With the launch of Ayushman Bharat, the landscape of Indian healthcare has seen a shift. The government is leaving no stone unturned to make this scheme a success. In fact, we may also say that the government is working on this in an almost ‘corporatised’ way. Professionalism & innovations, plus timelines and digitalisation are being given huge importance. Most of the ideas and innovations are also mainly taking place keeping PM-JAY in mind. One such innovation that has the capacity to elevate the quality levels of Indian hospitals – both public & private – are the fast track certifications of Gold, Silver & Bronze. The intention is to take quality consciousness to the deepest levels of Indian hospitals. While the work is on at full throttle, will such a move really prove a game-changer? Let us try and find out.
By: Jayata Sharma
So, how did it all start?TheQuality Council of India (QCI) had already started with revamping the NABH Entry-Level Certification for Healthcare Organization (HCO) and Small Healthcare Organization (SHCO). QCI was preparing a new web portal called HOPE – Healthcare Organizations Platform for Entry Level Certification.
At the same time, the office of PM-JAY expressed their interest of launching certifications for entry-level facilities, which had the capacity to seep into the deepest corners of the healthcare system.
Their ideas matched & thus the AB PMJAY Quality Certification technology portal was prepared & the Ayushman Bharat fast Track Certifications were launched, by merging QCI’s already-in-motion activity on the same lines.
3 Levels of Certifications
The certification system consists of three levels – Gold, Silver and Bronze. As the name suggests, the Gold Quality Certification is the highest level of certification. Those hospitals with Joint Commission International (JCI) Gold Standard Certification or the National Accreditation Board for Hospitals and Healthcare Providers (NABH) Full Certification, can apply for Gold Certification. There is no extra cost for this level of certification, under the above circumstances.
The Silver Quality Certification is the second level of certification where those hospitals with National Quality Assurance Standards (NQAS) and NABH Entry – Level certification (HOPE) can directly apply. Again, there is no extra cost for this level of certification, under the above circumstances.
The final level of Certification is the Bronze level of Certification, which the hospitals with no prior certification can choose and apply for. The fee for this level varies from bed size of the hospital – starting from INR 12,500 to INR 30,000 (excluding the 18% GST).
The certification programme is a three-tier system to ensure step-by-step upgradation of empanelled hospitals to improve their quality of services. This certification programme will not only cater the government hospitals empanelled under the Ayushman Bharat Scheme, but will also focus on motivating the smallest of empanelled healthcare providers with no certification to come forward and apply for the Bronze Quality Certification, which is specially designed keeping in mind these healthcare providers.
There is no cap on locations or type of facilities, hospitals in every location in India can apply for these certifications.
A Fully Digital Initiative
It seems the days when ‘Sarkari’ works in India used to dread us, maybe left behind soon. With the Digital India initiative, plus an overall revamp of our working systems, India is becoming more and more technology-enabled. Taking a cue from this, the certification process has also been made completely digitised. End to end. With minimal manual intervention required. This has also ensured transparency in the certification process.
The whole process of quality assessment is carried out on a technology platform consisting of a Web Portal and an Assessor Mobile App. All the standards developed are objectively presented as questions for hospitals to answer online.
The assessment is done in two phases – (i) Desktop Assessment, where hospitals’ self-attested documents are verified online and upon successfully completing it, (ii) an Onsite Assessment takes place. Here, an Assessor visits the hospital and collects the required information through a mobile app developed for this purpose.
You apply digitally, pay digitally, you get assessed digitally. Desktop assessment happens digitally, even the certificate is given digitally. When hospitals request for a hard copy of the certification, QCI provides that. The only component which is missing is when the accreditation committee shows the entire format and the report, although over a platform, but they are still not able to do it remotely. The target is that over a period of time, every accreditation member sitting at their own place can take a decision and submit their decision on the portal itself.
So, how did the government build a robust IT system for this? Initially, the government did all the experimentation with various projects in the PPID structure, which was Project Planning and Implementation Division, when the Swachha Bharat campaign was ongoing. Once it succeeded, they started expanding to reports. Initially, their pilot was in the Swachha programs, since it succeeded, QCI did it in NABL, National Accreditation Board for Certification Bodies (NABCB) and now it is being done in NABH.
In a chat with Dr. RP Singh, Secretary General, QCI, we find out more on this initiative.
You are the brainchild behind these certifications. What was the idea?
One of the major criticisms that we used to get is that accreditation takes a lot of time. So, firstly, we wanted to address this. The new certifications will take about 25-35 days, as opposed to 6-8 months for normal accreditations.
Secondly, the initial thinking has been that accreditations are a voluntary system and the government has not really mandated it. Hence, the idea was also to handhold these people so that they can go on a quality journey. Plus, we have attached incentives to these certifications; so, more people have started applying.
