|
Working Towards Affordable Accreditation
Less than eight months after NABH standards were finalised,
already 20 hospitals across India have applied for it. Now, NABH is also chalking
out accreditation for blood banks and diagnostic centres, discovers Rita
Dutta
 Accreditation
is a step that any hospital with an eye on quality would essentially take. The
increasing role of health insurance, rise in number of medico-legal cases and
awakening of patients about their rights have led to increased demand for healthcare
accreditation in India. Medical tourism has further fuelled the demand.
Though the country has witnessed an onslaught of international accreditations,
they were either found to be expensive or not tailored for the Indian healthcare
industry. Thus was born the need for a national accreditation system. This is
when the Quality Council of India (QCI), an autonomous body set up by the Government
of India, announced the National Accreditation Board for Hospitals and Healthcare
Providers (NABH), a not-for-profit initiative.
And ever since NABH standards were finalised in February this
year, its core team has been working towards making more healthcare institutes
across India accept it. Its efforts have already borne fruit with as many as
20 hospitals across India applying for it and 40 more preparing for it. The
audits have also begun for hospitals like BM Birla Heart Research Centre, Kolkata
and Malabar Institute of Medical Sciences, Calicut.
|
Some Applicant Hospitals
For NABH Accreditation
|
Narayana Hrudayalaya, Bangalore
Kasturba Hospital, Manipal
Escorts Heart Institute & Research Centre, New Delhi
Dharamshila Cancer Foundation and Research Centre, Delhi.
Rockland Hospital, New Delhi
Indraprastha Apollo Hospital, New Delhi
The Calcutta Medical Research Institute, Kolkata
BM Birla Heart Research Centre, Kolkata
AMRI Hospital, Kolkata |
Benefits Of NABH
What is driving most hospitals to NABH is that while close to JCI in standards,
NABH is more cost-effective. According to an administrator, whose hospital has
applied for NABH, "We have applied for NABH as their standards are very
similar to JCI and we have to pay only one-tenth the cost of JCI."
As a broad estimate while the accreditation charge is around Rs 70 lakh for
JCI, it is around Rs 7 lakh for NABH for a 500-bed hospital. Estimates say that
cost of implementing NABH is less than Rs 2 per bed per day.
|
Girdhar
Gyani, Secretary General, QCI (right ) is
seen signing the MoU, while Dr Michael Hodgson
AM, President, ACHS International, looks on
|
And how does NABH score over various ISO standards? To begin
with, ISO is a certification and not an accreditation. "ISO is generic
and not specific to healthcare industry. Moreover, it does not call for clinical
audits, it centres only on systems. Accreditation on the other hand, focuses
on competency in terms of its staff, equipment, premises, facilities etc with
respect to the scope of services being rendered by the healthcare organisation,"
says Girdhar Gyani, Secretary General, QCI.
 "Accreditation
should not lead hospitals to increase prices with patients bearing the
burden" - Somnath Das
Co-Chair
Accreditation Committee
NABH
|
Somnath Das, Co-Chair, Accreditation Committee, NABH, opines
that more hospitals will be able to afford accreditation, when the cost of accreditation
is not a hurdle. "Accreditation should not lead hospitals to increase prices
with patients bearing the burden. Actually, Cost of Poor Quality (COPQ), if
attacked, can bring in potential savings which can be passed on to the patients.
If we as a national accreditation body think about citizens of India, then more
hospitals getting accredited means safer the delivery and quality of healthcare,
which is the very motto of any accreditation," he adds.
Experts say that NABH accreditation is not just affordable, but also sustainable
in the long term. Accreditation also means data mining over time, a reflection
of clinical and operational benchmarking. "Data mining will be the biggest
asset for the industry to take the quality standard forward. Further, there
will be Objective Elements (OE) as mandate which will bring stringent controls,"
explains Das.
