Kerala’s Quality Leap in Public Health Knowledge without practice is sterile,

1. Kerala’s Quality Leap in Public Health Knowledge without practice is sterile, But practice, without Knowledge is blind … Dr.Dinesh Arora IAS, Mission Director, National Rural Health Mission & Managing Director, Kerala Medical Services Corporation, Kerala

2. PRESENTATION PLAN • Need for Quality in Health services • Health Systems Approach – FOCUS….. • Challenges facing health services • Determinants of Quality in Health Care. • The QCI/NHSRC INTIATIVE: “Accreditation” • Essential Quality Standards for Labs • The Journey SO FAR………………. • The Roadmap Ahead

3. Why excellence in quality for Kerala? • Indicators do not lie but, they may not reflect the ground reality. • You can’t dive in a river thinking that average depth of the river is five feet only. • Implementation of NRHM for last three years have given a solid platform to venture into the new field of quality health services.

4. Need for Quality in Service Delivery! • Healthcare Scenario in Kerala is going through a phase of transition and evolution. • Private expenditure on healthcare is increasing. • Quality of health services offered by Private Institutions is PERCIEVED to be better. • Till date we have focused on infrastructure without laying emphasis on processes and monitoring the outcomes. • Credibility of the institutions to be restored. • Health insurance/RSBY. • High literacy and high health seeking behavior.

5. Health expenditure by financing sources Central Government 2% 6% 13% 2% 5% 72% State Government Local Government Firms Households External Support • Per capita expenditure on Health • Total per capita expenditure on Health : $ 23 • Per capita expenditure out of pocket : $ 18 • Per capita public expenditure : $ 5 Source: National Health Accounts, India, 2001-02, MOHFW, GOI, 2005

6. Private Public Who delivers major share of health service in Kerala? Public-Private sector shares Immunizations Antenatal Care InstitutionalDeliveries Hospitalization Outpatient Care NonCommunicable Ds 0% 20% 40% 60% 80% 100%

7. Health Systems Approach Functions of the system (to perform) Objectives of the system STEWARDSHIP (oversight) ) RESPONSIVENESS (to people’s non-medical expectations) CREATING RESOURCES DELIVERING SERVICES HEALTH (investment and training) (provision) FAIR (financial contribution) FINANCING (collecting, pooling and purchasing)

8. Value Proposition • Patient focus leading to better quality of services and satisfaction of patients • Professional excellence and improved outcome • Enhanced confidence of patients in accessing the treatment • Minimizes the chances of negligence • Makes the hospital safer for patients and public • Clean image • Patient • Transparency creates educated, engaged consumers • Incentives for choosing the right providers • Incentives for wellness and compliance Improved Quality Improved Health Improved Efficiency Improved Affordability • Mission • Supports transformation of health care delivery system • Fulfills promise to put our members’ health first • Delivery of affordable products

9. “It is possible to fail in many ways. While to succeed is possible in one way (for which reason also, one is easy and the other is difficult - to miss the mark easy, to hit it difficult)” Aristotle

10. What should we focus at? “STEEEPP” • Safety: Minimizes errors and injuries • Timeliness: Minimize unnecessary wait times & delays • Efficacy: Consistent with evidence based measures of over/under utilization • Efficiency: Use of financial resources • Equity: Access • Patient Centered: Satisfying to users • Process Oriented: Proper Documentation

11. Decisions are based upon training and experience Care is based on visits Professional autonomy drives variability Professionals control care Information is a record Knowledge is shared and information flows freely Care is based upon continuous healing relationships Care customized to patient need and value Patient is the source of control Decision making is evidence-based Ten Rules for Achieving the Aims OLD RULES NEW RULES 1 2 3 4 5

12. 6 Preference for professional roles over the system “Do no harm” is an individual clinician responsibility Secrecy is necessary The system reacts to needs Cost reduction is sought Waste continuously decreased Needs are anticipated Cooperation among clinicians is a priority Transparency is necessary Safety is a system responsibility 7 8 9 10 Ten Rules for Achieving the Aims OLD RULES NEW RULES

13. Achieving Aims and Rules Requires • News ways of delivering care • Effective use of information technology (IT) • Managing the clinical knowledge, skills, and deployment of the workforce • Effective teams and coordination of care across patient conditions, services and settings • Improvements in how quality is measured • Payment methods conducive to good quality

14. Poor Infra structure Infrastructure • Age old building with unscientific design during expansion • Architectural deficiencies in upgrading the newer technologies • Patient-centered and patient / environment friendly concept were not brought when there was expansion and amalgamation of newer technologies and infrastructure

15. Patient load • The patient load is high in government sector mainly belonging to lower income profile • OP,IP and delivery are comparatively greater • Management of non availability of beds and uniformity of care is intricate during epidemics

16. Lack of Knowledge about Quality as a subject • Developing the dormant concept of quality and changing the attitude, behavior, knowledge and skill of staffs • Building competent and frontline quality champions

17. Information strategy Performance & Quality themes / takeaways Data Collection Data Reporting Data Analysis Typical Effort Desired Effort Data Evolution • Hospitals make significant investments for regulatory purposes, which limits the value • The goal is to push the EFFORT CURVE to the right through increased staff competency, use of quality tools and automation of data collection by strengthening efficiency of Medical Records

18. If we do not know … “ If you do not know where you are going any road will get you there. - Lewis Caroll ” If we do not know what is happening we can not act or will not hit the target or the action will be simply Hazardous, wasteful and frustrating. The system will die and so is suicidal for us. THEN WHICH IS THE ROAD LEADING TO QUALITY IN HEALTH SERVICES?