Thirdly, things have changed recently with the Insurance Regulatory and Development Authority of India’s (IRDAI) proposal that for any cashless transaction in a hospital, they will have to get NABH certification. This is when National Health Authority (NHA) came up with these fast-track certifications.
One important thing to highlight is the transparency level here. Any kind of assessment that QCI runs, is totally transparent and we don’t give power to the assessors. The inspector raj that was prevalent in India was because there was lot of power in the hands of the assessor. Now, we have a changed scenario. We have technically-competent people going for assessment and they only collect evidences, the final decision takes place at the backend.
Your target is to certify 7000 hospitals. Work is going as per plan?
We have the capacity to certify about 200 hospitals every day. So, the speed and systems on our end is not the issue. What is hampering the speed is the readiness of the hospital to go through this process, which will and is taking time. Our capacity is much higher than what the funnel is. So, when the funnel is totally populated, then we would be able to do more, turnaround time will be much faster. In fact, we are working with the hospitals to improve their readiness quotient & move it faster.
Industry Speaks: Dr. Sangita Reddy, Joint Managing Director, Apollo Hospitals Enterprise Ltd.
The National Health Authority’s initiative to certify PM-JAY empanelled hospitals based on quality standards is indeed a laudatory step to ensure high quality of care and patient safety. This step of the government will serve to improve patient confidence in the care provided at hospitals that are part of the Ayushman Bharat network. Very often quality does come at a price. However, if one looks at the overall health and wellness status of an individual, high quality care ends up being cheaper in the long run because it will have minimal side effects. The move will also motivate empanelled hospitals to focus on continuous improvement in quality of care provided as well as facilities and infrastructure. With over 18000 hospitals empanelled to date, the certification will allow segmenting of hospitals based on the quality of healthcare, and increase transparency for the patients.
What are the other challenges?
The biggest problem that we are facing is that there are lot of statutory compliances. Most of the hospitals are not able to complete these statutory compliances because many regulators are also involved, like fire safety, biomedical waste, and more. All these are needed to get the certification.
And for obvious reasons, we cannot undermine or move past without these regulations in place, it will jeopardise the safety of patients and the hospital.
Doctors are also generally not very technology savvy, so it has been a major challenge to make them understand and bring a change in their mindset to adopt technology and speed things up.
In the public sector hospitals, one big problem is of human resources; nursing staff for example. In the ICU, there is a requirement of suppose 2-3 nurses per bed, with just 8 hours of duty for each. Now, most of the hospitals do not have this compliance. So, they apply with the vision that they would be able to complete the process of recruiting people till the certification happens, but they are not able to do so. Therefore, in the public sector there are only about 10% of hospitals, which have been accredited, whereas other 90% is from the private sector.
| AB-PMJAY Quality Certified Hospitals as on 14th November, 2019|
6 hospitals have been AB PMJAY Gold Quality certified
Apollo Hospitals International Ltd, Gujarat
N. Mehta Institute of Cardiology Research Centre, Gujarat
Cygnus Superspeciality Hospital, Haryana
Government CLSC Spine Institute Physiotherapy, Gujarat
Sanjiv Bansal Cygnus Hospital, Haryana
Kashyap Memorial Eye Hospital, Jharkhand
VK Neurocare and Trauma Research Hospital, Haryana
2 hospitals have been AB PMJAY Silver Quality certified
MGM Hospital and Research Centre, Madhya Pradesh
SKR Hospitals & Trauma Centre Pvt. Ltd.
Few hospitals have applied for AB PMJAY Bronze Quality Certification, but not yet certified.
How did you achieve time reduction on overall accreditations?
We have removed the pre-assessment, which directly reduces about 6 months. Pre-assessment was required earlier, when people were not familiar with the concepts of certifications and accreditations. However, now you usually have quality managers or similar people in your own hospital system who have worked earlier on accreditations and can guide internally.
Plus, the desktop review can also be done by the hospital’s own office staff. That is how we have squeezed the time limit. Plus, we have strict deadlines for our own selves, to give the certification within 45 days. So, 45 days is what we aim for as far as entry level certification is concerned, 90 days is what we aim for full accreditation. This has been replicated in the fast-track certifications too.
Once you reduce the man day efforts, the cost of accreditation on the hospital automatically comes down.
Do you foresee the fees getting increased in the future?
We don’t have to increase the fees; all this innovation is taking place to decrease the fees while ensuring quality.
Industry Speaks: Shobha Mishra Ghosh, Asst. Secretary General, FICCI
Ayushman Bharat is set to transform India’s healthcare landscape by moving closer to target of Universal Health Coverage and SDG3. The government has fast-tracked various initiatives aimed at achieving these targets including enhancing the quality of services through standardisation and accreditation. Over 18,000 hospitals empanelled under PMJAY include several hospitals that have no accreditation. NHA has made a significant stride by framing bronze, silver and gold accreditation ratings with QCI. This will help ensure a minimum level of quality, ability to stratify providers and empower beneficiaries to gauge the level of facilities available in different empanelled hospitals. Further, ratings should be coupled with optimal payment models and viable reimbursement rates to incentivise quality, efficiency and clinical outcomes.
