Qualitinomics: Healthcare Quality Simplified

To our patients—who deserve the best quality care

Contents

India: The Healthcare Destination of the World

Quality in Healthcare Is Non-Negotiable

Apollo’s Laser Focus on Patient Safety

1. The Right Structure Is the Only Key to Success

2. Hospital Accreditation: Our Journey

3. Quality Improvement Essentials: First Step of Improvement

4. The Right Plan Is the Base for the Right Execution

5. Team Engagement: A Silent Driver of Quality Patient Care and Safety

6. Risk Management

7. Importance of Surveys and How to Conduct Them

8. Clinical Pathways

9. Quality Indicators: What Gets Measured Gets Improved

10. Incident Reporting: Report It to Stop It

11. Collaborative Governance in Hospitals

12. Measuring Reliability in Healthcare: Think–Plan–Act Differently

13. The Right Culture Drives Safety

14. IT in Healthcare Quality: An Optimistic Outlook

CASE STUDIES

Case Study 1: Medical Record Completion

Case Study 2: Patient Falls

Case Study 3: Surgical Safety

Case Study 4: Medication Error Analysis

Case Study 5: Employee Health and Safety

Case Study 6: Anaesthesia and Surgical Care

Case Study 7: Surgical Site Infections

Case Study 8: Pause the Pressure Injury

Case Study 9: Apollo Safety Development Model: Building a Culture of Safety at Apollo Specialty Hospitals

Case Study 10: The Quality for Excellence (Q4E) Programme

In Gratitude

Chapter Contributors

About the Book

Copyright

FOREWORD

India: The Healthcare Destination of the World

THE PROFESSION OF medicine has always been admired, valued and held in high regard. Doctors across the globe are deemed to be no less than gods, as they can save or change lives. Medicine is a very serious profession which comes with great responsibility. Even the slightest of mistakes or misjudgement by a medical professional could cost a person their life.

Today, India has become one of the world’s most cost-effective healthcare destinations with the latest technology tools deployed across care delivery. In recent years, our country has emerged as a major hub for medical tourism. It is considered among the top six medical value travel destinations in the world, with a market that is expected to reach $50 billion by 2025.

When I came back to India to start Apollo, it was my dream and resolve to help provide high quality healthcare at par with the best in the world.

Today, I look back with pride at what we have achieved in the last forty years. Besides cutting-edge technology and state-of-the-art facilities, we have created a close-knit family of doctors and staff dedicated to one single mission: top-notch healthcare with a human touch.

Apollo Hospitals Group, the first corporate healthcare in India, has been a driving force in strengthening the engagement between the healthcare industry, academia and government.

Our unrivalled knowledge base, top-notch doctors, extensive experience, affordable treatment and premier hospitals have enabled us to lead the medical tourism market. We have pioneered open heart surgeries and cardiac catheterization in the early ’80s, simultaneous kidney–pancreas transplant, the first en-bloc combined heart and liver transplant and more life-saving procedures.

Our numerous hospitals have been among the first in India to receive international healthcare accreditation by the America-based Joint Commission International (JCI) and NABH.

Furthermore, to give a boost to skilled manpower in India, we have collaborated with the Ministry of Rural Development, Ministry of Skill Development and Entrepreneurship, Government of India and the National Skill Development Corporation (NSDC), and state government entities and corporates, to make healthcare education more practically relevant. We have propagated a paradigm shift from the traditional teaching approach to one that elicits interest, nurtures curiosity and encourages questioning.

We offer various up-skilling courses for healthcare professionals, and skilling courses for school and college students. The focus is on imparting job-specific skills that will make the Indian healthcare professional a part of the much sought-after global workforce.

Ensuring world-class medical facilities to every individual in India has been our mission. We are committed to achieving and maintaining excellence in healthcare for the benefit of humanity. ‘Tender Loving Care’ is a way of life at Apollo Hospitals and the values and vision of Apollo Hospitals Group have transformed the Indian healthcare landscape.

Purity, patience and persistence have fuelled the success of Apollo Hospitals in meeting the changing healthcare needs in India.

The quality of healthcare and its direct impact on patient well-being is a deep concern. Our mantra is to identify the need of India and fill the lacuna using the trio of innovation, technology and commitment. The best of doctors and facilities—and most critically, the human touch make Apollo Hospitals Group one of the most sought multispecialty hospitals in India.

This book is yet another important step in our continued quest for excellence. In these pages, we explore an integrated approach to achieving even higher levels of quality, while always being anchored deeply in empathy and compassion. I personally believe that it is our humane approach to healing that makes us the most trusted name in healthcare.

