Hospital Accreditation in India - Standardising healthcare

The Indian healthcare delivery system consists of varied health institutions and mixed ownership patterns. Private and/or public-private partnerships dominate the tertiary care, while secondary healthcare is a lopsided mix of both, private and public and government health systems cater mostly to primary care. It is estimated that there are more than 15,000 hospitals operating in the country, of which 30 per cent are in public sector. However, number of beds in the public sector is almost four times that in the private sector. While 80 per cent of hospitals in the private sector have less than 30 beds, about 10 per cent of hospitals are with beds in the range of 30-100. Only six to seven per cent of the hospitals are with more than 100 beds.

In terms of expenditure on health, the private and public investment is roughly in the ratio of 80:20 respectively. With regards to healthcare and services spending, 62 per cent is self-sponsored. The Government contributes 24 per cent, employer provides for 9 per cent and only 5 per cent comes through insurance. This is dismal, when we discover that only Rs 250 crore is being collected for health insurance, whereas life insurance gets Rs 25,000 crores and even non-life items get Rs 9,000 crores towards insurance.

The call for quality

Until a few years ago, most people in healthcare were convinced that higher quality meant higher costs. If people wanted better healthcare, they would have to be willing to spend more. Better quality meant new technologies, new medicines and more staff. While all this was evidently being worked upon, paucities in access, affordability, efficiency, quality and effectiveness of health services have remained the same. There have been numerous instances of poor care, inadequate facilities, unnecessary interventions and insufficient information that has called for a closer look at our healthcare delivery system. Concerns on quality of health facilities have been generated lately because of increasing awareness among the consumers. Market forces, such as medical tourism, insurance and corporate sector have accelerated the demand for quality in healthcare services. As a result there is a growing demand from consumers for better healthcare as the lack of quality assurance mechanisms limits their demand for appropriate health services.

In such settings healthcare quality requires regulation & accreditation. Barring few a states, regulation in healthcare is almost non-existent. Regulation is mandated by Government and is based on minimum standards, inspection, enforcement & public accountability. Government is working on introducing regulation in all segments of healthcare delivery. Accreditation on other hand is voluntary. Accreditation is based on optimum standards, professional accountability and encourages healthcare organisations to pursue continual excellence. In most developed economies there are very strong financial incentives to seek accreditation. Governments acknowledge that independent assessment programme by way of accreditation should be encouraged with incentives, more so for secondary/tertiary level of hospitals to bring in the best in terms of patient safety and quality of care.

Indian national accreditation structure

The attempts to evolve a voluntary accreditation system began in late 1980s with the Bureau of Indian Standards putting down standards for 30, 100 and 250 bed hospitals. The National Institute of Health and Family Welfare had also specified rules for more than 50-bed hospitals. Since health is a State subject, there have been attempts in some States to incorporate standards for hospitals. Such compartmentalised initiatives have led to further fragmentation of an already segmented industry. The lacuna lies in not having a united and single system to monitor the functioning of hospitals in India and the stringency of compliance to established standards.

Accreditation is one of the mechanisms identified in WTO agreement as means to promote universal acceptance of conformity assessment results. Realising the need for establishing a national accreditation structure, that was suitable to the Indian conditions and credible in the eyes of international markets, an inter-ministerial task force was set-up up in 1991. The report of the task force was brought out in January 1993. As an outcome of its recommendations, Quality Council of India (QCI) was established in 1997 as an autonomous body. The mandate given to QCI was to establish and operate the national accreditation structure and obtain international recognition for its accreditation schemes.

National Accreditation Board for Hospitals and Healthcare Providers (NABH) has been set-up under the national accreditation structure to establish and operate accreditation programme for healthcare organisations. NABH is an institutional member of International Society for Quality in Health Care (ISQua). The Board has representation from all stakeholders including government, consumers and healthcare industry. The structure incorporates Accreditation Committee, Technical Committee, Appeal Committee, Secretariat and a panel of over 100 assessors/surveyors selected among clinicians, hospital administrators and nursing supervisors. They have been empanelled after having qualified through a five days training programme.

Accreditation standards

NABH’s accreditation focuses on learning, self development, improved performance and reducing risk. Its assessment relies on establishing technical competence of healthcare organisation in terms of accreditation standards in delivering services with respect to its scope. It goes beyond compliance and calls for excellence on continued basis. It is this feature, which makes it market driven involving all stakeholders; be it consumers, empanelling agencies, regulators and other third parties.

NABH accreditation is based on optimum standards, professional accountability and encourages healthcare organisations to pursue continual excellence. Cardinal principles of accreditation evaluation are as follows:

• Hospital operations are based on sound principles of system-based organisation, which are transparent and objective
• Accreditation standards are implemented and institutionalised into hospital functioning
• Patient safety and quality of care, as core values are established and owned by management and staff in all functions and at all levels
• There is a structured quality improvement programme based on continuous monitoring including feedback on patient care services

The evaluation process incorporates interview with patients, residents and staff. It calls for on-site visit to patient care areas and to departments addressing issues related to physical assessment of infrastructure, medical equipment, security, infection control, etc. as required in the accreditation standards. In short, the accreditation involves a is comprehensive review of not only facility but also of clinical competence of hospital to deliver services within its scope.

NABH’s roadmap

As of today, the accreditation programme for hospitals is fully functional. Out of 30 applicant hospitals, two have already been granted accreditation and rest are undergoing different stages of evaluation. NABH will soon be launching accreditation for blood banks, diagnostics centres (imaging services), dental hospitals/ clinics and ayurveda hospitals. A rough estimate shows that about 250 hospitals in secondary/tertiary level will be able to comply with the NABH accreditation standards (edition 2005) in next two years. The next in line are about 300 medical colleges, as the hospitals attached to these colleges are expected to operate at the highest level in terms of patient safety and quality of care ¾the cardinal points in accreditation standards. There have been concerns that many of these hospitals, operate below par and there is a need to drive these hospitals to seek accreditation. The fact that these hospitals are nurseries for our budding doctors, it is all the more necessary that we set high standards in terms of clinical processes in these hospitals. Putting the two figures together will mean 550 hospitals are potential hospitals to make up for Indian accredited healthcare hub in what we call first phase. These would be taken as referral centres for patient safety and quality of care. On one hand, these will motivate other hospitals to raise bar and prepare for accreditation and on the other hand, they will be our showcase for the medical tourism.

Considering that there are more than 15,000 hospitals in the country, debate has begun on what would be the status of remaining hospitals and nursing homes. This includes about 600 district level hospitals, which cater to masses. The standard for such hospitals will comparatively have lower yardsticks for management related issues, yet maintaining same level of patient safety. NABH is working on developing a separate set of standards to address these issues. These standards are expected to be announced in Jan 2007 and made operational by April 2007.