The Kayakalp Initiative
It is a scheme launched by Union Ministry of Health and Family Welfare to encourage and incentivise health facilities in the country to keep the facilities clean and hygienic. The purpose of this initiative is to appreciate and recognise the healthcare organisations’ effort in creating a healthy environment. It promotes cleanliness, hygiene and infection control, creates and share sustainable practices related to improved cleanliness in health care facilities linked to positive health outcomes.
Performance parameters to be assessed
- Hospital/Facility Upkeep
- Sanitation and Hygiene
- Waste Management
- Infection Control
- Support Services
- Hygiene Promotion
Interested HCO/SHCOs can apply for Kayakalp while registering themselves on HOPE portal. A certificate will be issued by the Ministry of Health and Family Welfare to all the compliant health care facilities.
“We will provide 10% more on base rates to Silver category hospitals and 15% above the base rate to Gold accredited hospitals”
Dr. Arun Gupta, Executive Director, National Health Authority (NHA), in conversation with Health Biz Insight, on Ayushman Bharat’s Fast-Track certifications
What was the philosophy behind launching Ayushman Bharat’s fast-track certifications?
NABH has been in existence since almost a decade and we have not even touched a 4-figure number in accredited hospitals. Entry-level NABH certifications are also just around 3,000.
Now, when we launched Ayushman Bharat, we defined the packages, the service providers, the patient categories. The next logical step was to define quality.
One parameter is to check outcomes, but that is a lengthier process. So, we decided to have defined quality inputs. Which can be achieved by accreditations; the current numbers of which, are low.
We have about 18,000 hospitals empanelled with us right now in PM-JAY. In a best-case scenario too, if we assume all accredited hospitals have come under our umbrella, we still only have 16% certified hospitals. Hence, we wanted to diffuse the mystery on accreditations and bring a simplified version of it. This is when we approached QCI, which was making the HOPE portal at that time, which matched with our thought process and thus we joined hands on it.
What are the direct benefits to hospitals?
Better patient safety, good outcomes, goodwill, patient trust, more footfalls. On an instant basis, we will provide 10% more on base rates to Silver category hospitals and 15% above the base rate to Gold accredited hospitals. So, if a hospital bills us for 1 crore, they will directly get 10-15 lakh additional by us.
How was the process simplified?
We sat together with the people who have worked on the field, on the floor level. After which we formulated simple processes with even more simplified language. So that people feel emboldened to go for it. We have also uploaded the entire guideline on the website.
Especially for the Bronze category, we have made the guidelines even simpler. Once they get Bronze, then they may be encouraged to achieved Silver & Gold too.
Industry Speaks: Dr. Suganthi Iyer, Dy. Director, PD Hinduja Hospital & Research Centre, Sr. Medico Legal Consultant & NABH Assessor
It will help in the journey towards quality, attainment of a level of good healthcare delivery to patients, ensure safety of patients and maintain perseverance of quality healthcare. In addition, citizens have a fundamental right to good health, AB PM-JAY is helping to deliver good healthcare to all in smaller towns and peripheral areas too, which was difficult earlier. Even small healthcare organisations can start journey towards quality healthcare delivery with this initiative.
After feedbacks from the sector, some changes in the Health Benefit Packages were made. How was it done?
Health benefit package (HBP) was designed and given to NHA to fuse it with Ayushman Bharat and roll it out. Immediately feedbacks started coming in – mainly highlighting that the terminology is not consistent, rates are not favourable, etc. There was a dissatisfaction among the industry & people were taking it as a reason to not empanel with PM-JAY.
So, that is when we started working on removing the aberrations. For instance, in some cases, the cost of the implant itself was more than the package for the whole procedure.
We wanted to create a workflow for this. That’s when we approached the Department of Health Research, which has been undertaking a study on Costing in Health since 2017. They already had the data of public hospitals, which we acquired. It was a speciality-wise costing data.
We also did many meetings with various specialist committees, wherein we showed them comparative data and rates of various schemes like CGHS or any state scheme as compared to Ayushman Bharat. There were reasons asked, some changes suggested, which we incorporated and finally a costing method could be derived.
Oncology is also a huge issue in India. For which, we looked at 4 major sets – paediatric cancer, surgical oncology, medical oncology & radiation oncology. Tata Memorial Hospital was the best facility for data on this & thus we signed an MoU with them to undertake costing for these. They worked on it with the help of the National Cancer Grid.
