NABH releases Patients' Charter during the 2nd National Conclave of NABH Accredited HCOs

During the recently concluded 2nd National Conclave of NABH Accredited HCOs held during 17th & 18th November 2012 at New Delhi, NABH along with Disease Management Association of India (DMAI) has released a Patients' Charter on patients' rights and responsibilities along with Doctor's code of practice to address these right and responsibilities.

To view the proceedings on the conclave, visit the page by clicking here.

To view the Patients' Charter, click here.

NABH has more than 150 accredited hospitals in India today and the number is growing with each passing year. The patients' charter will help the accredited hospitals to provide enhanced patient-centered care along with higher assurance on quality of care.

Maintaining accreditation is the challenge, not getting it

Recently I was having a discussion with my fellow quality consultant, Parul, about our experiences in NABH implementation and some of the regular challenges we face. One of the things on which we both had the consensus was the fact that the hospitals still have not realized how quality and accreditation impacts them today and tomorrow.

The journey for accreditation begins with the organization and its management affirming its faith and commitment to quality. Quality is a way of life and it requires some difficult choices to be made on how we will do business and how we plan to serve our clients, i.e. patients. Quality demands that the compromises that an organization has been making till date need to be removed. Quality expects each individual to follow highest standards of professional conduct and comply with the established policies and procedures. Compliance with quality requirements ensures the organization also complies with all the statutory and legal requirements. Quality provides the overall framework for organizational operations.

At the time of accreditation, a hospital and its team temporarily gets into an energized state and somehow achieve the compliance. At times they are backed by skilled quality consultants who provide appropriate advice to the management, thereby simplifying the accreditation process. But the real challenge begins after your hospital receives accreditation.

You would start displaying the NABH logo in all your brand communication and you would highlight that you have cracked the tough NABH accreditation in your marketing programs. But if the necessary culture has not been established and your staff is not actually committed to quality, slowly but surely non-compliance will set in. The infatuation with the accreditation will be gone and the hard reality will arrive, i.e. it is extremely difficult to follow the standards if you do not believe in them and that you don’t have the necessary culture to support quality improvement.

The surveillance audit after 18 months from the date of accreditation will be the real test of an organization's ability to sustainably implement and maintain NABH standards.

Let me also bring another reality check here. The standards themselves keep undergoing transformation. The NABH standard for hospitals is in its third edition and other standards are also under revision. In due course of time, the standards will become stricter and the quality processes are expected to mature as the standards mature. Again, if the ownership for quality is missing among the staff, the organization will fall flat in re-accreditation audits.

Therefore, it is advisable that an organization should not hurry into its campaign to achieve accreditation. Rather, it should apply thought on why it needs accreditation and what is its commitment. Is accreditation just for the show, or is it a business decision? Are you committed to upgrade your processes when the standards undergo revision? Do you have the requisite organizational resources to ensure compliance with the standards in the longer run, or are you in only for a short run?

Keep the auditor in mind while implementing quality standards

Auditors are a tribe that everyone fears. People imagine them as enemies, trying to point out faults in their work even when they have given their best and “nothing more can be done”. The audit is seen as a cat-and-mouse or hide-and-seek game, where the seeker seems to be on a mission to ‘get you’.

Worry not, because an auditor is not an inch like that. The audit is a third-party review process, where someone who is unbiased and un-involved in a process reviews its performance against an established set of standards. The interest of an auditor is to affect change for the betterment of the client. The auditor plays the role of an observer, whose task is defined by his checklist, and he doesn't go out of his scope. He makes his observations backed by evidence.

It is this objectivity which brings respect to the work of the auditor. In case of NABH, the participating hospitals can even put a complaint if they are not satisfied by the auditor’s report considering bias or malicious intentions. The collection of valid objective evidences provides the grounds on which NABH recommends accreditation for a hospital or rejection of their application.

But do not consider the auditor as a naïve individual either. The auditor is generally an industry expert with sound experience and having undergone training in audit process. By the way of audit-trail, cross-verification and collection of evidences, the auditor makes a case for awarding or not awarding accreditation to a client hospital. There are unscrupulous elements/hospitals who try to fudge records, tell lies and temporarily create processes which seem to show compliance to the standards. But it is the task of the auditor to affirm the trust of the patients in the hospital via accreditation. So an auditor has to smartly criss-cross facts and fiction to come to right conclusions.

Therefore, it is advisable that you must follow the standards in letter and in spirit because you can’t fool the auditor and there are mechanisms to identify and capture non-compliances. However, also use the audit process effectively to seek suggestions for improvements because that is your opportunity to take advice from the industry expert.

World Quality Month – November

This is the time of the year when global quality community across industries comes together to assess its journey in quality and to discuss the new milestones needed to be achieved in the future. We in Indian Healthcare are also on our journey, backed by the Quality Council of India and NABH, to improve the quality standards and improve the experience of care delivered to our patients.

