AHPI’s 4th Global Conclave on Healthcare Delivery at Chennai during 10-11 February 2017

December 24, 2016 by · Leave a Comment
Filed under: Announcements, Events & Updates, Healthcare Quality 

AHPI is organizing its 4th Global Conclave at Chennai during 10-11 February 2017. The Conclave will deliberate on Future Model of Healthcare delivery in the form of INTEGRATED CARE. The sessions have been uniquely designed to bring hospitals and allied healthcare industry including pharmaceuticals, medical equipment and IT industry among others under one umbrella to deliver seamless, safe and affordable care across regions. The Conclave has been conceived to offer road map for delivery of universal health care for developing nations. Special interest sessions and activities will be on anvil for delegates from SAARC and ASEAN countries.

Click here for more information



AHPI Speakers


For any other information / clarifications on registrations, please reach out to :

Ms.Rama Venugopal | Executive Director | M/s.Value Added Corporate Services P Ltd | “VANITHA”, No 5, Third Avenue, Besant Nagar, Chennai – 600090|

Ph:+91 044 24462337/38| Email: rama@valueadded.in|Mob :9840870532




Britain’s Patient-Safety Crisis Holds Lessons for All

November 6, 2013 by · Leave a Comment
Filed under: Healthcare, Hospital, Patient Safety 

A post by Maureen Bisognano in Harvard Business Review here

In August, Dr. Donald M. Berwick presented the report from the independent National Advisory Group on the Safety of Patients in England (A Promise to Learn — A Commitment to Act: Improving the Safety of Patients in England) to Prime Minister David Cameron in London. The “Berwick Report” reflects on serious problems at the Mid Staffordshire NHS Foundation Trust that arose over several years, and the abysmal care received by patients at the trust’s Stafford Hospital in Stafford, England, during that time. I served on the advisory group, and I’m still asking how a trusted organization could deteriorate so completely without the leaders’ awareness or action? Could it happen elsewhere? How can we, as leaders, prevent these failures in the future?

Read more

The Journal of National Accreditation Board for Hospitals & Healthcare Providers

October 30, 2013 by · Leave a Comment
Filed under: Announcements 

NABH is in process of publishing its Journal “The Journal of National Accreditation Board for Hospitals & Healthcare Providers”. The Aim of the journal is to provide an international forum for quality assurance issues of concern to professionals in the pharmaceutical, health and environmental industries, and to promote excellence in practice in these fields.The journal will address research, policy, and implementation related to the quality of health care and health outcomes for populations and patients worldwide. Read more

6 Steps to Encourage Patient Safety Innovation at Hospitals.

December 29, 2012 by · Leave a Comment
Filed under: Healthcare, Hospital 

Following evidence-based practices is critical for preventing harm in a healthcare setting. However, what happens when there are no evidence-based practices? Hospitals are being called upon to innovate and create patient safety protocols to fill gaps in the literature and adapt existing practices to different environments.

Detroit-based Henry Ford Health System has been recognized nationally for its commitment to patient safety and its innovative solutions to challenges. It was awarded the 2011 Malcolm Baldrige National Quality Award and the John M. Eisenberg Patient Safety and Quality Award in 2011 for reducing system-wide harm events by 34 percent and system-wide mortality by 12 percent from 2008 to 2011. William Conway, MD, senior vice president and chief quality officer of HFHS and CMO of Henry Ford Hospital in Detroit, and Sue Hawkins, senior vice president of performance excellence at HFHS, share six steps hospitals can take to drive innovation in patient safety.

1. Create a robust patient safety program. To encourage patient safety innovation, hospitals have to first create a structured program of patient safety and an infrastructure that enables people to test and share ideas. HFHS started the “No Harm Campaign” in 2008 with a goal of reducing harm events by 50 percent by 2013. The campaign has a clear structure, including committees dedicated to different kinds of harm and monthly reporting requirements.

2. Develop a culture of safety. Fostering innovation also depends on a strong culture of safety in the organization. Ms. Hawkins says HFHS develops this culture through educational offerings and training. The system also assesses leaders’ and staff members’ perceptions of the culture through surveys.

The employee engagement surveys also include questions related to safety assessment, from how leaders promote a culture of safety to how employees address safety concerns that arise. As part of the curriculum, each employee receives a tool kit and individual coaching on communication about safety as necessary. Leaders are expected to improve culture in their areas based on feedback from the survey. All HFHS leaders are also trained in managing a just culture when errors do occur.

3. Hold people accountable. Holding people accountable for patient safety in the organization motivates them to find ways of overcoming challenges to meet goals. In the No Harm Campaign, HFHS’ definition of harm includes all types of harm, whether preventable or not. “When you’re holding the team accountable for improvement, they have to come up with innovations because if something appears to not be preventable, it’s forcing you to fix it, to come up with new approaches,” Dr. Conway says.

For example, following standard best practices to reduce catheter-related blood stream infections in hemodialysis patients resulted in only modest improvements at HFHS, which motivated the team to develop new best practices. HFHS established an antibiotic lock protocol, in which a solution of gentamicin and trisodium citrate is instilled into the catheter lumen after each patient’s dialysis session. This practice has led to a 34 percent decrease in dialysis mortality since its implementation in 2008.

In addition, HFHS was innovative in its approach to managing anticoagulants, which is one of the highest risk medications. The team developed the Pharmacist-Directed Anticoagulation Service in 2008, a practice in which pharmacists direct the dosing of anticoagulants and follow certain protocols to manage the medications.

