Concept Project Report

Final Version Concept Project Report Pilot Project for Cluster Based Accreditation Support to Hospitals in Kerala Under IMA-NABH Initiative IMA Hospital Board of India

Contents Section I - Background...3 Section II - Project Concept and Organisation of Services...7 Section III - Project Operationalization Plan...16 Section IV - Financial Plan and Analysis...19 Section V - Summary & Conclusions...22 P a g e 1

Figures & Tables Figures Figure 1: Various Levels of NABH Accreditation Info-graph... 5 Figure 2: Geographical Overview of Cluster Distribution... 8 Figure 3: Overview of Cluster Based Services For NABH Accreditation Support... 9 Figure 4: Cluster Based Accreditation Onsite and Centrailsed Services Overview... 10 Figure 5: Project Organisational Structure... 13 Tables Table 1: Overview of Hospitals Under Various Stages of NABH Accreditation... 4 Table 2: Cluster Organisation and Distribution of Districts... 7 P a g e 2

Section I Background The Indian healthcare delivery system consists of varied health institutions and mixed ownership patterns. Largely private sector and public-private partnership owned institutions dominate the tertiary care, while secondary healthcare is a lopsided mix of both private and public; while 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 out of pocket expenses. The Government contributes 24 per cent, employer provides for 9 per cent and only 5 per cent comes through insurance. There have been numerous instances of poor care, inadequate facilities, unnecessary interventions and insufficient information that have result in demand 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 improvement of quality of 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 scenario healthcare quality improvement requires a judicious mix of regulation & accreditation. By laying down standards for all aspects of institutional care together with a roadmap for achieving the same, patients will slowly develop confidence that healthcare they receive conforms to certain accepted norms. 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. The Clinical Establishments Act legislated by the Government of India is a first step in bringing in licencing norms for healthcare facilities. Since health is a subject on the concurrent list; the various state governments are in the process of developing their own legislations and framing the rules for implementation of the law. However there is wide spread fear among the small and medium hospitals owned mostly by doctor entrepreneurs that the clinical establishment act and its rules will become an avenue for corruption and bureaucratic interference through creation of another system of Licence Raj. P a g e 3

Accreditation on other hand is voluntary process 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. (Source: Hospital Accreditation in India - Standardising healthcare). While licencing standards deal with essential standards which must be ensured in all hospitals / institution under a specific category; accreditation process looks at compliance levels of many desirable standards. Hence it is commonly agreed upon that those hospitals which are accredited by a robust and well accepted accreditation programme does not need to undergo the periodic inspections mandated under the various clinical establishments act. NABH 2015-2015 Penetration and Acceptance among Hospitals National Accreditation Board For Hospitals & Healthcare Providers (NABH) accreditation scheme was launched under the aegis of Quality Council of India (QCI) in 2005. It has emerged as a viable and robust accreditation program and has achieved good penetration among the corporate, tertiary care and higher end private facilities. Though some public health facilities have achieved accreditation the overall numbers from this sector are minimal as yet. MCI approved teaching hospitals also have not yet adopted accreditation in high numbers. Table 1: Overview of Hospitals Under Various Stages of NABH Accreditation Accreditation Programme Accredited Progressive Level Awards Applicants Hospitals 299 7 460 Hospitals Pre Accreditation Entry Level Small Healthcare Organisations SHCO Pre-accreditation Entry Level 6-64 50 1 161 1-11 Source: NABH Website, Accessed on 30 June 2015 Though NABH also launched a specific standard for Small Health Care Organisations (SHCO) aiming at small under 50 beds; non-super specialty hospitals; the same has been confined to single speciality centres like ophthalmology hospitals. The large bulk of small hospitals mostly under 30 beds and often owned by doctors entrepreneurs in smaller towns and cities across the country has remained out of the ambit of accreditation. P a g e 4

