Details for Reform Option "Quality Improvement in Government Hospitals, Himachal Pradesh"
Low management capacities at health facilities, lack of policies and guidelines from the State, as well as structural problems of the centralised health system are key problems of the Public Health Sector leading to inefficient use of scarce resources and deficiencies in the quality of services provided.
With decentralisation and planned increase in hospital autonomy arise the need for a well-functioning management system in public hospitals. Furthermore, the establishment of Aspatal Kalyan Samities (AKS), or Hospital Management Societies, which generate their own income by levying user charges, makes improvement of services provided in these hospitals a must.
In mid-2002, a quality improvement initiative was started in one Pilot Hospital of Himachal Pradesh in Una district. In late 2003 this initiative was extended to 4 other Pilot Hospitals (Bilaspur, Rohru, Palampur, Ghumarwin). In these 5 Pilot Hospitals an initial basic assessment was conducted by a trained International Standard Officer (ISO) auditor from Germany and an Indian expert in hospital management.
After the assessment, a planning workshop was conducted with participation of hospital staff. The findings of the Basic Assessment were presented to the staff, based on which Quality Circles (QCs) were formed for systematic quality improvement in different areas—Infection Control and Hygiene, Sanitation and Waste Management, Out Patient Department (OPD), In Patient Department (IPD), Surgical Care, Documentation, etc. The Quality Circles were supported to prepare action plans for removing weaknesses identified during the basic assessment and to gradually improve their respective working area.
A Quality Core Group (QCG), consisting of the Hospital in-charge, a Doctor, the Matron and representatives of different professional groups within the hospital, was formed to coordinate and support the activities of QCs. A Quality Representative, who received specific training in Quality Management (QM), was appointed to mediate between QCs and the QCG and to do a close follow-up of the work of QCs.
Though proper evaluation of the QC has not been carried out yet, it definitely has helped in developing standards for hospital maintenance. So far 25 self-assessments and 13 peer reviews have been carried out which are yet to be analysed.
But work of QCs has shown that a considerable part of the problems identified during the basic assessment was solved by the QCs.
Expenses are met from the revenue collected through user charges.
Zonal Hospitals in Una, Bilaspur, Rohru, Palampur, Ghumarwin in 2002-2003.
Approximately one year.
Trouble shooting: Hospital staff is encouraged to contribute to problem solving and process improvement within their hospital, instead of waiting for problems to be solved by the higher level authorities.
Structural gaps: Identification of structural problems that hinder quality management and have to be solved with support from the State.
Lack of resources: The scarcity of resources limits quality improvement activities, especially with regard to infrastructure and equipment. The high patient load and the overburdening of staff in some of the Hospitals limit their capacity and willingness to do “extra work” for QM.
Frequent transfers: Trained staff is withdrawn and new staff has to be trained. Therefore, frequent transfer of staff creates an unstable working environment which is not conducive to QM.
Lack of incentives: either negative or positive within the government setting leads to low motivation of some of the hospital staff to improve quality of services.
A prerequisite for the QM initiative to be successful is the willingness of higher authorities to provide support to the Hospitals (e.g. in form of financial support and training).
Hospitals should dispose of some funds to finance QI activities either through State budget or AKS funds.
Training on QM has to be provided to key staff within the Hospitals and in the Directorate.
Time needed to work on QI should be given to the staff without expecting staff to work outside working hours.
Who needs to be consulted
State government authorities. It may require the approval from the state cabinet for the Hospital Standards.
Sustainable if the central authorities keep supporting the initiative and if hospital staff receives necessary training and support.
Chances of Replication
In 2003 the counterpart decided to include all public hospitals that have a Hospital Society in the Quality Management initiative. QI activities could also be started in primary and community health centres.
Identifying areas for improvement and developing solutions for identified problems empower the staff to contribute to the continuous improvement of their working environment. Nevertheless, for solving very complex or structural problems and for continuously improving key processes within the hospital, further technical support and training are needed.
Dr. Anuradha Davey, Research Consultant, National Institute of Medical Statistics, June 2006.