Dynamics Of Accreditation Of Private Hospitals

In developing countries like India, where health services are delivered mainly through private health providers, regulation is an essential instrument of Government policy, says Dr Varsha Zende

The private sector plays a crucial role in Indian healthcare industry. Known as the 'for-profit sector', the private sector accounts for a substantial proportion of healthcare in India (50 per cent of inpatient care and 60-70 per cent of outpatient care). In spite of this fact, the domain has received relatively less attention from the policy makers of our country as compared to the public sector. Consequently, the private healthcare delivery system in India has remained largely fragmented and uncontrolled, and there are clear evidences of serious quality of care deficiencies in their practices. Problems of the private section are many: inadequate and inappropriate treatments, excessive use of high-tech technology, wasting of scarce resources, medical malpractice and negligence, to name just a few.

Since quality is a crucial factor in healthcare, initiatives to address quality in healthcare have become worldwide phenomena. Mechanisms used in other countries to produce greater efficiency, accountability, and better governance in hospitals are not yet deployed in India. A commitment to quality enhancement throughout the whole of the healthcare system involving all health professional groups is essential to ensure that high quality in healthcare is achieved, while minimising the inherent risks associated with modern healthcare delivery. There are many methods for the assessment of quality in healthcare, licensure, certification etc and one of these budding concepts is the accreditation system. Accreditation can prove to be a gold standard in quality of care assessment and will not only improve incrementally the standards of care provided, but also prove to be an extremely effective measure for verification of compliance of standards.

Accreditation primarily has four inherent properties:

• It is voluntary.
• Reviews are conducted by (external) professional peers.
• Governed by a local body.
• The ultimate aim is to encourage incremental growth and development within the healthcare unit.

Accreditation usually involves:

• Measuring one healthcare unit against another equivalent one, which proves to be a great motivator as it encourages healthy competition.
• Providing feedback to the accredited organisation on its progress towards quality goals and areas requiring attention.

The quality and standards of healthcare improve the overall standards of 'achievable ideal quality' rise. This incremental raising of standards is called 'ratcheting' and is a quality unique to accreditation which is not found in other (ie licensing and certification) quality assessment processes.

Accreditation System In India

In the Indian context, there have been efforts by consumer bodies, groups of health professionals, hospital organisations, and non-Government organisations for drawing standards.

• The Bureau of Indian Standards (BIS 1988) has laid down standards for 30, 100 and 250-bed hospitals.
• The National Institute for Health and Family Welfare (NIHFW 1992) laid down standards for more than 50 beds, which is only for the hospital equipment.
• In Andhra Pradesh, Vaidya Vidhya Parishad has laid down standards for secondary level hospitals in the Government sector.
• In Pune, health committee of Lok Vignyan Sangathana came up with routine pre-operative investigations before minor surgery.
• In Mumbai, CEHAT, a non-profit health research organisation has come up with a document on 'Proposed minimum standards for 30-bed private nursing homes'.

Unfortunately, all these proposed mechanisms to ensure regulation were not well received by the medical professionals for various reasons. The reasons ranged from fear of being asked to make huge structural changes, to costs incurred, to losing face in public because of non-accreditation status etc.

Models Of Accreditation

There are different models of accreditation, which are broadly classified into three pertinent models, especially in developing countries. With each model, the criterion of accreditation changes as the focus shifts from structure to process to outcome.

The first model of quality assessment gives priority to standards related to available facilities in the clinical unit. Here, the criterion of accreditation is based on the availability of basic healthcare facilities like equipment, human resources and space specifications.

The second model lays stress on quality assurance i.e. process indicators and sets standards for those institutions striving to arrive or improve quality of care. Hence, accreditation is based on satisfying some basic indicators of quality and involves ranking based on levels of quality.