In 2014 NABH launched more simplified accreditation standards as a sub set of the main accreditation standard termed Entry Level Accreditation standards with a view of bringing these small hospitals under the ambit of accreditation. The entry level program brings in a step wise approach to achieving full accreditation where these small hospitals can initially try and achieve a intermediary level of Entry Level accreditation and Provisional Accreditation prior to full accreditation at a viable costs and in a scenario where it would take a lot of infrastructural, regulatory compliance and process improvement to achieve full accreditation. Figure 1: Various Levels of NABH Accreditation Info-graph Source: NABH Website IMA NABH Collaboration IMA and NABH has signed an Memorandum of Understanding (MoU) for collaborating for promotion of the NABH entry level accreditation among small and medium sized hospitals across the country. IMA Hospital Board of India (IMA-HBI) an official wing of the IMA will be implementing this understanding with the following key activities; P a g e 5

Mobilize its resources to create awareness programs and engage hospitals and SHCOs to attend sensitization programs and enroll to work towards pre-accreditation level certification. Advocating with Central/State Governments, IRDA, Insurance Companies and other stakeholders for making NABH Pre-Accreditation Entry Level certified hospital eligible for empanelment under various public and private insurance scheme and also consider for any proposed added benefit IMA HBI proposes to engage small healthcare organisations and hospitals across the country through its membership network for adopting the entry level accreditation and proposes to set up a programme for technical support for these hospitals to obtain entry level NABH accreditations. The pilot of this program will be initiated in the state of Kerala under the aegis of Hospital Quality Assurance Committee who will roll out this programme across the state with a proposed initial enrolment of over 200 hospitals. P a g e 6

Section II Project Concept and Organisation of Services The IMA-HBI proposes to roll out a pilot programme for centralised consultancy and facilitation support to various hospitals owned or operated by IMA member doctor entrepreneurs for obtaining NABH Entry Level Accreditation through a cluster approach in Kerala. This cluster approach envisages simultaneous standardised facilitation support and consultancy to group of hospitals located in the same geographical region of the state in preparing them for NABH entry level accreditation. This approach is expected to have following benefits; Reduction is cost of technical consultancy support costs to the individual hospitals Availability of sustained and verified technical consultancy and facilitation services. Collaborative approach and overall improvement of the health systems through coordinated efforts of hospitals. Overall improvement of quality of healthcare services and health sector staff competencies. Fostering an environment of sharing of best practices and mutual learning among hospitals Creation of a common platform for interactions with accreditation body, regulatory authorities etc. The pilot initiative of IMA HBI is expected to enrol over 200 hospitals across the state and expected to take these hospitals to entry level accreditations with in a period ranging from 8 to 18 months depending upon their current capability level and organisational learning efforts. A. Organisation of the Pilot Initiative for Cluster Based Facilitation of Accreditation Approach in Kerala IMA HBI proposes to divide the state into four geographical clusters for the purpose of centralised facilitation and consultancy services to hospitals based on geographical proximity and density of private hospitals in these districts. The districts included in each cluster are provided in the table below; Table 2: Cluster Organisation and Distribution of Districts Cluster Districts Nodal District Cluster I South Kerala Thiruvanthapuram, Kollam, Pathanamthitta Thiruvanathapuram P a g e 7

Cluster II Central Kerala Cluster III North Central Cluster IIV North Alappuzha, Kottayam, Ernakulam, Idukki, Thrissur Thrissur, Palakkad, Malappuram Kozhikode, Wayanad, Kannur, Kasarkode Ernakulam Thrissur Kozhikode In the pilot phase each of the above clusters is expected to enrol 40-60 hospitals for facilitation support for accreditation. These clusters have been formed based on congruent district to reduce travel for the facilitators and participants from the hospitals for sire visits and centrally conducted activities like trainings. Figure 2: Geographical Overview of Cluster Distribution P a g e 8

The technical consultancy and facilitation support activities for each cluster will be provided through establishment of a Cluster Knowledge Support Center(CSC) which will be located at the nodal district for each cluster. The Cluster Knowledge Support Centers (CSC) will be manned by facilitators who are trained in the NABH standards who will provide consultancy and facilitation support to the cluster members. The CSC will also conduct centralised support through trainings and continuous mentoring support through their online portal and helpline numbers. B. Cluster Knowledge Support Centers (CSC) Based Service Concept The technical consultancy and facilitation support services offered by the project through the CSC to the member hospitals is a composite of several components covering onsite assessments, education and training, knowledge management support etc. An overview of these components is provided in Figure 2. Figure 3: Overview of Cluster Based Services For NABH Accreditation Support In order to optimise effort and costs, the cluster approach provides an opportunity to centralise several activities. These activities will be provided through workshops and group interactions done at the nodal district. P a g e 9

