A couple of decades back when corporate healthcare was beginning to take firm hold in the Indian landscape, assumption was that given the high service standards and the charges levied, quality would be a given. Being treated with respect and dignity and next to zero wait times for appointments with doctors and diagnostics were reasons enough for patients to flock to corporate hospitals for even minor ailments that could easily be dealt with by their family physicians at 1/10th of the cost.
BY DR GARIMA SINGH
Almost two decades later, for patients, being treated with respect and dignity is an acknowledged right and they are also better informed about medical conditions and treatment options available to them courtesy the internet. No longer is patronisation acceptable to them. It has, therefore, become imperative for corporate healthcare to differentiate itself by not only high service standards and latest equipment but also by how they deliver demonstrably superior outcomes by structuring end to end solutions for patients with specific conditions (without increasing cost burden).
To remain relevant in the minds of patients, every decade has to be marked with some unique contribution from corporate healthcare providers that impact patients positively. If previous decade was focused on service excellence this decade will be marked by corporate hospitals providing to the industry a unique care delivery model and governance model that directly impacts patient outcomes positively without adding any additional cost. Given the current economy where margins are under immense pressure, it is imperative for solutions to be found that do not increase cost burden yet yield positive impact.
The project report below shall help hospital administrators and leaders (both public and corporate) in structuring their clinical departments to meet their reputational and clinical outcome goals. The project undertaken was to integrate emergency patient care services across a network of hospitals for improved clinical outcomes and operational efficiencies. It is well known that emergency services have the most visible impact on patient outcomes and reflect the quality of care provided by a healthcare institution.
As a network of hospitals this corporate chain leadership expected standardisation of clinical protocols, optimal infrastructure and manpower deployment to be able to save lives and deliver improved clinical outcomes. SIPOC was used as a tool to identify key departments in the value chain and project sponsor and project lead too were identified. One on one discussions were held with all stakeholders and also with renowned international and national authorities in the field of emergency medicine. The outcome of the above discussions was that we needed to fundamentally rethink how we structure and govern ER departments across network of this corporate chain. It was agreed that the world was moving away from single chair concept to an executive group with accountabilities for standardised trainings, credentialing, clinical guidelines and protocols. With approval of the leadership team, first of its kind clinical governance model in India was initiatedthe Central Emergency Services Committee.
This committee was chaired by the Medical Director (senior most clinical administrator of the group). And its permanent members were ER heads of all the network hospitals, nursing head for the group, head of ambulance, head of medical and service quality, head of IT and head of legal. This forum is unique in India and, given the positive results we have seen, it has potential to be replicated in other clinical departments in various corporate chains and also in public sector hospitals where the administrative command is common, for instance, hospitals run by Delhi Govt. This model of governance will benefit our patients and community at large.
The next step after establishing the governance platform was to establish terms of reference and to have them approved by the leadership team. The ER motto, patient expectations and strategic plan were listed and monthly reviews were established. The key focus areas identified by the forum were:
1. Staff: To be trained, qualified, motivated, with appropriate skill and grade mix.
2. Infrastructure: Size, resuscitation areas, vulnerable area, triage, waiting area, reception, staff and patient conveniences, equipment maintenance, consumable stocks.
3. ER processes: Standard protocols for head injury, myocardial infarction, stroke, sepsis, major trauma.
4. Coordinated emergency care throughout the patient care pathway; shared ownership across clinical departments, collaborative approach with specialists and diagnostics.
5. Monitoring and knowledge of outcomes: IT based adverse event reporting, mortality and morbidity reviews, complaint monitoring to highlight individual or system failure.
6. Commitment of senior management to ensure adequate resources (finance, equipment and infrastructure) and active visible management engagement with emergency, leading to empowered and motivated emergency department staff. The initiative was aimed to assure patients of faster and better emergency medical care.
A questionnaire was adapted from IFEM standards to assess the emergency dept on various parameters such as complexity/ acuity of care and emergency footfall, services available. Based on the information gathered, units across the network were accorded levels and commensurate deployment plans were enforced across each network hospital. Uniform credentialing, privileging, hiring norms too were established.
Admission and discharge criteria to and from ER were developed for each unit to ensure that best possible care is provided within the units; also transfer to higher centre protocols were set up to ensure that patients are transferred to an optimal facility for lifethreatening conditions when infrastructure in a particular unit was sub optimal.
Through the high-powered management team representation, resource allocation was ensured and ER dashboard comprising 28 structures, process, outcome measures was reviewed monthly. This rigour in governance and laser sharp focus on emergency services built trust with local communities surrounding the network hospitals. This was evidenced through the feedback received by a third party on behalf of the corporate chain.
TIPS FOR SETTING UP/ REVIEWING CLINICAL DEPARTMENTS TO ENHANCE CLINICAL OUTCOMES
• List the problem pertaining to clinical specialty taking strategic inputs from apex management team and tactical inputs from bottom up.
• List all the stakeholders in the care delivery value chain and seek information from national and international authorities.
• Build a strategic plan and a progress report.
• Link stated goals to organisation goals\ seek apex management approval.
• Gather baseline information.
• Benchmark against world’s best.
• List performance metrics (dashboard)
• Rigorously review the progress report
• Looping back to the apex management team once a quarter
28 structures, process, outcome measures was reviewed monthly. This rigour in governance and laser sharp focus on emergency services built trust with local communities surrounding the network hospitals. This was evidenced through the feedback received by a third party on behalf of the corporate chain.
This innovation in clinical governance has paved the way to meet and surpass expectations of patients when they are in extreme pain or facing life and death situations. In such times, patients need to know they are in safe, empathetic, environment where qualified teams are working in tandem to bring them timely relief and save their lives.
STRATEGIC IMPACT OF THE PROJECT:
• Higher patient satisfaction score.
• Uniform policies and protocols across network leading to medico-legal risk mitigation.
• Improved process measures leading to better outcomes (for instance, door to balloon time for MI patients and door to CT / MRI time for stroke patients).
• Reduction in nursing attrition on account of better work environment and training inputs.
• Greater team integration in ER (nurses, doctors and paramedics).
• Emergency response centre was set up and manned by emergency trained doctors well versed in dispatch protocols to ensure timely advise and dispatch of ambulance with appropriately skilled staff.
• IT enabled real time monitoring patient vitals while in transit
• Seamless pre hospital and in hospital care.
This project has won two national awards and that bears testimony of its potential.