Accreditation of service hospitals: Time to move towards state of readiness

Dear Editor,

We read with extreme interest the editorial titled ‘Accreditation of Armed Forces hospitals: An imperative now’ by Chatterjee published in Med J Armed Forces India 2017;73:213-215.¹ We compliment the author's effort in highlighting the salient issues for every one of us to realize and ponder.

We partly agree with the author's argument that the service hospitals are not uniform in their practice and standardization of care processes have become diluted over several decades. This may be perceived dilution whereas reality may be different. We have service set ups all across the country. Some are smaller hospitals and few are big enough to cater for few basic specialities. There are quite a few set ups with tertiary care capability too. One of the important components of standardized system is the continuity of care. The hospital administrators have to struggle many times to get a suitable relief during leave of specialists posted. Basic speciality service providers have to leave for training and temporary duty commitments without ensuring continuity of care in their absence due to either partial or no relief at all. Though the provision exists for hiring the services of civil experts, busy clinic and other commitments of these specialists does not allow arrangement of mutually convenient timing and venue. Clientele may prefer to go to nearby private set ups just for the sake of convenience, not because of distrust or personal choice to avoid service hospitals. Unless we ensure complete continuity of care in all our hospitals, implementation of other standards becomes less practical. The base of the care pyramid has to be strong enough. As we agree with the author that there is requirement of integration of multiple specialities and subspecialities, such modernization can only sit on top of a strong and stable base. Too much of sub-speciality oriented approach makes such care availability skewed towards command hospitals or metro cities. Those men and families posted in smaller places are not to be ignored and clear policy to ensure continuity of care should be implemented at all such places. There is a need to change the mindset that ‘cannot leave subspeciality centre unmanned’ to ‘cannot deprive the provision of basic speciality care’ at every service establishment with significant clientele load. This step alone can result in much better patient outcome and improved clientele satisfaction.

Issues surrounding the human resource deployment hinder our efforts to seek full accreditation process. Services are unique with medical and paramedicals trained to work with man power constraints. We are tuned to deliver well even when doctor/patient/nurse ratio being skewed. Our hospitals ensure outcomes comparable to best of the centres in the country, if not more, even with these man power limitations. Unfortunately accreditation agencies do not accept this rationale. Management of medications is another sore area. Enormous amount of paperwork involved, need to strictly adherence to the allotted budget and procurement procedures fatigues the system. Complaints pertaining to medicine availability are unavoidable at every hospital. Fear of raid by the regulating authority despite working honestly for the sake of patient satisfaction does not give room for flexibility in procurement process and ensuring ready availability. No one would wish to be that ‘one man’ which an enquiry can blame squarely. Though the financial powers of the various end user administrators have been enhanced recently, the huge amount of procedural requirements and time-bound channels in procurement makes it prone for adverse observation by the accreditation agencies.

Despite the limitations highlighted above, there is scope for moving towards accreditation readiness. Annual inspection processes can be tweaked to ensure the compliance towards ‘doable’ objective elements of accreditation standards. Ensuring patient safety checklists and educating medical and nursing staff towards safety requirements can be practiced even at the smallest hospital. Adverse drug reaction monitoring can be implemented and studied at every ward. Each sentinel event can be analysed and corrective steps can be implemented. All ‘Look-Alike: Sound-Alike’ medication segregation can be easily ensured. Patient record keeping can be streamlined at every place with minimum effort. Regular internal and out- of- unit satisfaction surveys can give sufficient feedback to improve quality and safety. It would then be possible to ensure incremental improvement in quality and safety which is the crux of accreditation process. These initiatives can help us to switch from ‘failing to keep pace with continual quality improvement’ to measurable improvements in quality and safety enhancement, however small or big the set up may be.

The need of our clientele is quite different compared to those outside the armed forces and our accreditation policy should be targeted towards satisfying their needs. There should be laid down policy guidelines for the expected standards of the hospital for which we can use the template of the practices in vogue modified to the need of services. To ensure compliance of standards we must ensure that the hospital staff should be trained for the required processes and standards of the accreditation agencies. Specific goals for each type of hospital should be predetermined so that the health delivery system relevant locally becomes strengthened with scope for continual quality and safety enhancement.

Reply.

Dear Editor

Appropos the Letter to the Editor on the subject matter. The author(s) of the Letter to the Editor have correctly identified some of the existing challenges for service hospitals to attempt an effort to seek accreditation of the hospitals. However the editorial only provided an overview to the subject of accreditation and its relevance or otherwise to the service hospitals. The article did not attempt to elaborate on the various issues which impact on the various standards for accreditation.

The authors of the Letter to the Editor have raised the challenges of availability of specialists, continuity of care, comparable outcomes of care, management of medication, “raid by regulation authority” and finally moving towards accreditation readiness. The steps highlighted subsequently indicate the need to focus on various parameters of care to achieve readiness for accreditation.

Undoubtedly resources are short and always will be. However that does not deter other government hospitals from seeking accreditation and being accorded the same. For the Armed Forces Medical Services (AFMS) we need a calibrated approach, taking up a few hospitals at a time and addressing the constraints of their resource limitations as the processes and outcomes of those hospitals are measured and improvement cycles are put in place. The same has already been taken up as mentioned in the editorial.

The issue of comparable outcomes is not quite as simple as the authors to the Letter to the Editor presume. An organization like National Accreditation Board for Hospitals and Healthcare Providers (NABH) requires data on both clinical and non-clinical/administrative processes and outcomes across 683 Objective Elements with 70 Indicators. It is certain that no service hospital and that includes hospitals which have undergone the accreditation assessment are yet up to meeting all the criteria and measurements. Hence comparability is only across a very small spectrum of functions. However that does not deny service hospitals the opportunity to seek and be accredited. The philosophy of continual quality growth is based on this principle that when a hospital achieves the accepted score for accreditation it is accorded this status and thereafter it continues to improve across the various scope of functions. The entire process has been made as objective as is currently feasible, in tune with global best practices in accreditation of healthcare organisations.

Moving to a state of readiness is not a goal. Getting accreditation is. Every challenge that will be encountered will need to be addressed, NABH has agreed to certain waivers for the AFMS hospitals and certain scores would not impact severely on our efforts to seek accreditation. Thus the other major stake holders of the AFMS would have to do hand holding as the hospitals cannot do it alone and would have to be in support. The authors of the Letter to the Editor would certainly benefit by going through the standards and objective elements once, and their concerns are very well appreciated.