Hospital audits help maintain standards of patient care. And with increasing growth in medical tourism, the booming healthcare sector must provide the best services possible. Hospital in India must ensure that audits take place regularly and they maintain the established standards.
Titash Roy Choudhury
Today, the Indian healthcare sector is standing at the gateway of great success and tremendous growth, be it the millions of jobs that this sector is creating or the revenue it is generating. And it is at this juncture that we need to focus on maintaining this success that can be ensured by effectively conducting hospital audits. After being introduced in the year 1969 by the then health minister of India Dr Sushila Nayyar, hospital audit had slowly blurred into oblivion. It is only in the recent past that we have seen a resurgence of the concept, with hospitals, management and patients taking an active interest in it. And the Indian accreditation body that had begun its operation only in 2007 has till now accredited and subsequently audited only 100 hospitals and is still in the process of evolving. So, in comparison to international methods and techniques of hospital audit, India is still at a nascent stage. But what we have to understand is, how the whole process of audit enfolds in Indian context and how India can compete with other countries when it comes to hospital audit.
The main objective or purpose of any hospital should be towards creating an environment that would be able to provide the best and uninterrupted services to its patients. A hospital audit is a structured and professional screening of the quality of services provided by any hospital against established criteria. Hospital audit has been defined as ‘an evaluation system in which established standards are used to measure performance. Once corrective action has been taken about problems identified through a review process, performance is re-measured after an appropriate time period.’ And it is through a proper systematic hospital audit that a hospital can help build its credibility and image in the eyes of its patients.
The development
The scenario has changed immensely with these regular audits; today with the mushrooming of hospital and growing individual income, health has become a priority for Indians. Indian patients today put a lot of value to the quality of healthcare provided by the hospitals. “Hospitals have to create patient care and safety impact, the moment a patient is admitted to the hospital through processes and infrastructure,” says Suresh Lulla, Managing Director, Qimpro Consultants Pvt Ltd. Indian patients in recent years have an array of hospitals to choose from and so the competition among the hospitals to maintain their standards and improve them as and when required has become stiff. This led India to establish its own accreditation system in 2005, which also takes care of hospital audits. “There is no mandate passed by the government of India for auditing or certification of hospitals in India yet, but looking at the pressure society and conscious customers will bring, this will soon become an important tool for the hospitals to prove their performance and competence,” Lulla adds. Before 2005 the scenario of hospital audit was bleak, unpromising and neglected, but with its growing importance again among Indian medical system it is time we had a hard look at this concept. And before delving deep into the processes and systems of audit in India we need to look at the position of hospital audit in India from the global perspective.
“Hospitals have to create a patient care and safety impact, the moment a patient is admitted to the hospital through processes and infrastructure.” - Suresh Lulla, Founder & Mentor, Qimpro Consultants Pvt. Ltd.
India’s global standing
Countries like the US, Australia or Canada had their standards for audit set years ago and these standards are acknowledged world over. Joint Commission International (JCl) was established in 1917 in the US and since then has been acknowledged universally in different countries. Other systems like Australian Council on Healthcare Standards (ACHS) and Canadian Council on Health Services Accreditation (CCHSA) have been long established and implemented throughout the world. However, it was only after the establishment of National Accreditation Board for Hospitals and Healthcare Providers (NABH) in 2005 that India has its own accreditation system, and NABH began its operation only in 2007. So comparing a four-year old system with age old systems like JCI or CCHSA is not justified. Though Dr Gayatri Vyas Mahindroo, Director, NABH differs in her opinion. She avers, “NABH has recorded an excellent growth over the last four years, and has been accredited by ISQua indicating that it is nowhere below or above the other international systems like JCI. On the other hand, it is more practical and realistic for the Indian socio-economic conditions. India is a culturally sensitive country and NABH has considered that at every step.” Lulla reiterates this point. He says, “JCI is stringent and stiff for Indian hospitals along with being expensive. NABH is a more customised version of JCI for Asian countries and that is why it is being accepted in countries like the Philippines.”
Striking a similar chord, Dr Mahindroo avers, “The rules followed by the Quality Control of India (QCI) when it comes to audit are very strict and till now NABH has accredited approximately only 100 hospitals from among hundreds of applications. It is practical and achievable for Asian countries and our process is very strict and rigorous.”