The response time of a national accreditation is also quicker. "If something
goes wrong with the accredited hospital, then it is faster for a national accreditation
body to react and respond to the crisis than an international accreditation
body without an office in India," explains Gyani.
Similar to Canada and Australia, the day is not far, according to Gyani, when
Indian insurance companies will approach accreditation bodies before empanelling
hospitals on their board. "Accredited hospitals are always safe and insurance
companies would like to play safe," he elaborates. The CGHS has already
approached QCI for inspection and accreditation of any new hospital desiring
to be on the CGHS panel.
Steps To NABH Accreditation
According to YP Bhatia, Chairman, NABH Accreditation Committee, "We encourage
the hospitals to do a self assessment first. Then a small team of our assessors
is sent to assess preparedness of hospital for accreditation. A time frame is
given to apply the standards and thereafter the final assessment is undertaken
by the full team comprising a clinician, nurse and an administrator. The accreditation
committee grants the accreditation based on objective evidence submitted by
the assessment team." On the scorecard, hospitals would have to secure
70 per cent on 100 standards and 503 objective elements. A hospital has to score
a minimum of five in each standard.
The accreditation is applicable for a span of three years. "Within this
time, at least once a year, we will send our team to check whether the hospital
is following our standards," says Bhatia. Can the accreditation be annulled
within the three years? "Apart from our own assessment, if we receive complaints
and read about non-compliance of standards in the media, we might cancel the
accreditation after assessment," cautions Bhatia.
What is the minimum and maximum time that a hospital would take to get NABH
accreditation? "A hospital with well-defined systems and processes takes
around 9-12 months to get through with the accreditation steps across the world.
This is directly proportional to the awareness and preparedness a hospital has
as against the said accreditation standard. If we consider the NABH standard,
a first-time initiative will range between 12-16 months," states Das.
MoU With ACHS
To consolidate its position, NABH has recently entered into an MoU with the
Australian Council on Healthcare Standards (ACHS). Representatives of NABH visited
the ACHS headquarters in Sydney, to ink the agreement on July 4, 2006 in the
presence of the Consul General of India.
NABH will benefit from the over 30 years of learning of ACHS. It will also help
NABH in speedy preparation for recognition by International Society for Quality
in Health Care (ISQua) for both its standards and accreditation programme. "The
ACHS accreditation programme called ‘Evaluation and Quality Improvement
Programme’ (EquIP), will now be available to Indian hospitals wanting an
overseas accreditation at an affordable cost," says Das.
The agreement entails ACHS supporting NABH to develop a local accreditation
programme, joint participation on site surveys during accreditation and helping
QCI on its pricing policy of accreditation. "ACHS has agreed to share the
best practices developed over the years having direct impact on quality and
safety of care through joint education programmes," informs Das.
"This agreement is a clear sign that Australian accreditation
is respected throughout the world," says Dr Michael Hodgson AM, President,
ACHS International. (Read interview with Brian Johnston, Chief Executive, ACHS,
on accreditation in Australia)
How would ACHS benefit? "Ultimately, the Australian framework will benefit
from the lessons of our colleagues in India, a country with around 20,000 hospitals,"
he says. And why did QCI choose ACHS? "We are both not-for-profit bodies
sharing same ideologies," replies Das.
Recent Initiatives
A lot of hard work and sweat has gone into popularising NABH and training assessors.
Soon after it was launched, NABH held training centres in five set-ups—two
were in Delhi, one in Mumbai, one Kolkata and one Bangalore. ACHS is helping
NABH train the assessors as per international standards. In the training programme
of five days, around 100-odd professionals comprising medicos, nurses, paramedics
and administrators were exposed to the NABH standard and assessment process
was followed by an exam. Further screening was done at the NABH secretariat
on the participants and post-screening 76 assessors were empanelled. The assessors
are paid Rs 6,000 per day per institute visit.