19. Accreditation of selected hospitals in Kerala MOA signed between QCI and Govt of Kerala for accreditation of 19 selected hospitals on QCI appointed consultancy for preparation of hospitals for accreditation 514 standards in 10 chapters Quality assurance officers were posted.

20. NABH Accreditation Programme – 3 phases III II I • Review / Assessment • phase • Pre-assessment survey • Assessment Survey • Implementation Phase • Implementation of QMS • CA/PA • Internal Audits • Preparatory phases • Gaps • Making up of deficiencies • Review of policies / procedures / protocols • Developing the best practices • Process mapping • QMs / SOPs

21. Implementation Pyramid External assessment/accreditation Review of NCs and corrective measures NC/defects Internal audit/mock survey Implementing the program Management review of QMS Formulation of criteria and standards Developing HIS Identification and mapping of processes Training of all staff Developing manuals/SOPs Defining key objectives Awareness campaign Formulation of Quality team Commitment from the top Educating management and staff

22. Determinants of Quality in Health care Process (SOPs / Procedures / Operating Systems etc. Quality Structure (infrastructure to the Laid down norms) Outcome (Change in patient’s Status / Clinical Indicators / Feedback / Surveys / Occupancy)

23. Quality Improvement in Healthcare-Kerala. How? Full on a time schedule Well planned and meticulously executed Commitment from the Top Organization Wide Quality Hiring a consultant Continuous on-going process Work Culture of the hospital Training at all levels No shortcuts

24. Where do we want to be ? What is the Gap? Where are the Gaps? Where are we? Bridging Gap To Reach Goals

25. Gaps Data Disconnect: Hospitals have enormous data that doesn’t become relevant business information Quality Gaps: Quality is a top priority, but there are staff knowledge gaps, little IT supports and no benchmarks Resource limits: Under utilization of money, time and technical support NO standards: Best practices or performance target are available, but unused. Missed opportunities: Application of technology to share ideas, lessons and innovative technology freely Non linkage: No efforts for tying the existing frame work together

26. Standards for Hospitals 3rd Phase of QMS implementation 2nd Phase of QMS Implementation • W and C Hospital, Thiruvananthapuram • Taluk Hospital Cherthala, Alappuzha • General Hospital, Ernakulam • W&C Hospital, Kozhikkode • ICCONS, Shoranur, Palakkad 1st Phase of QMS Implementation • Taluk Head Quarters Hospital, Sulthan Bathery, Wayanad • District Hospital, Palakkad • Payannur Taluk Hospital, Kannur • District Hospital, Kanhangad, Kasaragod • Taluk Head Quarters Hospital, Thodupuzha, Idukki • Sree Avittam Tirunal Hospital Thiruvanathapuram • General Hospital, Pathanamthitta • District Hospital, Kollam • New Medical College, Mulakunathukavu, Thrissur • Taluk Head Quarters Hospital, Chavakkad, Thrissur • District Hospital Manjeri, Malappuram • District Hospital , Mananthawady, Wayanad • District Hospital, Kannur • General Hospital, Kasargod Phase wise progress: Hospitals for NABH accreditation • Note: • All laboratories in the medical colleges, District Hospitals, Women & Children Hospitals, Taluk Hospitals listed above are also going for Essential Standards for Medical Laboratories under Quality Council of India. • The 3rd phase hospitals are fully set for entering the fourth phase of NABH accreditation. • The hospitals in the 1st and 2nd phase of the chart is widely undergoing major and minor civil structure changes, recruitment of additional staff, procurement of biomedical equipments and other additional requirements along with the various stages of process corrections in implementation of Quality Management System.

27. NABH accreditation • Sensitization of various professionals • Identified and implemented training requirements • Identify and addressed all infra structure, statuary and legal compliance • Target dates for completing documentation and implementation • Periodic review 27

28. The Bottom Line … “ Having the right people for a job alone does not necessarily guarantee success, but the absence of such persons might well be an impediment to achieving that success anyway. ”

29. The journey so far • Awareness of the concept: rising awareness and change in mindsets about the necessity to focus on quality, which may not be an immediate revenue earner, but will spell long-term benefits • Role of NRHM: National Rural Health Mission, Kerala thereby act as a key enabler in popularizing the concept of accreditation through public awareness and sensitization programmes via the print and electronic media • Appointment of Quality Assurance Officers & Biomedical Engineers per district for Government Hospitals / Medical Colleges/ Taluk Hospitals / W&C Hospitals • Gap Analysis: existing facility was analyzed to know where exactly healthcare facility and delivery system of Kerala stands

