STANDARDS : THE HEARTBEAT OF HOSPITALS

STANDARDS : THE HEARTBEAT OF HOSPITALS

Sunil Nandraj, Anagha Khot and Sumita Menon

There is a growing pressure on health care providers and professionals to maintain and improve the quality of provision of health care services. The expectation from the people for quality medical care is high, especially the middle classes. This paper examines the issue of quality and standards with specific reference to private hospitals. It provides an overview of the theoretical understanding of the terms quality & standards, the present quality of care and existing mechanisms for monitoring. It urges for an accreditation system for private hospitals as one of the alternatives, which would be more participatory and transparent.

With the opening of the Indian economy, quality is the buzz word with international Standards Organization (ISO) certifications issued by organizations both at the national and international level. In the present age of quality revolution with its emphasis on quality leadership, quality enhancement, quality assurance, total quality management, total quality management, quality level and quality of life among others are becoming the mantras not only in the industrial settings but also in the human service organizations. The Oxford English dictionary defines 'quality' as a noun meaning degree of excellence (Oxford dictionary, 1984). The Bureau of Indian Standards (BIS) defines 'quality' as the totality of features and characteristics of a product or service that bear on its ability to satisfy stated or implied needs. (BIS, 1992).

Quality medical care involves methodology used to assess and ensure quality development of guidelines regarding appropriate methods of quality assessment to improve care provided and increase overall access to health care of high quality. The measures include reducing unnecessary admissions, assessing the appropriateness of average length of stay, the number of consultations and the number of days spent in hospitals. The outcomes include rate of avoidable deaths, preventing hospital infection, avoiding surgeries and invasive procedures when not necessary and reducing the instances of post operative complications and readmissions. Avedis Donabedian, the guru of quality assurance in his contribution to the assessment of health care lays emphasis not only on the technical domain (defined as knowledge, judgement and skill of providers) but also on the interpersonal. This consists of patient communication to the physician for purposes of both the diagnosis and determination of preference for treatment and physician communication to the patient for purpose of information on the nature and management of illness (Donabedian, A, 1988)

The first step in improving quality of care is an articulation of standards that are needed for the provision of care. The key concepts for the definition of standards are firstly, that standards are a degree of excellence, secondly, standards serve as a basis of comparison, thirdly, that standards are a minimum with which a community may be reasonably content, and finally, that it is recognized as a model imitation. Standards are classified broadly as written or explicit standards, and unwritten or implicit standards. Ideally standards should be written and explicit as this allows both the data collection process and the assessment of care to be based on clearly delineated agreed upon bench marks rather than relying on the discretion of assessors (Fooks. C & Rachlis M, 1990). There are minimum standards which generally represent a level of acceptability and minimum standards are a must to meet. Beyond the minimum there are desirable or optimal standards. Minimum standards should be achievable by all, optimal standards on the other hand represent a degree of excellence. Conformity to specified requirements are based on collective judgments. Standards have to be developed and maintained and would include both the organization and the management's standards, standards for clinical /professional practice.

Existing situation with regard to standards in Inida: The private health sector in India is the most dominant sector in terms of financing and utilization of health services. The share of the private health sector is around 4 percent of the Gross Domestic Product as compared to the government, which is around 1 percent. Recent studies conducted bring out that for indoor care around 50 percent and ambulatory care (out-patient) nearly 70 to 80 percent of people utilize private health facilities in the country.

Only recently due to pressure by the judiciary many facts are emerging. In 1991 the Chief Justice of the Bombay High Court directed the Bombay Municipal Corporation (BMC), to set up a permanent committee to oversee and supervise the implementation of the Bombay Nursing Home Registration Act (BNHRA), 1949, and make recommendations.

The committee as one of its tasks decided to look at the functioning of existing hospitals and nursing homes in the city of Bombay. As part of the committee, 24 hospitals and nursing homes in the eastern zone of Bombay were studied (Nandraj S, 1994). The major findings of the study were that a seventh of them were functioning from sheds or lofts in slums and more than half were located in residential premises. Most of them were congested, lacked adequate space, passages congested, entrances were narrow and crowded and there was inadequate space for movement of either trolley or stretcher. Only 15 of them had a Operation Theater (OT) out of the 22 who were supposed to have. It was observed that in some the OTs and labour rooms were in rooms originally designed as kitchen. Some had OT's that were as 48 sq.ft and leakages were to be found in the OT and labour room with paint from the ceiling and walls peeling off. Seventy seven percent did not have a scrubbing room. Many of the hospitals and nursing homes were ill equipped, especially those providing maternal health services. For instance many of them did not have resuscitation sets in the labour room for new born babies. In case of emergency availability of supportive services like ambulance services, blood, oxygen cylinders, generators etc. were insufficient. Out of 24 hospitals and nursing homes only 1 hospital had employed a post graduate doctor, whereas 10 of them had doctors trained in other systems who were providing treatment in allopathic medicine. Less than a third have qualified nurses and most of them had employed unqualified nurses. It was found that in 38 percent, the hospital premises were dirty and beds in the general ward were unclean. The number of toilets and bathrooms were not in proportion to the number of beds provided in the hospital. While these facts relate to Bombay, it should be apparent that the situation in the private health sector in other cities is likely to be similar, or perhaps even worse.