The challenge that we face looks insurmountable: India is a vast geography, with about 40,000 hospitals of varied sizes and there are no common standards of care or practice followed in all these centres. The industry also has been blamed for many malpractices and this has strained the doctor-patient relationship to some extent and created a dent in the trust that the patients put in their doctor’s ability to heal them. Yet there is a silver lining in the clouds.

Industry has accepted to self-regulate itself and has shown commitment and enthusiasm in accepting the accreditation and NABH standards as a means to re-establish the faith of the patients in our hospitals. There are wider discussions now on the ills plaguing the industry and many inner voices are coming out to question the practices and find an acceptable solution for a sustainable future. The govt. is also playing an active role in positively regulating the industry so as to identify the black sheep from the herd. Then there are awareness mediums online which are enabling patients to take appropriate decisions about their health.

As hospital quality professionals, it is our responsibility to define our role in the broader context of our organizations and partner with the internal stakeholders in building consensus on implementing quality standards and continuously improving them as a means to achieving enhanced patient care as an end.

Let me also state here that NABH is one point of view on healthcare quality in India, and there is a scope of further opinions to co-exist with it. I remember talking to the CEO of a famous ophthalmic hospital in Bangalore and he was complaining that the NABH standards are not suitable for single specialty hospitals like his' who delivery community-care to the masses. Then there are other administrator friends of mine who manage smaller hospitals built 20-30 years back when the current building bye-laws were not there and there was no QCI. They find it challenging to comply with the contemporary accreditation standards.

My idea is simple. NABH accreditation is also a voluntary accreditation standard for hospitals and is based on the mutually agreed upon standards. There is a scope for similar such initiatives by various segments of the industry who might find it difficult to comply with the infrastructure requirements, but they can formulate standards which would guide and regulate their clinical processes. I must admit here that the care processes and infrastructure go hand-in-hand, but it is also true that many hospitals are not going the NABH-way because some of the standards are unacceptable to them or put their operations at risk. In such circumstances, a separate set of standards which are inclusive of this community’s requirements, yet firm on the clinical standards, would go a long way in main-streaming quality standards.

We are living in changing times as the healthcare industry embraces practices such as lean, six sigma etc. from other industries. There are some centres of excellence who have taken a lead in such newer practices, but a majority remains out of the network. The reason for this is that the success stories of a few have not been replicated in others and we lack professionals with implementation skills. We also have not ventured on peer-benchmarking to explore the opportunities for healthy competition.

I believe the future looks optimistic and our journey is going to be long and arduous. Therefore, we need to continuously work together and build bigger and more inclusive networks of healthcare quality professionals to bring innovation in quality standards and implementation strategies and also to award and appreciate thought-leaders in this field.

Understanding the Cost of Compliance to NABH standards

As an NABH consultant, one of the challenges I face everyday is the hospital management's attitude towards compliance cost. The general feel I get from the clients is that once they pay the fee of their NABH consultant, they feel assured of getting the accreditation without incurring any other cost.

I write this post specifically to educate my colleagues who are in healthcare quality about the importance of estimating the cost of compliance.

There are many kinds of cost you would come across while implementing NABH standards. While many of these may seem basic, but the fact is that generally hospitals cut corners in many areas to keep their costs low and keep themselves profitable. Once the same hospital decides to go for accreditation, all such costs come to surface.

Think about some of these:

1. The increase in usage of gloves for infection control.
2. The need for fire extinguishers for compliance to fire safety norms.
3. The renovation needed in OT as per NABH guidelines.
4. The expenditure on patient education material and posters.
5. Printing of new forms, thereby leading to the dumping of inventory of all older forms.
6. The amount of stationery required for data collection for computation of performance indicators.
7. The expected reduction in the numbers of beds because of existing cramped up spaces.
8. The loss of clinicians’ time in treating patients because of their involvement in conducting clinical audits, in meetings for analyzing the data and in strategy meets for improving quality of care.
9. The additional HR professionals required to create and run an NABH-mandated recruitment and appraisal system.
10. The need for setting up a proper medical records department which will finally lead to an investment in an EMR.
11. The number of AMCs a hospital has to roll out to cover preventive maintenance of electrical and medical equipments.
12. The salaries for full-time quality professionals.

I can go on and on in identifying these costs which invariably a hospital has to incur to achieve compliance. But unfortunately most hospital managements overlook these costs or we quality professionals are not able to communicate the need for budgeting these expenses to the management.

I think there is a dire need for us to develop models to estimate this cost of compliance when we start any accreditation program otherwise managements lose their interest in accreditation mid-implementation because they are not ready to or they are not able to afford these costs. We can drastically improve the success rate of accreditation programs if we can help managements budget these expenditures pragmatically and not lose time and interest in the quality implementation programs.

