Standards in hospitals

G D Kunders

Recognising that the care of the sick is their first responsibility, hospitals must at all times strive to provide the best care and treatment to those, who are in need of hospitalisation. Some hospitals, in very early times, accepted certain values and principles that conformed to high professional standards. Other hospitals seeking similar goals soon joined them. This led to the development of definition of principles, responsibilities and standards in patient care, ultimately encompassing almost every aspect of the hospital including its design, construction, operation, maintenance and environmental safety. Standards are used to describe the broad bases and fundamental policies as well as specific details for levels of patient care. They also apply to supportive and administrative services that are directly or indirectly concerned with patient care or affect it one way or the other.

In the beginning, all standards were voluntary standards without any authority of law. Imposed upon themselves of their own accord and acting in concert with other institutions which shared common interests and had similar purposes, many hospitals established standards in every area of hospital operation. Standards were also promulgated by professional organisations based on professional ethics, tenets and ideals. These were applied for purposes of approval, registration, and accreditation and for the promotion of professional ideals. For example, in the US, a whole gamut of basic principles must be complied with for a hospital to be accredited by the Joint Commission on Accreditation of Hospitals.

Mandatory standards are those established by the government/licensing/regulatory body that derives its authority from a basic law. They represent what a legally constituted agency deems to be necessary for the welfare of the people and are reasonably attainable in the light of generally accepted ethics, competencies, methods and resources. However, a standard does not necessarily represent the ideal.

Legal standards, for example, generally state the minimum that should be adhered to under the penalty of the law, and the tendency is to attain just that.

For voluntary standards they represent the starting point towards excellence at the other end of an ascending scale. In some areas or sections, it may be desirable, even necessary, to exceed the minimum standards for optimum function. For example, the standard door widths of inpatient patient rooms are 3’ 8”, which satisfies most applicable codes, to permit passage of patient beds. However, wider widths of 3’ 10” or even 4’ 0” may be desirable to reduce damage to doors and frames where frequent movement of beds and large equipment may occur.

A standard may be defined as a measure of quality established on a voluntary basis by those subject to it, or imposed upon them by a legal authority. One of the most dramatic achievements of the American College of Surgeons was the “Hospital Standardisation Movement” initiated early in the twentieth century. With high ideals, the founders drew up, what is known as the “Minimum Standard” which became a veritable constitution for hospitals, in which were set forth requirements for the proper care of the sick. The usage of the term “hospital standardisation” paralleled the emphasis on standardisation in industry. The standard was made effective by an annual survey of all hospitals having 25 or more beds. When the first survey was conducted, only 89 hospitals in the United States and Canada could meet the requirements. Thirty-three years later, 3,353 hospitals were complying with the requirements. This is significant considering that compliance with standards was voluntary.

One of the reasons that prompted the surgeons in particular to spearhead the programme was the most unsatisfactory state of medical records in the early years of the century. They were so meagre and poor that most applicants for Fellowship in the College could not produce satisfactory reports of 50 major operations and 50 minor operations required as part of the credentials to accompany their applications.

In 1952, the Joint Commission on Accreditation of Hospitals took over the programme, accepting as its initial list the roster of hospitals furnished by the College. The founder member organisations of the Joint Commission were the American College of Physicians, the American College of Surgeons, the American Hospital Association, the American Medical Association and the Canadian Medical Association. This is how standards came into being in American hospitals and since then they haven’t looked back. The focus of all efforts in hospital standardisation was the patient. The objective was to give him the best professional, scientific and humanitarian care.

Standards are performance-oriented for desired results. For example, experience has shown that it would be extremely difficult to design a patient room, an operating room or a coronary care unit smaller in size than the generally recognised standard and then have space to satisfactorily perform the functions and procedures normally expected to be performed in those rooms.

Quality, a synonym for standards, is of paramount importance to hospitals. At no time in history have hospitals been under so much attack for failure or deterioration of quality as they are today. Malpractice suits are becoming common and there is growing criticism of hospitals for their various acts of commission and omission. Negligent and unethical practices in patient care, mismanagement, lack of probity and accountability, unhygienic conditions in and around the hospital, high incidence of hospital-acquired infection because of lack of quality assurance programmes, environmental pollution caused by hospital’s waste disposal, to name just a few.

For businesses across the world, quality has become a strategic imperative and a formidable competitive weapon – their very survival depends on it. They have come to realise that in this volatile business world engaged in cutthroat competition, rivalry and competition should focus not so much on price as on quality. If they do not take heed of customer’s satisfaction by offering quality goods and services, they are doomed to fail. To protect their interests, manufacturers and service providers give guarantee and warranty against anufacturing defects or shortcomings in service.

If quality is important to manufacturing industry, how much more should it be to the hospitals! There is no guarantee or warranty in hospitals against quality failure. A defective surgery, a negligent act on the part of a doctor, a nurse or a technician can put the happiness of the patient, even life, in jeopardy. The ill effects of such mistakes could be costly, permanent and irreversible. A case in point, many of us remember the costly mistake an ophthalmologist in Hyderabad committed some years ago. By gross negligence, he removed the good eye of a ten-year old girl instead of the cancerous one thus rendering her totally blind for life. That is not by any means a solitary case.

In the patient’s mind, service is tantamount to quality. Only quality assurance in hospitals can bring happiness, satisfaction and delight to patients and restore the smile on their faces. Sadly, there are no standards in Indian hospitals. And given the poor facilities in and the condition of a vast majority of our hospitals, it would be laughable even to think of accreditation by the Joint Commission on Accreditation of Hospitals of USA (JCAHO) or its international arm. The Joint Commission International (JCI) whose standards are stringent and quite simply, unattainable. And the cost is unconscionably high said to be USD 100,000 for a 600-bed hospital and recurring cost of re-accreditation every three years, not to mention the high cost needed for upgrades which only a handful of cash rich corporate hospitals can afford.

Ultimately, this cost will surely be passed on to the patients. As of now only Indraprastha Medical Corporation and Teleradiology Solutions have the distinction of being accredited, the former by JCI and the latter by JCAHO.

In a country, where charitable and not-for-profit hospitals abound, most of them struggling to stay afloat, even the standards set by the National Board for Testing and Calibration of Laboratories (NABL) have not found many takers. High cost is said to be the deterrent. Moreover, if the exercise of getting accreditation by JCI and JCAHO is to attract foreign medical tourists, it is a pretty unconvincing reason for the huge investment that is involved. If hospitals are spruced up with cutting edge facilities to cater to foreign customers, making them unaffordable to the common man in the process, who cares for millions of our own patients?

Conversely, there are quite a few hospitals across the country without JCI and JCAHO accreditation, which have been healthcare destinations for foreign patients nevertheless. This means that these hospitals have the potential for becoming centres of excellence if only they have standards. In the considered opinion of this writer, what India needs are standards that are reasonably attainable and affordable. They should be made mandatory minimum standards that should be adhered to under the penalty of law.

However, no standards would work on the ground unless they are enforceable and audited for compliance. The Quality Council of India (QCI) which is said to have been entrusted with the task of drafting standards, or the Indian Healthcare Federation should be asked to set standards that are tailor-made for Indian hospitals. Hospitals that pursue excellence and higher standards will of course of their own accord go beyond the minimum.

The writer is a hospital consultant and author.

E-mail:gdk@vsnl.net