Second Indo-German Dialogue on Social Policy: Quality Assurance in RSBY Health Care Institutions New Delhi, 24 th to 26 th of April 2013

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1 Second Indo-German Dialogue on Social Policy: Quality Assurance in RSBY Health Care Institutions New Delhi, 24 th to 26 th of April 2013 Introduction: Recommendations The German Federal Ministry of Health (BMG) and the Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ) GmbH through the Indo-German Social Security Programme (IGSSP) jointly organized a workshop on the topic Quality Assurance in Health care - Hospital Management at New Delhi from 24 th to 26 th of April 2013 with focus of quality assurance in healthcare with regard to RSBY, the national health insurance scheme for the poor in India. Following recommendations emerged out of extensive discussions and deliberations, as well as prima-facie field observations made in a span of three days. Rashtriya Swasthya Bima Yojana (RSBY) is a national level initiative and its objective is to provide health care access, as well as quality health care services to the beneficiaries. Hospitals can be empanelled under RSBY if they fulfil a minimum set of criteria. In districts with lesser availability of hospitals some relaxation is practised. The quality of services provided currently by the empanelled public and private health care providers needs to be enhanced. Moreover, there is no consistent nationally applicable quality improvement process, which has been adopted by these providers. In view of this, RSBY provides an excellent opportunity for developing a consistent and nationally applicable quality improvement process for RSBY network hospitals to provide quality-improvement of patient centred outcomes and consistent services i.e efforts made to improve these outcomes through its network of identified health care providers. Managing performance and strengthening accountability in the delivery of quality health care in RSBY through network institutions has emerged as the most prevailing themes confronting RSBY administration as expectations continue to rise as the scheme progresses. The following activities are recommended,considering continuation of these activities during the 2 nd phase of IGSSP, Theyand can be categorized as immediate- activities can started without much preparation as preliminary work is already done, medium - some preliminary work say about 3 months will be required for starting this activity and long- planning and preliminary work may require about 6 months or more for starting this activity, These recommendations are an attempt to establish a system with better quality health care in RSBY network hospitals and is based on four dimensions of patient health care i.e. effectiveness, patient safety, patient centeredness and efficiency. Patientcenteredness is a principle which is mainstreamed throughout the recommendations. These recommendations are not limited to RSBY network 1 P a g e Second Indo-German Dialogue on Social Policy : Quality Assurance in RSBY health Care Institutions.

2 hospitals but can be considered for non -RSBY hospitals also, and will have a great impact on the quality of health care services of RSBY Network hospitals. 1. Strengthen accountability and improve performance across network institutions: a. Voluntary accreditation/grading of health institutions ( Immediate) Self-regulation through accreditation embodies a traditional philosophy that a free people can and ought to govern themselves through a representative, flexible, and responsive system, accordingly, accreditation is best accomplished through a independent association of health care institutions. Accreditation criteria and standards enhances the health care quality by improving the effectiveness of institution/s and ensuring that the Institution/s meet standards. Periodic review and evidenced based development of quality criteria and benchmark, Quality improvement process (Hospital Sensitisation workshop, Self-assessment by the hospitals followed by discussion and assessment by trained assessors,and then communication to the hospital for improvement) implemented by RSBY across five states has validated the parameters used. These parameters can be immediately used to categorize the hospitals and to be included in the hospital data collected during the time of empanelment by the Insurance companies. b. Continuous quality improvement of institutions: ( Long) Continuous Quality Improvement efforts can be undertaken by RSBY so as to ensure that consistent, high quality services are delivered to the beneficiary under the scheme; to improve the permanency, safety and well-being of beneficiary in care; to reduce the possibility of adverse occurrences and to maintain a system for continuous quality improvement with regard to patient centred outcomes. The continuous quality improvement can be implemented as a nationwide quality assurance and improvement system and support opportunities for continuous learning. The present initiative of quality improvement can be up scaled, help of external agencies can be considered. The health care institutions can be encouraged to improve their quality through incentivised payment structures i.e. hospitals with better quality grade will get higher package rate for a specified package. The existing A~E grading can be used. Hospitals in E category will get base package while the hospitals in above category should get incentives in the range of 10~25 per cent. The objective here is to create same conditions for all and the hospitals with lower grades will be incentivised to ascend to higher category. c. Creating mechanism and structures for reviewing empanelment criteria over time. ( medium) Network hospitals are the backbone and cutting edge of the scheme, and the numbers are growing and will grow as the scheme matures. To have a more objective criterion for including hospitals into the network fold, an 2 P a g e Second Indo-German Dialogue on Social Policy : Quality Assurance in RSBY health Care Institutions.