Among the major complaints against private hospitals & nursing homes are that of over charging, not providing the personalized care they claim to provide, subjecting patients to unnecessary tests, consultation and surgery, defunct equipment, not providing information about diagnosis and treatment, doctors absent for long periods even in the Intensive Care Unit, general disregard for patients and their highly commercial nature of functioning. Referrals are made to specialists and laboratories more for financial reasons rather than diagnosis.

In India private hospitals & nursing homes function without any monitoring by any authority or through a process of peer review / self monitoring. There are no standards of medical practice prescribed for private hospitals in terms of qualification of staff employed, equipment needed, administration, treatment offered etc. Except for the states of Maharashtra, Delhi and Karnataka there are no rules, laws, regulations legislation's for private hospitals functioning. The practitioners are supposed to function broadly under various medical councils setup for various systems by law. The functioning of the medical councils in the country leaves much to be desired. The registers are not updated, doctors who have died continue to be on the register, the trials are held in-camera, action has not been taken against doctors inspite of complaints made. Only recently the private practitioners and hospitals were brought under the purview of the Consumer Protection Act. The working of the consumer courts set up for speedy justice for redressals leaves much to be desired. Despite having one of the largest private health sector in the world, providing 70 percent of care in India, the fact that it should function practically unregulated is a matter of grave concern.

In the past one decade there have been debates and discussions on issues of functioning, quality, finance, monitoring, accountability and standards of private hospitals and nursing homes in the country. These have taken place between hospital owners, health professionals, researchers, activists, consumer groups and government functionaries. These efforts were mainly in two directions, one was to evolve minimum standards for hospitals and the other to develop alternative systems for ensuring quality of care. There have been attempts made by various government bodies to amend / evolve standards for private hospitals. In the states of Maharashtra and Delhi attempts were made to amend the existing legislation's to incorporate the minimum standards for private hospitals. There is a move by the states of Tamil Nadu and Bihar to enact legislation for the registration of private hospitals. The Bureau of Indian Standards (BIS) has laid down standards for hospitals ranging from 100 to 250 beds. National Institute of Health & Family Welfare (NIFHFW) has laid down standards but largely for 50 and more than 50 bedded hospitals and that too only for equipment. Most of the standards laid down by BIS, NIHFW etc. are meant for relatively larger hospitals located in major urban areas.

There have been concerned efforts undertaken by consumer and non-governmental organizations based in the cities of Bombay & Pune on this issue. Along with the consumer bodies, groups of health professionals and hospital organizations were also involved for drawing up standards and to develop an accreditation system. Medico Friend Circle along with other like minded organizations organized seminars, workshops and public meetings on the issue of standards in hospitals. The seminars and workshops came up with specific recommendations on standards and debated on the issues in detail. In Pune, the Health -Committee of the Lok-Vignyana Sanghatana took the initiative in preparing minimum standards for anesthesia before surgery came up with 'Routine Pre-operative Investigations for 'Minor Surgery' in A.S.A. Grade 1 patients'

CEHAT, a non profit health research organization as part of its project on physical standards in private hospitals: A case study of rural Maharashtra evolved a document "Proposed minimum standards for Private Hospital and Nursing Homes" for 30 bedded hospital providing Medical/Surgical/Maternity care taking into consideration various aspects of functioning. A one day workshop on "Minimum Physical Standards for Private Hospitals and Nursing Homes" was also held in Bombay. The participants for the workshop consisted of researchers, government officials, doctors from the public and private hospitals from urban and rural areas. The minimum standards were discussed in the workshop and the suggestions and comments from the participants were incorporated in the final document. (The document is available with CEHAT)

Accreditation of private hospitals as an alternative: As seen above there is an urgent need to evolve mechanisms which are participatory, democratic, rational, transparent, legitimate and involve all the constituents. The system should not only formulate standards but also monitor the process of measurement of compliance with them. The system which meets the above criteria is an accreditation system for hospitals.