Understanding Nigerian healthcare system and business scenario: Experiences from week 1 of my visit

A travel from one continent to another one can really change one’s perspective to life and people. I got a similar opportunity to travel and train my perspective on Nigeria during my current assignment. Along with my colleague, I am in Nigeria for a 3 week multi-project visit. One of the things we are doing is trying to understand the Nigerian healthcare delivery system through the eyes of the Nigerian providers. I am in the 2^nd week of the visit, so this post is coming right from the Nigerian soil at the city of Port Harcourt in Rivers state.

I would not make this post a travelogue. Rather a quick gist of some interesting observations about the country and its healthcare setup from the eyes of an Indian who travelled to this country for the first time. So you can expect a whole lot of comparison, because that’s a natural outcome of my observations. We have already visited 3 cities in the first week, i.e. Abuja, Lagos and Calabar. Abuja is the national capital; a very modern city built with a western town-planning. Lagos happens to be Nigeria’s commercial capital as most businesses are based here. Calabar is like Goa, an exotic place with a life of its own and an ample amount of peace to offer.

Abuja is a city with most of Nigerian federal govt. setup, so one can easily observe a lot of govt. offices of all sorts in the city. I was amazed to visit such a modern city and it appears and feels very formal, very bureaucratic. We were there in the city for a day only, but from our discussions with various healthcare providers and through our own visit to various places in the city, I felt the healthcare system in the city not upto the mark. More on it would come during the third week of our Nigerian visit. But an important thing to note is that there are embassies of many countries in the city and headquarters of many multi-national corporations in the city, so it has a healthy number of expats (with shifting population) who would pay well to access quality healthcare.

We spent most part of the last week in Lagos. The city has a long history as a major trade centre of Nigeria and continues to attract businesses as an important hub of financial activity. Mostly the roads get chocked by the traffic, yet one can feel the seriousness about business in this city. Spread over mainland and island suburbs, the city was better on healthcare delivery system availability. Yet, Lagos is very expensive in terms of healthcare costs and I think this can be partly due to the high commercial property rates and expensive labour in the city. Another source of high cost is power/electricity. It is mostly not available from the public utilities company, NEPA/PHCN. So most people and businesses use their own DG sets and power generators and UPS set-ups. Some hospitals quoted that as high as 90% of their power consumption is met by alternative sources only. Round-the-clock electricity availability is apparently the top-most worry of any Nigerian healthcare provider. But the good thing is that there are some good private hospitals and diagnostic centres that have done fairly well in attracting and retaining patients and building a brand over time. Lagoon Hospitals, Eye Foundation Hospital, Me Cure Diagnostic Services, Pathcare etc. have built great infrastructure in the city to enable good quality delivery system. There were other providers too who are trying to do good work in whatever little infrastructure they have built. But definitely there is a lot of appetite among the healthcare providers to attract investments and collaborate with other healthcare facilities across the globe to offer more and better healthcare services to their patients.

Calabar, to me, is like a small village. Quiet place with a small fixed native population. The whole atmosphere is the city is so laid back, waiting to go back to sleep each moment of the day. The people of the city are also mostly from middle and lower income category. Calabar is relatively cheaper than the other 2 cities that we visited, but there aren’t any decent private healthcare setups in the city. The city offers a good opportunity to create affordable healthcare facilities as many patients from the neighbouring states pour into the city for their healthcare needs.

Now time to share some interesting observations about the country. Nigeria is the most populous and one of the wealthiest African nations owing to its oil reserves (it is the 12^th largest producer of petroleum). Most of the GDP is contributed by oil exports and this happens to be a major source of employment. Nigeria has very little domestic production; therefore it is a major importer for almost everything that a common man requires. You name it, they import it. Therefore there is no concept of fixed MRP (Retail Price) in the country. 10 people would sell the same thing at 10 different prices. It took us time to understand that there is no apparent logic in pricing in this country. An Indian rupee (INR) is equivalent to about 3 Nigerian Naira (NGN), and 1 USD = 157 NGN. But we went mad trying to apply conversion here, because most things cost much higher compared to their prices in India. Mostly that is due to the reckless pricing that sellers do here. To their good fortune, buyers pay whatever money is charged to them. To give you an example, we were in a restaurant in Lagos which did not display prices of the items on the menu! (Of course, it was an exception).

In terms of road network and other infrastructure, we felt Nigeria is way ahead of India and a visit to Abuja can really give an Indian an inferiority complex. But Nigeria also falls short of India in many other sectors, including healthcare. I would say, Nigerian healthcare market is like Indian healthcare market of 1980s and 1990s when very little healthcare infrastructure existed, and with less focus on quality of care. Indian healthcare market witnessed a boom because of the larger and widespread participation of private healthcare businesses who invested heavily in expanding the infrastructure. Consequently, Indian doctors now-a-days find lesser reasons to work abroad. But that’s not the case with Nigeria. Brain-drain is very strong and many Nigerian patients would trust expat doctors more than their domestic doctors. Medical travel is partly a fashion and partly a necessity in this country. It is ironical to find extreme wealth and extreme poverty co-existing in Nigeria. Those who can’t afford don’t have access to any medical facility. And those who can afford would prefer to spend their money in seeking care abroad because of higher assurance of quality of care and status symbol.