3 institutional mechanism needs to be setup at the central level which can monitor the empanelment and suggest revisions as and when required. 2. Creating a brand for RSBY hospitals: a. Revisiting and revising criteria for empanelment using quality parameters. ( medium) The present empanelment criteria are very generic and can be revisited at the central level to accommodate quality parameters. The review should happen in context to the available evidences for improving quality of services in a Health Care Institution. The criteria agreed to be enforced through strengthened institutional mechanism through the State Nodal agencies and the insurance companies. An expert agency having expertise to make empanelment criteria can be engaged as Technical Support Partner (TSP) for the same. b. Creating a website profile of each RSBY empanelled hospital. (medium) Data is available with the RSBY centre regarding available infrastructure and capacities of the hospital; this coupled with quality grading can be used to create profile at the central level. This will help the different stake holders, beneficiary as well the help desks in identifying the hospitals, services available at the hospital, as well as performance of the hospital over the years. c. Creating a yearly performance report profile of the hospitals on RSBY web portal dis-incentivising hospitals not complying.( long ) The claims and the transaction data of the hospitals are now available at the central level. Using this data a yearly performance report linked to profile of hospitals can be developed. Based on yearly performance and quality grades the hospitals can be branded as RSBY Gold standard Hospital, Sliver standard hospital and Bronze standard hospital or a similar kind of branding can be evolved. 2. Developing quality processes for improve health care: a. Quality assurance through improving input standards and processes.( long) The present standards (17) and processes (138) used by RSBY needs to monitored and can be considered for updating and modification based on experiences. It is recommended that an external agency with expertise in developing Quality Standards and involved in measuring performance of hospitals based on evidences and process can be engaged for 2-3 years period for revising /laying down graded criteria Standards for empanelment of hospitals, and also conduct workshop /conferences /sensitization & awareness programmes up to district levels hospital for smoothly adopting revised standards. Same agency will be required to 3 P a g e Second Indo-German Dialogue on Social Policy : Quality Assurance in RSBY health Care Institutions.

4 review the criteria after feed backs for clarifications to client hospitals and community groups for some reasonable period say one year. b. Developing Standard Operating Protocols, benchmarks and clinical pathways for commonly occurring procedures and illness. ( Medium) Data is constantly flowing to the central server and commonly occurring procedures and illness can be listed out. Standard operating protocols and development of clinical pathways for commonly occurring procedures and illness will help. The network institutions, academic institutions and other organizations like APHI can be considered. Recommended that external agencies with expertise in healthcare delivery sector may be engaged on contractual basis for developing necessary model Standard Operating Protocols and development of pathways for empanelled hospitals. Guidelines as available on international web networks like GIN, can be adapted to meet and suit local requirements. c. Developing check lists for indications of surgery in commonly occurring procedures. (medium) In absence of any statutory regulations and standard treatment guideline development of checklist for commonly occurring surgical procedures will help in making the beneficiaries aware of indications and will prevent unnecessary surgeries. This will further be a step towards patient education as well as help the administrator to monitor and audit unnecessary surgical procedures. d. Promoting use of RSBY smart card as health card for storing patient personal record. (medium) RSBY since its launch, has catered to the health and medical needs of approximately 5.4 million people., The use of latest Information and Communication Technologies (ICT) has ensured effective implementation and proper management of the programme. This has further increased the scope and demand for quality health care under the scheme. Effective solutions are to be found out to cope up with this demand. The next stage in this direction is the restructuring of the relationship between patients, healthcare professionals, and healthsector authorities for the creation of e-health cards, The e-health card holds promise to improve the quality of healthcare and will allow healthcare professionals to access all the information concerning a patient s health immediately, regardless of their location, thus avoiding hesitation in urgent situations and optimizing quality of service 3. Measuring quality and auditing of quality of health care: a. Use of hospital transaction data and assured biographic data for setting benchmark quality standards. (long) 4 P a g e Second Indo-German Dialogue on Social Policy : Quality Assurance in RSBY health Care Institutions.

