Introduction and Background
In the past 60 years, India has crossed major milestones in healthcare such as greater life expectancy, decrease in infant death rate, wiping out leprosy and eliminating small pox. Regardless of the progress, India’s healthcare demonstrates crude inequalities. At one end of the spectrum is the rise in medical tourism, pulling in more than 2 lac global patients in 2006. At the other end, curable diseases like diarrhoea and malnutrition, particularly of children below 3 years, are continually predominant. Likewise, in comparison to South Asian countries like Bangladesh, Indonesia and China, vaccinations in India are still very low.
If healthcare staff is of different quality, so are the organizations they work in. Chronic overcrowding, less financial support, and facilities constantly being extended to the limit are attributes to Government hospitals in India. These institutions are targets of an economy that spends 2% or less of its GDP on healthcare services (Varkey & Kollengode, 2011). Typically, they sideline young skilled doctors and serve a workload of patients with a wide array of diseases for more than those seen in private hospitals, still are unjust victims of criticism amidst healthcare crisis. Indeed, their situations seldom give way to quality and safety. The present time witnesses two-thirds of the population seeking services of the private sector for their medical requirements. Interestingly, private hospitals and non-government training institutions have mushroomed in the past three decades as a response to the growing demands of students for medical education & training and of individuals looking for more personal and patient centred medical treatment. Moreover, Indian business also includes investments in health care to gain profit. Quality and safety are promptly catapulted into prominence (Varkey & Kollengode, 2011).
HealthCare Medical Centre (HMC) is a 500-bed medical assistant affiliate of the Indian Medical School. The hospital admits over 35,000 patients per year and conducts nearly 5, 20,000 ambulatory visits. HMC has been recognized by the All-India Health System Consortium (ASC) for being among the ten top performing medical centres in India in a specialized quality and safety study.
A robust and effective system must be incorporated into the core healthcare functionality of the organization for reporting lapses and faults of discipline even if no untoward event has taken place. Moreover, errors must be expanded to incorporate failure to advise patients about risk factors in regards to future harm. Errors must include failure to provide treatment of proven benefit like influenza and pneumococcal injection to old patients having chronic lung illness. In this context, HMC has the ability to perform well to learn from other situations and integrate these concepts into the current medical practice.
With fixed healthcare resources in the setup of growing population statistics, how can Indian hospitals like HMC ensure safe, well-timed, effective, and patient focused care is implemented? With ever growing malpractice and consumer awareness, medical tourism, rising attention to quality and recognition, what steps should the healthcare organization in question take?
The current paper proposes the science and methods of quality improvement (QI) as a strategy for tackling these issues. This article highlights the key principles for QI by studying the case of HMC (HealthCare Medical Centre) hospital.
Role of Human Resource in Quality Improvement
Several health care arrangements globally have been greatly focussing on human resources management (HRM) and its effectiveness in performance of the organization. Human resources are specifically among the key inputs to health systems; other two being commodities and physical capital. While speaking about health care, human resources is comprised of the various types of clinical and non-clinical workers responsible for public health treatment. Undoubtedly, the performance level and the benefits the healthcare system can offer greatly rely on the knowledge, talent and motivation of those persons responsible for providing health services. When exploring the healthcare system in a global setting, several common human resource issues and doubts arise. A few of these issues include the volume, composition and dispersion of the health care providers, personnel training issues, the degree of economic development in a territory, cultural and geographical factors (Kabene et al., 2006). When studying global health care organizations, it is equally significant to examine the impact of HR on health sector reform. With the particular health care reform procedure varying by nations, some common and major trends identified are efficiency, equity and quality goals. Several human resources approaches have been adopted in a move to increase efficiency. Services outsourcing arrangements have been setup to turn fixed staff expenses to variable expenditure as an efficiency improving catalyst. Human resources in health care also seek to increment equity or fairness. More organized planning of health services must be undertaken for strategies that aim at increasing equity pertaining to needs. The strategies include the creation of financial security initiatives, the targeting of particular groups and requirements, and re-disposition services. Improvement of the quality of services and patient’s safety is another essential part of the health sector reform. Commonly, health care quality is outlined in two ways, namely, technical quality and socio-cultural quality. The former describes the impact of the available health services on public health conditions. The latter refers to the level of acceptability of services and the capability of satisfying patients’ expectations. Indeed, enhancing the safety and quality of health care is a major constituent that shapes health reform processes. Human resource personnel encounter numerous obstacles in their effort to offer high-quality health care to the population. A few of these obstacles include budgets, poor congruency between various stakeholders’ values, greater turn-over rates, low team spirit in health professionals, and more absentees. It has been recommended that efficient usage of the spectrum of health care providers and good coordination. Medication faults take place very often in a health care system and they are linked to substantial clinical and financial effects. To combat errors, health care technologies are greatly being included in the health care system to increase effectiveness, quality and safety of medical care. Since clinical errors can occur randomly throughout the medication application process, hospitals like HMC must implement high-end technologies and solutions to control medication faults and subsequently enhance patient safety (Kabene et al., 2006).
Role of Technology in Quality Improvement
Technology is pivotal in the development of a framework for both Quality Improvement and the provision approach of optimal healthcare at low cost. Technology is known to facilitate communication amongst patients and hospital staff. Examples of implementable technologies in a healthcare setting are:
Computerized Physician-Order Entry (CPOE): It decreases errors associated with legibility, ambiguity, integrity, accuracy, and offers inbuilt assessment to supervise possible drug-drug interactions and drug side effects. When applied correctly, technology can heighten safety, speed, precision, and evidence-based support system and supplies practical approaches to improve healthcare. HMC’s healthcare scenario would greatly benefit via rapid incorporation of technology, allowing point-of-use services like telemedicine and other tele-wellness consultation as part of the cell phone technology that assisted in India's speedy development and bypassed the landline era.