There are just a few healthcare centres of excellence in Lagos, otherwise you won’t find a nationwide strong healthcare brand. Another peculiar thing about Nigerian healthcare market is that the providers do not like to advertise themselves much. While there are strict norms on healthcare advertising in India, nothing of such sort exists in Nigeria. But it still beats me why Nigeria providers do not spend on marketing. Very few would have a website of their own and many of the hospital websites are in such a bad shape.

I believe healthcare is in its infancy in Nigeria and probably the country needs to import ideas for healthcare innovation to build an efficient system and create affordability for the masses. For those looking at investing in Nigeria, I think you have made the right choice. But spend some dollars in understanding the market and the people before you bump into any surprises. For example, bank lending rate in this country is 20% plus. Yes you read it rightly. The bank would lend you for more than 20% and would expect you to repay within 12-24 months max. That’s crazy! Health insurance is near- absent and Nigeria would beat India in terms of out-of-pocket expenditure on healthcare. And Nigerians love to transect in cash because Nigeria is notorious for credit card and internet frauds. A consultation with a specialist can vary from 10K Naira to 30K Naira, that’s about 3K to 10K Indian Rupees just to meet the doctor! Of course, this is in-line with the high cost of living in this country.

We are currently in week 2 of our visit and stationed in Port Harcourt, another major trade centre in Nigeria. Wait till the next week for interesting insights on this week’s tour.

Quality Accreditation - The sustainable competitive advantage

Below is a whitepaper I had submitted for publication during a conference on Quality accreditation held in Pune.
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We live in exciting times in India. As an emerging market, India is at the centre of attraction of the world and everyone is talking about India as the land of opportunity. Indian Healthcare industry is one of the sectors of the economy which is leading this exuberance. All major consulting companies, be it KPMG or PwC, estimate double-digit growth figures for the healthcare industry for the next decade. An IBEF (India Brand Equity Foundation) report of November 2011 estimates healthcare industry size at US $280 Billion¹, bolstered by rising income levels, expanding middle class, an increasing appetite for premium services and conducive policy environment.

In all this hoopla, it is easy for anyone to miss the reality. The fact is that most investment in healthcare in India is by private sources and a lot of money in flowing into building new hospitals and adding more beds, given the low bed availability in our nation. According to World Health Statistics, India has 0.9 beds per 1000 population, way below the global average of 2.9². But most of this infrastructure is getting built in the metros and tier-I cities of the country leading to over-penetration in many areas. Most of this infrastructure is being built at a high capex. The mushrooming of hospitals in urban centres has led to an increasing competition among the various players. So on one hand, hospitals are grappling with higher costs, on the other hand they also need to fight tooth and nail with their peers to achieve moderate bed occupancy.

Indian healthcare also suffers from systemic flaws which haven’t been fixed due to misplaced priorities by both government and healthcare businesses. Even when the size of the industry has become US $50 Billion³, standardization of quality of care still remains a dream in our country. The pricing patterns even for common surgeries vary extremely in the country. Not many patients would agree that they could understand the processes or policies followed in the hospitals from which they received care. Most hospitals do not provide clarity on the services rendered by them and one can easily find examples of misrepresentation of services by hospitals in most of the Indian cities. Indian doctors have also been blamed for following unethical practices like prescribing over-medication and unnecessary diagnostic tests to pocket commissions from pharma companies and diagnostic centres respectively.

Visiting a hospital in India is a pain of its own kind. One can easily observe poor inter-departmental coordination and may even face eccentric rules and policies in a hospital. Most hospitals, for the sake of saving money, compromise on patient safety. While in the West, people are obsessed about preventing Healthcare-associated Infections (HAI) and there are elaborate studies on the risks to patients because of them, Indian hospitals are still sleeping over the issue. The biggest risk to patients arises from the inexperienced doctors and untrained medical professionals providing their services in our hospitals. Industry’s standard excuse has been the high rate of attrition and the huge demand pressures leading to compromises on quality of medical professionals. One can go on and on in identifying the problems that the industry faces. Finally, it is the trust of the patients that takes the beating because of these problems.

However, there has been a paradigm shift in how patients today consume healthcare services. In the internet age, patients are using social media to voice their opinions about the quality of care they receive at the hospitals. The present day patients question the treatment options offered to them by their doctors and many of them switch doctors easily if they are not satisfied. Gone are the days when patients trusted their doctors and hospitals with their eyes closed. The modern day patients demand healthcare providers to demonstrate quality in their services and deliver clinical excellence which is measurable and comparable.