30. The journey so far • Training: Sufficient training & awareness at various levels were among the key mechanisms of the QMS system • Committees: Committees were asked to form under various categories for a smooth execution of decisions, improvements and for effective evaluation • Nodal Officers, one each from Doctors and Nurses, Public Relation Officers are also an inevitable part of the execution of decisions made by the authorities • Site Visits under Mission Director: After all these activities started functioning there were still gaps which were identified and required a higher level intervention

31. Quality Manual…… • Policies and procedures • Work instructions • SOPs/DPs • Forms and formats • Data sheet • Job responsibilities • Quality assurance • Safety assurance • Committees • Legal, statutory and regulatory requirements (licenses and guidelines)

32. NABH Accreditation • Management responsibilities documented • Scope of services offered by the hospital • Scope of services of departments • Patient rights & Responsibilities • Emergency services • Admission, assessment reassesment,continunity,discharge • Quality assurance programme and Audit • Sentinel & Adverse events • Regulatory services • Public Health & Engineering • Disaster Management • Information management • Medical record

33. NABH Accreditation • Management responsibilities documented • Safety • Smoking policy • Disaster management • Hazardous materials • Human resource planning / Policies • Orientation and Training • Appraisal • Disciplinary • Grievance handling • Employees health • Personal Record for each staff

34. NABH Accreditation • Services provided by each department documented • Specialties • Blood bank • Pharmacy and medications prescription • Chemotherapy • Narcotics and psychotropics • Radioactive substances • Medical gasses • Infection control programme and manual • Rehab • Research • Nutrition

35. “The best way to escape from a problem is to solve it “ Brandon Francis • “The important thing about a problem is not its solution but the strength we gain in finding the solution” Ashleigh Brilliant

36. Reaping fruits • For the healthcare system as a whole:growing level of Patient Satisfaction and signi-ficant improvement in the various Performance Measures, as evaluated by Medical, Adminis-trative, Financial and Infrastructural Indicators. • For the patients: quality of care, access to quality focused organizations and to privileged medical staff, better safety conditions and pain management, safer transport and continuity of care. • Staff: professional development, increased professional satisfaction, leadership & ownership, and a good working environment. • Community: For the community at large, translated into a quality revolution, marked by access to comparative database and disaster preparedness (epidemic and physical).

37. Growing patient satisfaction Reception Waiting area Doctors Pharmacy Lab Radiology Nursing services House keeping Patient feedback survey at W&C Trivandrum

38. 64 Gap Analysis Phase 1 Percent Hospital names W&C TVM W&C KKD THQH Cherthala Phase 2 GH Ernakulam GH Kanjahangad THQH Payannur DH Kottayam Phase 3 THQH Thodupuzha THQH Bathery

39. 60 Phase 2 Training and Awareness Percent Phase 1 Hospital names W&C TVM W&C KKD THQH Cherthala GH Ernakulam GH Kanjahangad THQH Payannur DH Kottayam Phase 3 THQH Thodupuzha THQH Bathery

40. 20 Implementation of QMS Percent Phase 1 Hospital names W&C TVM W&C KKD THQH Cherthala Phase 2 GH Ernakulam GH Kanjahangad THQH Payannur DH Kottayam Phase 3 THQH Thodupuzha THQH Bathery

41. 3 W&C Trivandrum GH Ernakulam DH Kottayam Phase 1 W&C KKD GH Kanjahangad THQH Thodupuzha THQH Cherthala THQH Payyannur THQH Bathery ICCONS Phase 2 Phase 3 Phase wise implementation Percent Gaps addressed 96 95 94 90 84 67 60 75 66 64 Training and Awareness 95 96 96 95 98 65 50 80 65 60 QMS implementation 80 75 75 70 70 20 15 40 30 20

42. Roadmap

43. Layout modification for previous slide Roadmap Initial assessment by QCI June – August August – September September – October • Recruitment and filling up of vacancies • Procurement and furniture's (in principle) • Completion of training programmes • Approval and issual of policies, SOPs and Wis • Audit training session for the core-committee • 1st mock audit • Identification of NCs • CA&PA • Closing NCs • Identifying the grey areas in processes • Addressing them • Discussion with authorities and consultants

44. “Everything should be made as simple as possible. But to do that you have to master complexity” Butler Lampson

45. HIGH END GROWTH follow logarithm of decreasing gains Health Indicators Input WE NEED MASSIVE INVESTMENTS IN PROCESSES AND ENHANCING CAPABILITIES ……THEY ARE PEOPLE CENTRIC……..

46. Compliances achieved by forerunners NA 7% NC 4% PC 20% FC 69%

47. NC PC FC NA Compliances details as per standards 80 70 60 50 40 30 20 10 0 AAC COP MOM PRE HIC CQI ROM FMS HRM IMS

48. Accreditation of laboratories in Kerala

49. Labs fundamental to patient health 70% based on lab test results Prescrip-tion treatment and therapy Patient follow-through Lab test results Clinical diagnosis Patient health

50. Labs: Healthcare’s Foundation Pharmacy therapists and specialists Hospitals, clinicians, clinics Medical laboratories and collection centres