I hope this book will serve as a useful reference for those working tirelessly towards building a robust healthcare ecosystem. Above all, my wish is for this book to inspire the next generations of the Apollo family so that our successors can be just as proud of our legacy as we are today.

Dr Prathap C. Reddy

Founder–Chairman, Apollo Hospitals Group

Quality in Healthcare Is Non-Negotiable

IBELIEVE IT would be fair to say that enhancing the quality of care rendered to patients has been like a rule, since the time of Hippocrates. Subsequently, innumerable iconic individuals have contributed to the quality improvement movement and catalysed positive change for humanity at large.

The nineteenth-century obstetrician Ignaz Semmelweis, renowned as the ‘Father of Hand Hygiene’, championed hand-washing for physicians; the embodiment of care Florence Nightingale instilled Listerean principles of infection control in hospitals. There is a long list of such innovators who have all been instrumental in making quality a non-negotiable aspect of healthcare. In 1951, in USA, a firm set up the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) for the accreditation of quality in healthcare.

There are considerable evidences highlighting that accreditation programs improve clinical outcomes and these programs should be supported as a tool to enhance the quality of healthcare services.

Accreditation involves the trained external peer reviewers to evaluate a healthcare organization’s compliance and compare it with pre-established performance standards.

In India, concerted efforts towards it began only at the turn of the millennium. A needle-eye focus on quality in healthcare is hugely pertinent in India, as there are vast discrepancies in the standards of health infrastructure, human resources, care protocols and even regulations, with public health continuing to be a state subject in the country.

Earning a patient’s trust is paramount in medicine, and accreditation provides a recognizable hallmark of quality. Yet, even in early 2000s, a plan to achieve quality accreditation was considered audacious for an Indian hospital, especially the hallowed distinction of being recognized by the Joint Commission International (JCI), the global ‘Gold Standard’ of healthcare accreditation.

It was an inherent pioneering culture that motivated us in Apollo to start thinking about an accreditation from JCI. Personally, this seemingly uphill endeavour proved to be a defining moment of my career in healthcare. Supported by the founding family and the senior teams of Apollo, in 2003, I travelled to Oakbrook, Illinois, USA.

In a strange turn of events, in the neighbourhood that I was staying in Oakbrook, I met Karen Timmons, who at that time was president and CEO of JCI. I would be remiss if I did not acknowledge her encouragement, which helped me return home to India with the resolve to make sure that one of our hospitals would soon be accredited with this ‘Gold Standard’ in quality.

My father and founder–chairman of Apollo Hospitals, Dr Prathap C. Reddy, chose Indraprastha Apollo Hospitals, Delhi to be the first in our Group that would prepare itself for the JCI accreditation. For an Indian hospital, getting ready to achieve JCI accreditation was no easy matter. It was an unprecedented initiative, and no one knew what JCI’s requirements were. My sister Suneeta who helped Indraprastha Apollo at that time had always wanted an international accreditation. Dr Reddy put Late Dr Mehrotra in charge, who then put together a team, which took off in full steam from day one. Supporting him, Dr Anupam Sibal, Apollo’s Group Medical Director, ensured that all the requisite ‘best practices’ were put in place.

The JCI Standards Manual was dissected, and a set of crisp but detailed policies was created. A lot of documentation was introduced by way of plans, medical records and standard operating procedures. The infrastructure was revamped. Every day was arduous, but our end goal—of accreditation—made it worth the while.

It was landmark day, when after twenty-four months of preparation, on 13 June 2005, a team of three JCI surveyors reached India to carry out the first-ever JCI survey for a hospital in India. Five days of feverish activity ensued: every inch of the facility was covered and all systems and processes were studied. On 18 June 2005, a preliminary report was handed over to Indraprastha Apollo Hospital, with a recommendation for the hospital to be accredited based on an assessment of 1,033 measurable elements. They say the first step is always the hardest, and it was no different with our first JCI accreditation. Since then, eight hospitals in the Apollo network have been accredited by the JCI, and India has forty-one JCI accredited facilities as on date. Any thought process must be translated and without the efforts of Hari, Anupam, and Gaurav, we would not have achieved what we have in quality at Apollo. On the behalf of the healthcare sector, I thank you all along with other stalwarts like Dr Giridhar Gyani, Dr Atul Mohan Kochchar, Dr Jonathan Perlin, Dr Vijay Aggarwal, Dr Narottam Puri, Dr Naresh Trehan, Dr Ashutosh Raghuvanshi, Dr Devi Shetty and many more of you who make this possible every day.