Till a decade back, hospital accreditation was unheard of. National Accreditation Board for Hospitals and Healthcare Providers (NABH) was established in 2006 to bridge this huge gap between what the patients demanded and what the healthcare providers were offering. NABH standards for hospitals (1^st edition) began with 504 objective elements spread over 10 chapters and 100 standards and in its latest revision (3^rd edition) the NABH standards for hospitals have grown to 102 standards with 636 objective elements. Accreditation requires a healthcare provider to demonstrate its compliance to standards and after a stringent assessment process they are given the accredited status. This assumes significance in the light of the fact that till date only 138 hospitals⁴ in India have been able to achieve accreditation from NABH. According to one estimate, India has about 40,000 hospitals of small, medium and large scale⁵. Therefore, as per this estimate, not even 1 percent of hospitals in India have NABH accreditation.

In this scenario, accreditation presents a unique opportunity to healthcare providers. Quality accreditation can provide a sustainable competitive advantage to healthcare businesses if they build their strategy around creating NABH standards compliant infrastructure, policies and processes. A closer look at NABH standards indicate that the standards promote adherence to global best practices of healthcare delivery and there are detailed guidelines on measuring performance of hospitals on pre-defined quality indicators. Through a systematic approach, any healthcare business can achieve compliance to these standards. But it is easier said than done. Accreditation requires an organizational culture change which needs to be sustained for a longer period of time. A culture developed on the bedrock of quality care and patient safety will provide utmost quality assurance to patients and the community at large. Recent trends also indicate that patients have become more aware about accreditation and they are basing their choice of hospital on whether the hospital has any kind of accreditation or not.

Given the fact that only quality-focused hospitals will be able to achieve accreditation, it would ensure that those hospitals will always remain on top of the preference list of the patients. While the competing unaccredited hospitals may boast of great infrastructure, good doctors and affordable pricing, patients will not risk their lives with such institutions when an accredited facility is available in their city. It is a commonly known fact that in the matters of health, patients do not take their decisions based on the price of the treatment. Rather, they base their decisions on the treatment style of the doctor and assurance of better clinical outcomes. An accredited hospital would definitely enjoy an edge over its unaccredited peers. Since achieving accreditation is not an easy thing and an applicant may take couple of years to pass the NABH audit, this would ensure that an accredited facility stands out from the crowd.

In conclusion, it can be seen that there is a paradigm shift in healthcare industry in India. Accreditation bodies like NABH will play a vital role in ensuring delivery of quality care through the hospitals which are accredited by them. While there is an intense competition among hospitals, ones which have received accreditation will be able to provide greater assurance to patients about the quality of their care delivery system, something which their unaccredited peers cannot provide. Healthcare businesses need to have a strategy on leveraging accreditation to convey their superior care system to the patients. Since not even 1% of hospitals in India have received accreditation, this situation presents an opportunity for healthcare businesses to establish sustainable leadership position in their target markets by aligning their organizational culture and infrastructure to comply with quality accreditation standards.

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Sources:

1. Healthcare Report by IBEF, November 2011, URL: http://www.ibef.org/download/Healthcare50112.pdf, last accessed on August 8, 2012

2. The Times on India Online Article titled “India doesn't have even 1 hospital bed per 1,000 persons”, October 2011, URL: http://articles.timesofindia.indiatimes.com/2011-10-10/india/30262811_1_beds-tertiary-care-aiims, last accessed on August 8, 2012

3. The Economic Times Online Article titled “Indian Healthcare to double size to $100 bn by 2015”, January 2011, URL: http://articles.economictimes.indiatimes.com/2011-01-28/news/28428766_1_healthcare-sector-private-equity-indian-healthcare, last accessed on August 11, 2012

4. NABH, URL: www.nabh.co/main/hospitals/accredited.asp, last accessed on August 15, 2012

5. Views on Healthcare Quality Blog titled “eNABHle: Achieving NABH accreditation”, May 2012, URL:  http://ikureknowledge.blogspot.com/2012/05/enabhle-acheiving-nabh-accreditation.html, last accessed on August 15, 2012

HospiArch Bangalore: Voices from the Conference

The latest edition of AMEN’s series of conferences on Hospital Planning, Design and Architecture, aptly named as HospiArch, was organized on August 18^th and 19^th at API Bhavan, Bangalore. The event saw participation from over 100 delegates from different hospitals, architectural firms, consulting companies, engineering professionals and healthcare management students. The conference, supported by Hospaccx India Systems, is one of its kind event in India which attracts such a diverse set of audience. HospiArch is a 2-day conference which involves talks, panel discussion and Q&A sessions which are a rich source of knowledge to understand planning and design related issues for hospitals.