5 Benchmarks in the terms of age at surgery, Average Length of Stay, average claim size etc. can be evolved and used for defining procedures and Standard Operating Protocols and clinical pathways at the central level. Adequate risk adjustment provisioning should be made while setting quality benchmarks using the transaction data. b. Feedback at the time of discharge. (immediate) / Institutionalizing patient survey (medium) What makes hospitals really patient friendly is a profound respect and understanding of patients needs. Patient feedback is the ultimate response to any quality initiatives undertaken. A short feedback should be developed with focus on quality of health care and all the participating network institutions should collect these at the time of patient discharge. This facility has to be incorporated into the transaction software. An expert external agency can be engaged on contract basis for analysing patient and staff feedback forms received in soft copies from central organisation and bring out areas of improvement needed with recommendations for action at local and central level. This will only make RSBY empanelled hospital services patient centric and patient friendly, as well as inculcate a habit of getting feedback and concern of patient satisfaction. This may require staff education and training. c. Post treatment survey ( medium): Satisfaction of the beneficiary is the ultimate aim of any health care delivery system. One of the measures of satisfaction is cure of the ailment and the morbid condition preceding hospitalisation. A post hospitalisation feedback on the services as well as the status of treated condition will be very useful in improving the quality of services provided by the institution. Before publishing the report data should be considered carefully and must be risk adjusted. The feedback can be piloted in few states through the ASHA workers (accredited Social Health activists) under NRHM (National Rural Health Mission) or through contracting external agencies. 4. Supporting of improvements: a. Peer Review for improving quality ( immediate) Professional peer review by organization like Association of Provider of health care in India (APHI) can help the hospitals in focusing on the performance of professionals, with a view to improving quality and upholding standard. Professional peer review activity is widespread in the field of health care, where it is best termed Clinical peer review. Further, since peer review activity is commonly segmented by clinical discipline, hence the focus on of this kind of review should be restricted only on quality care by the hospitals. Peer group approaches work very well in western countries but not here in India especially if you have a shortage of doctors. Peer review process is very difficult to conduct than to an audit process. Cultural aspects also influence the viability of this 5 P a g e Second Indo-German Dialogue on Social Policy : Quality Assurance in RSBY health Care Institutions.

