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.