NABH is holding sensitisation programmes and technical sessions in all six
metros, targeting audience from the healthcare industry. It has chalked out
road shows in the metros and has tied up with CII for creating awareness. Says
Dr Mohan Thomas, Chairman, CII Western Region Healthcare Sub Group, "While
it may not be difficult for corporate hospitals to get NABH accreditation, we
are trying to convince nursing home owners about the benefits of a national
accreditation."
NABH is also in talks with state governments, corporate houses, and private
players to implement accreditations. "NABH accreditation will revitalise
some of the large healthcare groups like CGHS, PSU hospitals, Government hospitals
and defence hospitals," says Gyani.
The Roadblocks
|
Facts About NABH
|
| CII formed a national taskforce committee in 2004
to come out with draft standards in association with Indian Healthcare Federation.
The first draft of 600 pages was prepared by early
2005. These were handed over as input to the technical committee, set
up by QCI/NABH to draft present set of standards.
NABH has three committees: Accreditation Committee,
Technical Committee and Appeals Committee.
|
While the NABH has fulfilled a long-standing need for a national
accreditation, experts feel that similar standards cannot be applied for all
types of healthcare institutes. According to health consultant and MD of HOSMAC,
Dr Vivek Desai, "NABH should have separate standards for nursing homes,
public hospitals and corporate/trust hospitals. As Resource Based Relative Value
system is used to decide cost in hospitals, such systems should also be used
for accreditation standards. Otherwise, the institutes will find it difficult
to sustain NABH." Taking a cue, NABH is already deliberating on the demand
for less stringent guidelines for institutes with fewer beds and different sets
of guidelines for critical care, says Gyani. NABH guidelines will be modified
every two years.
Others are apprehensive about bureaucratic hassles crippling the functioning
of NABH. Dispelling fear, Bhatia says, "QCI is an autonomous body and NABH
is also autonomous. So, there is no bureaucracy involved."
NABH is also plagued by dearth of funds to create awareness and lack of qualified
people helping hospitals to prepare for NABH. "Only Rs 50 lakh was sanctioned
for this year by the planning commission as promotional budget. We have been
promised a bigger budget next year," says Gyani.
Others fear about NABH surveys being biased and influenced
and NABH assessors promoting their individual company for gap analysis of hospitals.
"To rule out bias, we are encouraging institutes to be on our panel of
assessors than individuals," maintains Bhatia.
| Who Can Be NABH Assessors? |
| Clinician: An MBBS with 10 years of experience,
of which five years are working in a healthcare institute.
Nurse: For diploma in nursing, 15 years of
experience. For BSc/MSc nursing, it is 10 years of experience.
Administrator: Five years of experience in
a hospital.
Initially, the assessors are sent as observers.
After three visits, they can be upgraded as lead assessors. While anybody
related to healthcare can get trained for NABH, only clinicians, nurses
and administrators with the said experience will be deployed to assess
for accreditation.
|
The Way Forward
 "Within
the next three to four months, NABH guidelines for blood banks and diagnostic
(imaging) centres will be finalised" - Girdhar Gyani
Secretary General
QCI
|
NABH's ambitious target is to complete assessing 50 hospitals
by the end of this financial year and another 200 within
the next year, says Gyani. Riding on the instant popularity,
NABH is already chalking out accreditation standards
for blood banks and diagnostic (imaging) centres.
"Within the next three to four
months, the guidelines for blood banks and diagnostic
(imaging) centres will be finalised. Please note that
the guidelines are not for pathological labs as NABL
has already taken care of that," says Gyani, adding,
"There are around one lakh clinical labs in the
country, run with minimal infrastructure and standards.
The labs would be encouraged to do self-declaration
to the state Government about their infrastructure and
manpower. QCI is proposing to extend support to various
state Governments in evaluation of minimum structural
standards."
