Quality Accreditation In Hospitals Leaders of quality assurance programmes must be able to generate interest and commitment without burdening clinical and administrative staff with an activity they neither understand nor believe in
Hospital accreditation has been defined as 'A self-assessment and external peer assessment process used by healthcare organisations to accurately assess their level of performance in relation to established standards and to implement ways to continuously improve'. Hospital quality assurance systems are operational control systems intended to fulfill specific expectations for treating patients. Clinicians have customarily enjoyed a great deal of autonomy in their practices. The mechanisms for monitoring and assuring quality of the care provided have tended to be based on internal peer review. Time, however, has torn away much of the curtain of professional mystique. The changing healthcare environment with revised hospital accreditation guidelines have sharpened the clinical and administrative hospital staff's concern for evaluating the quality of care they provide. Clinicians now see accreditation standards as a framework by which organisational processes will be improved and their patients are better cared for. Physicians and administrators now must face the challenge of establishing comprehensive and vigorous systems of quality assurance and learn to avoid the traps that impede implementation of such systems. Quality assurance is a very simple process that deals with finding problems and fixing them. A comprehensive definition of quality health care would be 'The optimal achievable result for each patient, the avoidance of physician-induced (iatrogenic) complications, and attention to patient and family needs in a manner that is both cost effective and reasonably documented'. Importance of Accreditation In Hospitals Accredited hospitals offer higher quality of care to their patients. Accreditation also provides a competitive advantage in the healthcare industry and strengthens community confidence in the quality and safety of care, treatment and services. Overall it improves risk management and risk reduction and helps organise and strengthen patient safety efforts and creates a culture of patient safety. Not only does it enhance recruitment and staff education and development, but it also assesses all aspects of management and provides education on good practices to improve business operations. International accreditation like JCI creates a mark on the world map and increases business through medical tourism. Few Quality Accreditation Programmes for Hospitals There are several quality accreditation standards. However, few that are common to hospitals are Joint Commission International (JCI) , National Accreditation Board for Hospitals (NABH), ISO 9001-2000, Malcolm Baldridge etc. The most common ones being ISO and NABH. Other ones being departmental specific like NABL etc. Difference Between the Accreditation Standards ISO is more process driven and is better for back-end departments like Accounts, HRD etc, while NABH and JCI are clinically oriented standards to directly impact patient care. Accreditation Standards (NABH and JCI): Patient Centered Standards (Functions related to providing patient care)
Healthcare Organisation and Management Standards: (Functions related to providing a safe, effective and well-managed organisation)
The Accreditation Process Begin with accreditation process by education: Educate the leaders and the managers and explain the benefits, advantages, process, timeline, etc. of the accreditation. Baseline Assessment: Use knowledgeable and credible evaluators (either internal or external consultants) (PRAXIS takes on consulting assignments for accreditation process) who will critically and objectively assess each area and conduct a detailed baseline assessment of the organisation's current adherence to the standards and each measurable element. Score as Met, Partially Met, or Not Met and cite specific findings and recommendations. Also collect and analyse baseline quality data as required by the quality monitoring standards e.g. medication errors, hospital-associated infection rates, antibiotic usage, surgical complications, etc. Establish an ongoing monitoring system for data collection (e.g. monthly, with quarterly data analysis) to identify problem areas and track progress in improvement. Action Planning: Using the findings of the baseline assessment, develop a detailed project plan starting first with priority areas of the core standards. Responsibilities, deliverables, and timeframes should be assigned. E.g. Revise informed consent policy, develop a new informed consent statement, educate staff in the next two month time period. Chapter Assignment: Look for good people skills, time management skills, and consensus building skills and assign oversight of each chapter of standards to such a respected champion/leader who will identify team members from throughout the hospital and carry out the process. Policies and Procedures: In addition to overall project plan, it is often helpful to compile a list of all required policies and procedures that will need development and revision. Continue to monitor your progress in meeting the standards, such as through a mini-evaluation of each chapter at regular intervals (e.g. quarterly). Final Mock Survey: Plan for a final 'mock survey' at least 4-6 months in advance of the target date of the actual accreditation survey. Use evaluators (internal or external consultants) who were not involved in the baseline assessment and preparation, who will look at the organisation with a fresh and objective eye. Need to plan final revisions and corrections based on the findings of the final mock survey. Final Survey The success of any quality assurance programme depends almost entirely on the commitment and interest of the administrators, nurses, paramedical staff and physicians. Leaders of quality assurance programmes must be able to generate interest and commitment without burdening clinical and administrative staff with an activity they neither understand nor believe in. This will help move quality assurance out of its current paralysis in some hospitals. Quality assurance is to succeed in its goal to identify and correct problems and to improve the quality of patient care. |
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Healthcare and Marketing or Healthcare Marketing? Consumerism driving a change to result in healthcare marketing
"Who are the most commanding people in the healthcare industry today?" It's actually the 28-year-old young woman who is contemplating whether to get a cosmetically fitting white ceramic crown versus a silver one for her dental treatment. It's also a 40-year-old man who can get his blood test at the local diagnostic centre or get the phlebotomist to come home and collect his sample while he still unwinds in the comfort of his house on a lazy weekend. These two examples illustrate the emerging trend of healthcare consumerism. Though the healthcare field is characterised by complexity, rapid change, evolving distribution, consumer-purchasing behaviour, and pricing and reimbursement pressure; awareness and technology now empower patients to make their own healthcare choices, rather than simply accepting the options lay down by a traditional health system. The influence of healthcare consumerism today extends to every professional working in the healthcare system compelling providers to respond to consumers' evolving expectations, which are mainly based on choice, control, convenience, and customer service. Healthcare is now purchased from a wholesale and retail-oriented marketing model. Earlier, healthcare organisations did not need to market their services. The providers operated in semi-monopolistic environments. There was an almost unlimited flow of customers, and revenues were essentially guaranteed. This situation began to change. Increasing choice for consumers opened the door to competition. Healthcare organisations began to appreciate that to sustain in this new 'bad' world, they would have to introduce modern business practices into the healthcare arena and adopt concepts and methods long established in other industries. This led to the concept of direct marketing. Unfortunately, in the early years healthcare professionals did not like the amalgamation of the words healthcare and marketing. Many misconstrued marketing for advertising, and, advertising on the part of health services providers was considered inappropriate. Though prescribed marketing activities became common early on among healthcare organisations like pharmaceuticals, medical equipments and medical supplies, targeting physicians and employers, marketing campaigns targeting healthcare consumers i.e. patients were relatively rare. Healthcare service providers had long resisted the incorporation of formal marketing activities into their operations. Nevertheless, physicians, hospitals and other healthcare organisations had been 'marketing' themselves under the facade of public relations, physician-relationship development, community services, and other activities, but few health professionals equated these with marketing. The use of marketing techniques have proliferated. Modern healthcare programmes, such as freestanding diagnostic centers and rehabilitation clinics, began using marketing as a means of luring patients from the already established sources of care. Healthcare marketing, however, initiated as an unstable concept. The marketing professionals that healthcare imported from other industries failed in their effort to adapt existing marketing techniques to healthcare uses. Marketing healthcare was not the same as marketing a soft drink! While few methods and techniques could be transferred untouched from other industries, most approaches had to be customised to healthcare. Furthermore, experienced marketers from other industries were not familiar with the healthcare market and, were therefore unable to appreciate the need for long-term initiatives in this industry.
