Health Care Quality : An in-depth interview with Dr. Manisha Dogra.

“There can be no excellence in patient care without monitoring quality of healthcare services”


Mr. Sarfaraz Lakhani of Calibre Creators (CC) had the opportunity to interview Dr. Manisha Dogra.  The discussion brings out some very key facets of Hospital Quality and its importance to patient outcomes.  Here she shares her thoughts about her journey, the challenges and future of quality and makes interesting reading.


Dr. Dogra is a dynamic healthcare professional with 13 years of extensive experience in Hospital Administration and healthcare quality.  She is currently associated with a premium healthcare organization in Mumbai.  Adding to her qualification of BAMS, she has furthered here academic credentials with a Master’s Degree in Hospital Administration (MHA) as well as achieved certification as an NABH Assessor (Entry Level).  She has also had the privilege of working with 2 to 3 renowned multi-specialty hospitals in Mumbai.

She has endeavoured to achieve Clinical excellence, Operational excellence, implemented Quality initiatives and accreditation (NABH & JCI), is excellent at clinical engagements and resolving issues/ patient grievances to improve efficiency and satisfaction in patient care. With core strength in planning, administration, and monitoring consistent readiness of all quality management, regulatory requirements, and quality-improvement processes, she is also good at people management to achieve/ align employee satisfaction with organizational goals. 

With the following quote, “the quality of a man’s life is in direct proportion to his commitment to excellence”, she carries a vision of achieving clinical excellence & quality in patient care.

Dr. Dogra’s achievements in the arena of Quality for the last 5 to 6 years for tertiary care set ups….
•    Successful NABH Surveillance Assessment
•    Successful NABH Ethics Committee
•    Successful NABH Re-Accreditation
•    Successful JCI Accreditation
•    16 Quality Improvement Projects (In sync with other departments)
•    Improvement in Net promoter Score by 30% (Patient satisfaction)
•    Certification - NABH Assessor (Entry Level)   


CC.1.    Please tell us about your current role?

Dr.MD: I am currently attached to a reputed multi-specialty tertiary care centre in Mumbai of a capacity of more than 300 beds.  My broad core responsibilities are:
•    Planning, administration, and monitoring consistent readiness of all quality management processes, compliance with regulatory requirements and quality-improvement processes.
•    Manage the Continuous Quality Improvement Programs.
•    Monitor clinical quality
•    Responsible for Accreditation's


CC.2.    How has the Quality journey been and what were the challenges?

Dr.MD: It has been an interesting & challenging journey of Quality for me.  I am fortunate to get this opportunity, as it gave me a good platform to channelize my 13 years of rich experience in Hospital Administration.

With a good mix of Helping, Persuading & Organizing skills, it has been a very interesting and challenging journey for me in healthcare quality.

The “Helping” interest area in me indicates a focus on assisting, serving, counseling, or teaching other people. With the “Persuading” interest area, I focus on influencing, motivating, and convincing other people to get involved and not leave anyone behind.  My “Organizing” interest area is focused on working with data, information and processes to keep things arranged in orderly systems so that they progress towards the larger goal.

Challenges encountered by me in this process are :
1) Lack of proper integration of Quality Assurance (QA) in system;
2) Weak methods of communication of Accreditation standards;
3) Poor measurement of compliance with clinical care  standards;
4) Constraints on the work of quality improvement teams;
5) Inconsistent Support system;
6) Constricted feedback on performance, benchmarking with peer groups;
7) Staff support (avoiding blame, providing training), Incentivising (Motivating for continuous improvements);
8) Systems development (Configuring & re-engineering towards requirement at user end and meeting patient needs). 
These are some of the challenges that push me harder and harder to achieve the desired outcomes.


CC.3.    On a daily basis, how do you monitor quality is being practised?

Dr.MD: Measuring & monitoring the quality of health care is important because it tells us how the health systemis performing and leads to improved care. Quality measurement in health care is the process of using data to evaluate the performance of health plans and health care providers against recognized quality standards.

I have been successful in monitoring quality by the following means:
•    Being regular in conducting weekly audits of departmental processes
•    Incident analysis to identify the Root Cause
•    Periodic Analysis of Patient feedbacks
•    Conducting Mock drill and analysis
•    Organising Trainings on various trainings
•    Periodic Self-assessment audits of NABH standards
•    Monitoring the effectiveness of various committees
•    Periodic revaluation of gap closure for the above audits

I engage the whole team in the process and that his how we all understand the problems and come out with effective solutions to address them.


CC.4.    How do you align your staff to be motivated about delivery qualitative healthcare?

