How Hospital Accreditation Can Help Improve Quality Of Care

Half of India’s households don’t use a government health facility when in need, according to the fifth National Family Health Survey, conducted between 2019 and 2021. They are put off by the poor quality of care (48%), by the long waiting time (46%), by the health facility’s distance from their home (40%), by the inconvenient facility timings (25%) and by absent health personnel (15%). As a result, India’s out-of-pocket expenditure on tertiary healthcare has increased from 16.1% to 23.3% between 2014-15 and 2019-20. Tertiary care is more expensive than primary care and secondary care, and is most likely to push a family already struggling with money into poverty.

Most of India’s best hospitals in the private sector have had their quality standards and turnaround times evaluated by the National Accreditation Board for Hospitals & Healthcare Providers (NABH), a healthcare organisation accreditation body. The NABH offers entry-level certification as well as comprehensive accreditation.

“Our entry-level accreditation is suitable for hospitals that are just starting on the journey of quality consciousness and improvement,” said Atul Mohan Kochhar, chief executive officer of NABH. “[Comprehensive] accreditation is a much more in-depth exercise to ensure quality across the health facility.”

However, accreditation eludes India’s government hospitals, which account for less than 1% of accredited organisations.

Accreditation and periodic assessments ensure that the hospitals implement and stay committed to quality and practices, experts say. Government hospitals may not have the requisite infrastructure, documentation and financial authority to seek and maintain such accreditation, we found. These public hospitals do not do any better on the government-backed National Quality Assurance Standards certification either, as we explain later.

How accreditation improves the quality of health services

Accrediting institutions lay down patient care guidelines to ensure that clinicians assess patients appropriately, draw up accurate care plans, prescribe appropriate diagnostic tests and medication, and provide the right intervention; and nurses assess patients and care for them properly, C.S. Ramakrishnan, chief executive officer of Acme Consulting, a Chennai-based large healthcare consultancy working in the area of quality and process improvements, told IndiaSpend.

“Underlying this care is accurately working biomedical equipment and an indoor environment that is free of infection,” said Ramakrishnan. Periodic assessments by the accrediting institution ensure that the hospital stays committed to the prescribed quality and safety practices, he added.

The evaluation process also requires organisations to establish optimal turnaround times for out-patient consultations and diagnostic services. The evaluators assess the ratio of providers to beneficiaries--that is, doctor-patient and nurse-patient ratios--to determine if patients are likely to experience delays in getting the right treatment.

At the Atal Bihari Vajpayee Institute of Medical Sciences and Dr Ram Manohar Lohia Hospital, New Delhi, “The NABH entry-level certification conferred in April 2023 has helped create an awareness of quality, safety and processes in the hospital,” according to director and medical superintendent Ajay Shukla.

The preparation involved training the majority of staff in responding to emergency situations, said Shukla. “Manuals and standard operating procedures for important hospital processes were laid down and are now being implemented. Committees to ensure patient safety and the quality of patient care services were established. Key performance indicators were identified, and are now being captured and analysed to evaluate the efficacy of key hospital processes. We are now determined to work towards full accreditation.”

Why is getting NABH accreditation a challenge for govt hospitals

The NABH accreditation process is based on structure, processes and outcomes--pillars of a quality model first developed in 1966 by Avedis Donabedian, an American professor of public health with a special interest in evaluating the quality of medical care. Donabedian’s perspective was: it takes an appropriate structure and correctly practised processes to arrive at desirable outcomes.

Government hospitals, especially the older ones, have a lot going against them insofar as their structure is concerned. Structure implies the infrastructure, the buildings as well as the equipment, and the regulatory documentation associated with those.

In that context, “most government hospitals lack appropriate zoning in their operation theatres and central sterile supply department--an NABH must-have--and fail the NABH’s stringent air-conditioning temperature, humidity and air quality standards”, says Ramakrishnan.

Also, many existing government hospitals don’t have mandatory licenses such as a building occupancy certificate from the respective town planning authority, licenses for critical equipment, a no-objection certificate issued by the fire department, a license from the pollution control board for the generation of bio-medical waste, etc., continues Ramakrishnan.

The reason for the lack of such documents could be the building layout: It might not be amenable to containing infection or to the evacuation of patients. Or, the building plans may not be available. Or, safety equipment like fire-extinguishers or waste-handling machines like incinerators may not have been installed. Diagnostic equipment could be missing, or out of order, or malfunctioning.

Administrators of government hospitals generally lack the financial authority to remedy such situations, despite growing awareness of accreditation and the desire to offer a quality service.

“If an equipment or system fails, we are dependent on the state government to issue orders for a replacement,” pointed out Pallavi Saple, dean of Grant Medical College and the JJ Group of Hospitals.

A similar inability to buy essential consumables that are centrally procured can thwart the quality of health processes in a government hospital.

Processes are implemented by people and here too, a major issue with all government hospitals and medical colleges is the frequency of staff transfers and closely related to that, insufficient staff training.

“Transfers of doctors, nurses and paramedics are beyond the control of the administration but these could cause staff shortages or a service to be discontinued or the staff to not know how to execute a process, all of these situations aren’t acceptable in an NABH accredited hospital,” said Saple.

We reached out to the office of the secretary, medical education, and were asked to contact Rajeev D. Nivatkar, the commissioner of medical education, Mumbai, who remained unavailable for comment. We will update this story when we receive a response.