The Day 1 of the conference started with the Keynote address, delivered by Dr. (Wg Cdr) M.D. Marker, Medical Director - Bhagwan Mahaveer Jain Hospital Bangalore. In his speech, he addressed issues pertaining to architectural challenges involved in building a new hospital. He stressed the need for a hospital planner while designing a hospital and advocated a functional design approach.

His talk was followed by a presentation on “Planning & Designing a new hospital” by Dr. Alexander Kuruvilla, CEO - Medica Synergie Pvt. Ltd. Bangalore. He shared his vast experience in the field and the general steps for building a hospital such as feasibility study, market survey and project cost estimation & management. The highlights of his talk were his suggestions on having greenery, pipe music, aquarium & pleasant colours to keep the patients and relatives calm with in the hospital.

Dr. P. Satyanarayana, Retd. Professor of NIMS Hyderabad & Director of SVIMS Tirupati, took a session on “Factors that influence the bed utilization”. According to him, high cost of constructing physical infrastructure & facilities, high costs of running the hospital, high customer expectations and high cost of hospital expansion, modernization and modification bring sharp focus on bed utilization. He shared a few bed utilization indices, like Average Length of Stay (ALOS), Bed Occupancy Rate (BOR), Bed Turnover Interval (BTI) and Bed Turnover Ratio (BTR) as performance indicators. He advised to hospitals that while deciding to create more beds, they should consider factors like current availability of beds in an area, prevalent payment methods in the area (like cash or cashless), age of population (a higher life expectancy tends to raise general bed utilization), bed distribution (no. of ICU, PICU, ER and ward beds), availability of extramural medical services and medical customers & social patterns.

His presentation was followed by another talk by Mr. Radhakrishna, CEO - Narayana Hrudayalaya Hyderabad, on the topic of “Budgeting & financial planning for a new hospital project”. He gave elaborate prescription on planning of hospital project involving multiple steps. He suggested going for a market research, which would cover statistics on demographics, performance analysis of top 4-5 leading hospitals in the vicinity, identification of specialties and specialists, financial feasibility and project report. Next factor was the Land, its location and cost, legal formalities and statutory requirements for use of land for hospital purpose. When it comes to hospital building, he discussed factors such as cost of construction, various approvals, Floor Area ratio and determining built-up area per bed. Next thing he covered was medical equipment, its purchase costs and technology-relevance. He also touched various means of financing the project, such as equity or unsecured loans and debt/external funding. He finished his discussion by sharing some key ratios, such as debt-equity ratio, debt service coverage, bed occupancy rate, EBITDA margins and ALOS for measuring project performance.

Mr. Naresh Duble, DGM - Business Development at Armstrong World Industries (India) Pvt Ltd. Mumbai, presented on “Hospitals are for people - Design Solutions” and touched various facets of Acoustic comfort, green building and thermal comforts. Another presentation on “Designing a CSSD - Techniques and Trends” was given by Ms. Anuradha Desai, Manager - Getinge India Pvt. Ltd. Mumbai. She used elaborate layouts to explain her points. An interesting topic she discussed was about Super-CSSD which is out sourced CSSD for various hospital in countries like France, U.K, Singapore in which linen is sent for sterilization in super CSSD and dispatched back to hospital.

The last presentation of the first day was given by Dr. Marker on “Planning & designing lab & other diagnostics areas of the hospital”. His advice for planning and designing a lab was to focus on three areas: Strategic Planning, Structure Planning (scope of services & future expansion) and Operational Planning (functional lab Area). He also discussed about location and space requirements for a lab.

The Day 1 also witnessed a power-packed panel discussion on the topic of “Hospital Planning, Design & Architecture - Issues, Current Trends and Challenges”. The panel of 5 included Dr. P. Mohanakrishnan, CEO – Malabar Institute of Medical Sciences Calicut & Kottakal, Dr. Narendranath V., Chief Administrator – MS Ramaiah Hospitals, Mr. Tarun Katiyar, Principal Consultant – Hospaccx India Systems, Mr. Ramanand Prabhu, Director for Sourcing & Marketing – Global Healthcare Solutions and Dr. (Wg Cdr) M.D. Marker, Medical Director - Bhagwan Mahaveer Jain Hospital Bangalore. The panel discussion was moderated by Mr. Anuj Jindal, Senior Consultant – Hospaccx India Systems.

The discussion started with Mr. Jindal asking the hospital administrators on the panel to share their insights on common mistakes that they have come across that administrators have made while designing their hospitals. Dr. Mohan highlighted that administrators make a mistake when they do not create people-centric hospital designs. The structures are not built keeping in mind the needs of the employees and of the patients and their attenders.

Dr. Narendranath shared his experience with respect to the balance which needs to be maintained between academic and patient care requirements in the teaching hospital.