Dr.MD: I have been a staunch advocate of involving the staff, in discussions of incidents for the Root Cause Analysis (RCA), Corrective Action Preventive Action (CAPA) (which by itself is a continuous learning process). Conducting periodic interactive training sessions for their departmental SOPs and hospital wide policies, as well as NABH standards, followed by organising Quiz programmes, help them to understand the importance of their activities and how it is linked to the overall organisational goal of achieve the desired quality outcomes.As a result of which they are made conscious of doing the right thing in a right manner.
   
It must be recognized that today, medicine is increasingly becoming technology driven. New technologies create new methods for producing errors and therefore, constant vigilance and newer methods to stay in tune with new technology and monitor them is required to track these.

One powerful tool that I used is implementing “anonymous incident reporting” by the Consultant’s, Doctor’s, Nurses and Technicians working in high risk areas without having any fear of repercussions or being negligent and it has so far delivered the desired result. Lapses of discipline, errors or incidents are noted and dropped into a ‘ballot box’. The head of department opens the box at periodic intervals and uses the reports to generate a discussion on how practices can be improved.  It creates an environment where free dialogue is encouraged and no one feels threatened about consequences or job security.All the above measures are included as part of daily practice, thereby installing a culture of ownership for safety & quality by everyone involved.


CC.5.     Documentation is a very important part of the entire process.  Does it ever lead to delays in clinical or other process because one has to comply with them first?

Dr.MD:  Documentation is admissible as evidence and is the core requirement of an Accreditation body to substantiate the claim of having of having followed the due process.  Incomplete documentation in patient clinical records can cause the organization legal problems and lead to payment of settlement fees which can be very high, given the recent rulings by courts in favour of patients, can cause you to lose your license, contribute to inaccurate statistical databases, cause loss of revenue/reimbursement, and result in poor patient care.  The purpose of complete and accurate patient record documentation is to foster quality and continuity of care.

It is important to continuously train staff on the importance of documentation as lapses here could be detrimental to the sustenance of the Accreditation and other problems cited above.

Documents are the only piece of evidence that can be produced to measure quality of performance or services and therefore become the most important activity in the entire spectrum of quality healthcare delivery.

    
CC.6     What would be your suggestions to make the role of various committees more effective in driving the quality initiative?

Dr.MD:  In my opinion, it would be:
•    To revisit frequency of the committee meetings.  If the gap between any two meetings is too long, then frequent meetings will be required and it will also depend on the size of a hospital or range and volume of patients catered to.  If there is an extended delay in measuring performance and if corrective is not taken quickly, the time lag in between will lead to more reported incidents with consequences.
•    Remedial measures, adequate monitoring of CAPA done by the respective committees to be assessed.  Time should be devoted to measure the impact of CAPA and must be continuous until the desired outcome is achieved.
•    Any requirement for involving education sessions that help the committee understand the new developments & how it impacts the quality outcomes.  This must be thoroughly planned and there should be a strong connect between the Quality department facilitating the education and those delivering it.
•    Regular evaluation of Individual committee members to ensure that they are actively engaged in the process
•    It goes without saying that “High risk”areas to be devoted more attention and are looked at with more seriousness.
•    What could we do differently in the meeting to improve the substance of discussion?  How can the Convenor of meeting ensure that discussion is meaningful, is based on analysis of data and everyone is actively engaged and committed to the overall goal.
•    Revisit Terms of Reference (TOR) of each committee for amendments.  This should be done at periodic intervals to stay relevant.


CC. 7    How did you get associated with healthcare quality?

Dr.MD:  In my earlier roles, I was a part of the Quality process (third party evaluations (NABH & JCI Assessments for Accreditation)and had a complete approach and commitment to delivery of quality healthcare.  I developed a keen sense of interest and realised that this is the future and what I want to be doing in the years to come.  I got myself to get fully involved and kept on upgrading myself through workshops, training programmes, etc.


CC.8.    Why do you think quality in healthcare is important?

Dr.MD:  There can be no excellence in patient care without monitoring quality of healthcare services.
   
During the past 2–3 years, improving patients’ experience of health care has become a higher and more visible priority.Quality from a patient’s point of view, relates not only to outcomes but also to a more humane, respectful treatment, convenience, and timely access. Yet, physicians often believe that quality should be based more on what is done to patients than what happened to them and how it happened.


CC.9.    How does quality based systems and processes impact employee and patient satisfaction?

Dr.MD: The quality debate is primarily about “what” processes should be used and what outcomes should be achieved or, in financial terms, how to maximize return on investment. This necessitates the development of a clinical evidence base and adherence of practice to what is known or believed to be appropriate and effective care.

Other attributes of any healthcare system such as overall capacity and technological capability also affect these outcomes. Quality of care efforts must focus at both, the macro (population) and micro (individual) levels. While the ultimate test of healthcare systems may be their impact on health outcomes at the population level, many population level health outcomes are more susceptible to non-medical factors such as sanitation, education and housing than to the influence of healthcare services.

