MAY/JUNE 2004
FEATURE
Wockhardt, excelling behind new quality assurance infrastructure, eyes accreditation
The Indian health care industry is undergoing a period
of transformation, marked by increased competition, a heightened focus on
quality and performance improvement, and the rapid growth of the private
health care sector. Wockhardt Hospitals, Ltd. has already established itself
as one of the leading health care organizations in India, but now, with
help from HMI, Wockhardt’s leadership have set their sights on establishing
a strong reputation internationally.
“Since HMI first began working with Wockhardt to establish new hospitals,
we have been operating with the view that quality management needed to be one
of the key components,” said Dr. Harvey Makadon, HMI vice president for
health systems. “Wockhardt wants to be the first hospital in India to be
accredited by Joint Commission International (JCI), but beyond that, and perhaps
more importantly, the leadership have a real commitment to quality of care and
excellence in customer service.”
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| The Mulund facility staff is using a new health information system to track patient data. |
Wockhardt Heart Hospital in Mulund (Mumbai), which opened
in July 2002, is the scene of the organization’s efforts to gain international
accreditation. HMI and Wockhardt are continuing a process begun in May 2003,
when the partners initiated the development of a Performance Improvement
Plan designed to help create a sustainable quality improvement model for
the hospital that was aligned with the vision and values of Wockhardt. A
Care and Quality Improvement Council made up of representatives from various
areas of the hospital is driving the implementation of the plan. Committees
have been formed to focus on different aspects of quality and patient care,
such as infection control, health information management, patient safety,
and clinical quality performance indicators.
Sharon Kleefield, HMI director of health care quality, said the leadership
of Wockhardt have made considerable progress implementing the Performance Improvement
Plan and its associated committees and project teams. “They are focused
on defining the processes and specific outcome measures for care of patients
as they move throughout the various departmental functions of the hospital,
and on establishing a process for reviewing these processes and measures in
order to address shortcomings in the quality management system.”
It should be emphasized that instituting these measures is about more than
simply imposing a system and playing according to its rules—systemic
changes are, first and foremost, changes in behavior and attitude. Wockhardt
is taking major steps toward empowering its staff to take active roles in the
hospital’s progress, with the Performance Improvement Plan serving merely
as the mechanism to support dialogue about what changes are in order, help
the staff to develop an approach to driving change, and provide a structure
to guide the implementation of changes.
Dr. Lloyd Nazareth, general manager of Wockhardt Heart Hospital, has been a
champion of Wockhardt’s quality improvement efforts since the beginning. “Today’s
Indian health care consumer is more knowledgeable and discerning than ever
before. We believe that in the next decade these consumers will determine the
success or failure of our hospitals,” he said. “Quality will be
the single most important differentiator of our services. Quality and performance
improvement initiatives will also help us to control costs, thereby making
our services as affordable as possible for more people.”
Immediate improvements—and a course
for sustainable progress
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| Nurses play a key role in the quality management efforts at Mulund. |
An HMI team visited the Mulund hospital in January and
came away impressed by the level of enthusiasm and commitment of the Wockhardt
staff. Although the hospital has increased its volume, staff, and clinical
specialties over the past year, it is still small and manageable enough
to allow the leadership to shape hospital practices for the long term. HMI
and Wockhardt see the performance improvement work being undertaken at Mulund
as the model for other Wockhardt hospitals, including facilities in Bangalore
and Kolkata. “We envision a consistent network approach for continuously
improving patient care,” said Kleefield.
HMI is helping Wockhardt to measure its performance improvements—and
the related quality control mechanisms—against the very detailed and
comprehensive standards established by the JCI, the world’s most recognized
international accreditor of hospitals (see sidebar). This process involves
not only understanding the standards and putting these criteria in place in
the hospital, but also communicating new quality management protocols across
the organization, providing appropriate training to enable not only dailyimprovement
but also continuous review, and ensuring that the right outcome indicators
are in place to measure success.
“Using the JCI standards to guide improvements in the Wockhardt hospitals
makes sense, not only because of the immediate progress it allows, but also because
the standards provide a context for ongoing education for the leadership and
staff about how to achieve the highest level of patient care,” said Makadon. “However,
because JCI accreditation is a lengthy process, we have to recognize the value
of prioritizing the different metrics of performance improvement in order to
improve care today. HMI and our colleagues at Wockhardt are continually putting
our heads together to answer some important time-sensitive questions: What needs
to be addressed now? What mechanisms need to be created? Where do gaps exist
in the process?”