Also the facilitation process for NABH accreditation will have several activities especially periodic assessments and monitoring visits which would require the facilitators to visit the hospital / facility to make these facilitation efforts effective. Hence the facilitators located at each CSC will conduct both these centrailsed and onsite activities according a planned calendar ensuring outreach to all the member hospitals of the pilot. Some of the activities especially knowledge management activities like development and operations of a centralised web based knowledge portal and publications will be centralised through the head quarter office. Overview of these on-site and centralised services planned are provided in Figure 3 given below. Figure 4: Cluster Based Accreditation Onsite and Centrailsed Services Overview C. Detailed Description of Technical Consultancy and Facilitation Support Components I. Onsite Activities & Components Initial Assessment Each enrolled facility will be visited by the consulting and facilitation team from the CSC and an assessment of the facility, statutory & regulatory compliance, current process gaps, level of documentation and man power capacity will be studied. Based on the assessment an Initial Assessment & Gap Analysis report will be submitted to the hospital detailing the actions required to be taken by the hospital for increasing compliance to the accreditation standard requirement. P a g e 10

Facility Type SHCO 50-100 Beds Above 100 Bed No of Person Days 1 2 3 Monitoring & Implementation Visits The facilitators will make on site visits to each hospital in a pre-determined interval to assess the progress of implementation of various processes and action plans based on initial assessment report findings. These visits also in parallel gather insight on the speed of the hospital progress to various stages of accreditation like application and assessment. The number of such visits will be dependent on the size of the hospital Facility Type SHCO 50-100 Beds Above 100 Bed No of visits (One man day each) 2 3 5 Mock Assessment The CSC facilitation team will conduct a mock assessment based on the feedback from periodic implementation visits; to ascertain the readiness and compliance levels to accreditation standards of the hospital. The mock assessment report also will form a final checklist of issues to be resolved and actions to be ensured prior to final assessment visits from NABH assessment team. Facility Type SHCO 50-100 Beds Above 100 Bed Person Days 2 4 6 II. Centrailised Activities and Components Training and Capacity Building The CSC facilitation team will conduct centralised trainings for the selected team members from each enrolled hospitals. The core areas covered in these trainings are; NABH Standards and their implementation Development of Policies & Procedures / Documentation Management Hospital Infection Control Patient Safety Quality / Key Performance Indicators Development & Monitoring Documentation Review and Guidance The CSC team will provide constant guidance and support to the enrolled hospitals for development of various required documents like manuals, policies and procedures. This P a g e 11

will be done through a process of desktop reviewing of documents developed by the hospital teams based on trainings and model documents provided to them. Continuous Support and Helpline Each facility will have an identified facilitator who may be contacted at any time for hand holding and guidance. Apart from the same the project will operate a centralised helpline with dedicated phone number and email id where the enrolled hospitals may call or mail in any queries regarding accreditation process. The project will ensure the hospital is contacted and the queries are clarified within 24 to 48 hours depending on the complexity of the issue Online Resource Centre IMA HBI will develop and maintain an online resource centre portal and each hospital will be provided with login id and passwords for accessing the portal. The portal will contain various resources and applications which will be helpful for the hospital preparing for accreditation like; Models of policies and standard operating procedures Models of various clinical and non-clinical forms Training manuals and materials Model posters and signage designs Information Resources on Infection Control, Patient Safety and Medication Management Accreditation and Quality Improvement Tools Publications IMA HBI will support the efforts of the enrolled hospitals through various publications like periodical new letters, monographs and guidance documents sharing the latest updates and information from NABH, new evidences and practices in the area of healthcare quality and best practices. Figure 5: Summary View of Essential Service Package for Enrolled SHCO / Hospital Essential Technical Consultancy & Facilitation Package IMA-NABH Scheme Services Type of Hospital (Bed Strength) SHCO 50-100 100+ Onsite Services Initial Assessment Visit 1 2 3 Monitoring and Implementation Visits 2 3 5 Mock Assessments 2 4 6 Offsite / Centralised Services Training and Capacity Building Documentation Review & Guidance Continuous Support and Helpline Online Resource Centre Access Publications P a g e 12