Moreover, NABH has also submitted a proposal to the Ministry
Of Health for accreditation of primary healthcare centres (PHCs). "We want
to test the waters with pilot studies and thereafter go for national level accreditation
for PHCs," says Bhatia. While the right steps are being taken by a band
of committed people to regularise Indian healthcare system, experts suggest
that the national accreditation should be mandatory and not a voluntary option.
|
'India Should Not Allow A Fragmented
Approach To Accreditation'
 Australia's
leading healthcare accreditation agency, Australian Council on Healthcare
Standards (ACHS) is an independent not-for-profit organisation dedicated
to improving quality in healthcare through continual review of performance,
assessment and accreditation. ACHS member organisations represent 84 per
cent of public beds, 94 per cent of private beds and 87 per cent of all
available beds in Australian health services. Brian Johnston, Chief
Executive, Australian Commission on Safety and Quality (ACSQ), tells Rita
Dutta about the evolution of ACHS standards and steps that India should
take for a successful national accreditation
Please brief me about the various accrediting
bodies in Australia.
For healthcare, generally there are more than 10
that generate standards and either directly or indirectly offer accreditation
programmes. This is a problem for many providers of services who either
voluntarily or because of legislative requirements, seek accreditation.
This situation is currently being reviewed by the
Australian Commission on Safety and Quality, which has been established
by the Australian Health Ministers, to take the lead role for Australia
on the safety and quality agenda in healthcare. India is strongly advised
not to allow a fragmented approach to evolve. Whilst there is a strong
case for specific standards to apply in some circumstances, for example
in relation to pathology laboratories, they should form part of an integrated
framework.
There are also several private organisations which
accredit to the ISO standards. However, the ACHS is the largest healthcare
accreditation body in Australia, our member organisations represent 84
per cent of public beds, 94 per cent of private beds and 87 per cent of
all available beds in Australian health services.
Are there for-profit accreditation bodies in
Australia?
There are several 'for-profit' organisations which
accredit to the ISO standards. However, their market share is very small.
Since ACHS accreditation is over 30-years-old,
how have the standards evolved over the years?
The major changes include greater emphasis on the
outcomes of care; the focus on a comprehensive organisation-wide framework,
rather than separate units within a healthcare organisation and the increased
focus on clinical care and consumer participation.
The process for developing the standards is also
more robust and consultative. They are developed in close consultation
with industry experts in a variety of different fields. For instance,
our most recent review of standards began with an examination of the relevant
literature and a comparison of the EQuIP standards and criteria with those
of other countries. The most recent set of standards is the 17th time
ACHS has revised its standards. The new standards come into effect from
next year.
Did ACHS click right from the word go? If not,
what were the hurdles that ACHS has faced over the years?
Whilst accreditation had a very substantial amount
of support from the outset, there were misgivings expressed by some sections
such as certain state Governments. It took several years to gain that
support and India should seek to gain the support of key stakeholders
in both the public and private sectors from the outset.
In India, emphasis on quality and medical tourism
are driving hospitals towards accreditation. What compels Australian hospitals
to get accredited?
'Medical tourism' is not a major issue in Australia,
although being accredited has significance from a marketing perspective,
whether patients come from home or abroad. In Australia, the various reasons
why organisations seek accreditation are performance requirements for
the public sector, contractual requirements that govern funding by third
parties, such as health insurance funds; and risk management, with performance
assessments carried out by respected, independent organisations, such
as ACHS and legislative requirements in relation to licensing of private
facilities. Many organisations though are simply committed to quality
as it is a key component of their culture. Accreditation can be an important
strategy to influence organisational culture.
How similar and dissimilar are NABH standards
from ACHS?
First observations are that there are strong similarities,
although NABH has developed a lot more of them. Australia is a mature
country in terms of accreditation so the emphasis of the accreditation
programme is only placed where it needs to be, for example, clinical care,
governance and key support areas.
How different is ACHS from ISO or JCI?