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| Quality and safety in the operating room is just one focus of the Care and Quality Improvement Council. |
A committed team effort
For Nazareth and his staff, the first task was to unite the core management
and clinical teams around the goal of building the quality infrastructure.
It’s a time-intensive program that demands a lot from the staff, but
as Nazareth pointed out, this group is now very motivated to make JCI accreditation—and
the benefits of high-quality patient care—a reality. “JCI accreditation
would, first of all, put a stamp of approval on all of our efforts over the
last two years to build an institution that does not compromise on quality,
safety, and ethics,” he said. “We hope to be ready for a mock
drill by the end of the year, and then we should be ready for the actual
accreditation by the middle of 2005. This will mean a lot of work for all
the members of our staff, particularly the core group of 25 Quality Champions
we have trained.”
Over the next few months, the Mulund quality team will be working to establish
patient safety systems in areas like medication, infection control, and emergency
medicine. They are also designing a formal competency assessment system for
all staff, as well as a training program to support ongoing professional development.
A group of Quality Champions will initiate patient education and information
initiatives, and the hospital will continue training all staff in patient relationship
management and customer service skills. “Our medium term goal is to be
recognized as the best provider of quality health care in Mulund by the end
of 2005,” said Nazareth.
Copyright 2004-2005 Harvard Medical International • http://hmiworld.org/
The handbook of the Joint Commission International (JCI) Accreditation program
is thick with detail, with the very fine points of what hospitals should strive
for laid out in the jargon of quality: standards, benchmarks, metrics, compliance.
During a recent visit to HMI, Dr. John Helfrick cut through the bullet points
and explained that JCI accreditation is not only a process for raising the
standard of care provided by hospitals, but also of energizing the people within
them.
“Accreditation is about human nature. There have to be standards, and there
must be people coming around to see that you are meeting them,” said Helfrick,
who consults with organizations about quality improvement for JCI. International
recognition is closely intertwined with obtaining accreditation through the JCI. “JCI’s
mission is to develop and review patient-centered standards that are culturally
adaptable, as well as a process that stimulates improvement.”
The JCI is a division of Joint Commission Resources, the subsidiary of the Joint
Commission on Accreditation of Healthcare Organizations (JCAHO). JCAHO was formed
in 1951 to oversee accreditation of hospitals in the United States, and in 1997
JCI was established with the mission of accrediting hospitals outside the U.S.
American accreditation standards were judged inappropriate internationally, leading
to the creation of an international task force that by 1999 had completed the
first set of standards to guide hospital improvement. To date, the JCI has accredited
55 hospitals in 13 countries.
JCI defines a standard as a statement of expectation that defines the structures
and processes that must be substantially in place in an organization to enhance
the quality of care. Helfrick points out that JCI’s accreditation philosophy
is focused on maximum, not minimum standards. JCI’s goal is not to force
the closure of hospitals that fail to make the grade (JCI is not a regulator),
but rather to identify hospitals that need improvement and help them to develop
strategies for doing so.
JCI’s hospital standards are organized around important functions within
the hospital, and designed to be interpreted (and reviewed by JCI accreditors)
within the culture and legal frameworks of a given country. The standards are
divided into Patient-Centered and Health Care Organization Management standards.
Patient-centered standards measure access to care and continuity of care, patient
and family rights, patient assessment, patient care, and patient and family education.
The hospital itself is judged by its demonstrated commitment to quality improvement
and patient safety, prevention and control of infection, governance and leadership,
facility management and safety, staff qualifications and management, and information
management. Hospital standards are also divided between “core“ or
threshold standards that all organizations must meet to be accredited, and “reach” standards
that guide better practice. During a three to five-day survey process, JCI’s
accreditors assign scores to the hospital in these areas.
Standards, measures, and aggregate scores—but again accreditation depends
on people. “An organization preparing to seek accreditation must be open
and honest about its strengths and weaknesses,” said Helfrick. “Excellence
depends on creating a blameless culture. Too often, individuals are blamed for
errors when the flaw is really in the system. This discourages error reporting,
and therefore contributes to a faulty view of where an organization is and what
it needs to do to improve.”
For more information about JCI accreditation, visit the Joint Commission Resources
website at www.jcrinc.org.