Quality of care in health services has been identified as one of the key elements on the path to Universal Health Coverage (UHC), and fundamental towards achieving the health related goals and targets outlined under the Sustainable Development Goals (SDGs). The importance of QoC towards achieving our goals for better health services and outcomes is increasingly gaining visibility across academia, policy and implementation. For example, recently, the Lancet Global Health Commission on High Quality Health Systems in the SDG Era (HQSS Commission) was set up to generate evidence and provide solutions for quality improvements in the context of low and middle income countries (LMICs). QoC is particularly relevant in the context of LMICs such as India, where the health system is highly privatized, and characterised by high out of pocket expenditure, with enormous challenges of regulation and quality of care. It is a system which continues to face challenges of health financing, infrastructure, and human resources among others.
One of the pathways to improve QoC in any health system, is via the accreditation route. Accreditation has been accepted globally as a regulatory intervention to set standards, and monitor quality of care. The idea behind an accreditation programme is to evaluate a health care organization via self and external assessment, against predetermined optimal standards, to improve and set standards of care. In addition, as countries like India use the insurance route towards achieving universal coverage (the pros and cons of this warrants a separate blog!), it offers an opportunity to use accreditation as a tool to set standards and monitor quality of care at the level of service provision.
The concept of accreditation originated in the United States of America. Over time, the use of accreditation grew more widespread, including in LMICs. There exist national and international standards across sectors, including health. In India, international standards such as those set by the Joint Commission International (JCI) are used by healthcare providers, in parallel to national accreditation systems. At the national level, the National Accreditation Board for Hospitals and Healthcare Providers (NABH) was set up in 2005. It provides accreditation, certification and an empanelment programme, for health care organizations, ranging from large (greater than 100 beds) to small hospitals, imaging centres to blood banks, community health centres, and clinics across the country. The accreditation system evaluates three interrelated components: structure, process and outcome (Donabedian framework) of the hospital services. The NABH accreditation is further accredited by the International Society for Quality in Healthcare (ISQua) – this implies that NABH standards are at par with global standards.
The NABH accreditation system is a graded one, with progressive levels of accreditation starting from pre-entry, to full accreditation. This gives an opportunity for even smaller hospitals to apply for accreditation, and work towards improving quality of care irrespective of size of hospital, and resources.
The standards framed for accreditation cover critical aspects both for organization and patient. For example, standards for quality of care are established for multiple aspects of the patient-provider interaction. QoC norms begin with the entry of patient to the hospital. Standards can encourage the establishment of a well-defined registration, admission process and treatment plan including discharge and referral process. From the perspective of internal management and processes, standards can be used to improve quality of elements such as the management of inventory (such as drugs, supplies). Guidelines can inform the provision standards for a more effective infection prevention and control programme, by setting norms for actions like the formation of a multidisciplinary infection control committee, responsible for regular functioning of infection control practices in the premises such as hand hygiene, safe injection practices, antibiotic policy, regular disposal of waste etc. Effective functioning of a healthcare facility/hospital is an important aspect of the guidelines, and the NABH model sets standards applicable to different types of health facilities. The accreditation system encourages and incentivises an environment of continuous quality improvement, actions including regular monitoring of indicators like incidence of medication errors, mortality rate, patient satisfaction index, employee satisfaction index etc. Accreditation can also be used to impact the health system, for example by setting a basic minimum criteria for the numbers and types of human resources employed in a healthcare facility (based on the size of the facility, utilization and other factors defining the set norms) , as per the health service utilization.
Accreditation as a tool to improve QoC touches multiple aspects of healthcare provision, and indeed the health system. This, in turn, provides a route towards better quality of care on the path to UHC. Accreditation has been recognized as one of the most successful interventions to improve QoC globally. It offers both tangible and non-tangible benefits associated with it. The concept of accreditation, and ensuing recognition of having achieved a level, can motivate a facility to do better, validate a facility’s QoC and therefore attract more patients. Standards can enhance the training and capacity building of staff, thereby increasing the motivation of staff. Patient satisfaction increases due to the improved services like reduction in waiting time for the services received, improved infrastructure, standardization of care. In addition, improving quality of care to match set standards can also be incentivized. For example, the CGHS (Central Government Health Scheme) and ex-servicemen contributory health scheme (ECHS) have made provision to offer more remuneration to hospitals accredited by the NABH.
Integrating accreditation with social health insurance schemes, for example by making it mandatory for empanelled facilities to be accredited, in a country like India, may serve as a route of regulation to improve the quality of services provided. Towards this, there is a close cooperation between the insurance industry and NABH. One can leverage this by empanelling accredited institutions, setting standards for services upon which reimbursements are based, and incorporating other regulatory mechanisms.
Health systems are complex adaptive systems, and strengthening systems is critical for universal health care. At the level of the facility as well, there are various subsystems/departments, changes in one impact another and in turn affect patient care. Hence, accreditation may provide a roadmap to run the various subsystems more effectively. A recent incident in India highlighted the gaps in the health system and its impact at the level of the facility. Over 50 children died as a direct result of the unavailability of oxygen in the hospital. The unavailability of oxygen was the result of failures at multiple levels of the health system, and the outcome tragic. Accreditation could perhaps encourage health facilities, and provide guidance to health facilities to have systems in place which would ensure that such gaps in the delivery of care do not take place. Indeed, following this, the Indian Medical Association recommended the implementation of NABH standards in public hospitals also, so that people can receive a basic minimum quality services at an affordable cost.
At a time when health systems are struggling to provide even basic levels of care, and in low-resource settings like India, accreditation, particularly in phases can provide the framework, the know-how and the motivation for healthcare facilities to improve their quality of care. It can support large-scale insurance schemes to empanel hospitals which have adhered to minimum quality of care standards, and been accredited towards it, thereby providing a mechanism for regulation and monitoring of QoC. Accreditation can also encourage the intrinsic motivation for facilities and personnel towards doing better.