Bonne Sante 2016 – Transparency in Empanelment & Regulation of Hospitals August – 2016 Strictly Private and Confidential 1

Agenda 2 Accreditations & Incentives Regulation of Providers “AS IS” Empanelment “AS IS” Challenges in Accreditations

3 Empanelment “AS IS” > Factors Empanelment of Healthcare Providers for any Scheme is based on – PIECE P - Peace thru Trust I - Infrastructure available E - Expertise available C - Cost effectiveness E - Emergency Services Across the country, the above factors have been in use – Combinations & Permutations Weightage variation The variations for the Empanelment are based on – Care variability o Primary o Secondary o Tertiary o Critical Geographic variability o Provider o Beneficiary Disease variability o Chronic vs. Acute o NCD vs. Infectious

4 Empanelment “AS IS” > Challenges Empanelment today, is a Utilization Centered Concept rather than a Patient Centered one, though some factors are inbuilt for patient care Myths – Higher Utilization is directly proportional to Higher Profit Better Quality Care costs More Money This sometimes leads to dilution of – Patient Rights Patient Safety Currently, there is no ‘stick or carrot’ for delivery of better quality of healthcare, at optimal cost. In India, even as consumers we also do not measure Healthcare Outcomes to determine utilization of a provider/doctor. The Doctor – Patient relationship is sacrosanct with no place for second opinions.

5 Empanelment “AS IS” > Way Ahead With mass schemes introduced, in the recent past, empanelment is now about the availability of healthcare across an array of services, geographies & specializations. Due to heavy utilization & stabilized operations, the next step is Measure of Quality in Healthcare Services & Facilities. There have been systematic surveys & studies which paved the way “Quality”, some of them being – 1.NABH – National Accreditation Body for Healthcare Providers 2.Clinical Establishment Act 3.WHO – Patient Safety Protocol 4.GoI Studies of Quality Assurance Guidelines esp. for the Reproductive, Maternal, Neonatal, Child & Adolescent Health (RMNCH+A) 5.JCI – Joint Commission International Accreditation The accreditation factors in – Outcome Based measurements Control Mechanisms & SOPs Continuous Improvement

6 Quality of Healthcare > Define “It” Quality of Healthcare is defined differently by different stakeholders Treating Doctor/Provider – ‘ The kind of care that would relieve the patient’s agony & restore health to the best possible level, irrespective of the cost involved’ Patient – ‘ The best possible treatment that is timely, safe, affordable & can restore health to my earning capacity at the earliest’ Quality Gurus – ‘ Quality is not an act, it is a habit & is done in the right prescribed manner, even when no one is looking’

7 Regulation > The “Need” Regulation – Defined as a rule or directive made & maintained by an authority In an ideal world, the healthcare providers are to be Self Regulated & Disciplined by practicing as per the Medical Gold Standard, Evidence Based Medicine. However, we do not live in an ideal world…….Hence the need to regulate The regulations followed are encompassed in the accreditation elements Hence, being an accredited provider would mean assessing, accessing & measuring processes to be more accountable to the end customer.

8 Accreditation > NABH Vision Interpreted – To create Patient friendly & safe hospitals, at par with global measures, through process of self & external evaluation The NABH standards are 102 with 636 elements; based on the Quality Approach of DMAIC – Define, Measure, Analyze, Improve & Control Major elements of NABH integrating to the MDG (Millennium Development Goals) Continuity of Care Care of Patient Management of Medication Patient Right & Education Hospital Infection Control Information Management Systems

9 Accreditation > Benefits & Challenges Accreditation benefits are manifold, the biggest benefactor being the patient Patients - Rights Safety Satisfaction Hospitals - Continuous improvements Community confidence Benchmarking Hospital Staff - Professional Development Capacity Building Regulatory - Legal & mandatory requirements fulfilled NABH accreditation is a tool to measure the degree of excellence in healthcare, however, is a tough cookie to crack More apt for bigger hospitals Expensive in application & implementation Time consuming High commitment levels required Higher rates of attrition observed Documentation & training needs effort Cross functional teams require to work in tandem Change management for measurement of results

10 TNCMHIS Empanelment > The future The future of Provider Networking for Mass schemes such as the TNCMHIS would be based on Accreditations like the NABH, however elements would need to be customized based on the size & location of the Hospitals. The incentives for being accredited are already in place, however there needs to a penalty approach too, if the non accredited hospitals continue to not follow the standards defined, within a time frame Disruptive mechanisms in Empanelment would encompass fair competition amongst hospitals to have the best measures of Quality Outcomes & Patient Safety Protocols

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