On a freezing and rainy day in Delhi, I had the honor of speaking at the fifty second annual national conference of the Indian Academy of Pediatrics, PEDICON 2015. This year, the theme of PEDICON was Quality Development for Every Child.
The day started with an introduction to quality in healthcare from Dr. Ajay Gambhir, President of the National Neonatology Forum of India. Dr. Gambhir stressed the need for standardized physician procedures and practices, quality assurance in clinical practice through use of clinical guidelines, and openness and collaboration with organizations outside the physician community that work toward improving quality in healthcare delivery. Dr. Gambhir poignantly noted that 2015 was the first time PEDICON had featured a session focused on quality.
I was a part of the panel discussion on quality in pediatric healthcare. The panel was chaired by Major General Pawan Kapoor, Technical Committee Chairman, National Accreditation Board of Hospitals and Healthcare Providers. Other speakers at the session included Dr. Harsha Bilolikar, Consultant Pediatrician, Northamptonshire, UK; Dr. Akhil Sangal, Chief Executive Officer, Indian Confederation for Healthcare Accreditation; Dr. Deepak Singla, Senior Consultant and Pediatrician at Maharaja Agrasen Hospital; and Dr. Zainab Zaidi, Director, Healthcare Sector Skill Council.
Dr. Sangal began the discussion with an overview of the work of the Indian Confederation for Healthcare Accreditation. He explained that quality is achieved by improvement every single day. It comes from within when we want it and work for it. It cannot be forced, in his view. Consistent awareness, persuasion, and guidance can change lives. The Confederation ensures that the right professionals do the right things at the right time, the right place, and at the right cost through regular education, awareness raising, and training. The Confederation shares its knowledge bank of best practices with hospitals. This information helps hospitals ensure continuous improvements in their quality of care. The work of the Confederation helps to prevent errors and to reduce the costs of care for all. It enables more people to reap the benefits of modern medicine.
The Confederation focuses on a partnership paradigm rather than on adversarial relationships. The Confederation believes that each institution has one or several good practices. Through the sharing of these good practices, institutions can help all to improve rather than forcing each to continuously reinvent the wheel. The Confederation stands for inclusive participation. It believes in a solutions approach rather than the traditional fault finding and correction approach. The Confederation provides long term solutions by identifying the root causes of problems rather than relying on superficial fixes.
Next, Dr. Bilolikar spoke about the quality of education in pediatric care in the UK. Dr. Zaidi discussed skill development opportunities in pediatric care. Deficiencies in human resources, both in terms of skills and numbers, continue to pose a challenge for the healthcare sector. In turn, these continued challenges affect efforts to provide universal health coverage for all. The Healthcare Sector Skill Council is a unique initiative of the Confederation of Indian Industry, the National Skills Development Corporation, and healthcare service providers. The Skill Council creates a robust and vibrant ecosystem for quality vocational education and skill development in the allied healthcare space in India.
Over the next ten years, the Skill Council will facilitate the training of 4.8 million allied health workers and paramedics. Through extensive industry consultation and participation, the Skill Council has developed national occupational standards for twenty seven unique job roles in allied health. The Skill Council hopes to work with a range of healthcare organizations, hospitals, and the physician community – including the Indian Academy of Pediatrics and the National Neonatology Forum – to improve the skills of allied health workers and paramedics.
For my presentation, I shared the work of our Quality and Process Improvement team in India. ACCESS Health has successfully piloted collaboratives in neonatal care and eye care. We currently coordinate and run a large perinatal quality collaborative called Safe Care, Saving Lives, in the states of Andhra Pradesh and Telangana. We have partnered on this project with Aarogyasri, the social insurance program in the two states. In all of our quality improvement projects, we work closely with the Institute for Healthcare Improvement (IHI). We use their model for improvement. Their model is a framework that has been successful all over the world.
We have enrolled twenty five hospitals – a mix of large, small, public, and private – in phase one of the Safe Care, Saving Lives project. We have helped them to identify areas of greatest need to reduce neonatal mortality in their local environments. An expert clinical panel created an outline of potentially better practices drawn from existing evidence and the literature. These practices address the three biggest areas responsible for neonatal mortality: birth asphyxia, sepsis, and complications of prematurity. The ACCESS Health project team visits these hospitals once every two weeks. Over the past three months, we have helped these hospitals to assess their current processes. We have enabled them to incorporate the new practices by encouraging them to make small changes to their processes. These small changes are executed by the hospital teams over short one to two week cycles. After each improvement cycle, the ACCESS Health project team helps the hospitals study the data to assess improvement in processes and outcomes. The hospitals then adopt and incorporate changes incrementally to achieve sustainable improvement.
At one of the medical college hospitals in the Safe Care Saving Lives project, fewer than ten percent of high risk deliveries were attended by a person trained in neonatal resuscitation, before the start of the project. The reason for this gap was routine: “This is the way it has always been done here.” The staff blamed others for the problem: Obstetrics doesn’t call the pediatrician on time. Pediatrics doesn’t come when the obstetrician calls them. Our project team worked with the hospital staff to steer them away from finger pointing. We asked the hospital staff to hold the system responsible and to try to change the system. As a result, the hospital team introduced a new on call system. Trained pediatrics residents now receive a call on their mobile phones ten minutes before delivery. Three weeks after the introduction of this new system, more than seventy percent of high risk deliveries were attended by trained resuscitation personnel. There have been no grade II or III birth asphyxia admissions to the neonatal intensive care unit during this time.
Following the presentations, the panelists opened the discussion for questions from the audience. Most of the audience questions focused on the practical how to’s of engaging in quality improvement: How can a practicing pediatrician include quality improvement within his or her scope of work? Can quality improvement be achieved in a resource restricted public health environment? The panel members explained that quality improvement is possible, regardless of the size, budget, or resources of a hospital or clinic. Quality improvement can be achieved by monitoring practices and processes followed in the hospital or clinic, using quality improvement tools, such as the model for improvement from the Institute for Healthcare Improvement, and by following practices that are advocated by the World Health Organization, UNICEF, the Indian Academy of Pediatrics, and the National Neonatology Forum.
The main aim of this conference session was to share information on quality improvement and other public health initiatives in pediatric care. Quality improvement has not been a part of the curriculum or any discussion at medical colleges in India. Nor has it been included at any previous PEDICON. These sessions will help the physician community to look at quality more seriously. The inclusion of quality in the conversation will encourage them to incorporate quality improvement in their day to day activities in their individual clinics and hospitals. Professional development sessions on quality, like this one, will encourage physicians, clinics, and hospitals to monitor their practices and processes and to test out improvements on a small scale before implementing them across the board. I hope that quality remains an integral part of future PEDICONs. I hope that more and more physicians and other healthcare providers emphasize and place more importance on the delivery of high quality care to all.