Over the years, the Medical and Quality Team led the creation of The Apollo Standards of Clinical Care (TASCC) to establish standards of clinical care that ensure that every Apollo Hospital delivers safe and quality clinical care to its patients, irrespective of the location and size of the hospital. TASCC embodies sets of process requirements and outcome measures that underlie the Apollo Hospitals’ approach to clinical care. In this manner TASCC makes up the double helix of the Apollo Group’s clinical fabric.

Apollo’s success with the JCI accreditation forged an all-new charter for Indian healthcare. Sangita, Dr Trehan and many others visited Thailand to study their Quality Council and had many deliberations before they presented a document to the Government and Quality Council of India. The Quality Council of India established the National Accreditation Board for Hospitals and Healthcare Providers (NABH). A think tank was assembled from within the healthcare industry, comprising the brightest minds. The first set of 509 objective elements were announced in 2006.

The NABH accreditation system is a graded model, with progressive levels of accreditation—starting from pre-entry to full accreditation. This gives even smaller hospitals an opportunity to apply for accreditation and work towards improving the quality of care, irrespective of the size of the hospital or the resources available.

Currently, there are more than 900 healthcare facilities accredited by NABH. In addition, NABH is accredited by the International Society for Quality in Healthcare (ISQua)—which implies that these standards are at par with global standards.

At this juncture, I would also mention that the quality journey provided immense clarity in raising the bar in clinical excellence. It certainly held us in good stead while combatting the COVID-19 pandemic: when the Indian Council of Medical Research (ICMR) started authorizing labs to perform RTPCR, the NABH accreditation was an essential criterion.

Also, to fortify India’s fight during this unprecedented crisis, the Apollo Hospitals Group harnessed its accreditation experience, spanning a decade and half, to standardize testing, infection control protocols, isolation, augmentation of capacity, human resource deployment and treatment protocols. The accreditation requirement of epidemic preparedness came in handy. This expertise helped the quality team led by Gaurav Loria in developing the ‘Red Book’, a compilation of standardized treatment protocols for COVID-19, which was updated over fifty-two times and continuously shared with healthcare organizations across India.

Personally, I have always believed that healthcare is the business of caring; it is a service, beyond being an integral element of the infrastructure. Therefore, it is vital that leaders in healthcare lead with empathy and persevere to transform access, experience and outcomes by putting people at the heart of all that they do. Hence, high tech must always be accompanied by high touch.

Healthcare is rapidly becoming digital first. There are huge investments being made into advanced technologies that will soon bridge gaps and make high quality care truly accessible to all in need. Nevertheless, an aspect of utmost importance to the successful adoption of digital health initiatives is the integration of patient voice into decisions to ensure a human-centric care experience. I must acknowledge our Medical, Quality, Nursing and IT Team for their dedicated work and futuristic thinking.

In the present day, across most parts of the world, a critical element considered while developing health policies is the quality of care in health services. Therefore, it has also been identified as essential towards achieving the health-related goals and targets outlined under the Sustainable Development Goals (SDGs).

Today’s quality is tomorrow’s sustainability. In view of this, I firmly believe that each of us must be committed to meticulously addressing aspects of our performance that have an opportunity for improvement, and contribute to building healthier ecosystems and communities.

Dr Preetha Reddy

Executive Vice-chairperson, Apollo Hospitals

References:

1. P. Gupte, Healer: Dr Prathap Chandra Reddy and the Transformation of India (Delhi: Penguin Books, 2013).

Apollo’s Laser Focus on Patient Safety

THE FOUNDING FATHER of medicine, Hippocrates, knew what science later proved through clinical studies—the mind and the body are intimately linked and one cannot be healthy without the other, which is why, no matter how evolved the physical aspect of treatment, it is the physician’s healing touch that makes all the difference.

We are fortunate to live in these times when cutting-edge technology—Proton therapy, robotic surgeries, artificial intelligence and more—enable us to save lives with a promise of good quality living for years to come. Simultaneously and equally, enhancing the quality of care rendered to patients while they are under medical care is of prime importance.

With the incredible advances in medical science, the world of healthcare is growing increasingly complex. Naturally, this carries with it some potential adverse events such as errors and risks. Therefore, a cornerstone of patient safety is continuous improvement aimed at minimizing errors and learning from adverse events.

For instance, take the simple case of mix-ups in medication. From the doctor writing a prescription to the purchase of medicines from the pharmacy and their administration to the patient by the nurses, one error at any step of the process can lead to grave consequences.

