On March 30, 2015, our hospital was awarded A+ grade in a six-monthly assessment carried out by the empanelment committee for the Rajiv Gandhi Jeevandayee Aarogya Yojana (RGJAY). The committee reviewed the self-assessment submitted by the hospital and cross-checked the information by applying National Accreditation Board for Hospitals and Healthcare Providers (NABH) Audit tool.
RGJAY is a public-private health insurance scheme, run in the 35 districts of Maharashtra, to meet the health expenditure of poor and underprivileged sections of society for identified diseases under 30 specialties—972 medical and surgical disorders and 131 procedures. The scheme is meant for below poverty line families—those with an annual family income below Rs 100,000. The major beneficiaries are patients with cancers, orthopedic and surgical problems, life-threatening illnesses requiring intensive care, and those presenting with accident-induced multiple injuries.
The scheme, launched in our hospital in November 2013, provides coverage for meeting all expenses relating to hospitalization of beneficiary up to Rs. 150,000 per family per year in any of the empanelled hospital in Maharashtra.
How do we run the scheme? The beneficiaries of the scheme approach Arogyamitra in our hospital who verifies their documents, registers them and helps them see a specialist. Our doctors assess the patients, investigate them, figure out if their disease is covered by the scheme and admit them. We obtain digital pre authorization from the insurer and extend cashless inpatient treatment and surgery to the beneficiary. All in-hospital documents are sent to the insurer, who scrutinizes and approves the the bill and pays the hospital as per agreed package rates. In addition, we provide free follow-up consultation, diagnostics, and medicines under the scheme up to 10 days from the date of discharge.
To assess the quality of healthcare in our hospital, the audit team used nine standards to measure us: human resources, facilities management, infection control, monitoring medication, patient medical records, standard operating protocols, quality in patient care, transparency in pricing and patient satisfaction indices.
A hospital, as the saying goes, is no place for sick people. Hundreds of thousands of patients visit the hospital seeking lasting relief from the myriad of disorders that hit them. In a teaching hospital, they are treated by a large team that often comprises of interns and residents who learn by doing it; nurses waiting to be adequately trained; technicians yet to perfect their skills; and surgeons on the learning curve. A team of experienced health professionals works with them: teaching them the right methods, correcting their mistakes and helping them acquire and hone clinical skills. Overlooking even one step can have irremediable consequences—surgical site infections, poor outcomes, medication errors, prolonged hospital stay— to name just a few.
“These deeply complex problems have a deceptively simple answer— Standard Operating Protocols (SOPs),” said Dr SP Kalantri, professor of medicine. “A short, straightforward medical checklist and standard operating practices can greatly reduce the chances of failure in life-or-death situations. And our residents, nurses, technicians, paramedics, administrators, and faculty —across the disciplines— not only learnt how to incorporate these standards in the patient care but also showed that these evidence-based SOPs can help us deliver healthcare- correctly, consistently, reliably and safely,” he added.
Take for instance, operation theaters. “We routinely assess all patients before they undergo operations; inform them the benefits and risks of an operation, explain them the pluses and minuses of the alternatives; administer surgical safety checklists, and use evidence-based practices in the operating rooms,”said Dr Vijay Sharma, assistant professor of anaesthesiology.
Hospital acquired infections often mercilessly hit hapless patients in the hospitals—bugs attack the surgical sites, infect mechanically ventilated lungs, wander in the bloodstream and thrive in the urinary catheters. We taught our residents and nurses how to recognize, track and prevent these infections by simple checklists. The audit team saw Google drives being used to collect data on ventilator-associated infections. No less innovative was the use of pivot tables to analyze outcomes—broken by department, ward and disease.
“Our door-to-needle time in treating heart attacks is less than 30 minutes, “pointed out Dr Sachin Agrawal, assistant professor of medicine. “We were often overlooking or omitting steps in the multitude of tasks we performed every day. The SOPs have helped us minimize our errors and maximize benefits,” he added.
“We blend public health with clinical care. This year, we organized about a dozen health camps in the communities we serve, and took doctors from diverse disciplines in the neighborhood villages. We made public aware of the scheme and were able to identify patients who could benefit from the scheme,” said Dr Ashok Mehendale, head, department of community medicine.
“We got to learn so much in the last 15 months,” said Dr Sachin Pawar and Dr Bharat Sontakke, assistant professors in physiology and anatomy. Entrusted with the task of implementing RGJAY in our hospital, they seized this opportunity to move beyond their departments to gather a rich experience. “We constantly see all stakeholders—patients, social workers, paramedics, nurses, doctors and insurance agencies. Indeed we found this assignment professionally rewarding and emotionally satisfying,” they said.