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?

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.