Dr Girdhar Gyani, is widely recognised as founder of healthcare quality in India. During his tenure as Secretary General, Quality Council of India (2003-2012), Dr Gyani played pivotal role in formulation and operating of National Accreditation Board for Hospitals and Healthcare Providers (NABH), for the first time in the country. He was Principal Coordinator in developing of accreditation standard for hospitals and getting it accredited by International Society for Quality in Health Care (ISQua). This was followed up with development of standards for Blood Banks, Radiology Centres, Dental Clinics, Wellness Centres, and AYUSH Hospitals.
NABH has been the single most important initiative which has dramatically changed the healthcare scenario in INDIA, bringing Patient Safety at the centre stage. NABH has emerged as key criteria for evaluation of hospitals for variety of government and private paying schemes.
Currently Dr Gyani is working as Director General, Association of Healthcare Providers (India). AHPI represents vast majority of healthcare providers in India and it’s mission is to build capacity in Indian health system with focus on patient safety and affordability.
Here he talks about the challenges of quality in healthcare delivery and patient safety, in conversation with M Neelam Kachhap
- What does quality healthcare encompass?
Like in any sector, quality in healthcare stands for ‘Value for Money’. The quality has two dimensions; one is measurable and other is by perception. Both are important. Healthcare being a complex subject, patient tends to attribute quality more by perception. It is therefore important that hospitals lay equal emphasis on soft side of treatment which sometime we refer to as managerial quality.
Quality in healthcare is formally described in terms of Structure, Processes and Outcomes. There are quality accreditation standards, which specify requirements with reference to these aspects. The accreditation standards are certifiable by independent designated agencies, by which consumers can make informed choice for particular hospital.
- Is there a difference between perceived quality and technical quality in healthcare?
As I mentioned above, perceived quality comes more from managerial aspects. Here hospital gets compared with any other service institute say like hotel. How patient is received, how the patient is seen? How the patient is heard? How the patient’s needs are met? All these make up for perceived quality. Technical quality is what we term as clinical quality, by which clinical outcomes are monitored and measured. This quality actually decides whether hospital has defined protocols and follows standard treatment guidelines etc. It is obviously difficult for patient to understand about this aspect of quality and is best left for accrediting agencies.
- What resources (in the form of organizations, funding, training and information) are available nationally?
At the time of independence, the healthcare was confined to public sector. It was well structured by way of rural infrastructure by way of sub-centers, PHCs and CHCs to provide for primary and secondary care. To supplement we had district hospital and teaching hospital to support for secondary and tertiary care. As population went on growing, this infrastructure proved to be in-sufficient. With government not able to allocate matching resources, private sector took the lead and began investing in secondary and tertiary care, more so in tier-I/II cities. Today we have 1.4 per cent of GDP coming from government, whereas private sector investment has grown to be about 3.6 per cent.
Another key resource is human resource by way of doctors, nurses and allied health workers. This resource creation is highly regulated and somehow our regulatory framework has failed to respond to the growing demand.
- What resources are most important to improve quality in health care?
Human resource is most critical factor, without which health outcomes or quality cannot be improved. WHO has recently released ranking of 191-countries in terms of health system reforms. Countries with lesser spending on healthcare have higher ranking than India. Likewise BRICS nations, having higher spending than India, occupy lower ranking. The key is how effectively a country utilizes resources including manpower. India suffers not only from lack of doctors and nursing staff but also suffers with skewed presence of healthcare facilities. The two factors are inter-linked. As there is shortage of doctors, they are not available for tier-II/III cities and therefore private sector is unable to invest in such locations.
- Can government hospitals get accredited? How will it help them?
Accreditation basically helps hospital to define and establish quality governance framework which directly impacts patient safety and which is important whether hospital is government or private. As we are aware, millions of medical errors are reported to occur in developing nations, it is necessary that all hospitals adopt accreditation standards. Somehow accreditation got projected as marketing tool for medical tourism, which is wrong. In most developed nations, paying agencies link accreditation with empanelment as accreditation is seen as best cover to safeguard the investment under insurance. Similarly in many nations, the regulation is linked with accreditation, which symbolizes government’s concern for patient safety of population.
- Is India ready to embrace quality and accreditation in healthcare?
Accreditation means patient safety and therefore all stake holders should pitch for accreditation. To begin with payers including government and insurance companies must link accreditation with empanelment of hospitals. This can become single most important step as driver for accreditation. IRDA has issued directive that all healthcare organizations must take at least entry level NABH certification without which they will lose empanelment with insurance companies. This directive needs to be strictly enforced. Similarly government insurance schemes must offer incentives to hospitals to take accreditation as done by CGHS. In the long run, we need to make this as movement by aggressive awareness among the community by projecting accreditation as the mark of patient safety. Before doing this, we need to build capacity by training healthcare professionals so that hospitals are enabled to implement accreditation standards.