The quality effort included contributions from the HMI team, as well as 35 members of the staff at Wockhardt Heart Hospital.

“Dramatic and documented”: Quality efforts at Wockhardt earn international accreditation

Wockhardt Hospital, Mumbia, has been accredited by Joint Commission International (JCI), only the second health care provider in India to earn this distinction. The recognition comes just two years after HMI and Wockhardt began developing a sustainable quality improvement model for the hospital, as the foundation for network-wide improvements for the Mumbai-based health care organization of Wockhardt Hospitals, Ltd.

Since 2000, HMI has been working with Wockhardt on education and training programs, the development of facilities and clinical programs, and the implementation of operating systems across its hospital network to improve patient care, staff training and development, and quality management. In 2003, the newly opened facility in Mulund provided an opportunity for the partners to implement a program that is expected to serve as the model for performance improvements at Wockhardt’s other hospitals, including facilities in Bangalore and Kolkata.

Lloyd Nazareth, MD, general manager of Wockhardt Heart Hospital, led a core quality team that included representatives from the medical, nursing, and administrative departments at the hospital. This group worked closely with HMI to institute a comprehensive quality improvement plan, establish training in quality management and patient safety, and foster open dialog about how to drive improvements. It was a time-intensive and demanding effort, but as Nazareth pointed out, the group was very motivated to make JCI accreditation—and the benefits of high-quality patient care—a reality.

Elizabeth Brown meets with members of Wockhardt’s nursing staff.

The HMI quality team was led by Sharon Kleefield, PhD, director of health care quality, and included Harvey Makadon, MD, vice president of health systems; Elizabeth Brown, RN, MSN, MBA, director of clinical services; Albert Gillis, RT, MBA, director of health care facilities development; and Ryan Wildes, program coordinator. John Helfrick, DDS, MS, FACD, FICD, who has joined HMI in the role of senior consultant, brought to the effort a rich background in health care quality that includes leadership positions with JCI and numerous quality-related initiatives around the world.

Dr. Lloyd Nazareth

Said Helfrick, “Wockhardt’s JCI accreditation is a remarkable achievement that gives purpose to all of the hard work of the physicians, nurses, administrators, and staff at the hospital. But the process of preparing for accreditation is really more important than the recognition itself. The improvements at Wockhardt in both quality of care and patient safety are dramatic and documented, and we have real-time evidence of the assets of the preparation process.”

Maureen Potter, executive director for international accreditation at JCI, said, “The JCI accreditation standards for hospitals are intended to stimulate continuous, systematic, and organization-wide improvement in daily performance and in the outcomes of patient care. The citizens of India should be proud that Wockhardt is focusing on this most challenging goal—to continuously raise quality to higher levels.”

In October, soon after receiving official notification of Wockhardt’s accreditation by JCI, Dr. Nazareth reflected on the two-year effort in an interview with HMI World.

HMI WORLD: Of all hospitals in the Wockhardt network, why was the heart hospital in Mulund chosen as the one in which this quality program would be pursued?

NAZARETH: The Mulund hospital was commissioned in 2002. Most of the other hospitals in the Wockhardt network at that time were about 10-12 years old. We felt that it would be easier to implement and experiment with new ideas and concepts in a new facility rather than in one of the older facilities.

HMI WORLD: What has been developed and implemented in terms of quality and patient safety?

NAZARETH: Right at the inception we, along with HMI, put a Performance Improvement Plan in place. This was the roadmap on quality and patient safety that would guide us over the next few years. This plan divided all of our activities into structure, process, outcome, and review areas. Along with this we established a training calendar that outlined the mandatory and optional training that every staff member would need to undergo. We established interdisciplinary committees to oversee activities such as infection control, emergency preparedness, information management, pharmacy, and therapeutics.

All of our departments have developed written protocols for all activities. These are proving useful in standardizing care as well as in training new recruits much more rapidly. These protocols will also help standardize practices across our entire network of hospitals.

In the area of safety, we have a safety committee that oversees this activity. We have tried to address many of the national patient safety goals, particularly in the areas of patient identification, medication safety, and operating room safety. We have achieved considerable success in our attempts to reduce medication errors.

HMI WORLD: During the pursuit of quality improvement (and in preparation for the JCI survey) what were some of the obstacles that your team had to overcome to make this work?

NAZARETH: Having a new hospital and an entirely new team to work with ensured that we did not face one of the major challenges that halts a lot of quality improvement work, namely resistance to change. However, the attrition rate in nursing across the country is very high, as many seek employment in the Middle East, Europe, and United States. This meant that we often had to keep retraining nurses.

HMI WORLD: What would you say were some of the keys to the hospital’s success?

NAZARETH: In the beginning we formed a core quality group of about 35 people. This group was composed of all senior, middle, and supervisory management. It was this group that underwent extensive training in quality management. This group took ownership of quality and the JCI standards and worked relentlessly over 18 months to ensure that these standards were complied with across the organization. The outcome of this exercise has been that today we have a large number of “quality champions” in the organization who can actually teach and train others on quality. We have also identified a pool of key professionals who can lead the organization as we expand.

HMI WORLD: Did nurses and other non-physician members of the staff play a role in the quality improvement efforts?

NAZARETH: By nature of the design of the standards, JCI requires that all components of the organization contribute significantly to the accreditation effort. Our nurses and administrative support staff played the major role in ensuring that we got accreditation. In fact, more than 85 percent of the core group driving this effort were from the nursing and administration groups. There are specific standards applicable to nursing and an equal number for other administrative support areas. Of the three JCI auditors [who surveyed our hospital in August], one was a nurse, and the other was a nurse administrator.

HMI WORLD: The monsoons that leveled India in July came just weeks before the JCI survey. How did the hospital respond when the monsoons occurred? Did you witness a notable difference in the way the hospital was able to function that was a result of the quality improvement?

NAZARETH: Most of the city was flooded for three or four days, and our hospital was cut off from the rest of the city. The state power had to be shut down for a period of almost 24 hours. Many hospitals in the city had to evacuate their patients as they did not have adequate backup for such a situation. Our hospital had developed a community disaster management plan and had also conducted a number of drills for the same. These efforts proved useful, as our backup power generators were able to keep the hospital running for the entire period of power shutdown. We also had food, medication, and other supplies to sustain the patients and stranded staff for the days we were isolated. Our hospital also was in a position to accept patients on ventilator support who had to be shifted from centers that did not have adequate backup systems.

HMI WORLD: Accreditation is a wonderful milestone and a tribute to the efforts of everyone at the hospital. How will Wockhardt maintain the momentum of this effort?

NAZARETH: Our greatest challenge will be to hold the gains we have made. We do realize that JCI accreditation is merely the start of the journey. To us quality is not a sprint but a marathon. We are now focusing on service excellence, service recovery, and establishing functional service standards for every department where there is a customer interface. We are also trying to comply with the national patient safety goals declared for 2006 by the Joint Commission on the Accreditation of Healthcare Organizations. Our leadership team is also replicating these initiatives and efforts at our new 350-bed facility due to be launched in Bangalore early next year. A lot of our staff will be supporting their colleagues at that hospital.

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