The formal recognition of marketing as a suitable activity for healthcare providers represented an important milestone for healthcare. Healthcare organisations then saw the daybreak to a flurry of marketing activities and got into creating aggressive campaigns. Medical professionals using jargon like 'the market' along with 'angioplasty', 'arteries' and 'vitamins' became more common. The term 'marketing mix' is now heard commonly in boardroom discussions housed in the same building complex where patient care is provided, emphasising on the 4 P's of Marketing: Product, Price, Place and Promotion. Today, the industry has matured into a sophisticated and competitive field, meeting the needs of knowledgeable consumers who are making their own healthcare decisions. The industry is now being compared to the hospitality sector, and is labeled as a service industry. The acceptance of marketing by health professionals realised the need for the establishment of marketing budgets and the creation of numerous new positions within the organisations. This culminated with the establishment of a marketing department with its' own budget and staff. Positions like general manager and director for marketing came into existence in many organisations with responsibilities of contributing to the bottom line, just like any other department. The evolution of marketing in healthcare has been slow and is still an ongoing process. After years of reluctant acceptance, and constant nervousness between those who enthusiastically accepted marketing as a function of the healthcare organisation and those who tenaciously resisted it, marketing has now become reasonably well established as a legitimate healthcare function. Though the industry still suffers from a lack of standardisation when it comes to marketing, healthcare marketers now have a much better understanding of the market and their 'target audience'. New approaches have been developed specifically for the healthcare market and reasonably sophisticated market research techniques have been put into place. Healthcare professionals now appreciate their existence in a service industry and have in fact extended the marketing fundamentals to 7 P's, the additional ones being People, Physical Evidence and Process. A core of healthcare marketing professionals have now emerged along with the tools necessary to plan and implement marketing initiatives with background on the factors that drive marketing approaches and consumer behavior in healthcare. Marketing departments and marketing budgets are under increasing scrutiny in today's healthcare organisation. Developing and implementing a communications and public relations program that meets the needs of both the hospital and its diverse stakeholders is increasingly gaining popularity. From planning and executing an advertising campaign to analysing patient satisfaction data, the evolution of healthcare marketing has been quite dramatic over the past few years. Physician referral 'cuts' have now been replaced by sophisticated terms like 'revenue sharing mode' and 'patient care' by 'customer focus'. Healthcare organisations are now using various means and tools for marketing their ‘product’. Electronic media, digital media, print media, television, radio are just few of the many options healthcare providers are now opting for. Hoardings and billboards now don't just carry your favourite actor selling a car or toothpaste, but also a doctor-patient relationship. It is now believed that when market planning, market research, and marketing communications come together to achieve planned strategic objectives, organisations succeed. Today, healthcare marketing appears poised to play a greater role in the new healthcare environment. Few marketing methods are Health education camps/ awareness programmes for consumers, CMEs for physician relation building exercise, medical camps, website, marketing to various referral avenues like corporate, insurance companies, smaller healthcare organisations, attracting international patients through medical tourism and promotional packages for various occasions.. |
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Nursing Job Satisfaction—Directly Proportional To Hospital Savings
Angels in comfortable shoes but uncomfortable emotions- partners at bedside, caregiver, emotional pillar, mother etc.
 "The perception is that physicians and hospital administrators often treat nurses as workers, not asclinicians and peers" - Dr Rashi Agarwal |
There can be little doubt that nurses form the fabric of medical care. They not only play the role of caregiver, but must assume a medley of other roles – including but not limited to technician, waitress and mother. They are the front line of surveillance and play the prime element in early detection of potentially life-threatening problems. There are no qualms about the fact that nursing as a profession is truly respected. Day in and day out, nurses not only take care of a patient's basic needs, they act as the constant pillar of support during difficult times, both physically and emotionally. But is nursing really understood?
In spite of nursing playing an extremely important they may be the most dissatisfied professionals in the world today. Job dissatisfaction among the hospital nurses is 4 times greater than the average for all other workers. One in five hospital nurses plan to leave their current jobs within a year. This is leading to both a supply and a demand shortage of nurses. Thirty three percent of the nurses below age of thirty are planning to leave their job within the year. Thus there is an aging work force with an average age of nurses being 45.2, higher than most professions. Job dissatisfaction has been identified as the main factor for nurses leaving the profession earlier than anticipated. Approximately 80-85% of hospitals have reported a shortage of nurses. By 2020 there will be a 20% shortage in the number of nurses needed in the U.S.