Quality Improvement definition:
Quality has been defined by the Agency for Healthcare Research and Quality (AHRQ) as “doing the right thing at the right time in the right way for the right person, and having the best possible results” (AHRQ). Instead, healthcare quality can be seen as the level up to which health services for people and individuals increase the probability of expected health results and are consistent with present professional knowledge. It is not suggested to concentrate on quality assurance, i.e. evaluating the services and products with respect to fixed standards; it is also equally essential to focus on QI which offers tools and mechanisms to increase the product/ process against analysing deficits (Varkey & Kollengode, 2011).
Measuring quality has played a pivotal role in any improvement arrangement. Invented by Shewhart (1931), statistical process control aided in bringing focus on measurements that had a statistical effect on the end results. Further, Donabedian (1997) stressed on quality as influenced by structure, process and results. In this context, structural standards pertain to the policies, layout, and procedures employed in the medical care delivery, such as worker education, experience, equipment availability, human resource levels, and so on. Process standards are means of measuring QI and act as proxies for expected results. For instance, use of rates for administering antibiotics within one hour of incision prior to surgery is a process measure and used as a proxy to reduce infection. Lastly, outcome or result measures are used in measuring the overall quality and assess the outcome of healthcare. Patient satisfaction information, death rate and occurrence of a particular disease, and one-month re-admission rates are good examples of outcome measures (Varkey & Kollengode, 2011).
Safety is a dimension of Quality which entails reduction of the risks of injury, infections, severe side effects, or other dangers in service provision. In safety, both the provider and the patient are involved alike. Patients must be secured from infections and side effects and health staff handling needles, drugs and blood must be protected by safety measure. Maintaining sterile conditions and transfusing blood with right techniques are added safety concerns associated with blood transfusions. Whilst safety may appear crucial in the provision of complex health services, there exist safety concerns even when basic clinical services are provided. For instance, if risk-eliminating steps are not applied in health centre waiting rooms, then customers may get infected from nearby patients. If a nurse or doctor fails to provide accurate instructions on how to prepare Oral Rehydration Solution (ORS), a mother may administer ORS to her child that contains severely high amount of salt.
Quality Improvement measures:
In order for a hospital to attain utmost quality improvement, the administration needs to undertake the following steps:
1. Detect the possible target of opportunity.
2. Combine data about optimal practice
3. Combine data about present on-going practice
4. Determine reasons for divergences between optimal and present practice
5. Generate a strategy for improving practice
6. Evaluate efficiency and cost-efficiency of the practice improving strategy
7. Check and decide whether or not the proposed strategy for practice improvement ought to be implemented and suggest ways to improve it.
More often than not, errors are caused by weak systems and not weak staff. Healthcare personnel need to be proactive and try to identify the weak elements in the system and apply suitable measures. For instance, when the laparoscope was installed in the organization 10 years ago, there was an outbreak of post-operative infections (Varkey & Kollengode, 2011). At that time, the staff failed to realize that a dedicated worker was needed to clean the laparoscope before its sterilization. Due to this major flaw in the system, the patients suffered from the staff’s lack of foresight.
In a quality improvement project, multi-branched treatments are more effective than single treatment for practice management.
A more practical and applicable definition of Quality is “a degree of correspondence between goals set and goals achieved in relation to patient care, without excessive use of financial resources” (Frostic, 1993). Similarly, the following quality and safety steps are implementable by any organization, public or private, which has the required commitment.
Patient identity: Accurate identity of patients is crucial during blood collection and transfusion, surgeries, and laboratory probe. Patients must wear a write band with their names and hospital ID, as identity according to the bed number or name is case file is inadequate.
Evidence-based medication: Following the 1999 report of the Institute of Medicine, the Save 100,000 Lives Cause was launched to contribute to the quality and safety promotion in healthcare. Common medical issues were detected for which simple medical treatments like drug therapy were seen to be effective. Here, the challenge wasn’t intellectual but of commitment to apply strategies already outlined for every patient’s welfare (Dasture, 2008).
Smooth communication amongst healthcare staff: A single stay in hospital generally involves interaction with several staff members. Errors might occur during shifts of the hospital staff and when daytime workers transfer duties to night doctors. Nurses ought to follow a protocol for obtaining verbal lab reports and other data on telephone to prevent mistakes (Pronovost et al. 2003).
More safety in healthcare delivery: multitasking occur naturally in the day-to-day activities of nurses and doctors with their attention distributed to attending casualty calls, patient emergencies, meetings, etc. Hospital staff must follow checklists and case files for common medical treatments to deliver daily care to patients mainly in ICUs to make sure that they don’t miss any component of care (Dasture, 2008).
Physical hygiene to avoid infections: Nosocomial infections can cost lives and add to death rates and hospital costs (Burke, 2003).
Today, healthcare is greatly technology driven. New technologies give rise to new methods for flaws and errors and it requires constant vigilance to tracks them. An effective and powerful tool applicable is anonymous problem reporting by hospital staff and technicians operating in high-risk areas. Issues on staff errors, medication concerns and incidents are marked and dropped into a ‘feedback box’. The department head then reads the reports and uses them to discuss on how practices can be amended. It encourages free dialogue and multiple opinions from health personnel.
When all the aforementioned measures are incorporated in daily working and practice, the seed for a culture of safety and quality in a hospital will be sown.
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