Dr. Marker gave an example from his professional experience wherein the statutory compliances and regulations were not completed understood before taking up the hospital project, thereby leading to considerable escalation of project cost and delay of the project by a couple of years. Mr. Tarun Katiyar took the example of small hospitals and their owners, wherein the doctors pump in their hard earned savings in building the hospital, but by the time the structure is built, either they lack enough funds to buy the medical equipments or they do not have enough working capital to run the hospital during the initial years of the hospital before it achieves profitability. This leads to the unfortunate situation in which the doctor either has to dump the hospital project or he starts looking out for buyers for his dream project.

Mr. Ramanand Prabhu highlighted the fact that hospital infrastructure and equipment is an important project cost and it has to be budgeted at the very beginning of the project and sourcing of same has to be identified well in advance. The panel also discussed innovative contemporary models of outsourcing certain departments to other specialized agencies who can co-invest in the projects, thus reducing the burden on the hospital administrators.

Day 2 of the conference witnessed 6 more speakers share their valuable experiences with the audience. The day began with Dr. Vinod Singh, Senior Consultant – Hospaccx India Systems, discussing the experience of their company in the field of hospital architecture. He stressed the fact that hospital architecture is very different from conventional architecture given the complex nature of hospital buildings and various loads requirements for the floors owing to heavy medical equipments and their power requirements.

This was followed by Prof. Dr. Usha Manjunath, Associate Professor – IHMR Bangalore, speaking on the topic of “Manpower planning for a new hospital”. She identified the importance of manpower planning as part of a new hospital project because of changing healthcare business paradigm, issues with availability of skilled manpower, vision of hospital promoters and the impact of policy issues on manpower requirements. Dr. Joy Bannerjee, Managing Director – Wiesermanner, discussed quality standards applicable to hospital planning, while Mr. Joseph Alexander, CTO - dWise Solutions & Services, discussed challenges in Hospital IT & Networking Design. Dr. Rajesh Kumar, Managing Director - Vijay Hospital Hosur, made a presentation on “Challenges in building hospitals in 2 tier towns” like the cost involved in the projects and the comparison of taking up a Brownfield project and a Greenfield project.

Lastly, Mr. Tarun Katiyar, Principal Consultant – Hospaccx India Systems, spoke on the topic “Re-planning & Re-designing an existing hospital”. His talk focused on the need for hospital renovation and how to go about it systematically. He gave elaborate examples of common mistakes hospital owners make while deciding to go for renovation of their buildings and suggested ways and means to avoid these mistakes.

In the end, HospiArch lived upto its expectation of being a source of great amount of learning for the participants and a good networking opportunity with the leaders in the hospital planning, designing and architecture services.

The next edition of HospiArch will be in Kochi next month. With the kind of conferences that happened earlier in Chennai, Hyderabad and Mumbai and now in Bangalore, HospiArch seems to be getting bigger and better. Let’s see what is in store for the audiences at Kochi in September. The last conference in the series in 2012 will be held in Delhi in December.

Accreditation Anonymous: Platform to collaborate for Quality professionals

Hi Healthcare Quality Community!

A friend of mine has taken this initiative to help us to collaborate and discuss issues pertaining to quality aspects in healthcare and accreditation of hospitals. The initiative is in the form of on Online Forum and it is called as Accreditation Anonymous and you can find the forum on this URL: www.accanon.com

The guiding thought behind this forum is to enable and support quality professionals to discuss matter pertaining to quality and accreditation in an environment where you can maintain your anonymity. The platform allows YOU to discuss sensitive matter pertaining to quality without getting named or without referring to a hospital.

This noble attempt, hopefully, will bring in healthcare professionals together to collaborate and collectively search for answers to their questions.

On behalf of my 'Anonymous' friend, I invite you to join this quality initiative.

In the support of STANDARDIZATION….

I think I should dedicate today to the concept of standardization. It is purely coincidence that I observed the need for standardization in two different aspects of healthcare today and I am writing on them on the same day itself. The previous mention was on having standardized patient satisfaction surveys across Indian hospitals (to copy the idea from HCAHPS).

I read this blog written by CQI CEO Simon Feary on how consistency can save lives. To read the blog, click here. His blog highlights hundreds of different types of bedside medical charts being used in UK hospitals leading to confusion among physicians and deficiencies in capturing important ‘vital signs’.

I think I second Simon’s demand for a consistent medical chart format that helps physicians to take appropriate decisions about patients’ health and safety. On the same thought, what are the opportunities for standardizing clinical documentation in our country?

The Handy Guide To Quality – Chartered Quality Institute

What is Quality? I keep bugging participants during my training sessions on NABH Quality Management System with this question and their answers vary a lot. Well, I found a great answer online today which I found to be the best.

This video, developed by CQI (Chartered Quality Institute), is a superb way to understand Quality in action. Incidentally, CQI also stands for Continuous Quality Improvement!