6 approach. Therefore, it is recommended that Peer group review can be experimented in few districts with high number of empanelled hospitals, especially districts like Varanasi in Uttar-Pradesh State. An external agency can be considered for piloting and developing standards peer review. b. Support of investments in quality (e.g. infrastructure, sanitation, equipment and training) ( long) In some districts of India there are excessive number of hospitals in RSBY and hence t is relatively possible to choose hospitals meeting quality grades. The excluded hospitals can be motivated to improve their quality grades for possible inclusion into RSBY Network. However, in most of districts there is shortage of hospitals and it is very difficult to choose hospitals with desired quality parameter without compromising the access of health care to the beneficiaries. Incentivising hospitals in these areas with financial support (through loans for infrastructural, educational and organisational support) can be considered to give these hospitals the possibilities to put effort to meet the desired RSBY quality grade requirements, as well as to ensure continuous effort in the improvement of the quality of services. E.g.: Financial support for creating training structures for helping these health care institutions. 5. Institutional mechanisms at Central level: a. Strengthening institutional structures for implementation of quality in RSBY.( long) RSBY implementation has undergone complex and challenging developments since its inception. The most significant development is expansion of RSBY to different categories of unorganized workers, as well as use of RSBY smart card platform for PDS and JBY and AABY as well as MNREGA. The critical issue is setting up of appropriate institutional framework at the central and state level to absorb the expansion of these challenges. The institutional structures for implementation of RSBY at the central level need to be strengthened with formal and sustainable mechanisms. A strong linkage and coordination mechanism with MoHFW needs to be worked out for continuous support. b. Advocacy for Patient rights and awareness.( long) In India there is very little perception about the rights of the patients even amongst the educated persons. Therefore blatant violation of patient s rights is a routine occurrence. However the situation can be changed if every citizen takes certain precautions while undergoing treatment or while taking drugs/vaccines etc. Patients rights emanate from human rights, constitutional rights, civil rights, and consumer rights, codes of ethics of medical and nursing profession. The Indian Constitution bestows certain rights on the citizens. One of them is Right to Life. A mechanism needs to be evolved for raising awareness among the beneficiaries. External agencies in healthcare sector with knowledge 6 P a g e Second Indo-German Dialogue on Social Policy : Quality Assurance in RSBY health Care Institutions.

7 about healthcare systems and quality health care management may be engaged for carrying out all India mass awareness on patient s right and education as well as education health care providers to understand and perceive patient rights. c. Creating federations of providers :( Medium) Presently all the providers are working as an individual entity without any negotiating power. An E- group has been formed recently for bringing them together sharing experiences and providing suggestions for improvement. Within the existing structures subgroups of different specialities and health care providers working with RSBY could be formed, who can contribute to quality improvement process, development of packages, clinical protocols and Standard operating procedures. d. Systematic evaluation A simple monitoring mechanism needs to be evolved at the central level for looking into the different aspects of implementation, as well as periodic evaluation of all the efforts undertaken. Process indicators are to be developed for monitoring the progress of implementation, as well as looking into the feasibility, applicability, acceptance, efficiency, costs of quality improvement measures.. 7 P a g e Second Indo-German Dialogue on Social Policy : Quality Assurance in RSBY health Care Institutions.

8 Summary of recommendations with time schedules: SN 1 Areas Strengthen accountability and improve performance across network institutions Recommended schedules Immediate* Medium$ Long# Creating mechanism and structures for reviewing empanelment criteria over time Voluntary accreditation/grading of health institutions Continuous quality improvement of institutions Creating a brand for RSBY hospitals Developing quality processes for improve health care Measuring quality and auditing of quality of health car Supporting of improvements Feedback at the time of discharge. Peer Review for improving quality Revisiting and revising criteria for empanelment using quality parameters Creating a website profile of each RSBY empanelled hospital Developing Standard Operating Protocols, benchmarks and clinical pathways for commonly occurring procedures and illness. Developing check lists for indications of surgery in commonly occurring procedures Promoting use of RSBY smart card as health card for storing patient personal record. Institutionalizing patient survey Support of investments in quality (e.g. infrastructure, sanitation, equipment and training) Creating a yearly performance report profile of the hospitals on RSBY web portal dis-incentivising hospitals not complying Quality assurance through improving input standards and processes Use of hospital transaction data and assured biographic data for setting benchmark quality standards Post treatment survey 6 Institutional mechanisms at Central level * 1. Immediate: activities can started without much preparation as preliminary work is already done, $ 2: Medium: some preliminary work, say about 3 months will be required for starting this activity # 3. Long: planning and preliminary work,may require about 6 months or more for starting this activity Creating federations of providers Strengthening institutional structures for implementation of quality in RSBY Advocacy for Patient rights and awareness. 8 P a g e Second Indo-German Dialogue on Social Policy : Quality Assurance in RSBY health Care Institutions.