Additional Services Services and visits beyond the numbers and days specified in the essential consultancy and facilitation services package will be charged extra separately based on a prepublished rate per visit or man days basis. D. Project and Manpower Organisation I. Project Organisation The pilot will be organised under the aegis and guidance of the IMA Hospital Board of India; who will manage the same on behalf of IMA and plan for national scale up on successful piloting. IMA Kerala has formed a Quality Assurance committee who will monitor and support the program at the district levels through each committee member from the district.\ An executive team will be formed supported by office and administration staff who will manage the day to day activities of the project like hospital enrolments, administration and accounts, management of the technical staff etc. Figure 6: Project Organisational Structure P a g e 13

II. Project Manpower deployment The project manpower requirement is provided as below. The same does not include the IMA members who are assigned as office bearers of the project. Positions Nos Project Executive Office Administration and Accounts Coordinator 1 Technical Team Team Leader / Senior Consultant 1 Consultant / Field Facilitators 10 Office Coordinator Cum Data Entry Staff 1 III. Manpower Sourcing The manpower especially the technical staff may be deployed by IMA directly based on consultancy contracts or may be acquired through a service agreement with a consultancy agency who may be engaged as a project technical partner. E. Technical Support Unit (TSU) Model IMA could opt for the Technical Support Unit model for operationalizing the project and engage services of a qualified consultancy agency that has broad based experience in healthcare quality consultancy and technical support for NABH accreditation. IMA may outsource the technical activities to this firm who will establish a Technical Support Unit for executing the project based on a detailed Service Level Agreement (SLA) based on which payments for services will be released. The Service Level agreement may specify that all the intellectual property rights of consulting products and platforms developed as a part of the project will lie with IMA as the owner of the proposed project. The key roles of the technical partner organisation are; - Establishment of the TSU with 4 Cluster Knowledge Support Units (CSU) at four nodal districts with sufficient staff / manpower - Develop detailed consulting and facilitation methodology and action plans for leading the enrolled cluster hospitals to accreditation status - Develop the knowledge and content products like knowledge portals and guidance documents required for the accreditation facilitation products. P a g e 14

- Execute the various consultancy activities like on-site visits, assessments and training as be pre-agreed schedule with IMA - Ensure sufficient number of trained and qualified Team Leader, Field Facilitators and other staff are available at all the time after due considerations for leave and attrition as per specifications of agreement with IMA - Periodic reporting to IMA Executive Team on project progress, deliverable and status of each enrolled hospital as per format and frequency as specified in agreement with IMA The key advantage of the TSU model are; - Ability to bring in the previous experiences, processes and knowledge of a professional firm who has successful track record for accreditations. - Ensures availability of technical staff like facilitators without investments and efforts on various human resources issues. - Does not require IMA to create a large infrastructure to manage the activities in the pilot phase. - Rapid operationalization of activities and development of project support requirements - Additional support in conceptualisation and modification of the cluster approach and its working during the pilot phase The TSU model also is in alignment with IMA s previous experience of using technical support agencies in its projects like the successful IMAGE project. P a g e 15

Section III Project Operationalization Plan The project will be broadly divided into following phases. Phase I - Project Initialisation Activities Phase II Pilot Initiative of Accreditation of 200 Facilities Phase II Project Learning and Reviews For Scaling-up A. Phase I Project Initialisation Activities Estimated to last 2-3 months Key activities include; - Identification of technical partner and developing an agreement for TSU - Manpower recruitment and training - Development of various consulting and facilitation collaterals online resource center, documentation models, training materials etc - Establishment of Cluster Knowledge Support Center offices is nodal districts - Promotion and enrolment activities B. Phase II Pilot Initiative of Accreditation of 200 Facilities Estimated to last 15 months Key activities include; - Operationalization of CSC. - Initiation of various consultancy activities and deliverables - Development / operationalization of online resource center and helpline C. Phase III Project Learning and Reviews For Scaling-up Estimated to last 2-3 months, and will start post 8-10 months of project operationalization. P a g e 16

- Review of project success ratios based on early accreditation trends - Development of project plans and discussion with various state IMA units for scaling up activities nation wide - Enrolment of additional hospitals as a part of project / scheme P a g e 17