Hospitals fail to meet the expectations of their employees far more frequently than the employers in other industries. Administrators should pay special attention to their most critical personnel and devise tailored solutions for retaining these individuals. Healthcare providers are having trouble recruiting and retaining their nursing staff which creates significant cost for hospitals. Direct turnover costs are only the tip of the iceberg. In addition, the hidden cost of lost productivity for departing employees. Staff turnover not only incurs large costs of hiring & training new employees, but also adversely affects the quality of patient care.
Inadequate staffing and heavy workloads for nurses impact patient safety. Nurse shortage is the leading cause for medical errors. Patients face a 7% greater likelihood of death for every patient above four assigned to a particular nurse. Having too few nurses may actually cost more money given the high costs of replacing burn out nurses and caring for patients with poor outcomes. A higher proportion of nursing care provided by degree nurses per day is associated with better outcomes for hospitalized patients. There is a strong and consistent relationship between nurse staffing and five outcomes in medical patients: length of stay, urinary tract infections, gastrointestinal bleeding, pneumonia, and shock or cardiac arrest.
Hospitals are “being run like a business” with “issues of patient care” of secondary importance.” Emotional support, education, encouragement and counseling are integral to the everyday nursing practice. However, these practices are not easily quantified and considered by managers as unjustified cost for the patients, who are also viewed as consumers. Therefore, only clinical responsibilities, such as medication administration, dressing changes, foley catheter insertions, and anything that involves tangible supplies, are quantified and incorporated into the organizational budget and plan of care for the consumers. If the funds now spent fighting or losing battle to replace disheartened nurses were instead devoted to improving job conditions, it is possible that the nursing shortage could be largely solved and the nations’ hospitals might still end up with significant savings.
| About PRAXIS |
PRAXIS is a consulting company and takes on projects for healthcare organisation. It provides support in all areas of quality, manpower, operational management, marketing etc. Few services provided include:
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The perception is that physicians and hospital administrators often treat nurses as workers, not as clinicians and peers. Often the role of a nurse is defined in relation to the physician and may still carry the image of “Handmaiden”. The hospital should implement and sustain a marketing effort that addresses the image of nursing and revise how nurses are valued. Nurse-physician relationships are one of the most important drivers of the work environment alongside forces such as autonomy, decision making, and professional growth opportunities. The patient safety literature also emphasizes the importance of the work environment in driving patient outcomes in the form of a safety culture. A safety culture is one that is devoid of hierarchy and not only allows, but expects individuals to speak up in the face of danger. The airline industry has been successful in transforming a hierarchical culture into a safety culture. Airline pilots don't throw objects in the cockpit, but sadly, surgeons still throw instruments in the OR. The hospital should construct practice environments that are inter-disciplinary and built on relationships between nurses, physicians, other health care professionals. Communication can be encouraged between physicians and nurses over coffee and breakfast a morning every week. This will help the most important care givers to patients know each other and work as a team to provide care.
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While nurses have no control over things that are required to provide good patient care, they are responsible and accountable for the health and welfare of their patient. Staff must be involved in defining and developing the practice of care in the organization since they are the closest to the patient. The nurses should be given control and provided with more responsibilities, autonomy, and opportunities to participate in policy decisions. No longer is top down control seen as desirable. Shared governance should be introduced which gives nurses equal footing with managers and physicians to allow them to participate in the decision making process that affect their practice. Shared governance creates a more satisfying work environment.
