What you should know about safety in private Indian hospitals

“I have greater assurance about product quality and service quality when I walk into a Sagar for a snack than when I go into a hospital!” (Sagar is a chain of restaurants in Delhi best known for serving South Indian food.) I have often said this to our consultants and managers to illustrate the unacceptably low levels of reliability in most healthcare delivery encounters – including at our hospital. And despite my having this realization and my being chief executive, there has been limited progress on improving safety and reliability in our own organization. So the natural question is, Why?

There is no simple answer. It’s a bit like asking why driving on Delhi’s roads is so chaotic and unsafe despite it being the capital of the country. Safety is impacted not just by your behavior and choices but also the environment. Behind an unsafe act of someone driving in the wrong lane may lie contributory factors like poor road conditions or lack of a safety culture which in turn may reflect a governance failure. In healthcare delivery, an unsafe act may reflect poor education (the quality of graduates of India’s medical and nursing schools is very variable), lack of standardization (often different consultants within a specialty in a hospital insist on different pathways for “their” patients thus increasing complexity and the chances of error), and inadequate staffing (many hospitals face high turnover and chronic shortages in the ranks of nurses and junior doctors). But this is not the complete story.

Consider the case of an elderly patient who requires surgery and has diabetes and hypertension. Often investigation and management of pre-existing conditions in such patients is postponed until admission on the night before for surgery. Even if blood sugar or blood pressure control is found to be inadequate, the admitting surgeon feels hesitant to postpone the surgery. If post-operatively the patient develops a cardiac complication, the nurse or junior doctor may not detect the condition in time, and thus increase risk. Should the patient die, it would not be uncommon for the surgeon and hospital to engage in finger-pointing –with the hospital blaming the surgeon for proceeding without adequately controlling risk factors and the surgeon blaming the hospital for poor support. The potentially preventable nature of the complication will not likely be disclosed to the patient’s family and the hospital and surgeon will want to “move on” from the memory of the “unfortunate” event.

Let’s analyse this case from a systems perspective. Private medical practice in urban India takes place in a competitive marketplace and both consultants and hospitals don’t want to risk losing patients by demanding treatment that may increase cost, fully discussing risks of the surgery, or revealing limitations of a hospital. Hospitals rely on consultant reputation to attract work and feel compelled to defer to consultant judgement about selecting patients. When complications occur, weaknesses in the system get revealed – particularly the inadequate defences to protect the patient.

There are other challenges – such as limited requirements for transparency making it difficult for anyone to really know about the safety record of a hospital or a consultant. Most of the time, unsafe acts don’t result in serious harm and this leads providers and patients to ignore the potential for harm. An environment in which any error is seen as negligence on the part of the providers also discourages openness and thus learning. Within the medical profession, understanding of safety science and capacity for leading change is limited as these topics are not part of medical education. In summary, the framework for clinical governance is weak in most hospitals.

Beginning the journey of making our hospital safer
So what can we do other than simply raise our hands in frustration and blame the “system”? The National Patient Safety Foundation of USA has outlined five concepts for transforming healthcare safety:

  1. Transparency
  2. Integrated care platform
  3. Consumer engagement
  4. Joy and meaning in work
  5. Medical education reform

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We are beginning to apply this framework in our hospital. We’ve started measuring outcomes in select specialties and sharing this information internally; we’ve publicly disclosed our caesarean rate and aim to share our patient feedback data soon. We’re working to redesign our care platform to enhance reliability and are exploring adoption of group practice for maternity care and checklists for making surgery safer. We’re improving consumer engagement by empowering patients with relevant information and giving them more time for informed decision-making. We’re training our nurses one-on-one to enhance their skills and engaging the entire care team to make them feel valued. And we’re encouraging doctors and other staff to enhance their ability for leading improvement – through lectures, case discussions, and online courses such as The Science of Safety in Healthcare offered by Johns Hopkins University on Coursera and the Open School of the Institute for Healthcare Improvement. Most of all we’re trying to get everyone to reconnect with their original purpose for entering the health professions and asking ourselves how we can be more in sync with that calling.

Taking on the goal of improving safety is like committing to a marathon without a finish line – it is daunting but also exciting. Along the way we hope to enjoy the highs of running a good race and doing our best for patients!