Categories of audit in India
To understand the concept of hospital audit in the Indian context we have to look at the types of audits performed in India. There are two types of audits; internal audit, which is conducted by the hospitals themselves, and external audit, which is conducted by QCI.
An internal audit is usually conducted by an internal audit committee on the basis of peer review and consists of senior doctors, nurses, infection control officers and other medical professionals. It follows a calendar or routine and this differs from hospital to hospital. But in case of any complain or emergency situation, department wise audits are conducted.
And as for the external audit or third party audit, it is conducted by NABH, which is a part of QCI. The latter is a quasi-government organisation established in 1997, which started its own accreditation format; NABH from 2005. “Once a hospital applies for an NABH accreditation we conduct a preassessment. Based on the findings of preassessment, the hospital takes corrective action and applies for final assessment. Once the accreditation is granted, a surveillance audit is conducted within 18 months of accreditation. Thus, it is a continuous quality improvement tool rather than one time exercise. Process audits, document audits, mortality and morbidity audits, infection control and hand hygiene audits, medication safety audits, clinical audits are requirements for NABH standard implementation,” informs Dr Mahindroo.
“NABH has recorded an excellent growth over the last four years, and has been being accredited by ISQua indicating that it is nowhere or above the other international systems like JCI.” - Dr Gayatri Vyas Mahindroo, Director, NABH
And for few special chains of hospitals like Fortis or Apollo both the procedures are followed as Uma Nambiar, Chief Quality Officer, Fortis Healthcare (India) Ltd highlights, “Few hospitals under the Fortis banner have NABH accreditation and for. them audit is primarily conducted by QCI, but for others internal audit is mostly done department wise. Fortis will be coming up with a standardised process of audit that will be conducted by an internal audit team to be formed by the hospital. Along with this internal audit, hospitals will also have external audit - to be performed by trained auditors. This will be a quarterly process to be started in this fiscal year.”
Audit has become part of the Indian healthcare system in the recent past and has been implemented in a full-fledged way only after the establishment of NABH in 2005. Before that internal audits may have been prevalent but were in a dormant stage and doctors were very skeptical about audit. But today with increase in the number of hospitals in public and private sectors and increasing awareness and knowledge of the doctors, audit has become an integral part of the health care delivery system. “Till few years ago, clinical audit was an unknown term in the Indian healthcare industry, but today doctors know the importance of audit and with growing leverage on the patient safety measures and quality of care provided to the patients, hospitals are taking initiatives on their own to better and improve their services,” Dr Mahindroo adds.
Standards of audit followed
In India, health is under state regulations, so each state has its own set of standards. Along with that hospitals also have to follow some statutory legal requirements like Pre-Natal Diagnostic Techniques (PNDT) Act and others. NABH also has formulated some basic standards for hospitals drafted by a technical committee that provides a framework for quality assurance, management and improvement. “The established standards are developed with the focus on patient safety and quality of patient care. The dimensions of these standards are either operational centric or management centric, they cover management of medication, infection control, quality management and the hospitals are in a continual process of improvement,” Lulla informs.
Further, hospital chains like Apollo or Fortis have come up with their own set of standardised guidelines. Apollo Group of Hospitals, with a view to objectively measure and improve clinical quality across all its hospitals, has set up ACE@25, a clinical excellence scorecard, which was launched in January 2009. ACE @25 is a clinical balanced scorecard incorporating 25 clinical quality parameters, chosen from the world’s best hospitals including Cleveland Clinic, Mayo Clinic, National Healthcare Safety Network, Massachusetts General Hospital, AHRQ US, Columbia University Medical Center and US Census Bureau. “All hospitals report the data online every month. A team of 20 auditors audit the ACE@25 data at all locations every six months,” informs Dr Anupam Sibal, Group Medical Director, Apollo Hospitals Group.
Along with that there are department specific standards that focus on a particular department. “There are different norms for different specialties. These are set according to department like obs gynae, medical, surgical or according to the type of audit like long stay audit, patient care audit, histopathological audit,” says Vinay Lazarus, Director - Administration, G M Modi Hospital. The audit looks into any kinds of deviations from these standards and records them. “The audit findings should be used for improvement and not punishment,” Dr Mahindroo opines. The audit should be followed by preventive and corrective actions, which will be verified in the next audit.
