Not long ago, the concept of quality simply meant the absence of defects from a manufactured physical good. In healthcare, quality tended to be limited to established standards for structure and process in clinical care. We now understand that this ‘limited quality’ or ‘little q’ view restricts our ability to satisfy our customers. To address this challenge, the Quality Council of India (QCI) took on the responsibility of expanding our approach to one of ‘total quality’ or ‘Big Q’ in all disciplines, including healthcare.
More specifically, the National Accreditation Board for Hospitals and Healthcare Providers (NABH) was established as a constituent board of QCI. The NABH standards for hospitals provide a framework for quality assurance and quality improvement. The standards focus on patient safety and quality of patient care. Over and above, NABH accreditation provides assurance to the stakeholders that the hospital complies with statutory and regulatory requirements.
All these measures are in the right direction. So why is it that we, as patients and customers, do not perceive the expected positive difference post-accreditation of a hospital? Quite simply, the emphasis is on quality assurance only. Not quality improvement. QCI was quick to realise this gap and appointed Qimpro as an implementation partner for a National Demonstration Project (NDP) to facilitate Lean Six Sigma (LSS) in nine NABH accredited hospitals in western and southern India.
LSS Projects
The LSS Projects identified at the various hospitals addressed a wide spectrum of chronic problems in non-clinical processes. The selected projects directly impacted patient experience.
Turn-around time for patient discharge: Turn-Around Time (TAT) for Patient Discharge was the most popular problem in the NDP and as many as six hospitals had identified it as a project. The key drivers for this change were:
- Challenging the mindset against preparing discharge summary on the previous evening.
- Collaborative ownership between nursing and doctors for minimising the time taken to check and approve discharge summary.
- Collaborative ownership between nursing and accounts for minimising the time taken to prepare the final bill and intimate the same to the patient’s relative.
Idle waiting time in OPD services: Idle waiting time in OPD was also a popular project in the NDP. The key drivers for reducing waiting time were:
- Streamlining the appointment process and encouraging more appointment patients.
- Improving the patient flow between the various laboratories through better coordination.
- Advance intimation to patients with special needs before they came for the appointment.
Turn-around time for laboratory reports: Several hospitals opted for improving this process. The key drivers for reducing the TAT for lab reports were:
- Reducing wasteful effort of maintaining multiple entries for the same patient in multiple
registers. - Making radiologists accountable for releasing reports after a fixed number of images were completed. This also included a structured escalation process if reports were not released on time.
Turn-around time for OT services and OT utilisation: Some hospitals selected TAT for OT services and OT utilisation for their LSS project.
- The main driver for change in this process was the reduction in the pre-surgery and post-surgery cycle times.
- Reduction in pre-surgery cycle time was achieved by pre-ponement of all activities related to surgical consents and financial approval to previous evening.
- Reduction in post-surgery cycle time was achieved by improving the efficiency of clearing the OT after completion of surgery.
Turn-around time for ambulatory services: One hospital focused on ambulatory services.
- The key driver for reduction in TAT for ambulatory services was extensive training and sensitisation of the nursing and ambulatory staff regarding the criticality of their process.
- Also, mock drills were conducted by senior staff to demonstrate that shorter TAT was possible.
Turn-around time for comprehensive health checks: Another hospital focused on comprehensive health checks.
- The key driver for reducing the TAT for comprehensive health check was the realignment of patient movement between the various test centres that best suited the layout of the hospital. A printout of the layout, along with the patient’s route during the health check, was presented to the patient. This helped in saving idle time lost in searching papers, for the next test centre.
Key success factors
- The top management at the nine hospitals were personally involved in implementing the improvements for their LSS projects.
- The above led to the team members taking ownership of the projects. Implementing the change was seamless.
- The identified problems had high visibility. Hospital staff faced frequent patient dissatisfaction in these problems areas.
- The structured methodology for problem solving generated significant positive interest among the team members because they could visualise the distinct possibility of a practical solution at the end of their projects.
- Process mapping, facilitated collaboration amongst team members. Several commented that this was the first time they had actually stepped out of their silos and practically “seen” the complete end-to-end process.
Conclusion
Make a habit of quality improvement. Challenge the standard!
About the author
He is the Founder & MD of Qimpro Consultants; Founder & Director of BestPrax Club; and Chairman of the IMC Quality Awards Committee – IMC RBNQA; IMC Juran Medal. He is Regional Coordinator – Western India, Quality Council of India; and Director – Membership Retention and Engagement, Global Benchmarking Network. He is also a Member, Governing Board, Institute of Health Management Research
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