personal experiences

I had posted my personal experience at DocPlexus – a community of doctors in India and received an overwhelming response. Here is the follow up post:

Dr abha

1. I have verified that the hospital I was at is NABH-accredited since 2016. So now the process, validity and usefulness of NABH accreditation itself are also of concern. How can a hospital with such gross lack of basic processes of infection control and other quality protocols be granted NABH accreditation? What really is conveyed by NABH accreditation seal when we see one on a hospital? I have been involved with Joint Commission accreditation as a hospital executive in US for decades and am intimately familiar with accreditation processes and what it entails. Therefore, I am even more dismayed now.

2. I have followed up with the hospital management and they said they are investigating. Same with NABH and they are also looking. Well, at least both of them responded to my messages promptly. Will wait to see the quality of response.

3. Let us distinguish doctors and hospitals as related but two different entities. While there is room for a lot of improvement on all sides, the root causes and remedies aimed at these two entities are different. I am outlining some thoughts below.

4. Doctors: As many comments in my previous post outlined, the medical knowledge imparted in our medical schools is excellent but we are lacking in any education in humanism, empathy, caring and understanding the suffering of a fellow human being. Medical students are influenced by their professors and teachers throughout the course of their future career, so I wonder if our educators and professors don’t display these “softer” attributes either. Later in the career, as trained professionals, young doctors are working in hospitals and ecosystems that don’t encourage empathy and value “hard core” clinical skills above such softer skills.

a. Would MCI or medical curriculum setting bodies consider mandating that some lectures or set hours be put aside for teaching humanity and empathy and the art of healing. For example, can a book titled “The Lost Art of Healing” by my revered mentor Dr. Bernard Lown be a requisite course book for medical students or some reading material by another renowned humanist physician Dr. Abraham Verghese be as mandatory as reading Guyton, Ganong, Harrison and Schwartz? Of course, many other such resources exist – these two just readily come to my mind.

b. I often hear it’s the system – what we as doctors alone can do? I believe we can do a lot to convey empathy. To start with, can we please do a physical examination on all of our patients? It takes a few minutes and entails connecting with the humanity of the patient through our hands and our stethoscope. No NABH required, no change of systems required, doesn’t cost us any money. We just have to w ant to do this. The lack of connection with the patient lies at the root of the corrosion of trust in patient-physician relationship that I have observed so rampantly these days.

5. Hospitals – As outlined in my 2013 book,”Patient Safety: A Case-based Comprehensive Guide”, we must aim at improving systems as opposed to punishing individuals.

a. The issue is inadequate systems not bad people. My belief is that people who cared for me are fundamentally good people with good intention. They come to work every day to do their best. The problem is that they are working in an ecosystem that doesn’t provide them the tools, technology and processes to deliver care that meets the high or even basic standards of quality.

b. Here is a concrete example in regard to hand-washing. Can we put signage at every patient’s bedside that simply says – EVERYONE WHO TOUCHES YOU MUST WASH THEIR HANDS AT YOUR BEDSIDE. IF NOT, PLEASE CALL EXTENSION 1234 FOR A RS. X VOUCHER. This intervention itself is extremely low cost as the signage is cheap. The question is whether the hospital leaders and owners are willing to be held accountable and are willing to hold their staff accountable? Can NABH mandate such an intervention in every NABH-accredited hospital?

c. With commitment and interest, I’m sure hospital executives and management can come up with many such solutions to ensure quality care processes are followed.

6. Role of consumers: Since most patients in India pay out-of-pocket in cash, they as consumers can demand value for the money paid. The challenge is that they would not be aware of what good quality care is. I am thinking of writing a patient-oriented “guide to safe hospitalization” handbook to raise awareness among patients and families (as many commenters noted, many times doctors and their family members also end up being consumers).

7. Role of payors: As I understand, the insurance penetration in India is increasing gradually and slowly including private insurers and government insurers. I think they should demand adherence to core quality processes before granting empanelment to a hospital. Finally, purely voluntary adherence to quality care processes is difficulty in any environment especially in India.

There should be a carrot and stick approach including:

(a) Aligning financial incentives to quality – (Insurance, hand washing examples above)

(b) Aligning regulatory incentives to quality – operating license for a hospital is dependent on adherence to quality

I am sure there are many skeptics who would say that none of this is doable; as an eternal optimist, I beg to differ, in advance.