“Fortis will be coming up with a standardised process of audit that will be conducted by an internal audit team to be formed by the hospital.” - Uma Nambiar, Chief Quality Officer, Fortis Healthcare (India) Ltd.
Protocols guiding an audit
In any audit, be it financial or medical, certain rules and regulations need to be followed, and a few set protocols would guide the audit. For a hospital audit there are few set protocols as put forward by professionals, which states clearly that an auditor should be a qualified and experienced professional. “NABH assessment team comprises a clinician, nurse and hospital administrator. Our assessors assess the hospital as a whole and all the relevant processes’ are verified, be it the management or patient care” Dr Mahindroo informs. Audits should also be planned with set formats & standard, and the purpose should be simple and clearly stated, as Lazarus puts it. “Apollo holds ACE @ 25 audits for all its hospitals for which data is audited on the basis of a defined audit guide. Apollo also has a defined format for holding mortality review or mortality audit” adds Dr Sibal.
Is cost a key factor?
Regular assessments of hospital functioning might be taking a toll on the finances. However, Dr Mahindroo informs, “There is a myth in the public that NABH is costly but it is contrary to the fact. Hospitals are required to deposit the application fee based on the number of patient beds, which is very reasonable by every standard.”
Cost for conducting an audit usually differs. An internal audit may not cost much in monetary terms but usually takes up a lot of manpower. On the other hand, external audits may incur some cost to the organisation. Thus, cost might not be an imperative factor for conducting audits. Even if a hospital is reluctant in paying for external audits, conducting internal audits will not be expensive. And considering that NABH has helped Indian hospitals to no longer shell out money for expensive international accreditation and audits where the organisation has to pay for the auditors, their stay and every other aspect.
Benefits of audit
In a developing country like India, health care is flourishing at a higher pace than the other sectors and to continue this upward graph, audit should become an integral part of healthcare system. “One should work towards constantly modifying and upgrading its systems and audit helps in this process. The medical world is changing everyday with introduction of new technology and new studies” says Dr Mahindroo. She adds if a hospital is not updated from time to time then the sector will lag behind. An audit also provides confidence to the hospital staff. “For all categories of hospital staff there is an established set of guidelines to help and monitor their activities. For example, even a ward boy in an NABH-accredited hospital knows about basic rules of hospital infection prevention. An NABH-accredited hospital educates patients and their families about their rights and responsibilities. The benefit of implementation of quality systems adds to the employee and patient satisfaction,” remarks Dr Mahindroo.
An audit also ensures improvement of the quality of services provided by the hospital, which in turn usually results in long term financial benefits to the organisation along with improvement in patient care that guarantees increased patient satisfaction and patient footfall. Decrease in medical errors and adverse events also help in creating a brand image for the hospital and build the credibility of the organisation. “The process of audit ensures consistency in delivery of clinical and non-clinical services; it also addresses the habit of continual improvement,” feels Lulla.
Dealing with the loopholes
This process is not completely flawless; it has certain areas that need to be worked upon, as Dr Sibal points out, “Some of the major loopholes are on the part of commitment, participation and seriousness for the audits. Audits in Indian scenario are still more or less considered as an obligation and are done only to fulfill the requirement of various accreditation or other external agencies rather than for the improvement of hospital processes and quality in actual.” Low number of auditors is also a concern for hospital audit in this country.
Hospital audits if utilised efficiently and rigorously help the hospital to perform better both for itself and its patients, but until now they have never been meticulously implemented in India. But the scene is changing with changing attitude of both doctors and patients. It has just begun to gain momentum in India and needs acceptability by the hospital systems and medical fraternity as an improvement initiative rather than a fault finding mechanism.
“Audits in Indian scenario are still more or less considered as an obligation and are done only to fulfill the requirement of various accreditation or other external agencies.” - Dr Anupam Sibal, Group Medical Director, Apollo Hospitals Group
CREDITS: Suresh Lulla, Founder & Mentor, Qimpro Consultants Pvt. Ltd.