Proactive state govts help improve patient care in government hospitals

Getting NABH accreditation would be easier if the government wanted state-run hospitals and medical colleges to have that accreditation, because then, all the infrastructural and procedural gaps impeding the process would be sorted out, said Saple. “As things stand, we have been focusing on accrediting our laboratory and on getting NAAC accreditation for our teaching; we will work on NABH accreditation one department at a time.” The National Assessment and Accreditation Council is an autonomous institution of the University Grants Commission working towards making quality assurance an integral part of the functioning of higher education institutions.

In Tamil Nadu, the government has decided to get NABH accreditation for all the medical colleges in the state. In the first phase of this initiative, in 2021, four small medical colleges--at Theni, Thiruvannamalai, Kanyakumari and Dharmapuri--were asked to work towards accreditation. At the time, R. Balajinathan, presently the dean of Thanjavur Medical College and Hospital, was posted as the dean of the Theni medical college.

“The National Health Mission Tamil Nadu Health System Project sanctioned Rs 3.32 crore to uplift the status of the Theni government medical college,” said Balajinathan.

Two years on, the Theni medical college and hospital is in the final stage of the accreditation process while the Thiruvannamalai medical college has recently been certified compliant with the NABH entry-level standards.

Balajinathan is now working on entry-level NABH accreditation for the Thanjavur Medical College and Hospital. “Accrediting the hospital will improve the cleanliness, help introduce a patient-friendly ambience and patient-safe environment, ensure that staff are properly trained and experience job satisfaction, and improve the quality of health services.”

In Tamil Nadu, as well as in neighbouring Kerala, the government is pushing the health infrastructure to boost its standards, and is willing to fund that process.

“ACME Consulting has worked with both the governments of Tamil Nadu, under the Tamil Nadu Health Systems project (funded by the World Bank) and Kerala, under the National Rural Health Mission project, to modify operation theatres in hospitals aspiring for NABH accreditation,” added Ramakrishnan.

Widening acceptance for accreditation

While the health departments in Tamil Nadu and Kerala, to name two, are encouraging government hospitals to get NABH accreditation, the National Health Systems Resource Centre, a premier think-tank for the Ministry of Health & Family Welfare (MoHFW), doesn’t see such certification as helpful.

Approaches for certification/accreditation like NABH, ISO 9001:2008, Family Friendly Hospital Initiative (FFHI), Kerala Accreditation Standards for Hospitals (KASH), etc., adopted by different states prior to 2013 as a platform for improving the quality of care were found to be inadequate for government health facilities as those standards did not meet the requirements of public health system, said Atul Kotwal, Executive Director, National Health Systems Resource Centre.

Kotwal’s observation is based on the findings of a 2012 assessment--called for by the Ministry of Health & Family Welfare but conducted by an external agency--which concluded that the existing standards did not address government health priorities such as reproductive, maternal, newborn, child and adolescent health, national health programmes, and schemes such as Janani Shishu Suraksha Karyakaram, Janani Suraksha Yojana, etc. Also, the existing models were found to be resource-intensive, externally-driven processes that are hard to sustain.

However, Kotwal emphasised that “the health ministry remains committed to ensure that services provided at public health facilities in the country are comparable with best hospitals in the country”, and therefore, “to realise this vision”, in 2013 and 2014, the government launched the National Quality Assurance Standards (NQAS) that are recognised by the International Society for Quality in Healthcare (ISQua).

“The NQAS aim at defining and improving the quality standards in clinical, supportive, and outreach services, and, in turn, strengthening the health system,” said Kotwal.

The NQAS assess all the preventive, promotive, curative and rehabilitative aspects of various National Health Programmes besides the routine and emergency care being provided by the health facilities. The health standards are broadly grouped into eight areas of concern to improve accessibility, availability, affordability and adherence to clinical processes to ensure improved health outcomes.

A dedicated institutional framework has been put in place at the national, state, district and facility level for the implementation of various quality initiatives. National and state-level quality certifications are recognised by the Insurance Regulatory & Development Authority and the National Health Authority. Additionally, states have the flexibility to include any state-specific programme or scheme as per the local needs under the existing measurement system of NQAS.

Some other strategies adopted by the MoHFW to improve the quality in services in public health facilities include: Kayakalp, a mandatory annual assessment to improve cleanliness, sanitation and hygiene; SaQushal, an assessment tool for ensuring patient safety in secondary care institutions; LaQshya, an assessment of labour rooms and maternity operation theatres; MusQan, an assessment tool for child care services; and Mera-Aspataal to capture patient’s feedback for the services.

However, even this parallel quality framework hasn’t penetrated deeply into the public health system. Only 4,886 primary and secondary healthcare facilities were NQAS certified as on June 30, 2023, according to the National Health Systems Resource Centre. That means NQAS certification covers only 2.48% of the 157,819 sub-centres, 30,579 primary health centres, 5,951 community health centres, 1,224 sub-divisional hospitals and 764 district hospitals.

We reached out to the office of the Union health secretary, and were asked to contact joint secretary Vishal Chauhan, who remained unavailable for comment. We will update this story when we receive a response.

Quality: The need of the hour

Working towards any accreditation is an exercise. Some sets of standards are more demanding than others. The Union government’s Ayushman Bharat Pradhan Mantri Jan Arogya Yojana quality certification acknowledges both the NABH standards as well as the NQAS (for public health facilities), and in fact, equates the NQAS national level certification to an entry-level NABH accredited hospital.

Every effort to improve the quality of care counts. Today, “insurance regulators are demanding quality accreditations from empanelled hospitals,” points out Kochhar, adding that “quality is rightly being seen as a component of value-based care, and the focus on healthcare outcomes has increased”.

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