Focus

A Model State

As part of the initiative of Government of Gujarat to implement Total Quality Management system in district hospitals, CHS and PHCs, a PHC in Vadodara became the first PHC in India to receive NABH. But will Gujarat Government be successful in overhauling its dilapidated public healthcare, asks Nancy Singh

You must have seen the latest advertisement by Videocon, whose tagline declares 'Change is Good'. It is apt to copy the same for Gujarat's healthcare scene. A true example of the power of change or willpower. Every healthcare activist loves to cite the initiatives of Gujarat Government and laments over the fact as to why other states are not following suit. It is the first state in the country to sign up a Rs-300-crore Memorandum of Understanding (MoU) on 7th July, 2007 with the Quality Council of India (QCI) to strengthen its over 1,000 Primary Health Centres (PHCs) and 270 Community Health Centres (CHCs) through various capacity building exercises of QCI. As a part of this resolution, the first-of-its-kind PHC at Gadhboriad village in Naswadi taluka of Vadodara district got accredited

recently by NABH after two long years of the make-over. This is the first PHC in the country to get NABH accreditated. "The project is aimed at upgrading the standards of the health centres through focal points like patient's clinical safety, rights of the patients and improving the quality of care, to name just a few. Under the MoU, we will act as the technical advisors for the state Government for the entire project, by training their team through capacity building," says Giridhar Gyani, Secretary General, QCI.

Gujarat: The Change Agent

The move of accrediting even PHCs emerged after Gujarat got 24 district level hospitals in the state registered for NABH. This was the first time that a state Government eagerly came forward to register its hospitals under a national accreditation. "After this, state Governments of Kerala and Tamil Nadu have been prompted to register their hospitals under NABH. They have received 60 and 12 accreditations so far," informs Gyani. Besides, Delhi has six, Madhya Pradesh five and Uttar Pradesh has one NABH accreditations to credit. "Gujarat has the commitment and passion to place Maternal, Newborn and Child Health (MNCH) at the centre of the development agenda and is testing innovative and evidence- based strategies," says Rita Teaotia, Principal Secretary, Health and Family Welfare Department, Gujarat.

The Makeover of PHC

Like thousands of the PHCs in our country today, PHCs in Gujarat was no different. But the one that has made history is a four-decade-old PHC at Gadhboriad village in Naswadi taluka of Vadodara district. Gadhboriad, is a tribal village in the interiors of Naswadi taluka, which is a major health centre for a population of 32,000 people residing in 49 villages in its proximity. The story of the makeover of this PHC began two years ago. At that time, this PHC was a site for occasional deliveries and this project was launched with a single-minded vision to make it a 24-7 maternity care centre. "Earlier, the PHC had no basic facility with leaky roofs and inadequate infrastructure. The condition was not any less good than that of a bus depot! It was impossible for the patient and the relatives to spend a night over there. And for serious cases, the residents had to travel 90 kilometres all the way to Vadodara. But because of the accreditation process, the scenario has changed," shares Amarjit Singh, Commissioner of Health, Gujarat. But, "today, it is a 24X7 PHC unit wherein over 70 to 80 deliveries are carried out every month and caters to over 50 patients everyday as opposed to 24 earlier. Even the patient inflow at OPD is heavy due to availability of doctor in the state," proudly says Dr JL Meena, State Quality Assurance Officer, Gandhinagar, Gujarat. The accreditation of the healthcare centre was based on the parameters of patient satisfaction, community satisfaction, employee satisfaction and environment protection. It is equipped with antenatal care unit, baby warmers, neonatal kits and other amenities for safe deliveries apart from 24-7 availability of staff, as mentioned earlier. "The Gadhboriad PHC has adequate staff and health workers who have been trained for various tasks. The PHC here meets the requirements of the NABH standards and we will further bring in more improvements," informs Dr Meena. The PHC at Gadhboriad before the facelift The PHC after the renovation

TQM: The Action Plan

"QCI will act as the technical advisors for the state Government for the entire project, by training their team through capacity building" - Giridhar Gyani Secretary General QCI

Health programmes in the past have been beset with problems such as limited capacity, lack of programme standards and guidelines, and an obsession with quantified targets rather than client satisfaction. "The new quality parameters introduced by the state Government seek to address problems of poor sanitation and cleanliness in hospitals, staff shortage in every category, damaged and pathetic condition of the building and campus, poor signage system in hospitals, absence of patient satisfaction monitoring system, lack of a measurable parameter for patient safety and absence of legal compliances," shares Gyani. Hence, Total Quality Management (TQM) system was introduced to tackle all these problems, as also the issues of lack of accountability and planning in delivery of care to patients, lack of blood bank/ storage facility in some hospitals, and the absence of quality standards such as medical audit, management of medication, patient care, facility management and safety, information management system and infection control.