Historically, quality in health care has been an implicit judgment at the level of patient-physician contact. Quality has been largely addressed through professional registration, review of professional appointments,and less through the formal peer review processes. Over the last two decades, this has changed dramatically, with increasing recognition that quality improvement cannot be seen just as a by-product of other processes.

Process based quality management systems are very important for a safe treatment environment in any healthcare organisation.


CC.10.    What are some of the common problems encountered by hospitals in implementing and sustaining quality?

Dr.MD:  Following are the challenges, usually encountered by me in my work experience.

Challenge 1: Convincing people that there is a problem. One fundamental, but often poorly met challenge for improvement efforts is that of convincing healthcare workers that there is a real problem to be addressed. Clinicians and others may argue that the problem being targeted by an improvement intervention is not really a problem; that it is not a problem ‘around here’; or that there are far more important problems to be addressed before this one.  Trying to convince clinical teams who think they are already doing well to change, is likely to be futile unless they can be shown that action is really needed.

Challenge 2:  Convincing people that the solution chosen is the right one. Improvement interventions are often ‘essentially contested’: everyone may agree on the need for good quality but not on what defines good quality or how it should be achieved. Clinicians and others may resist change on grounds that interventions lack sufficient evidence or are incongruent with preferred ways of practising that already appear to deliver good results.

Challenge 3:  Getting data collection & monitoring systems right.   Data collection and feedback are indispensible to improving quality. Data helps in demonstrating the scale of a quality problem and presents evidence of what is happening in response to an intervention. But data collection, monitoring and feedback systems are remarkably hard to get right: they are often poorly understood, poorly designed and poorly implemented.

Challenge 4: Organisational Culture. Trying to secure improvement in situations where organisational capacity is inadequate, and culture is adverse or non-conducive can result in emotional exhaustion and evaporation of support. Differences in morale, leadership and management in organisational settings may lead to variation in outcomes.  Organisational cultures supportive of personal and professional development, and committed to improvement as an organisational priority, are, unsurprisingly, more likely to provide an environment where improvement efforts can flourish.1

Challenge 5: Sustainability. e.g.; Clinicians and managers interest may dwindle when, at a project's end, they are faced with new, competing priorities.


CC.11.    From your vast experience, what are some of the key learning’s that you would like to share? Please share at least 5 if not more.

Dr.MD:   Key Learning’s with Quality:
a.    Continuous improvement.  A very important facet of quality.
b.    Reduction in errors.  If uncontrolled, it can spiral beyond control.
c.    Less variations & disparities in care, i.e. standardisation
d.    Collective learning – Foster’s learning and creates an equitable environment
e.    Systems improvement – the scope is endless.  Learn from errors.

The best part is that all the above 5 are interlinked to each other and by themselves are of no consequence.


CC.12.    If you had to change about 3 things or more in the delivery of healthcare services with regard to quality care, what would they be?

Dr.MD:  In my opinion, specifically in India and other developing and under-developed countries, the following three factors have largely been influential in healthcare quality not being where it should have been
a.    Lack of understanding for Quality improvement Processes
b.    Myths about Quality
c.    Compromise on Quality to save costs and increase profit


CC.13.    One of the perceptions is that delivery quality healthcare leads to increase in costs. Is that true?

Dr.MD:  Strong financial performance is associated with improved patient reported experience of care, the strongest component distinguishing quality and safety. Financially stable hospitals are better able to maintain highly reliable systems and provide on-going resources for quality improvement.

Financial impact of Quality & Safety - When a hospital makes more profit, it has the capacity to finance investment using debt, pay higher wages presumably to attract more skilled nurses / doctors, its quality of care would generally improve. While the pursuit of profit induces hospitals to enhance both quantity and quality of services they offer, the lack of financial strength may result in a lower standard of health care services, implying the importance of monitoring the quality of care among those hospitals with poor financial health.

Performance-based payment incentives may improve care but may also add new financial burdens to facilities that treat the uninsured population. As such, a provider’s payer mix may need to be considered in the design of QI programs if they are to be sustainable.
   
Despite the significant investment in Quality Improvement (QI) efforts and encouraging data regarding their effectiveness, less is known about how these programs have affected the financial status of Healthcare organizations. Past research has demonstrated that delivering high-quality care in the current healthcare system—and particularly within healthcare organisations, meaning hospitals  — does not always save costs and increase revenue for the provider.

If health care workers are of varying quality so too are the institutions in which they work. Government hospitals are characterized by chronic overcrowding, underfunding, and facilities perpetually stretched to the limit. They are the victims of an economy which spends less than 2% of its GDP on health. They turn out bright young doctors and look after a workload of patients with a spectrum of diseases far broader than found in the private sector; yet are at times the unfair target of criticism during healthcare crises. Their circumstances seldom allow quality and safety to appear on their radar.