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Inappropriate staffing is another major concern of nurses today as adequate staffing is essential for the delivery of quality care. The hospital should increase the staff and should not assign more than four patients per nurse. Appropriate staff mix should be maintained, i.e. various specialized nurses in the respective specialized units should be hired, which reduces the workload. Most nurses entered their professions to help care for those in need. However, many nurses who focus on patient care feel unable to spend adequate time with their patients. Consequently, they are then forced to forgo the very reason that they entered nursing in the first place. Because hospitalisations are shorter, nurses spend a higher percentage of their time admitting and discharging patients, as well as teaching them important home-care skills and providing relevant information. Nurses complain about the amount and complexity of paper work that has resulted from a multitude of actions by regulatory bodies and the re-imbursement industry. Nurses find they are spending more time with paper than the patients. Tasks not requiring a nurses’ educational preparation will be delegated to qualified assistive personnel. Electronic documentation systems should be introduced and aggressive process improvement initiatives that help standardize and streamline documentation should be taken. New technologies that reduce paper records and the repetitive entry of information should be added. Hence primary nurses will have time to give patients the benefit of their knowledge and skills.
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 Nurse-physician interaction is one of the important drivers of work environment |
Acuity in hospitals has been rising rapidly, due to the declining average length of stay and to new technology that allows rapid assessment, treatment and discharge. Hospitals are increasingly becoming large intensive care units, with cardiac monitoring, respiratory assistance and intense treatment a growing part of the average patients plan of care. Thus, skilled and specialized nurses are in great demand. There is a clear link between higher levels of nursing education & better patient outcomes. Therefore education programs should be introduced and nurses of all educational levels should be promoted to pursue higher education. The hospital could provide tuition re-imbursement and scholarships to nursing students who contract on joining the facility on completion of education. The hospital can re-introduce intensive training programs for nurses in specialties like operating room, critical care and neonatal care where demand is high. This helps to retain nurses who are looking for a transfer opportunity as well as recruit new staff. It also builds a career development path for staff.
Currently, nurses have such intense workloads. Many nurses work nights, weekends, and holidays to care for patients that they often find themselves working overtime just to complete their assigned duties. This overtime increases nurses’ dissatisfaction with their job, and may create an antagonistic relationship with their hospital. Employers must find creative ways to lower workloads so that nurses can go home on time. Mandatory overtime should be eliminated and scheduling options maximized.
High levels of dissatisfaction are consistent across all pay levels. To attract nurses to the hospital it should offer higher salaries, premium packages including housing for new nurses for up to six months, relocation coverage, insurance costs and coverage, pension, retirement benefits, and performance based bonuses. Nursing is a very stressful profession, presumably due to the fast paced nature of the job.
Nursing shortages can be consistent or intermittent depending on the current number of patient needing medical attention. In order to respond to this fluctuating census, health care industries have utilized float pool nurses and agency nurses. Float pool nurses are nursing staffs employed by the hospital to work in any unit within the organization. Agency nurses are employed by an independent staffing organization and have the opportunity to work in any hospitals on a daily, weekly or contractual basis. PRAXIS provides contractual nurses to a few providers and we have seen spectacular results with the practice.
Over the years, the number of dissatisfied nurses has been increasing. While reversing this trend will not be easy, it must become a priority. Beyond the quality of working life for nurses and quality of care for patients these practices may ultimately save hospitals money. The higher nurse staffing ratios result in shorter lengths of stay and thus reduce both hospital cost of treatment and indirect cost associated with a hospital’s liability and loss of reputation. With this era comes real evidence supporting the importance of healthy nurse relationships. With this era come issues that translate into value. Hospitals save money with lower recruitment and retention. Hospitals save money with lower morbidity and mortality. Hospitals gain market share when patients choose hospitals that deliver higher quality. Hospitals improve reimbursement and/or market share when employers and/or payers favor hospitals delivering higher quality. Healthy nurse working relationships are not just a nice thing to have; they are a competitive advantage.
If this fabric of medicine is not mended, then we can be sure that the entire system is not far from unraveling.
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