Under the system, a policy framework for NABH and NABL accreditation of public hospitals and laboratories, as approved by the state Government was launched, and empanelment of NABH and NABL consultants was undertaken in co-ordination with QCI. Appointment of Assistant Hospital Administrators (AHAs) for Government hospitals/medical colleges in a phased manner, and training at various levels, were among the key mechanisms of the TQM system, which also involved the development of quality steering committee for the state at all levels and nomination of district quality assurance officers.

Some of the practices implemented are patient satisfaction survey, employee satisfaction survey, clinical protocol, quality indicators, code blue alert (red for fire, yellow for external calamities, blue for cardiac arrest, black for bomb threat, pink for child abduction), disaster preparedness plan, basic infection control practices, fulfilment of patient rights, medication safety practices, facility management practices, incidence reporting system, safety inspection system, patient information, inventory management and quality control in diagnostics.

The Project Strategy

To be initiated in a phased manner, public hospitals in Junagadh, Rajpipla, Godhra, Gandhinagar, Sola, Mehsana, Valsad and Kutch, and a medical college in Rajkot will be accreditated in the first phase. CHCs and PHCs often lack basic infrastructure and adequate staff. Accreditation, it is hoped, will do away with the disparities. Of the 273 CHCs and 1,073 PHCs in Gujarat, the health department has chosen 48 CHCs and 158 PHCs for the first phase of accreditation. The budget for the first phase is Rs 25 lakh for CHCs and Rs 10 lakh for PHCs. QCI together with district health officials will provide technical support in the accreditation process. The first phase of accreditation will be completed within a year. "The selection of centres has been on the basis of workload. One CHC and three PHCs in every district will undergo the process," says Dr JL Meena, State Quality Assurance Officer.

The standard of accreditation for these centres however, will be lower than Government and private hospitals. The training of staff has already begun. The health department is in the process of carrying out a baseline study of all PHCs and CHCs, are not up to the mark. The study will offer a clear picture of the extent of problems at health centres in rural areas.

In the second phase, eight district hospitals and the remaining five medical colleges would be standardised, followed by accreditation of the remaining nine district hospitals in the third phase. The process of accreditation for this PHC and all other hospitals is very methodically planned and targets are set in three phases. (Read table).

After a thorough study of the on-ground situation and the formulation of various committees with specific role and responsibilities, the quality management team was developed. An assistant hospital administrator is appointed at the facility level and Quality Assurance Officers at the district level. An internal NABL training is administered to 25 members. The overall quality management is lead by a group of 40 team-leaders after getting trained by the QCI, out of which 19 are certified as NABH assessors. To introduce more quality personnel in the system, the Government has also introduced a post-graduate training course for additional directors, superintendents, and quality assurance officers. Fifty candidates have been already trained so far who make sure that the NABH guidelines are practiced.

Benefits of TQM

In a short period of its implementation since 2007, the TQM system has led to major positives and overhaul of the state's healthcare system. Patients have benefited immensely in terms of the quality of care, access to privileged medical staff, better safety conditions, safer transport and continuity of care. "The benefits of TQM have not, however, been limited to patients. The hospital staff has also gained in terms of their professional development, increased professional satisfaction, leadership and ownership, and a good working environment. For the community, this has translated into a quality revolution, marked by access to comparative database and disaster preparedness (epi-demic and physical)," says Gyani.

Big Task Equals Bigger Challenges

Big projects mean big money. Converting all the Government hospitals upto NABH level is a humongous task, to say the least. There are huge financial hurdles apart from human resource management. Informs Dr JL Meena, State Quality Assurance Officer, Gandhinagar, "The average additional expenditure per district hospital for NABH is a whopping Rs 3-4 crore." There are also logistic and operational hurdles like dearth of well qualified staff, old hospital architecture, upgrading a smaller facility to a larger one. "There is also a high level of reluctance from the staff to understand and implement NABH standards. Hence, a lot of time also goes in motivating and training the staff," adds Dr Meena. Moreover, since most of the staff is at the contract level, it has resulted in high attrition rate, which means the QCI members have to repeatedly train the new staff.

But with the Government support in hand, the policy makers and implementers are optimistic to say the least, as things are going as per planned. Along the way, the state Government plans to extend its TQM system to the medical colleges, blood banks and laboratories across the state to accredited by NABH/ NABL. It also plans to work in close coordination with QCI to develop a sustainable and viable quality accreditation programme for CHCs and PHCs which can be replicated nationally, while managing workload with assured quality. After Gadhboriad, the waiting list includes 48 CHCs and 158 PHCs that are scheduled to undergo the accreditation process. "This is not the end to it. We expect that we will be able to provide quality health service and many more CHCs and PHCs can get accreditation in future. We have retained some of the best quality assurance officers to monitor the services," says Amarjit Singh, the Health Commissioner of the State. Needless to say, a commitment has been made. "A commitment to continuous training of personnel to imbibe quality as a culture among its people. A commitment to strictly adhere to the quality manual in all its operations. A commitment to be abreast of the latest technology to become innovative. A commitment to be the best," concludes Gyani.

nancy.singh@expressindia.com