D. Project Activity Timelines Sl No Activities Months 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 1 TSU and CSC Establishment 2 Promotion and Enrolment Activities 3 Rolling out of services 4 Initial Assessment and Training Phase 5 Implementation Monitoring 6 NABH Applications and Mock Audits 7 Assessment Visits and Corrective Actions 9 Accreditations 10 Project Objective reviews 11 Scaling Up Plans 12 End line Review P a g e 18

Section IV Financial Plan and Analysis A. Assumptions For the projections of both expenditure and revenue the enrolled number of fee paying hospitals in the scheme is estimated at 200. Revenues from services beyond the essential consultancy and facilitation services packages has not been considered for the purpose of this financial plan and analysis B. Expenditure Plan Sl.No Activity / Item Quantity Frequency Rate 1 Human Resources 1.1 Amount in INR Team Leader & Sr. Consultant (One Person) 1 15 60,000 900000 1.2 Consultants / Field Facilitators - 10 Nos 10 15 35,000 5250000 1.3 Office Coordinators 2 15 15000 450000 1.4 Staff Welfare Expenses 1 15 3000 45000 1.5 Recruitment / Advertisement Costs 1 4 8000 32000 1.6 Insurance 15 1 1500 22500 Sub- Total 66,99,500.00 2 Infrastructure 2.1 Computers / Laptops 14 1 25,000 350000 2.2 LCD Projectors 4 1 40,000 160000 2.3 Printers 4 1 14,000 56000 2.4 Training Materials - Screen, White Boards Etc 4 1 10,000 40000 2.5 Work Stations 14 1 6,000 84000 Sub- Total 6,90,000.00 3 Travel Costs Sr. Consultant Travel & Per 3.1 Diem 1 15 18,000 270000 3.2 Facilitators Travel and Per Diem 10 15 12,000 1800000 3.3 Misc 1 15 10,000 150000 Sub- Total 22,20,000.00 Office Expenses & Other 4 Costs 4.1 Stationary 1 15 2,500 37500 4.2 Printing and Photocopying 1 15 3,500 52500 P a g e 19

4.3 Website Maintenance & Updating 1 15 5,000 75000 4.4 Telephone / Communication Costs 1 15 15,000 225000 4.5 Training Costs - Refreshments 1 15 10,000 150000 4.6 Office Space Rentals 4 15 10,000 600000 4.7 Training Room Rentals 4 15 10,000 600000 Sub- Total 17,40,000.00 5 Publications & Online Costs 5.1 Website Development Costs 1 1 50,000 50000 5.2 Printing Expenses 1 15 10,000 150000 5.3 Promotional Events Costs 10 1 12,000 120000 Sub- Total 3,20,000.00 Grand Total 1,16,69,500.00 C. Revenue Projections Hospital Size / Category Percentage Numbers Fees in INR Revenue in INR SHCO 40% 80 30,000 2400000 50-100 Beds 40% 80 50,000 4000000 100 + Beds 20% 40 1,00,000 4000000 Total Revenue 1,04,00,000.00 D. Break Even Analysis Particulars Amount in INR Projected Expenditure 1,16,69,500.00 Projected Revenue 1,04,00,000.00 Surplus / Deficit (12,69,500.00) In the current fee structure the project deficit is around Rs. 12.7 Lakhs. However this deficit is without calculation of the services tax which has to be paid on the fee collected. In the current scenario the project will break even only with an increase in the fee rates by around 25-30 % bringing in up to 25 Lakhs more in revenue and ensuring separate service tax is billed and collected on the fee paid to IMA-HBI. P a g e 20

Financial Projection With 30 % increase in Fee Revenue Projection Hospital Size / Category Percentage Numbers Fees Revenue SHCO 40% 80 40,000 3200000 50-100 Beds 40% 80 65,000 5200000 100 + Beds 20% 40 1,30,000 5200000 Total Revenue 1,36,00,000.00 Breakeven Analysis Particulars Amount in INR Projected Expenditure 1,16,69,500.00 Projected Revenue 1,36,00,000.00 Surplus / Deficit 19,30,500.00 P a g e 21

