Business Accent

Challenges of Implementing Quality in Smaller Hospitals

Though there are separate standards for small healthcare organisation, but those don't address some of the technical difficulties that the smaller hospitals are facing in implementing the quality standards

"Along with the quality improvement, the insurance companies, TPAs and corporate may extend better rates to accredited hospitals which may serve as 'boon in disguise'" - Aanshu Sharma Principal Consultant Medica Synergie Private Ltd

In the urban-centric privatised healthcare system, there has been a rapid social, cultural, economic and technological change. The system is getting complex and challenging with the rapid rise of aging population, lifestyle disease, growth of medical tourism and health insurance sector, rapid technological advancement, global shortage of healthcare staff, poor revenue cycle management, increased awareness about quality care and demanding patient's needs.

To tide over the challenges, it is imperative for the hospitals to make a changeover from the traditional management practices to more scientific management techniques and implementation of the quality management systems. With the Government organisations taking a pro-active step by making hospital accreditation a mandatory criterion for empanelment to its various PSUs, the hospitals are left with no choice but to acknowledge the national accreditation standards as a quality improvement approach to stay associated with the central Government agencies. Very soon, different state Governments and insurance bodies are planning to follow the same directives. Though accreditation is a voluntary process, with the Government and public pressure, it is important for the hospital to promote patient-centric healthcare environment in the context of continuous quality improvement and associate themselves with the national accreditation standards to stay competitive and sustainable in the rapidly changing healthcare market.

However, there are some challenges in implementing quality management system. Some of the issues hold true for bigger healthcare set-ups as well, but the intensity of the issues is much more in the smaller healthcare set-ups (less than 100 bed hospitals). The different challenges faced by the smaller hospitals in implementing national accreditation standards can be:

Escalating Costs

An accreditation system is a highly specialised, knowledge and cost-intensive endeavour. The acute need to cope with the advance in the medical technology, integrated hospital management system, sophisticated laboratory tests and equipment and implementing national standards, has led to an increase in the overall hospital expenses. A smaller hospital struggles to keep pace with the latest technology and simultaneous investment in maintaining the required set of benchmarks.

Infrastructural Deficiency

As many small hospitals in our country have seen a phased growth and have expanded from a smaller clinic, there is an acute shortage of space and a well planned infrastructure. Different departments, including operation theatre, critical care units, are not well planned and don't incorporate the required infrastructural mandates. Most hospitals don't have an appropriate power back-up facility for the critical equipment, support infrastructure for providing clean and sterilised equipment, or even a well equipped ambulance or emergency area or critical care unit to cater to the emergency needs of the patients.

Shortage of Healthcare Staff

There is an acute global shortage of qualified and experienced healthcare professionals across the world and Indian hospitals are worst affected. Planning commission report (2008) suggests that India is short of six lakh doctors, 10 lakh nurses and two lakh dental surgeons. Along with the global shortage in healthcare staff, smaller set-ups don't budget for competitive salary for healthcare staff including doctors, so it's difficult for them to even acquire and then retain the talent. Thus the hospitals are always short of manpower for which staff end up doing extended shifts and 'burnouts' are very common. Moreover, another observation which is shockingly quite common is that the hospitals, especially those run by doctor entrepreneurs, bridge the above demand-supply gap by recruiting non-allopathic doctors, especially in emergency and critical care units and as resident medical officers, thus encouraging cross-practice.

Inadequate Training

Most critical care staff is not BLS (Basic life Support) and ACLS (Advanced Cardiac Life Support) trained or certified. The healthcare staff, in many small and medium sized healthcare units, is not well versed with the biomedical waste, its management, hospital safety and risk management, infection control, medication management practices etc which are critical not just patient safety, but also employee wellbeing.

Increased Cost Pressure

The overall healthcare expenses are increasing in India and insurance companies are under tremendous pressure to reduce claim ratio for which they end up passing on the cost burden to the healthcare organisations. The smaller hospitals are thus sandwiched between the increased cost of maintaining quality assurance and on the other side poor revenue cycle management and increased pressure from the insurance companies, TPAs and corporates in extending more discounts to patients.

High-Customer Expectations

In recent years, productivity and efficiency of services in patient care have become a very important issue. With increased awareness and the emergence of consumerism, patients have become highly demanding and take an important role in the medical decision making process. They have begun to challenge the efficiency and effectiveness of service given by the healthcare providers. The healthcare system is publicly evaluated, commented and challenged and thus for these reasons, efficient services is one of the important aspects of healthcare delivery.

Inadequate Licensing

Most hospitals don't have all the licenses applicable in the hospital. For instance, excise permit to store spirit, AERB approvals (which has caught everyone's attention in the recent past due to radiation-waste mismanagement), NOC from the chief fire safety officer, lift license etc.

Laboratory Accreditation

The laboratory department in the smaller hospital doesn't conduct many tests and mostly rely on outsourcing of part or whole of the laboratory services. The in-house laboratory department acts little more as a stat laboratory. Compelling the hospitals to go through the laboratory accreditation even if they have opted for, and are preparing for hospital accreditation, requires extensive time, effort and cost and increases the complexity of the hospital operations.

Thus implementation of the quality management system has become a challenging task for smaller hospitals as it comes with a big 'price tag'. The solution that the hospital management is looking for is 'how to strike a balance between cost reduction and maintaining/raising standards'. There is no end towards quality enhancement, but the most important aspect is the attitude and the intent of the hospital to install an effective quality care environment with demonstrable quality improvement practices over time. Along with the quality improvement, the insurance companies, TPAs and corporate may extend better rates to accredited hospitals which may serve as 'boon in disguise'. It is impressive to note that the Government hospitals, at all levels of care, are taking the revolutionary step towards quality improvement.

aanshu.sharma@gmail.com