The third model is based on the citizen's charter. This model emphasises the fact that health systems should be accessible and acceptable to health-seekers. It uses indicators like providing accurate and relevant information to the users, information about the services rendered at the health unit, grievance redressal system in place etc. In deciding a model appropriate to the Indian context, it is necessary to have a pragmatic approach. We need to acknowledge the rudimentary nature of most of the hospital information systems and the transaction costs to participating hospitals.

The first model of facility-survey, can be seen as being partially pertinent in ensuring the basic facilities required for providing healthcare. In contrast, the second model which lays stress on quality of services provided would prove to be ineffective in the Indian context as of now. Initially, standards could be based on simple structural and process indicators- facility assessment, availability of protocols for key public health priority disease programmes and continuous medical training facilities for staff. The most relevant model of accreditation for the Indian health system is the people-centric model, which would ensure the presence of four A's viz. acceptability, accessibility, accountability and allocative efficiency. Ensuring the presence of the above would monitor utility of the available services and orient the health system towards performance management.

The emerging system of accreditation in India has to clearly mandate the uniformity of the standards used for the purpose of accreditation and the nature of the relation of accreditation bodies with the state and the role they would play in the health sector. Composition of the accreditation body has to be reflective of adequate and fair representation from each of the stakeholders group, Government officials, medical professionals, consumer groups etc. The accreditation body should be an autonomous body and have a restrictive relation with the state to be effective in regulating the health system. To make accreditation a feasible process it should be context-specific and the standards should be achievable within the relevant context.

Advantages Of Accreditation

• Assists in improving organisational quality, both structurally as well as functionally.
• Enhances the brand image of the hospital.
• Informs about competitors' relative quality.
• Government officials see it as a regulatory mechanism to harness the private healthcare providers.
• Financial institutions see it as a mechanism to control costs and increase their level of security in providing loans.

Concerns

There are a few concerns raised by the stakeholder groups, which need to be addressed by the accreditation board via providing accurate information and ensuring some sort of technical support.

• Added workload for staff and administration.
• New/advanced structural changes may be needed to meet standards.
• Increased efforts result in work-related pressures and stress associated with compliance efforts.
• Added costs of membership.
• Decrease in staff morale if not accredited.
• Inherent risk of losing potential and current patients if knowledge of non-accreditation becomes public.

Myths About Accreditation

• Punitive regulatory mechanism.
• Substitute for minimal standards.
• Easy to manipulate.
• Serves only bigger hospitals.
• Is extremely costly.
• Ultimately the patient will end up bearing all the transactional costs of the accreditation system.
• In a resource, poor setting will have a poor response.
• Targets only the private healthcare providers.
• Increases corruption largely in the health sector.
• Poorly-graded healthcare units may have to shut down.

To shatter these myths about accreditation, it is necessary to have uniformity in approach and implementation strategies both at the state and at national level. To ensure sustainability and viability in the long-run, emphasis should be on:

Involvement of stakeholders in the accreditation process right from its inception; evolving standards from minimum to evidence-based standards; and consumer awareness and awareness generation activities are critical to ensure long-term sustainability.

Financing Accreditation

Financing is another crucial factor that may determine the viability and the sustainability of accreditation in India.

Ongoing Financial Support Could Include:

• Hospitals using their grants for initially funding accreditation.
• Fees paid by the participating providers. This could help in retaining the interest levels within the private sector providers.
• Possible combinations of private and public sector involvement.

Membership fees: Contributions from medical associations, pharmaceutical companies and leading corporate hospitals. However, such contributions may raise important questions about the influence that such bodies may have on the accreditation process.

• Insurance companies may use accreditation as a tool to decide which healthcare organisations to reimburse.
• Grants can pour in from various bilateral/multilateral funding agencies, state Governments, corporate sponsorships etc.

Conclusion

The process of accreditation needs to be supported by our legislation to make it foolproof and to sustain the momentum. These steps would take accreditation process ahead, which would ensure an optimal level of healthcare to the masses.

The writer is Senior Research Officer at Centre for Enquiry in Health and Allied Themes (CEHAT), Mumbai.
E-mail: vz_2005@yahoo.co.uk