Using Quality Circles in developing a Quality Culture

Many Quality professionals who have been given the task of implementing NABH standards in their hospitals face this common challenge - "How do I bring about the change? How do I get everyone on board? How can I get everyone's involvement in the standards implementation process? Why is it perceived that quality is only my responsibility and not theirs' too?" These are common experiences that a quality professional goes through. She is confused about what should be the starting point of standards implementation. She cribs about lack of management support and that the staff is non-cooperative.

In an earlier article, I had highlighted that a Quality Culture is a must to ensure the long term success of the quality initiatives. In this post, I will discuss an important tool which will help you create that culture.

We have to start with the basic premise that our staff are not dumb. They are our knowledgeable colleagues who have years of experience and expertise in doing a particular job. We need their help in getting the standards implemented. It is a team effort. Therefore, we have to seek their collaboration. There is a huge potential locked in our manpower and we need to tap into that potential. The way we need to encourage their participation and get them involved is through engaging them in a meaningful discussion, which is open, collaborative, intellectually stimulating and a good value for their time. It is in this context that the concept  of Quality Circles (QCs) comes very handy. We need to understand and implement the essence of QCs.

A QC is a small group formed of the employees of an organization who are supervised by someone senior to them and they identify, analyze and discuss work-related problems and collectively devise solutions to them. The fundamental idea is that our people know the problems and they can also design solutions to those problems. Isn't it simple? The groups in the QC meet during the office hours and are free to discuss any topic they want to discuss related to their work. The supervisor needs to moderate the discussion to ensure that the group invests its time to diagnosing the problem with their collective insights and work together to propose solutions. The management can then decide to pick some of these solutions and suggestions to improve quality standards and organizational processes.

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By Camila Martinez

(Invited Post)

How to order the book on NABH Standards 3rd Edition?

Very often I get queries from readers on how they can purchase the book on latest NABH Standards. It's quite simple.

Please visit this link: http://nabh.co/main/hospitals/standard.asp

This leads you to the page where NABH address is mentioned and the process for ordering the book is explained. My experience has been that within a week of sending the cheque/DD, you are able to receive your book. However, there is no online ordering available for this book. So go ahead and buy this book!!

Building a culture of Quality as a pre-cursor to NABH implementation

Many times I am asked questions by administrators and hospital owners regarding the time it would take for their hospital to achieve NABH accreditation. With time I realised that this question presents an opportunity for me to educate them on the culture of Quality. Through this post, I would try to reach out to quality professionals, administrators, hospital managements and other healthcare professionals to involve them into a discussion on Quality culture and its relevance to Indian healthcare industry.

If you look at other quality systems like Six Sigma, Lean, ISO etc., these are mostly a philosophy and then crystallized into a methodology to achieve the desirable goals of the philosophy. The way I see Quality is that it is an approach to achievement improvements and always being concerned with the empty space in the proverbial 'half-filled glass'. A quality-mindset pushes you to devise better ways of doing your regular activities and again iterate to improve upon what we have already achieved.

To build a culture of quality, therefore, it is necessary to inculcate a mindset among all the stakeholders to think creatively and participate in continual improvements in the systems and processes of the organization. when we build such a culture, we are breaking the inertia among the professionals in our organizations and involving them in a participative process of finding better ways of doing things.

Before we delve into NABH implementation, we should first understand that it is also a quality system. Hence, the same fundamentals of building a culture of quality are applicable to NABH implementation as well. Quality professional in any industry would tell you that quality is not a one-day's job; rather it is a life-long striving to achieve perfection in what we do and upgrading the yardsticks by which we measure our performance.

We need to commit to Quality at the highest levels of management, which should trickle down the ranks by the way of goals and measurable objectives to achieve desired performance level. In the absence of the management commitment, it becomes difficult for the system to work coherently. We need to understand that NABH as a quality system is a tool to gear our hospitals towards a culture of making continual improvements every day. The system of assessment and surveillance audits is meant to gauge the compliance of the organization to this culture. The focus on the 64 measurable indicators is meant to give the hospitals a direction in how to measure their performance on quality parameters and to motivate them to improve their performance on these indicators by increased scores over a period of time. The fact that the standards themselves undergo transformation and that we are following the 3rd edition of NABH standards speaks for itself. The standards are responding to the changes happening in the industry and the increase in expectations of the patients from our hospitals. Any hospital planning to go for NABH has to also create systems that will be able to match the pace with which the standards are themselves expanding. To achieve this, therefore, we require a culture of quality in our organizations.