Section V Summary & Conclusions IMA-HBI based on its MoU with NABH proposes to launch a pilot scheme for provision of technical consultancy and facilitation for NABH Pre-accreditation Entry Level Accreditation and aims at enrolling over 200 hospitals across Kerala at the pilot stage. The consultation and facilitation services will be provided in the centralised cluster based approach for reducing the costs of consultancy to the hospitals. IMA-HBI fees are considerably lower than the market rates for technical consultancy support services for NABH accreditation. A Quality Assurance Committee has been formed by the IMA Kerala for leading the proposed scheme and promotional activities have been started at various districts with very positive response to the scheme from the hospital sector. IMA-HBI proposes set up four Cluster Knowledge Service Centres (CSC) located in Thiruvanthapuram, Ernakulam, Thrissur and Kozhikode; covering four regional clusters and these centers will become the focal point for consultancy and facilitation support for the project. These four proposed CSC along with a central unit will form the Technical Support Unit for the project who will report the Executive Team at IMA Head Quarters. The Technical Support Unit may be created by the IMA through own recruitments or out sourced to a competent consultancy agency with requisite knowledge, skill sets and technical capabilities. The model of outsourcing to a competent agency enables a quick start up to the pilot project and also relieves IMA of the burden of day to day management and monitoring of the project. IMA-HBI needs to develop the various systems and process for enrolment of member hospitals and provision of consultancy and facilitation support for accreditation of the hospitals at the earliest. The project will not be financially viable in the currently proposed fee rates and the same needs to be revised about 30 % for each category for the project to become financially feasible. IMA HBI needs to be clear about service tax implications on consultancy fee collected from various hospitals. P a g e 22

Section VI Annexures Annexure I Proposed Structure of relationship between IMA & Selected Technical Support Agency (TSA) A. Level Wise Assignment of Key Roles & Responsibilities for the Project IMA HBI, National Level Conceptualisation and detailing of the scheme and support activities Coordination with NABH on various aspects and support of the scheme Manage nationwide rollout of the scheme in coordination with various state schemes Review and approval of roll out of state specific schemes based on the template provided. Ensure scheme branding and ownership of the scheme contents and products and protecting intellectual property rights of the same. Coordination of the national pilot of the scheme along with Kerala State Branch IMA State Branch - Quality Assurance Committee / IMA HBI Affiliated State Level Nursing Home Boards Implementation of the state specific schemes Conduct of awareness and publicity activities for demand generation among hospitals in the state. Manage the enrolment of the hospital in the schemes including ensuring collection of appropriate professional fee. Coordination of project activities with the TSA / development of in-house teams for implementation of project activities. Manage project finances including fee collection and payments to TSA Ensure monitoring and evaluation of project goals and achievements through monthly reports from TSA and periodic project review meetings. Establish a grievance handling and dispute resolution mechanism to handle potential issues related to technical support between enrolled hospitals / SHCOs and TSA at various stages of projects Technical Support Agency Ensure availability of qualified and trained manpower for the technical support activities and develop a central project management team and various Cluster Knowledge Support Unit at the planned locations. P a g e 23

Undertake proposed technical support activities like onsite visits for initial assessment, monitoring support and mock surveys, trainings and centralised documentation reviews. Develop various consulting and technical support material for the scheme including policy / procedure models, formats, training materials etc and ensuring their availability through an online portal for the enrolled hospitals. Establish a continuous support desk / helpline with dedicated number and email for handling various support requests and clarification from enrolled hospitals and ensure documentation of the nature of the support requested including action taken and time taken for resolution. Ensure availability of equipment required for the project like computers, LCD projectors and other training aides through ownership or rental agreements. Maintain accurate documentation and reports of various activities undertaken including training records and submit the same to QA Committee of state IMA for reviews. Ensure reporting of project activities, progress and issues through submission of weekly and monthly activity reports and through participation in the project review meetings conducted by QA committee of IMA State Branch - Quality Assurance Committee / IMA HBI Affiliated State Level Nursing Home Boards B. Mode of Engagement The TSA will be engaged through an service agreement with a detailed Service Level Agreement defining parameters of services like staff qualifications, specification of various services activities like initial assessment, monitoring visits, mock audits etc, project time lines and definitions and limits of service deficiencies. The agreement will define the terms of engagement on a fee for service basis and specify the scope and time frame for these fee payments to the TSA. The TSA will report to the QA committee of IMA State Branch - Quality Assurance Committee / IMA HBI Affiliated State Level Nursing Home Boards; engaging them and will represent themselves as part of IMA-NABH Technical Support scheme and not as an independent agency through the period of engagement. The following issues will be specified with in the agreement with the TSA in detail to ensure the exclusive rights of IMA-HBI to the programme; Intellectual Property Rights The agreement will specify that the intellectual property rights to the various products and contents developed in course of the scheme implementation is vested with IMA-HBI after the term of the agreement is completed. Confidentiality The agreement will have sufficient clauses to ensure the confidentiality of information that comes into purview of activities undertaken as a part of the scheme belong to IMA and enrolled hospitals. The TSA will ensure P a g e 24