CC.14.    What kind of training is required to be imparted to staff to upgrade their skills to keep them attuned to the organisational commitment to delivery of quality healthcare?

Dr.MD:  Definition of quality can be explicitly stated - ‘without excessive use of financial resources’. In the same vein, the quality and safety measures listed below are implementable by any institution, government or private, having the necessary commitment.

a.    Ensure the SAFETY OF patient's identity. At times of blood collection, blood transfusion, laboratory investigation, and surgery, correct identity is crucial. Mistakes are not common but can be devastating when they occur.
b.    Use evidence based medicine to save lives: For e.g. a) acute myocardial infarction; b) central line infections; c) surgical site infections; d) ventilator associated pneumonia.  The challenge here is not intellectual, but one of determination to implement what is already known for the benefit of each and every patient.
 c.    Better communication between healthcare workers: Since a single stay in hospital may involve interaction with ten or more caregivers, errors may occur during changes in nursing shifts and when daytime junior doctors transfer care to emergency doctors at night. Proper documentation of unstable patients’ status in case files including DNR orders can avoid distress and futile resuscitation efforts in the event of a cardiac arrest.
d.    Safer delivery of health care: Multitasking is inbred into the daily life of doctors and nurses with the distraction of mobiles, casualty calls, and emergencies superimposed upon patient work and meetings. Staying focussed can lead to decrease in errors, picking up symptoms quickly and addressing them.Checklists and bundles should be followed for common clinical conditions for delivering daily care to patients especially in ICUs to ensure no component of care has been missed.
e.    Hand hygiene to prevent nosocomial infection: These infections cost lives and increase morbidity and health care costs.
   

CC.15.    Should healthcare quality be linked to Accreditation or can it still be delivered as a value with any Accreditation or external stamp of approval?

Dr.MD:  With the increasing awareness of Quality in healthcare, patients will certainly look forward to an accredited hospital. Quality and safety have always been of prime importance in healthcare. However, in the future, under health care reform and associated initiatives, a shift in the paradigm of medicine will integrate quality and safety measurement with financial incentives and a new emphasis on consumerism.

A system of transparency, consumerism, open outcomes, and financial incentives has clearly moved medical quality and safety into a much more regulated and financially incentivized realm.


CC.16.   What would you recommend to Hospitals who are still not keen on implementing quality in healthcare?

Dr.MD:  As per the individual requirements of patient, QI helps in yielding better results.  Quality improvement in healthcare lessens the time of healthcare initiatives.  Quality improvement helps in consulting the concerned specialist with least time lags.With challenges come opportunities. For providers who continue their ethical practice of keeping the patient as the focus and centre of the delivery system, there will be new and different ways of succeeding in health care. Better quality, safety, patient satisfaction, and competitive advantages that result will inure directly to the benefit of those providers.


CC.17.   Do you have any suggestions for strengthening the Accreditation Standards currently in force to make it easier for hospitals to implement without compromising in any way?

Dr.MD:   Yes. At the moment only two:
1.    Frequency of Programs of Implementation (POI) conducted should be increased by the Accreditation body to encourage more entries for accreditation.
2.     There should be more preliminary inspections by the Accreditation body with the motive of training the staff with the same.


CC.18.    What would be your recommendations for healthcare quality to become a strong movement in India?
   
Dr.MD:   Quality and safety have always been of prime importance in healthcare. However, in the future, under healthcare reform and associated initiatives, a shift in the paradigm of medicine will integrate quality and safety measurement with financial incentives and a new emphasis on consumerism.

A system of transparency, consumerism, open outcomes, and financial incentives has clearly moved medical quality and safety into a much more regulated and financially incentivized realm.


CC.19.    Any advice you would like to share with the readers and hospital administrators related to quality?

Dr.MD:  The challenge in the future is to ensure that the goals of improving quality and safety, as well as high patient satisfaction, continue to be the aim in the context of diminishing reimbursements and higher costs.

What is important is that health care providers understand this new delivery role and embrace it, while maintaining their professional role in collaborating with the patient to achieve the patient’s health care goals. Historically, quality in health care has been an implicit judgment at the level of patient-physician contact. Quality has been largely addressed through professional registration, review of professional appointments, and less formal peer review processes.

Over the last two decades this has changed dramatically, with increasing recognition that quality improvement cannot be seen just as a by-product of other processes.

So as I see it, future of Healthcare Quality, requires that we will need to reinforce both the modalities, i.e. the processes as well as have a humane approach to delivery of healthcare.

Dr. Manisha, I thank you for your time and sharing your views on a wide range of topics related to healthcare quality.  I am sure, readers will find a lot of ideas for strengthening their quality initiatives.


Note:
1.  The views expressed by Dr. Manisha Dogra are her personal and do not represent the view of the organisation she is associated with.
2. Calibre Creators shall not be responsible for the views expressed by her.