Grading of Healthcare Institutions An Advanced Quality Assessment Tool

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Grading of Healthcare Institutions - An Advanced
Quality Assessment Tool

• Role of Grading in Health Insurance

Amul Gogna Executive Director ICRA
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Issues Considered

• The emerging healthcare trend in India
• The need for Quality in Healthcare
• Existing External Quality Assessment Models
• What should be the Assessment methodology?
• Role of Grading
• Benefits of Grading

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Indian Scenario.

• India spends 5 GDP on health, highest amongst
  the developing countries (WHR-01).
• Health status of India as measured by DALE is 2
  yrs lt Iraq, 6 yrs lt Brazil and 9 yrs lt China
  (WHR-01).
• Pvt medical care infrastructure
  (profit/non-profit/charitable)- captures approx
  65 of total health care spending- highly
  fragmented (National Accounts Statistics, 01)

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Emerging Demand Trend .

• Out-of pocket consumers
• Increasing importance being accorded to health
• Increasing access to information
• Increasing quality consciousness
• Comparison Shopping

• Employers (as a payor)
• Economic liberalisation in India - emphasis on
• prudent mgmt
• Focussing on controlling healthcare costs

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. Emerging Supply Trend

• Short supply vs abundance
• gt 15,000 registered hospitals around 0.8 million
  beds
• On nationwide basis, - shortfall of 1.5 - 2
  million beds according to WHO
• But, in some pockets Over capacity as soon as
  2005
• Entry of Private players
• Gap in capacity met by private voluntary sector

• Health insurance
• Till recently, relatively cumbersome, restrictive
  under-marketed
• Better HI products ? significant growth of
  insured base
• Emergence of multi-location healthcare providers
• Inherent economic advantages

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Outlook on Emerging Trend

• Middle/high income group has increased choice of
  providers
• The underprivileged continue to throng
  state/voluntary
• infrastructure-which might also reduce with HI
• Increasing competitive intensity in urban health
  care sector
• Altered key success factors

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Need for Quality
Imperative for meeting countrys demand-supply
gap
Business imperative
Fundamental to professions ethics
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For Consumer Application of Quality
fundamentally difficult.
Consumer unaware of ailment/therapy
technicalities ? cannot choose intelligently
between therapeutic choices
Consumer unaware of outcome certainty ? cannot
frame expectations intelligently
Outcome success depends upon patient
cooperation bodys immune reaction ? difficult
to predict
Paucity of detailed outcome data in developing
nations ? objective assessment of care delivery
becomes difficult
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For Health Insurance Challenges Are Complex

• From Service Providers
• No standardised costing system
• Inflated and manipulated bills
• Wide unexplainable variation of fees between
  surgeons and hospitals across the country
• No objective indicator for quality service
• Increased no. of doctors visit
• Unnecessary investigations

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For Health Insurance Challenges Are Complex...

• From Consumers
• Hidden facts-pre-existing ailments often covered
  in nexus with/without doctors
• From Regulators
• Cannot introduce newer products without formal
  approval
• From Product Itself
• Product pricing based on competitive pricing and
  not necessarily on actuarial science
• Predominantly products covers diseases and not
  health--products designed for IP admissions (40)
  not OP services

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For Health Insurance Challenges Are Complex...

• From TPAs
• Inadequate scrutinisation of bills-Increased
  claim ratios
• List of exclusions mostly get included due to
  negligence--e.g HI also ends up paying for
  glocometer, exclusions valid in the 1st yr. of
  policy
• Doctors appointed are inadequately qualified-from
  alternative system of medicine
• Nexus between hospitals and TPAs to get higher
  of share

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Therefore a quality assessment model should be
able to.
Define the complexity intensity of care
provided in healthcare institution
Lastly, act as a positioning assessment tool
for hospital.
With these objectives alone it will be
beneficial to all the stakeholders
Add value to the service
Bridge the knowledge gap between healthcare
facility patient's expectations
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Quality Evaluation Models..
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Our Strength

• Grading matches our core competency-sector
  evaluation and analysis
• Entered Indian market as a Rating Agency 15 yr.
  back-completed gt 4500 assignments
• Unmatched analytical strength-professionals from
  varied background
• Diversified into offering credible opinion on gt40
  industry sector
• Independence and Credibility of opinion
• Societal needs mandated us to enter healthcare
  arena