Of course, to err is human, and errors are almost inevitable in the high-pressure environment of healthcare systems. However, the onus to achieve near-perfection in this crucial field is upon the leadership, and while the task is arduous, it is by no means unachievable.

The primary step towards ensuring seamless performance is to create an environment that is open and transparent. Safety-first should be a declared motto, and systems and policies must not only be put into place, but also implemented to the letter.

Personally, I have always believed in taking a holistic but systematic approach to any task at hand. And the field of patient safety is no different. The challenges are multi-pronged.

Besides medication errors, the potential risk factors include diagnostic errors, hospital infection risk, surgical care and injection safety, transfusion and radiation quality, to name only a few. Mistakes, overexposure, lack of hygiene in some or all of these can cause severe harm and need to be avoided at all costs.

Speaking of costs, let there be no compromise on the personal safety of a patient under our care. We make absolutely no room for even the slightest let up on our part, lest a precious life be harmed or lost. All of this is possible only when the collective mantra is ‘healing with a human touch’.

So real is the challenge of improving patient safety that the World Health Organization (WHO) has dedicated an annual day to it. In 2019, the World Health Assembly (WHA) adopted a resolution to observe World Patient Safety Day on 17 September. Let us support the worldwide mission to abolish healthcare risks and errors with all our hearts and might.

For the past several years, the healthcare system across the world has been challenged by pandemics and the large increase in non-communicable diseases.

Our best defence is the ability to create and nurture strong resilient patient processes. Understanding that every life is precious and what we can do together will be a force multiplier for the healthcare in every region.

Suneeta Reddy

Managing Director, Apollo Hospitals Group

1

The Right Structure Is the Only Key to Success

It is pertinent to identify opportunities to enhance the healthcare organizations’ operations for improving patient care by synergizing with others and promoting patient involvement as partners in the care delivery process.

To minimize harm and maximize benefits, the healthcare system must suitably implement a reliable competency framework to build motivation among staff and offer world-class services in a consistent manner.

This chapter mentions how a well-structured and well-defined competency framework plays a pivotal role in achieving an organization’s goals in line with its mission and vision. It also focuses on empowering the staff of an organization to drive a culture of quality and patient safety across all levels of the organization.

‘Quality is free. It’s not a gift, but it’s free. The inequality things are what cost money.’

—Philip Crosby

Introduction

HEALTHCARE ORGANIZATIONS THAT strive for excellence in patient care work in such an arrangement that all the systems, functions, processes, departments, units and people in the organization work together, in sync with the organization’s mission, vision, values and strategic direction, to cater to the requirements of the customer, i.e. the patient. The customers are the centre of all service delivery. While the top management is responsible for a strong culture of patient safety, the Quality Department is equally accountable for supporting leadership in developing processes that improve outcomes and reduce and mitigate errors. Although the leaders in such organizations express their support for the quality strategy, the quality champions make a personal effort to walk the path of quality.

The leaders express their commitment to driving and implementing the quality department’s annual operating plan, and support in delivering best practices to achieve the best clinical outcomes for their patients. They work directly with the quality team, integrating all operational quality improvement initiatives with overall quality Annual Operating Plan (AOP). They provide constant support to the quality team, with the required budget and resources to carry out quality improvement initiatives within the organization. They also plan for a strategy to achieve the system-level quality goals, and oversee the execution by reviewing the compliance status of quality activities and attending all clinical governance committee meetings. Further, they report the performance of the quality matrix periodically and seek their inputs to enhance the quality performance in their organization. The leaders thus drive the culture of quality and patient safety across all levels of the organization.

Team Competencies/Capabilities

A competency framework of organizations is a model that broadly describes employees’ combination of skills, knowledge, attributes and behaviours that enable them to perform a task or an activity successfully within a given job. Competencies are measurable behaviours essential in defining job requirements and recruiting, retaining and developing staff. It comprises a competency matrix—a tool to map required and desired skills.

The competency matrix defines the competencies that your team should possess in order to reach these goals. The main components of the competency matrix include core and functional competencies. Core values are ideologies that stimulate people’s actions and the choices they make. Core competencies provide the basis of the matrix, describing the behaviours of staff members. Functional competencies on the expected duties and responsibilities are assigned to the staff members for a given job.

Competencies empower the staff of an organization to have a clear understanding of the behaviours and the levels of performance anticipated to achieve organizational goal, as a hint of the behaviours and actions that will be valued, recognized and rewarded. Therefore, a well-structured and well-defined competency framework plays a pivotal role in achieving an organization’s goals in line with its mission and vision.

Competency Framework for Healthcare Quality Professionals

Accountability

Accountability