Grading of Healthcare Institutions - An Advanced Quality Assessment Tool

1. Grading of Healthcare Institutions - An Advanced Quality Assessment Tool Role of Grading in Health Insurance Amul Gogna Executive Director ICRA

2. 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

3. 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 < Iraq, 6 yrs < Brazil and 9 yrs < 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)

4. 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

5. …. Emerging Supply Trend • Short supply vs abundance • > 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

6. 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

7. Need for Quality Imperative for meeting country’s demand-supply gap Business imperative Fundamental to profession’s ethics

8. 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 uponpatient cooperation & body’s immune reaction difficult to predict Paucity of detailed outcome data in developing nations objective assessment of care delivery becomes difficult

9. 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 doctor’s visit • Unnecessary investigations

10. 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

11. 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

12. Quality Evaluation Models..

13. Our Strength • Grading matches our core competency-sector evaluation and analysis • Entered Indian market as a Rating Agency 15 yr. back-completed > 4500 assignments • Unmatched analytical strength-professionals from varied background • Diversified into offering credible opinion on >40 industry sector • Independence and Credibility of opinion • Societal needs mandated us to enter healthcare arena

14. 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.

15. 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 Categorisation of Hospitals

16. Categorisation of Labs and Blood Banks…. • Laboratories • Small • Medium • Large • Blood Bank • Storage Units • Stand Alone Units • Hospital Based • Regional Transfusion Centres

17. Validation of Benchmarks ICRA has established proprietary benchmarks based on: National and International Research on the subject

18. 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.

19. Healthcare Grading Concept…. Elements of Care Technical aspects of care Interpersonal aspects of care Select outcomes & Patient Feedback Resources Process  

20. 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

21. 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.

22. 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 Other Process Criteria….

23. 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

24. Voluntary Off site data compilation Consultancy offered On & Off site evaluation Independent Grading Committee awards grade Communicatedto institution Accepted, made public If not, kept confidential Regular monitoring for 3 yrs Grading Process

25. 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.

26. Benefits of Grading….. • Simple yet composite & robust indicator of scope of service • Facilitates comparison of value versus price • Consumers • 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

27. …..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 system’s capability & performance • Highlights efficiency of service

28. Our Grading Experience

29. Other Customised Studies…. • Team of dedicated healthcare analysts & professionals from different streams provides • More than 23 Grading assignments, 50 certifications and 5 consultations

30. Thank You