Healthcare organizations are looking at it in this way which is not an encouraging sign for the healthcare industry: Dr Clive Fernandes, Group Clinical Director, Wockhardt Group Hospitals
What is more important for you as a customer in healthcare – Quality of services or Accreditation of the organization? If I asked this question to anyone who is a customer of healthcare services, no prizes for guessing what most of them would answer. Obviously they all would answer Quality. For most the term accreditation in itself would invite a curious look as to what is this?
As per the Oxford dictionary Conundrum means, a confusing and difficult problem or question. How has the healthcare industry reached the crossroad wherein we have to choose between quality and accreditation as these were supposed to go hand in hand? The very existence of one meant the existence of the other, at least that’s the way it was envisaged. Today why is it that wherein the normal customer or staff is looking for quality of services the leadership’s main focus is accreditation as they feel that would entail quality?
A few important points for us to ponder over include –
1. Different perceptions of the outcome developing over a period of time – The outcome of Quality in healthcare when introduced was supposed to be the better patient clinical outcomes and safe patient care, accreditation was just validation by a third party of the same, in short accreditation was designed to complement quality processes. So how come we have reached the crossroad wherein we have to decide either one of them? Quality in healthcare when introduced created a positive hype for all stakeholders for different reasons. The ground level staff were excited about this new process as it sounded exciting; they got to learn some new processes like patient identification before certain things, evidence based hand hygiene protocols, practicing bundles to prevent infections i.e. VAP prevention bundle, the UTI prevention bundle to name a few, a few jargons like patient safety and checklists. The accreditation survey, when introduced was a great motivator as a third party was validating and actually certifying that safe and good practices were being followed in the organization. Top leadership introduced quality and accreditation in their organization to improve patient safety but also saw this as an opportunity to improve top-lines and revenues, nothing wrong with either expectation but then the goal post kept moving and has changed today. The very same staff perceive quality and accreditation today as more work and nuisance value and leadership perceives it as a hit to the organizations revenues. So how over a period of time did perceptions change? When the process of quality in healthcare was defined it simply meant doing the right things 365*24*7 even when no one is looking. Different tools like forms, checklists, evidence based practices were devised and practiced to ensure no step is forgotten and things are done the way defined. These forms and checklists were never accreditation requirements but good practices hence organizations started adopting them. Then came the phase wherein somehow “more is better and much more is much better” became the perception. So forms and checklists got bigger and bulkier, not safer. The goal post shifted and these forms were filled to satisfy the auditors rather than make care safer which meant filling them only during the days of the audit or when there are internal audits, making quality look the villain as filling bigger forms and checklists definitely means more work specially when it’s done selectively for a specific time period which coincided with the organizations accreditation survey.
2. Birth of a new syndrome in healthcare – Yes you read it correctly, as things moved on and awareness on quality improved every organization introduced a quality department staffed as per the size of the organization. A great step as re-enforcers to a new process are necessary. The job of this department was to train and guide staff on how to do their regular job in a safer way following these newly discovered quality tools like bundles and checklists etc. How to understand processes based on data of actual practice and make changes for improvement. But what happened over a period of time “Quality” became an “Accreditation” requirement only to be done by the quality department when the surveys happened hence the birth of the latest syndrome in healthcare “- It’s the quality department’s job syndrome”. How very strange? We suddenly need a department to do our job for us properly??
3. Data is King or is it King: Another conundrum – Peter Drucker a very renowned name in Management circles has very aptly said – “What gets measured, gets managed”. How very true and the same would apply to healthcare too. Here comes the conundrum again for organizations. They started collecting data on defined processes to improve their quality as required. Prudence or common sense would say if the data is showing the need for improvement in the process that’s what you do. But improving a process means changing people’s behaviour and mind set, not something impossible but would require a lot of time as well as courage as some tough calls would need to be taken for people not complying. Why I say tough calls is because many a time the non-complying group of associates who just don’t want to change their behaviour are the Physicians and some of the big names who are the top revenue earners. Make no mistake, at no point of time I am saying Physicians are resistant to change what I am saying is many a times they are not told why they need to change behaviour and do things differently, and when they are told most of the time they are told to change behaviour because the accreditation standard requires so, not because it would mean a safer outcome for the patient, resulting in generating more resistance to the desired change. So what to do next as accreditation requires data to showcase improvement? So the best way forward is to show data with near cent per cent compliance with processes during the survey. Good data means little or no questions asked, and that’s what is happening in many places without organizations realising they are fooling no one but themselves. However, in this process they have managed to convince associates and staff that they are more interested in accreditation rather than improving processes hence the conundrum.
4. Advertising / Showcasing – Has anyone ever come out on stage and said that they have brushed their teeth today? Obviously not this is a basic hygiene requirement for one’s own self. I have been to many a place to have a meal, I have never see the restaurant displaying a sign that food is cooked hygienically or they use fresh vegetables or food is safe to eat. Then I seem to think why do hospitals proudly display their accreditation certificate in LinkedIn and Facebook posts? Well there is nothing bad in celebrating success, but is it really that?? Is it to say we are a safe organization? Isn’t that what they should be in the first place, accreditation or no accreditation considering we are talking about healthcare? If that was the case why display once accredited every three years, as they are supposed to be safe 365*24*7? I am not against any organization that displays their accreditation provided they walk the talk. It is more of a self- introspection for organizations.
5. Cost of bad Quality never quantified – Quality the way it is currently being practiced in most organizations i.e. mainly only during the accreditation survey days, adds no value to the balance sheet as is being evidenced by healthcare leaders. There are no long term gains, how can there be when processes are practiced only to please auditors when they come to survey the organization rather than improve processes. In this era where every organization wants to rationalise cost, in layman terms called of cost cutting no prizes for guessing why quality processes are hit first (like maintaining desirable staff ratios, like a nurse patient ratio of 1:5 for general wards or getting clinical pharmacist 24/7). It is so because these are perceived as adding to the cost with no visible benefits because they are proactive processes which prevent harm. Since there is no harm, the cost of bad quality has never been quantified. Bad quality in healthcare would mean something like causing an unwanted infection thus prolonging the stay of the patient (that is an increased cost to the patient/ organization), loss of limb or at times loss of life (value never quantified even financially leave alone the mental trauma to the affected as well as the reputational risks and last but not least the litigation risks and its cost). Health care leaders who understand the value of bad quality will never ever think of rationalising these costs, no matter how tight the budget and cash inflows are, the important question is how many leaders understand this and want to bite the “cost of quality” bullet knowing that the benefits in the long run are immense both for the balance sheet as well as for the reputation of the organization.
The introduction of Quality processes in healthcare has made healthcare safer. There are various bodies like WHO, CDC, NAHQ to name a few which would have tons of data on their websites on how healthcare has benefitted by these processes. Accreditation as a validation methodology by a third party came into being to measure performance on stated parameters before certifying the organization as compliant. It was never an “either quality or accreditation” situation. There never was a choice between quality and accreditation. But today many healthcare organizations are looking at it in this way which is not an encouraging sign for the healthcare industry. It is time for Healthcare leaders to set the tone and the tone has to simply be, deliverance of quality 365*24*7 in all that we do. Accreditation will happen automatically.
by Dr Clive Fernandes,
Group Clinical Director, Wockhardt Group Hospitals |
Consultant at Joint commission International | Expert at ISQua
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