Patient safety improvements demand a complex system-wide effort, involving a broad range of actions in performance improvement, environmental safety and risk management, including infection control, safe use of medicines, equipment safety, safe clinical practice and safe environment of care.
Healthcare accreditation is one of the significant steps towards improving quality and patient safety. Amongst the several accrediting agencies across the world, the Joint Commission International, (JCI) stands out as the gold standard in healthcare accreditation. The patient safety journey for hospitals like the Apollo Group, formally started with Apollo Hospitals, Delhi becoming the first JCI accredited Hospital in India, in 2005. In the years to come, eight hospitals of the Group also became JCI accredited; taking the number of hospitals accredited by JCI to twenty-three in the country. The National Accreditation Board for Hospitals and Healthcare Providers (NABH) was formed after that, and today nearly three hundred hospitals are accredited by NABH across the country.
There is more to patient safety and health care quality beyond just accreditation. To further improve patient safety; Apollo Hospitals have taken several initiatives.
Patient Safety is defined as freedom for a patient from accidental or potential harm associated with healthcare, is an issue of rising concern all over the world. It is of foremost concern that ailing patients, coming to hospitals for treatment be protected from any further harm. So says even the Hippocratic Oath. Different healthcare organizations have gone the distance to tackle this global issue using different tools and to take examples from other industries like the airlines and nuclear reactors, where risk is carefully managed to prevent harm and create high-reliability organizations.
The Institute of Healthcare Improvement under the leadership of Don Berwick has laid down seven steps for improving patient safety. The first is to build a safety culture in the organization. The second step is to lead and support your staff. The third step is to integrate your risk management policy. The fourth step is to promote reporting. The fifth step is to involve and communicate with patients and the public. The sixth step is to learn and share safety lessons. The seventh step is to implement solutions to prevent harm. (www.ihi.org/)
One can understand the concept of patient safety encompassing the concept of “reliability.” It involves human lives. “Safety shows itself only by the events that do not happen” Erik Hollnagel had said. No one can understand it better than a patient harmed by medical error. Deaths and harm from medical errors are not inevitable but preventable. We must have this clarity of the task before us and commit to rolling up our sleeves and making it a reality.
There is more to patient safety and health care quality beyond accreditation. To further improve patient safety; Apollo hospitals have taken several initiatives. Apollo Hospitals have implemented standardized patient safety processes across their hospitals under the initiative “The Apollo Standards of Clinical Care” (TASCC) to set standards of clinical care to make it sure that all its hospitals offer safe and quality clinical care to all its patients, irrespective of location and size of the hospital.
TASCC comprises of the six components including Apollo Clinical Excellence @25 (ACE@25), Apollo Quality Plan (AQP), Rocket ACE (RACE), Apollo Mortality Review (AMR), Apollo Critical Policies, Plans and Procedures (ACPPP), Apollo Incident Reporting System (AIRS) and Safe surgery and ICU checklist.
ACE@25- Apollo Clinical Excellence @25
In the year 2008, the Apollo Hospitals Group completed its journey of twenty-five glorious years in the healthcare sector, which transformed the medical landscape of the country thereby creating an edifice that holds the hopes and dreams of millions. Keeping the expectations of our patients and the medical fraternity in mind, Apollo Hospitals created a dashboard, “ACE @ 25”.
“ACE @ 25” is a balanced clinical scorecard concentrating on clinical excellence, and incorporates parameters that are mission critical for the clinical milieu of the organization. This balanced scorecard directs on providing evidence based quality care and a safe environment for our patients and strengthening the functional capability of our hospitals, stimulating quality improvement while reducing variations.
The scorecard consists of two sets of indicators. Each hospital reports on a set of compulsory parameters and few location specific parameters defined for each hospital based on the availability of services. Each indicator has been lucidly described, and the numerators and the denominators have been delineated. Benchmarking establishes our Group expectations with weighted scores for the outcomes. The scoring system ensures that the segments measure up to a statistically significant range of figures which are further colour coded as green, orange and red. The cumulative score achievable is capped at 100. The ACE @ 25 balanced scorecards has been developed online, with live capabilities using our online ‘Apollo Lighthouse platform for monthly inputs with appropriate data, applying the Dot Net architecture hosted out of a central server at any one of our locations. The mechanism is so devised to keep the integrity and confidentiality of data concerning each of the Apollo Hospitals. The same also has an added layer of security over the web, lest any unauthorized personnel accidentally accesses it. To authenticate the data reported by the Group Hospitals, an ACE @ 25 audit team validates the records of all the Group hospitals. ACE is monitored in more than 35 hospitals of Apollo Group.