We need to question our existing practices, the way we do things and find out ways to improve them. NABH standards are your guide to ask these questions in a systematic way.

The importance of educating management on NABH standards

Many administrators and quality professionals leading the task of implementing NABH in their hospitals face this one particular issue quite often - lack of management support. While it is the management who has assigned them with the task of implementing NABH, quality professionals find themselves pushed against the wall when their various needs are rejected by the management. Where does the problem lie?

In my assessment, I feel that the hospital owners and the people holding top positions in a hospital make wrong decisions about NABH implementation when they are unaware of the requirements of the standards. Interestingly most people have some kind of opinion regarding NABH standards and when they talk about implementation of standards, they refer to their poor knowledge about NABH standards to make their decisions. It's also been a personal observation that when the management and top people and doctors are trained on NABH standards, they are very clear about what they need to do to achieve certain goals.

I think any NABH implementation process should first start with sensitization of management team and head-of-departments (HODs) or key managers on NABH standards and training them on the complete requirements. Once they have gone through the initial training, they would be better prepared to understand the demands put forth by standards, and accordingly they can see their commitment level to NABH implementation. This would go a long way in simplifying the work of a quality professional.

The Star system is in the works @ NABH

Now all that I write in this specific post is grapevine and hasn't been verified by me through proper sources. However, I got this news sometime back from a very trusted senior quality professional whom I know for many years.

We all are aware that NABH has separate set of standards for different categories of providers like small and large hospitals, clinics, dental clinics, ayurvedic hospitals etc. Very recently NABH pressed into action a provision in the accreditation called as Progressive Accreditation for hospitals. Progressive Accreditation is given to hospitals who have scored above a particular threshold but not the mandatory minimum score for achieving accreditation for 3 years. Under Progressive accreditation, a hospital is entitled for accreditation for 1 year, after which they undergo re-assessment with an objective to observe desirable improvement in compliance and score (Notice here that normally surveillance audit happens 18 months after awarding of the accreditation). At the moment, 2 hospitals have got the Progressive Accreditation, and I had the chance to speak to the administration in one of them. They have been able to achieve compliance to a large extent, but the committee was not very comfortable with a few Partial and Non Compliances. Having seen their compliance track record, the committee felt to motivate them by awarding Progressive Accreditation with a view to acknowledge their adherence, and to create an incentive for increasing compliance by these hospitals. Many more hospitals might be on their way to receive progressive accreditation.

Now, the news that I have got is that NABH is introducing a Star Rating system, where accreditation will be offered in 3 levels - 1, 2 and 3 Star. Two abridged versions of the main standard will be introduced, thus creating two step-down levels of the main standard. This is mainly to create avenue for more and more hospitals to come under the scope of accreditation.

My personal take on this prospective development is that it is a step in the right direction. NABH and accreditation is new to an otherwise old industry which has providers of all kinds and sizes and having establishments in remote rural areas to the large scale metros gifted with all amenities. How would having a monolithic standard going to help the industry if most of the participants find it impossible to comply with them.

By widening the scope of accreditation by relaxing some requirements, yet segregating the accredited hospitals through a Star rating system, will go a long way in boosting the confidence of providers to go for the accreditation.

For starters, a major benefit of accreditation is that it sets the organization on the path of continual improvement in quality of care delivered by them. If this group grows, it is going to benefit patients in the long run as they can see a systematic improvement in services of accredited hospitals.

Tricky issues: Standardization of hospital charges

Indian healthcare industry is unique in many sense. We have such a huge burden of patients on the existing facilities, yet penetration of modern medicine is low in the country. We always crib about the need for more medical colleges, yet we are net exporter of medical talent to the world. We are worried about quacks in our system, yet we also have some of the best doctors and healthcare systems in the world. We worry about healthcare being out of the reach of common man in this country, yet our pricing is one of the lowest world over.