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  • Arati Verma

    Dear Abhishek,
    My compliments to you for an excellent write up.
    Patient Safety is a fascinating conundrum, though if one looks at the
    big picture and how hospital care has evolved over the century, many
    procedures are now safely done, with minimal access surgeries, high tech
    equipment and highly skilled staff. More people are living longer and
    healthier, thanks to the advances of medicine, Those are the highs..or
    the ceiling level outcomes.
    It is the floor level outcomes, where
    patients suffer harm due to multiple opportunities of failure, such as
    inherent risks, poor communication and coordination, skill gaps, and
    several other other failure points which pose a risk to them.
    I am
    unaware of any hospital in the world, that has been able to reach “zero”
    adverse outcomes! This is because of poor or next to impossible process
    control, which seems to be difficult in the complex system of the
    hospital, too much dependency on the human factor, and many
    unpredictable situations with patient responses and treatment progress.
    With the entire world taking up this subject with so much intensity,
    there are huge opportunities for making the system safer, one step at a
    time, and reducing risk step by step.
    I am also very wary of
    allocating blame or judgement to staff. Society is not fully justified
    to hold staff individually accountable for patient safety, when there
    are many causes that lead to such events, which are beyond the
    individuals control. The risks are inherent, and many times
    unpreventable. Even if preventable, changing one staff from the scene is
    not going to reduce the problem. There should be legal immunity for
    root cause analysis and clinical audit of adverse events, if one wants
    to build transparency. Transparency is needed to be demonstrated by the
    top management and encouraged down the line in a non punitive, high
    trust environment. We should collaborate to share and learn from other
    hospitals, and at National levels. There should be National data,
    analysis, prioritization based on our context, and improvements should
    be enabled -hospitals should be given resources for adequate
    reimbursement models from insurance that permit proper systems for safer
    care. Safety does require investment and comes at a cost! Clinicians
    need to be empowered and take up responsibility for clinical
    governance. Their workload should be within defined limits.
    We are
    getting much better at speaking up, reporting incidents, and audit
    (thanks to NABH). Let us collaborate more and extend this dialogue
    across the community.
    Once again, congratulations for your efforts and leadership focus on this subject.

    With best wishes

    Dr. Arati Verma
    Sr. VP, Medical Quality
    Max Healthcare

    • Excellent points – look forward to collaborating and learning! Our understanding of root causes of clinical incidents was vastly advanced by Prof Charles Vincent’s work and I totally agree that one should not hold individuals responsible for systemic weaknesses that may set them up for failure.

  • Dr sujeet Jha

    Abhisekh
    excellent…
    In UK Very typical three questions are asked in Interview for a Junior Doc
    1.When have last reported Drug adverse report form ( yellow form BNF) If you have not done you may not get the job?
    2.when you would say …. “You don’t know” ..would call someone
    3.If you have not done Audit…you would not get a job
    In some ways its reward system(job) which works in UK
    In private Hospitals in India..I think internal Audit should be awarded financially by Management and you can start distributing for eg 100% of OPD fees in case you are Auditing your prescription or if you are surgeon you are auditing Infection rate ….
    Or You can put those Doctors as star performers those who are Audting…
    I think Consumer(patients) should be told directly

    • I now have other topics besides just diabetes to discuss with you. Great suggestions!

  • Vivek Jaiswal

    Great article, Abhishek. It is assuring to come across people like you who have the courage to not only acknowledge a problem, but also openly accept that they are a part of it too. I admire your openness in sharing what is being done to improve patient safety at your hospital. I hope more healthcare leaders would follow suit.

    Pardon my naivety for I do not have much experience in healthcare. My comment stems from managing customer experience for global brands and applying those concepts into improving patient experience. I believe patient feedback plays an important role in patient safety too. While it is important to have the right attitude towards patient feedback, it is equally important to enable feedbacks to reach the right person in the quickest possible way. This could immensely improve transparency (one of the five concepts above) and trigger the most appropriate corrective action before things turn for worse. We are trying to implement enterprise grade feedback systems in hospitals to enable swifter, more impactful actions that improve patient experience and brings patient safety to centre stage through data analytics and technology. I am keen on learning more about your vision of sharing patient feedback data as mentioned above. I’m sure it would be an eye opener for me.

    • Thanks for your comment. We are using the Net Promoter Score to measure patient feedback and have implemented a closed loop system to act on the feedback. We need to extend the scope of our feedback which is currently limited to inpatients only, and we need to do better at making systemic changes for improving care. However we are glad to have started. Watch our blog for a post describing our feedback system and results!

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