Few examples of ACE @25 indicators and institutes from where benchmarks are adopted. (Table1)
RACE – Rocket ACE
A dashboard of 25 clinical parameters was created to assess the outcomes of the six specialities under the Centers of Excellence (COEs). RACE safeguards that when the volumes increased the quality should not be compromised.
AQP – Apollo Quality Plan
Apollo Hospitals also detailed a comprehensive set of best practices by way of the Apollo Quality Program- A plan for the Group wide implementation of standardized procedures for clinical handovers, surgical care improvement, International Patient Safety Goals, zero medication errors, standardization of medical records, diagnosis and procedure codes and promoting innovation in quality improvement.
ACPPP- Apollo Critical Policies, Plans and Procedures
Apollo critical policies, plans and procedures were extended into 25 policies covering clinical care, managerial processes, nursing care and utility systems and infrastructural requirements. All Apollo Hospitals have established and implemented policies to address these processes. Prototype systems were provided to all hospitals which could customise these policies as per their procedures and processes.
AMR- Apollo Mortality Review
Triggers were recognised for mortality reviews to be conducted by all the Apollo Hospital. The deaths qualifying as triggers were also considered as per a predefined peer review checklist, presented in a mortality review meeting and categorised into defined categories. Sequential monitoring using statistical process control methods were used in the early identification of unfavourable trends. Formal, structured review of all deaths helped detect quality issues that would otherwise remain hidden, particularly around everyday processes of care.
AIRS – Apollo incident reporting system
Apollo Hospitals endeavoured to establish precise systems for reporting of information related to particular patient and staff incidents/near misses, along with some other serious health care errors and all sentinel events to the central leadership and to give a mechanism of tracking, trending, and follow-up of all such incidents that posed an actual or potential safety risk to patients, families, visitors and staff. These included patient fall rates, patient pressure ulcers, needlestick injury rates, missing patient records and legal cases. Hospitals with higher rates were advised for the improvement measures and to follow best practices being adopted by other hospitals. By concentrating on the events experienced by patients, our hospitals encouraged to promote a culture of safety that changes from individual blame for errors to comprehensive system redesign that decreases the chances of patient suffering and harm.
Surgical safety was assured through preoperative site marking, preoperative checklists and a final verification check before the start of any surgery by the whole operating team called the ‘timeout’. At the same time, we developed in consultation with intensivists and anaesthetists, a different checklist which was used in all the ICUs for every patient admitted. The ICU checklist of care included issues that were discussed daily for every patient in an intensive care unit and corrected deter omissions and mistakes wherever possible. It eased memory recall, especially with routine matters that were easily overlooked in patients undergoing more drastic events. It made explicit minimum, expected steps in complex processes. The checklist augments the daily, multidisciplinary team rounds and alerts the doctor when necessary items have been missed. Also, the ICU team’s collegiality and team bonding were improved by using an evidence-based tool to achieve the care goals. Both Safe Surgery Checklist and ICU Checklist implementation across the Apollo Group is closely monitored using defined indicators.
TASCC was an extensively planned program which monitored and evaluated specific indicators and the clinical and internal processes involved in patient care. Besides this, it assisted in identifying opportunities for development and provided a mechanism through which action was taken to make and sustain those reforms. Also, TASCC sought to enhance patient care and outcomes through systematic review of care against clearly defined criteria. This evaluation aided in achieving a better quality of patient care and service delivery leading to better utilisation of resources and lowering costs in the long run. In this manner, TASCC makes up the double helix of the Apollo Group’s clinical fabric. The institution of this program scorecard has helped improve the clinical care in the Group Hospitals, with most hospitals showing a steady improvement in their scores, taking them beyond just accreditation.
- WHO Patient Safety 2016
- Leadership guide to patient safety
www.ihi.org › Home › Resources › IHI White Papers
- ‘’Resilience Engineering: Concepts and Precepts’’ by Erik Hollnagel, David D. Woods, Nancy Leveson, Ashgate E-book