In this context, one can imagine the challenge NABH would be facing in adoption of its standards. I felt the need to discuss some of the practices that are commonly prevalent in Indian hospitals and how these become a roadblock in NABH implementation. I might not be able to suggest a sure shot way to handle these practices, however I will make an attempt to create awareness on these issues.

Doctors are a very knowledgeable lot and their skill levels may vary depending on years of training and experience. This has a bearing on the outcome of the treatment they offer to their patients. There can also be perceptions about certain doctors, i.e. patients might feel outcomes of one doctor is superior to others, whereas there may be no factual data for the same. It is therefore natural for doctors to feel that they have a right to charge a fee that is commensurate to their reputation in the market. More often than not, doctors from the same specialty in a hospital charge different levels of fee for same consultation, treatment and surgeries/procedure. For the hospital management, it is all about keeping doctors in good humour and allow them to follow their own personalized pricing policy for their patients as long as they bring business to the hospital.

The practice runs into trouble when the hospital decides to go for accreditation. NABH demands uniform pricing policy for all patients. For example, all patients in cardiology department in a hospital should be charged same consultation fee and same procedure charges, irrespective of which doctor they consulted. But you would know from your experience that this is not the case practically. Specialists charge different set of fee as per their own comfort.

For the hospital management, it can be the source of worst nightmare in ensuring that doctors comply to a standard pricing policy common to all consultant. I have been even asked by managements how they can circumvent this requirement of NABH through some innovative way! My answer to all of them is that there is no running away from standardization if they are committed to implementing NABH. If you compromise in one area, your get into the habit of compromising everywhere. That's against the very ethos of quality. Quality demands adherence to common rules.

I think the management needs to realise that they are making a long term commitment to Quality and NABH standards help them conclusively demonstrate their commitment to quality by complying to standards. Short cuts don't work. They never work!

One way to handle this issue is to first establish a Medical Advisory board which has representation from management and some senior consultants. The advisory board should come to a consensus that they are committed to implementing NABH. Then the board should have rounds of discussions with all their doctors to educate them about NABH requirements and their role in achieving compliance. I think the most complicated problems can be solved through open and transparent dialogue between different parties, and this is going to be the best way to bring a consensus among the management and doctors on the future course of action. It also lies with the management to define and explain to various stakeholders how NABH implementation will benefit them. By taking care of the anxieties and queries of the doctors, the management can win their trust in the times of change and breaking up of established practices.

There can be tough times, discussions can sometimes turn ugly. You could have some really hard headed doctors in your panel. Your visiting consultants may threaten to take their patients away to other competing hospitals. Some might actually start bad mouthing management's intentions. All this is part of the game. Ask anyone in any industry who was implementing quality standards, and they would unanimously tell you it is not easy. Having said that, it is also not impossible. 180 hospitals in this country have displayed their commitment to standards and that places them in a different league from other thousands of hospitals in our country.

Be open, be patient, communicate and listen, be respectful while dealing with disagreement and most importantly, don't lose the focus on the end goal, i.e. achieving long term commitment from everyone in your team to continually improve quality in your hospital.

Are there any NABH standards applicable to hospital marketing?

This was the question a friend of mine asked me recently. This gentleman is administrator of a 200 bed multi specialty hospital planning to implement NABH in their hospital. His question was interesting because out of all the departments in a hospital, only this one came to his mind. But his context of asking the question is what made me thinking.

I told him that as such NABH standards are silent on the aspect of hospital marketing. But if I stretch my imagination a little bit, I think there is one area pertaining to marketing which is covered in NABH. The standards require that the hospital should define its Scope of Services and display them prominently inside the hospital. If we look at it differently, what NABH demands is that the hospital should not confuse the patients by only saying that they are a multi-specialty setup. Rather they should specify which all specialties and services are offered by them and display them in a public area inside their premises as well. Therefore, indirectly NABH ensures that hospitals do not make unnecessary claims about services that they do not provide.

My friend went on to ask, what if hospitals misrepresent their services on their websites? Since we live in the age of Social Media, it is a powerful tool by which organizations connect with their customers. What if a hospital makes false claims about its services in an online medium? It is a valid concern of my friend, however I think this comes under the purview of MCI.

NABH has a specific role to play in ensuring quality in how healthcare services are delivered by the providers with clearly defined objectives of improvement in patient safety and quality of care.

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?