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ICRA Grading Methodology
ICRA Limited has developed the methodology for
Grading of Healthcare Entities in association
with Hospital Services Consultancy Corporation
(India) Limited, a wholly owned company under the
Ministry of Health Family Welfare, Government
of India.
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Categorisation of Hospitals

• Primary Care
• Ambulatory Care
• Clinic
• Center
• Nursing Home
• General
• Advanced
• General Hospital
• Small size
• Medium size
• Large size

• Specialty Tertiary Care
• Single
• Multi- Teaching / Non-Teaching
• Super Specialty Hospital
• Single
• Multi -Teaching /Non-Teaching
• Chronic Care Centre

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Categorisation of Labs and Blood Banks.

• Laboratories
• Small
• Medium
• Large
• Blood Bank
• Storage Units
• Stand Alone Units
• Hospital Based
• Regional Transfusion Centres

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Validation of Benchmarks
ICRA has established proprietary benchmarks based
on
National and International Research on the
subject
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Grading The Bottomline
Grading is an Independent Opinion on Quality of
Care a Provider is Capable of Delivering
Evaluates capability to deliver quality of care
from the user's (patient's) perspective. Not an
opinion on the correctness of diagnosis or the
probability of outcome of any therapy or surgery.
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Healthcare Grading Concept.
Elements of Care
Technical aspects of care
Interpersonal aspects of care
Select outcomes Patient Feedback
Resources
Process
?
?
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Resources.

• Core resources
• 1. Infrastructure, equipment and technology
• 2. Staffing
• 3. Financial stability
• 4. Governance and Management

The focus of assessment is on numerical
technical adequacy and appropriateness (number
and type) and availability (distribution) of
resources
Quantified as vital, essential and desirable and
scored
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Process
Patient Flow
Emphasis on the appropriateness of design
execution of CORE patient processes- effective
care delivery
Clinical Process
Emphasis on assessing robustness of clinical
decision making process assess variance in
activities.
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Other Process Criteria.

• Patient Safety
• Risk Management
• Documentation-evaluated for its adequacy,
  reliability accuracy.
• Medical records,Prescriptions, Direct
  observation by experts
• Research and Development w.r.t patient care
• Regulatory Compliance
• Hospital's registration, Fire other clearances,
  BMW mgmt
• Medical Ethics-
• Patient care patient/family rights issues
• Continuum of care
• Social Ethics

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Select Outcome Criteria

• Clinical
• Clinical credentialing-ALOS, BOR, BTR,
• Clinical audits-Medical Audit, Tissue Audit
• Clinical risk mgmt-HAI Cross Infection Rate,
  IMR, NODR
• Clinical effectiveness measurement-success rate

• Non-clinical
• Patient satisfaction survey - Random exit
  interviews
• Designed to record care orientation of Hospital
  staff
• (interpersonal aspects) Patient flow processes

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Grading Process
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Grading Symbols Definition
ICRA grades both the healthcare unit as an
institution specialities within the institution.
Grades are represented symbolically from H1 to H4
with further fine tuning of /- within the broad
bands of H2 and H3 Grade.
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Benefits of Grading..

• Consumers

• Simple yet composite robust indicator of scope
  of service
• Facilitates comparison of value versus price

• Medical comm. Healthcare Service providers

• Focus on functionality, Fosters commitment X
  compliance
• Minimally intrusive- Transparent, Provides
  feedback
• Grading-a positioning tool to
• Build patient perception Improves credibility
• Benchmark services in the peer group
• Grading-an assessment tool to
• Get a thorough, independent objective review

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..Benefits of Grading..

• Payors

• Public Sector Units, Health Insurers and TPAs
• Objective tool for selecting preferred providers
• Indicator of efficiency of service--can reduce
  cost
• of care and reduce the claim ratio
• Lenders and Investors
• A key input for business risk assessment

• Healthcare Regulators

• Indicates the healthcare systems capability
  performance
• Highlights efficiency of service

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Our Grading Experience
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Other Customised Studies.

• Team of dedicated healthcare analysts
  professionals from different streams provides
• More than 23 Grading assignments, 50
  certifications
• and 5 consultations

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Thank You