ACHS is a programme specifically designed for the
health industry that encompasses the key features of several other approaches,
including ISO. Its standards relate specifically to healthcare delivery
systems and are designed to facilitate the assessment of outcomes. In
other words, it poses certain questions— Does the system work? Is
it the most effective? Is it efficient? Most importantly, it is adaptable
to a range of different environments.
ACHS recognises the wide variety of organisations
and the differing environments in which health systems function. In Australia,
the standards are designed to facilitate interpretation and application
in many different settings.
Internationally, we advocate using a basic set of
standards as the starting point and then adapting them to the local scene.
This results in standards which are relevant and useful. The features
of flexibility in interpretation, adaptability to different environments
and being health-specific combine to distinguish ACHS' programme from
others.
How does ACHS charge? What are the various steps
to get ACHS accreditation?
The programme is membership based and organisations
enter into a contract for four years. The amount charged is dependent
on the size of the organisation. An important feature is that fees are
'community rated' which means that members pay the same amount, based
on their size and complexity, irrespective of where they are located.
In a country the size of Australia, it is important that geographic isolation
or distance from major cities is not an impediment to participation.
ACHS does not receive any direct Government subsidy
and the majority of its revenue comes from membership fees. In simple
terms, once the organisation has been accepted as a member, the accreditation
programme involves a major event occurring each year between ACHS and
the member organisation. The cycle starts with an organisation self assessing
their performance against the standards and then moving to having that
assessment verified by surveyors when they visit. Accreditation can be
awarded if the member organisation's performance meets certain requirements
and can be awarded for up to four years.
And what is the maximum and minimum time that
a hospital takes to get ACHS accreditation?
It usually takes between twelve and eighteen months
to achieve accreditation.
Has any other country adopted the ACHS standards?
Yes, it is working with several countries in the
Middle East, where we have adapted our international standards for use
in that region. We have been working with several hospitals in India that
are using the international version. In Hong Kong, the Australian version
is being used, although we expect to develop a Hong Kong version.
A number of other countries have used ACHS standards
in reviewing their own programmes. Also, ACHS regularly liaises with senior
staff executives from the standards, accreditation and quality improvement
programmes of a number of countries through the International Society
for Quality in Health Care.
The ACHS has an exchange programme of surveyors
with both Ireland and New Zealand. Quality Health New Zealand has recently
decided to align its standards with those of ACHS.
Does ACHS have any previous experience of Indian
healthcare market? If not, will it not be difficult to comprehend market
dynamics that dictate pricing?
The work with the QCI and NABH is of course collaborative,
therefore the ACHS will bring its experience and knowledge of healthcare
accreditation in partnership with the local expertise and understanding
of both QCI and NABH. As mentioned previously, we are already working
with several hospitals in India.
Because of the collaborative nature of the relationship
we will be guided by the advice of the QCI/NABH in relation to market
dynamics in relation to pricing. Our activities in both India and the
Middle East are undertaken with an Australian-based firm of private consultants,
Quality Healthcare Australia (QHA), the principal of which is Dr Robin
Pavillard. QHA is experienced in both countries and is playing a valuable
role in the development of a quality culture in participating organisations.
What is the future of healthcare accreditation
in developed and developing countries?
I think the future is strong in both settings. In
fact, there is a substantial increase in the number of countries introducing
accreditation programmes that are standards based. Why? Because standards
provide a framework for effective and efficient managers, and if properly
utilised, can support clinicians and organisations to minimise their risks
and optimise the services provided to patients. Standards can focus attention
on areas of most importance for all staff e.g. accessing services, infection
control, disposal of waste, safe surgical practice.
Most of all, they must be achievable and some compromises
might need to be made initially to encourage achievement through setting
realistic goals that can become more advanced over time. In a developing
country, there is a strong case for having different sets of standards
for larger, sophisticated hospitals from those that would be applicable
and useful to small rural services. The recognition system for achievement
should be designed to encourage improvement rather than punish poor performance
if sustainable, long-term improvements are to be achieved.
|
rita@expresshealthcaremgmt.com
|
