Industry Voice

Healthcare Grading - An advanced quality evaluation tool

The Government, traditionally the largest healthcare provider, is under pressure to meet the evolving and rising demand for healthcare services across the country.

Dr Shyama S Nagarajan

The most fundamental structural change affecting the Indian healthcare sector is the altering demographic and socio-economic profile of the country. The increase in the proportion of the working age group (15-54 years) is being accompanied by an unprecedented rise in per capita income, which is ushering in lifestyle and consumption patterns. With lifestyle patterns changing, the country's disease profile has been changing too, witnessing the rise in the incidence of lifestyle diseases. The increase in the population share of the elderly is also causing a change in the pattern of demand for healthcare services.

The Government, traditionally the largest healthcare provider, is under pressure to meet the evolving and rising demand for healthcare services across the country. This demand-supply interaction has created conditions for increasing private/voluntary sector participation in the delivery of healthcare services, opening opportunities for both preventive and curative care. On the supply side, there is increasing polarisation in terms of availability of healthcare services. While the population living in urban India is enjoying increasing access to healthcare services and options, that in rural India remains under-served, despite the fact that 80 per cent of India's population dwells in villages. ICRA observes that the existing hospitals are adding capacity in specialities where demand is emerging, and often promoting the added capacity as a separate, branded unit, to emphasise the specialty aspect. For instance, inpatient capacity in cardiac care is close to the point of reaching excess supply in certain cities. Even smaller healthcare institutions are increasingly allocating more beds for surgical and intensive care, at the cost of wards and rooms, perhaps because of revenue considerations.

The health insurance (HI) industry, which hitherto accounted for only a small share of the total expenditure on health, is also poised for a big leap, with private insurance products having been launched. Although with potentially far-reaching consequences, HI is yet to exert any significant pressure on the way hospitals compete or operate in India. However, institutional customers have emerged as an important source of regular and lucrative business for the health insurers.

Another important and positive development taking place in the Indian healthcare sector is the use of information technology (IT) to obtain real-time information on hospital management indices, handling medical records, networking various departments in a hospital, and providing tele-medicine services. Outsourcing also happens to be the current trend in hospitals, especially in non-clinical (such as laundry) and clinical support (blood bank, diagnostic services) areas. The drivers of outsourcing include the need to focus on core business (micro management of patient care following the increase in the number of super specialties), lack of space, rising cost of administration, and eagerness to avoid potential industrial relation problems.

These transformations in the healthcare sector have several implications. For users of healthcare service (patients), the choice is increasing. For healthcare entities, there is need to differentiate, and establish a favourable price-value equation. For regulators, the provision and quality of healthcare offered must be monitored. For insurers, healthcare entities with which they can associate themselves have to be identified. For lenders, the viability of healthcare entities must be ascertained. All these needs call for a system that can provide a credible, objective and unbiased opinion on the quality of care that healthcare entities are providing.

However, conceptualising quality in healthcare institutions is difficult for all the stakeholders—the providers, the receivers of care, the financers and the regulators. The patients are unaware of therapeutic technicalities, therefore cannot always choose intelligently, and as the outcome depends not only on the providers' diagnosis and treatment but also on the patient's co-operation and immune reaction, it becomes difficult for the patients to frame their expectations. The provider is also equally perplexed towards the standard of care to be delivered vis-à-vis the level of care envisaged to be delivered because of paucity of objective data, lack of regulation to regulate the mushrooming of hospitals in the country, and short supply of qualified medical and nursing staff.

Although HI is required to ensure affordability of care, it has not yet emerged as a major contributor in the Indian scenario due to various reasons. The service providers have not harmonised their costing system, leading to wide and unexplainable variation of fees between surgeons and hospitals across the country, which in turn results from the lack of an objective indicator for quality service offered, increased number of doctor's visit to the insured customer, unnecessary investigations, and inflated and manipulated bills. The consumers hide facts on pre-existing ailments often covered in nexus with/without doctors. The regulators insist on formal approval before the introduction of a new product, leading to delays. The product itself has a pricing system that is based on competitive pricing and not on actuarial science or diagnosis related grouping, and predominantly cover diseases and not health products, and are designed for inpatient admissions (40 per cent) and not outpatient services. The third party administrators (TPAs) do not have control over the increased claim ratios.

Therefore, a quality evaluation methodology adopted should be indicative of the purpose and nature of function, i.e. level/complexity of cure and the intensity of care provided. Given these needs against the backdrop of the paradigm shift taking place in the healthcare sector, to demystify the intricacies of quality of cure/care delivered. The grading of healthcare institutions while evaluating the two most important elements of care: the technical and interpersonal aspect of care offers an objective assessment on the capability to deliver care that is represented symbolically on a four point scale with +/- between the broad scales of H2 and H3 to highlight the subtle differences. The grading methodology is based on the evaluation of the triple Donabedian's framework of evaluation of resource, process and outcomes to arrive at the institution's capability to deliver care.

The resource criteria includes evaluation of:

Infrastructure and facility human resources: In infrastructure and manpower the focus is on adequacy (both numerical and technical), appropriateness w.r.t the mission and vision of the healthcare entity and the level of care that the healthcare entity declares to deliver.

Governance and management: Credit is given for having professionals of diverse occupational backgrounds, with proven organisational and leadership skills and knowledge of local and national healthcare issues on the board of the institution. The focus is on having clearly articulated objectives, policies, bylaws and performance targets with well-established quality culture and oraganisational culture. The track record of the institution and corporate governance issues offer subtle clues to analysis.

Financials: Emphasis is laid on financial stability and flexibility to operate the service properly, and to provide strategies to encourage superior performance.

The process criteria includes evaluation of key processes such as the:

Patient flow process: Delivering care effectively to each patient requires careful planning of patient processes, therefore emphasis on the appropriateness of design and execution of core patient processes.

Clinical process: Process by which clinical decisions are made is evaluated by random sampling to see whether certain protocol is followed or not as accepted in the medical community of the select specialty. Emphasis is laid on assessing robustness of clinical decision making process, assessing variance in activities and sequence of activities in clinical decision making process and ensure system for continuum of care uniformity of care. Grading at no point questions the decision made by the clinicians on the therapeutic intervention applied if the process adopted to arrive at the diagnosis is robust.

Other process criteria that are evaluated are:

Information generation and documentation system: To ensure adequacy, reliability and accuracy of data collected and information generated for the seamless functioning of the healthcare system.

Infection control system

Ethical practices: Focus in on evaluation of the practices to ensure ethical practice, taking care of patient care and patient rights issues.

The outcome criteria includes evaluation of the:

Clinical criteria: Focus is on system for clinical credentialing, clinical audits, clinical risk management, clinical outcome measurement. The focus is on analysing the trend of healthcare entity's utilisation and success indices.

Patient and employee satisfaction survey—a statistically significant sample survey is conducted to improve the confidence limits of a certain remark /assessment / comments made to understand the interpersonal issues.

E-mail: shyama@icraindia.com