After all this, we were able to cover costing for more than 1000 packages out of 1352. We also met individual specialists to do more work on the costs. Additionally, we arranged a national-level meeting with all states, after sending them the revised costing. After which the review committee okayd and finally the governing board passed it, which is finally the HBP 2.0 that is currently in practice.
“We had done the 1st Gold Certification Desktop Assessment in front of the media”
An insight into the quality focus of Ayushman Bharat’s fast-track certifications with Dr. JL Meena, General Manger, Hospital Networking & Quality Assurance, National Health Authority (NHA), Ayushman Bharat – Pradhan Mantri Jan Arogya Yojana (AB-PMJAY)
How have the quality standards improved in Indian healthcare?
I have been working in quality since 2002, when I was in Gujarat. We did it on a very small scale, with the Reproductive & Child Health (RCH) quality standards. Then in 2007, NABH came in and Gujarat was the 1st state to adopt NABH.
Earlier, there used to be a huge scare about these standards. However, slowly, as public and private, both hospitals started getting accreditations, the industry started adopting quality in a much better way.
Then there was no stopping. We started NQA certification, NABH entry-level certification, nursing assessments. We took in medical colleges too (though could not take them directly in NABH), so we started accrediting their blood banks, their labs under NABL. Even separate certifications were started for radiology set-ups. We also designed certifications for PHCs, for which QCI framed a different set of standards.
Tell us about your role in Ayushman Bharat’s fast-track certifications.
The initiatives we had implemented in Gujarat, we had to sort of replicate them under Ayushman Bharat. Though with few key areas – like the PM-JAY certifications had to be strictly time-bound, with focus on self-assessment, and stress on cultivating a culture of quality.
Plus, we wanted to formulate a certification process with no language barrier or extra complications. Because, we had seen that the implementation team at hospitals also comprise of lower level staff, which is usually not adept in English or complicated communication.
Also, evidence-based process with pictures and data was key. We have kept the entire process extremely simple and I had also uploaded the process video on You Tube, which has been viewed by 171 countries till date.
How important is inculcating quality as a culture in any organisation?
Very important. Quality has to always be imbibed in the culture and has to come from the heart. In my earlier works in Gujarat, we had created a system of monthly quality assessment (from 3rd parties) for hospitals, by creating a set of 20 questions. Now, we did doubt if the answers of all these questions have been filled in accurately or not. However, this exercise at least ensured that people have in mind that a quality assessment is to happen. Then slowly, this forms the culture of an organisation.
The next step is appreciation. Punishment will rarely result in pure quality.
For this, we started giving appreciation certificates to accredited hospitals at national level workshops conducted by QCI & NABH. Then we realised that not many people are able to achieved NABH. So, we also starting appreciating people at the Kayakalp initiative level (check above for Kayakalp).
We also started giving out appreciation certificates on the occasions of 15th August & 26th January, which ensured maximum visibility to the accredited hospital/organisation, which further helped improve numbers of certified facilities plus morally boosted the already-certified ones.
There is an increased focus on self-assessment of quality.
Yes. I think self-assessment is the best kind there is. As you know your strength and weaknesses, you can do a SWOT analysis yourself in the best way for improvement.
Are you also planning any surprise checks on hospitals?
Yes. Though our first focus is that industry gets sensitised on this. Post which, we do plan surprise checks. Having said that, our process has been made very robust, and mostly any such surveillance may not be needed. However, we will undertake such checks if we find anything amiss or someone raises a concern.
In fact, recently at one hospital, we did send our team to cross-check a certain flagged issue.
What are you doing to increase awareness?
We have already conducted more than 20 awareness workshops across India. Plus, we are planning regional workshops with hospitals. Along with this, we are also targeting and tying-up with organisations like FICCI, CII, FOGSI, consultancy firms, and more. We have plans to reach through various industry events as well.
How has been the response to this initiative?
We have seen more positive response than we had anticipated. When the first Gold certificate was given, the entire national and many international media covered it. In fact, to show the transparency levels, we had done the 1st Gold certification desktop assessment in front of the media. Additionally, our core implementation team has been very prompt and, on their toes, which helped us a lot.
The core implementation team members: Ankita Garg, Project Manager, QCI; Ridhima Madaan, Project Manager, QCI; Sukhdeep Kaur, Consultant, NHA; and Aman Kaher, Product Manager, NHA.
Summing it up
India is advancing, and healthcare advances at double the speed. In this day and age, it is vital to not compromise on quality of a service, which is the lifeline of any nation. The new-age certifications are surely targeting high quality healthcare services with reduced timelines, and such an initiative, if implemented well, can definitely be a game changer in India’s healthcare sector.
Support for Hospitals: In case of any support or issues, hospitals can raise the ticket on https://support.pmjay.gov.in/ or mail the issue on firstname.lastname@example.org. They can also call on NHA’s toll free number 14555/1800111565
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