detailed confidentiality agreement with each of its staff members who are deployed for technical support in the project. Arbitration and Jurisdiction limits for legal disputes The agreement will have specific clauses detailing arbitration process and jurisdiction of legal process if initiated by any party C. Monitoring and Evaluation The following records / reports will be ensured by the TSA as evidence for activities and visits undertaken as a part of the scheme and shall be auditable by IMA representatives; Visit Reports shall be maintained for all visits made by the TSA personnel onsite to the enrolled hospitals. The same shall detail the details of visiting technical personnel, details of hospital personnel met, visit timings and summary of activities undertaken. Training Minutes shall be maintained for all training activities undertaken as a part of the scheme and shall contain details and sign of participants along with details of topic, venue, timings and faculty. Other than above the TSA is expected to maintain and share copies of various consulting outputs like reports and technical clarifications provided in an auditable manner for detailed reviews as and when demanded by IMS representatives The following monitoring tools and mechanisms will be used for tracking project timelines and deliverables; Hospital Project Plan A project plan for each enrolled hospital will be developed based on the initial assessment visits and a copy of the same shall be submitted to IMA. Monthly Project Activity Report The TSA will submit a monthly report detailing technical support activities undertaken during the period, an analysis of time schedules against project plan, proposed activity plan for next month, a listing of hospitals where schedule slippages are happening with reasons for delays etc to the IMA. Project Review Meetings A project review meeting will be conducted on a fixed frequency (ideally once a month) by the office bearers of IMA / IMA-HBI associate board to review and guide activities undertaken by the scheme and performance of the TSA. It is expected that an end line project review and lessons learnt workshop will be conducted at the end of the national pilot stage of supporting 200 hospitals in Kerala to streamline activities of the scheme and share experiences nationally for scale up. P a g e 25

D. Complaints and Grievance Process As a large scheme bringing together diverse type of hospitals individually or organisation owned; with services provided by a contracted TSA; IMA will constitute a fair and independent process of handling of grievances and complaints from the enrolled regarding services provided through the scheme. All complaints and grievances will be reviewed and remedial actions instituted by a Grievances Committee headed by a senior IMA functionary well accepted to all stake holders. The chair of the committee will coordinate the process of complaints redressed through coordination with the office bearers of state IMA QA Committee / IMA-HBI associate board and the head of the TSA. Details of all grievances / complaints received and actions taken for redressal will be maintained by the committee and will form one of the basis for evaluation of performance of the appointed TSA. E. Payment Mechanisms for TSA Services Timely and fair settlement of professional fees payable to the TSA will be essential for ensuring continuous technical support for the scheme. Fee for Services Model: The TSA will be paid their technical services for completed / executed services for each enrolled hospital in the scheme by IMA on production of evidence of completion of such services (like initial assessment, training completion, mock audit etc) with endorsement from the hospital through predefined reporting tools. The details and quantum of fee payable of completion of such services for each category of hospitals will be defined in the service agreement between the TSA and IMA. The fee shall be inclusive of various costs incurred by the TSA while performing the services like travel costs, cost of equipment and venue rentals etc. Frequency and Mode of Payment The professional fee will be paid on a monthly basis on submission of a consolidated invoice listing the services completed with details and lists of applicable enrolled hospitals along with evidence of completion. The payment will be released after approval by the technical committee of the scheme. A part payment against invoice in the range of 50-60 % of invoiced payment may be released by the scheme secretariat to ensure fund flows to TSA and timely P a g e 26

payment of salaries to the technical staff employed by the project. The balance may be released with specified time period. The monthly payments will include applicable services taxes for the invoiced professional fee amount. P a g e 27