Accreditation is a process wherein standards are set and compliance with them is measured. CE Lewis gives a useful working definition of accreditation as "professional and national recognition reserved for facilities that provide high quality health care". This means that the particular health care facility has voluntarily sought to be measured against high professional standards and is in substantial compliance with them (Lewis C. E, 1984). In many countries accreditation systems are in place for the monitoring of standards in hospitals.

Under the present circumstances an accreditation system would be the best alternative for private hospitals and nursing homes. As this system one of the basic inherent factors is that it would be voluntary in nature, involve that various constituents and would be transparent.

Standards in hospitals would benefit most of the constituents of the health care delivery system as stated below.

Hospital owners / Administrators / Doctors: The accreditation system would help in assessing the hospitals for compliance to set standards, provide recognition to those meeting standards, assist them in upgrading standards, assist hospitals in continuos quality assurance. Furthermore, it would help them to compare performance with other hospitals, serve as a useful marketing tool, create a level playing field between the various providers, help in the process of collaboration with others constituents such as insurance companies, financial institutions. It would also help in the development of clinical and professional practice and help the hospital improve its internal management or and service delivery. Thus, accreditation can be seen as a new approach to assessing the quality of health care provision.

Patients / Consumers: Presently patients tend to be at a disadvantage in the process of selection of a health care provider due to non-availability of information. An accreditation system would assist the patient to make informed choices between potential providers. They would be aware of the type of services and quality of care to expect and be assured of certain minimum standard. It would also reduce their burden to develop their own systems for assessing the quality of care provided by a hospital. Furthermore, it would also provide the patient with a forum for his/her grievance redressal.

Government / Judiciary: The benefits of an accreditation system for the government and judiciary would be immense. The government agencies would be able to collaborate with hospitals for various activities based on accredited status. In addition an accreditation system would aid the government agencies in monitoring of the private hospitals, which would be more participatory & collaborative, corruption could be minimized. The accreditation system would be able to assist the judiciary in decision concerning medico-legal, malpractice and negligence cases among others.

Financial institution / Insurance companies: The accreditation system would allow the potential pool of competing providers to be reduced as those that fail to get or refuse to participate in accreditation could find themselves ineligible for consideration by insurers / financers. Hospitals that are accredited would be able to demonstrate their compliance to a certain set of standards for tem to receive any assistance from these bodies. On the other hand financial incentives may also be used to stimulate participation in standards and thereby improve quality of services provided by these institutions.

Presently CEHAT is conducting a study sponsored by the World Health Organisation on "Self-Regulation of Hospitals & Nursing Homes in Mumbai City: Need for an Accreditation System?" The study incorporates a methodology, which involves the various constituents in the health care services to collaborate and participate right from the initial stages in understanding and evolving an accreditation system. The first step undertaken is to make an assessment of & feasibility for an accreditation system from amongst the various constituents. These include hospital & nursing home owners, their associations, specialist associations, government, consumer organisations, insurance companies, financial institutions among others.

The study findings would reveal the opinion of the various constituents with regard to the need for an accreditation system, their views about an accreditation system and their willingness to participate in such a system. The study would also provide a framework with blue print for an accreditation system, which could be put in place by the various constituents. This study is currently in progress and the initial responses for an accreditation system, which could be put in place by the various constituents. This study is currently in progress and the initial responses for an accreditation system from the various constituents have been very enthusiastic. The accreditation system if implemented in Mumbai City would assure a system wherein the best quality of care with high standards is provided to the patients.

(This paper was written as part of project : Self-Regulation of Private Hospitals & Nursing Homes: Need for an accreditation System?" funded by the World Health Organisation. The authors are currently working as researchers at CEHAT)

REFERENCES

Bureau of Indian Standards (1992) : Indian Standard: Quality Systems – Vocabulary, Indian Standards Institution: New Delhi.
Donabedian, A. (1988) : The quality of Care: How can it be assessed? , Journal of the American Medical association, 260 (12), 1743-1748.
Fooks C & Rachlis M. (1990): Assessing Concepts of Quality of Care: Results of a National Survey of five self regulating health professions in Canada, CHEPA working paper series, MC master Univ, Canada 90-7 May 1990.
Lewis C.E. (1984) : Hospital Accreditation in New Zealand, Hospital 68, 8, pp-15-17 quoted in Tessa Brooks, Standards and Accreditation: Quality assurance program, Kings fund centre for health service development, Hospital Management International Hospital Federation, Sterling Publications, London, pg, 130-133, 1990.
Nandraj S. (1994) : Beyond the Law and the Lord: Quality of private health care. Economic and Political weekly, July 2,1994, 1680-1685.

(Background Paper for the Seminar on Ethics in Health Care, organised by Indian Medical Association, Mumbai, November 1997), Mumbai:CEHAT.

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