This 4-minutes video below can be a life-changing experience for some.

Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS)

Curiosity has its own advantages. It helps you discover things you may otherwise miss. I have recently started following ASQ’s CEO Paul Borawski’s blog titled ‘A View from the Q’. Last month he had posted a blog that asked ASQ’s Influential Voices bloggers to share their views on ‘taking quality beyond products’. He had very nicely summarized everyone’s views in another blog. On the Service quality in healthcare, Nergis Soylemez had shared her opinion on her personal blog. Nergis comes with a background in quality in manufacturing industry and currently works with a hospital in Dallas. While reading her post, I came across something called as HCAHPS. The reason I was curious about this acronym was because it was a “government initiative to provide a standardized survey instrument to measure patients' perspective on hospital care”. Interesting, isn’t it?

So I went to HCAHPS’ website to find out what exactly this initiative is and what purpose does it serve. I was amazed at the fact that something as simple as a patient satisfaction survey has been standardized across a country, which has an opportunity to “publicly report patients' perspectives of care information that would enable valid comparisons to be made across all hospitals”. That is, to enable “apples to apples comparisons to support consumer choice”. WOW!!

The survey form is simple, nothing great about it. You can download it here. Or you can directly have a look at the survey form here.

As Nergis points out in her blog, the survey measures the performance of the hospital’s services on “several factors associated with patient satisfaction such as nurse communication, staff responsiveness, hospital environment and pain management”. In my experience, the patient experience/feedback forms that I have seen have been more elaborate on the services which were offered to patients for assessment. But what we can learn from HCAHPS initiative is that there is definitely a need for a standardization of feedback system so as to bring in comparability.

In an earlier blog also I had written about an attempt by NABH to bring in an objective system to rank the accredited hospitals on their performance on set objective performance indicators and NABH 3rd edition is a step towards that direction. On patient satisfaction also, we need a similar initiative in our country.

Meanwhile, readers can also enjoy this blog by Regina Holliday. Click on the photograph to visit her blog. She writes on Medical Advocacy.

Which regions in India are doing well in NABH Accreditation? A peek into the accreditation data.

During a recent discussion with a friend, a question came up – Which city/state/regions in India are doing well in terms of NABH accreditation? No one had a number at hand, except that 137 hospitals hold the accreditation and 2 of them having their status as “Accreditation kept in Abeyance” as we speak.

I got a chance to do what I love the most – Data analysis! Here’s the summary of data I found from NABH’s website, with the reference link: http://www.nabh.co/main/hospitals/accredited.asp (last accessed on July 20^th, 2012).

Here’s an alphabetical listing of city-wise number of accredited hospitals as of date:

City/State	No. of Accredited Hospitals
Ahmedabad	3
Amritsar	1
Bangalore	14
Bhavnagar	1
Calicut	2
Chennai	6
Cochin	1
Coimbatore	5
Ernakulum	1
Faridabad	4
Gandhinagar	2
Ghaziabad	3
Gurgaon	5
Hyderabad	10
Jaipur	4
Kalyan	1
Kerala	1
Kochi	1
Kolkata	3
Lucknow	1
Madurai	1
Manipal	1
Meerut	1
Mohali	2
Mumbai	7
Mysore	1
Nagpur	2
Namakkal	1
Nashik	1
New Delhi	29
Noida	4
Pune	2
Rajkot	1
Secunderabad	4
Sholingur	1
Surat	1
Thane	1
Thiruvananthapuram	1
Trichur	1
Udaipur	1
Vadodara	4
Visakhapatnam	1
Total	137

If we do a region-wise segmentation, the numbers would look like this:

Region	No. of Accredited Hospitals
East	3
North	50
South	53
West	31
Total	137

Clearly, NABH had the major impact closer to its base as Delhi has the maximum number of accredited hospitals, followed by my home-sweet-home Bangalore and Hyderabad finishes third.

Among themselves, the four metro cities of Delhi, Mumbai, Kolkata and Chennai account for 45 accredited hospitals, which is one-third the total number of accredited hospitals. Of course, Kolkata only contributes 3 hospitals to this sum, so I would say just 3 cities contribute 30% of the total accredited hospitals. Shouldn’t it be a cause of concern?

Region-wise, I got a shocker, with Eastern India only having 3 accredited hospitals, which is a paltry 2% of the total. I guess either NABH has not promoted itself well in the east of the country, or there aren’t good standard hospitals in that region. I hope the former is true. North and South share among themselves more than 100 accredited hospitals. But in the Northern region, except for Delhi, other states haven’t done as well as they should have done. Clearly, there is need to create awareness about NABH in those states and I would be happy if we could help.

In the South, there is a relatively even spread of accredited hospitals in various states, but Karnataka seems to have the edge. One possible reason could be the fact that Bangalore is the hub of a lot of activities that NABH conducts in the southern region (as per my observation).