality of the service product. Functional quality describes the way in which the service product is delivered and the relationship between the company and its customers," adds Dr Murthy.

A fork in the road

Despite the consciousness, there is a general lethargy to adopt quality in hospitals. "Quality has to become a habit and a culture among all employees. This becomes a Herculean task for most hospitals," adds Anand.

"Lack of understanding the importance of maintaining a quality department and leadership commitment and appropriate coordination among the staff leads it to its sad demise," adds Dr Murthy.

Paucity of funds, lack of formal training for quality care, the reluctance to spend on infrastructure for achieving accreditation, lack of transparency in the system are some of the reasons meted out for lack of quality. In fact, many hospitals in the country go in for accreditation and set up a quality department to meet the benchmark standards.

But the department is conveniently dissolved once it gets the stamp of the body. "Hospitals should understand that quality is not just merely a stamp or a certificate to be hung up at the hospital and then displayed to your patients. It goes much beyond that," asserts Das. Verma puts in another perspective: "I think the reason would be that at some point, the jet of extra effort required to achieve a specific objective needs to be merged with the mainstream." Though hospitals may formally not have a department and a team, yet once organisations understand the concept and its intricate relevance to their hospital's gains, it is but pushing the envelope to a radical metamorphosis which is sure to happen.

nayantara.som@expressindia.com