4. Pilot programs.
 Specific patient safety protocols don’t have to be an all-or-nothing venture. In fact, piloting new projects provides an opportunity for leaders, physicians and staff to innovate, test new ideas and refine practices that can then be shared system-wide. Ms. Hawkins says results of pilots are shared with a steering committee all the way up to senior leadership and the board quality committee to evaluate their success.

5. Partner with researchers. Researchers can support innovation by testing new theories and providing data to support new practices. HFHS has a significant focus on research. “We’re a big research organization, so we have lots of physicians and scientists who love to dive into data. If we see blips we don’t understand, we take a harder look at what’s happening, brainstorm ideas and test them,” Ms. Hawkins says.

6. Participate in outside patient safety programs.
 Participating in regional or national patient safety programs can spur innovation by enabling different organizations to share their successes and failures. For example, HFHS participates in the Institute of Health Improvement programs, which inspired the system to create its own method of measuring patient safety metrics, according to Ms. Hawkins.



Medical Errors and Litigations are they preventable?

July 10, 2012 by · Leave a Comment
Filed under: Hospital 


Medical Errors and Litigations are they preventable?

The number of medical litigations is increasing worldwide. That does not necessarily reflect the quality of healthcare givers as much as it reflects the public expectations and awareness. Implementing healthcare quality standards is a key factor in maintaining public trust and significantly reducing the medical errors, ultimately reducing medical litigations. A comprehensive Enterprise Risk Management Program, focusing on patient and staff safety, is what is recommended for all healthcare organisations to harbour and implement.

Medical error is a preventable adverse effect of care, whether or not it is evident or harmful to the patient. This might include an inaccurate or incomplete diagnosis or treatment of a disease, injury, infection or other ailment. Medical errors happen when something that was planned as a part of medical care doesn’t work out, or when the wrong plan was used in the first place. Medical errors can occur anywhere in the healthcare system hospitals, in clinics, outpatient surgery centres, doctors’ offices, nursing homes, pharmacies or even in patients’ homes.

How big is the problem?

According to the 2005 commonwealth fund International Health Policy Survey, it is estimated that 22 per cent of admitted patients in UK hospitals experience a form of medical error. This is estimated to be around 23 per cent in Germany, 25 per cent in New Zealand, 27 per cent in Australia, 30 per cent in Canada and 34 per cent in the United States of America.

Comparable figures are not available for the developing countries. Under or non-reporting is the main reason for the unavailability of accurate medical errors data in the developing countries. This is mainly due to the unavailability of a robust reporting system with clear case definitions and accountability for reporting. The fear of litigation and the absence of a legal safeguard are added factors.

Can we prevent medical errors and hence litigations?

It is of extreme importance to define the common causes of failures in the healthcare environment in order to prevent errors from happening. Root cause analysis is the preferred method to highlight the real causation. Individual staff negligence, on the average, constitutes less than 10 per cent of the root causes for medical errors. Therefore 90 per cent are correctable system issues that need the utmost attention of healthcare organisations. Communication failure is the leading root cause followed by lack of proper orientation and on the job training, proper patient assessment with missing vital information, staff credentialing, privileging and competency assessment, compliance with policies and procedures, safety of the environment, leadership, lack of care continuum and care planning and finally the organisations own culture. Physicians and nurses usually fail to communicate due to a historical hierarchical issue, past and vast experience of nurses and their level of empowerment and finally due to the different personal communication styles.

A comprehensive enterprise risk management programme, focusing on patient and staff safety, is what is recommended for all healthcare organisations to harbour and implement.

Enterprise risk management and patient safety

In general, risk management is the process of identification, assessment, and prioritisation of risks followed by coordinated and economical application of resources in order to minimise, monitor, and control the probability and / or impact of unfortunate events or to maximise the realisation of opportunities. In enterprise risk management, a risk is defined as a possible event or circumstance that can have negative influences on the enterprise in question. Its impact can be on the very existence, the resources (human and capital), the products and services, or the customers of the enterprise, as well as external impacts on society, markets, or the environment.

There are 2 main approaches to risk management

The proactive approach: Works on forecasting and identifying risks and designs or implements well known and tested solutions to prevent it from happening. This approach has shown by time to be the most effective, but requires a lot of skills and experience.

The reactive approach: Where all errors are collected and analysed, focusing on finding common system issues that could be corrected in order not to repeat the same error. It is much simpler than the pro-active approach but still requires skills, dedication and expertise.

Proactive risk management

Improve communication

Most organisations find the I-SBAR communication acronym to be a very useful pro-active tool to be utilised in all patient care related communications. It definitely eliminates the nurse / physician sensitive issue as well. The acronym stands for

“I”   :    Introduce yourself and the reason for calling
“S”  :    Situation for the patient (age, gender, general condition)
“B”  :    Background of relevant details, including medical history
“A”  :    Assessment and the related findings
“R”  :    Recommendation/request

Failure of hands off written communication between shifts

This is a well-recognised cause for medical errors. Hands off communication occur between the same category of healthcare givers (for example physician to a physician) at the end of a shift or the beginning of a new shift. The Agency for healthcare research and quality advocates the use of the ‘Five Ps’ for hands off communication which stands for: patient, plan, purpose, problems and precautions.

Multi-disciplinary patient care meetings

At times the most responsible physician is unable to reach a diagnosis or formulate a definite plan of care for his/her patient. This is the time to call for a multi-disciplinary meeting involving all healthcare givers looking after the patient and also to invite suggested specialities that may help in solving the problem at hand. It is best to involve the patient/family in the outcomes of the meeting with full explanation so all agree on what is required to be done. The meeting is to be carefully documented in the patient’s file, including the patient / family understanding and agreement.

Standardised verbal and telephone orders

This is a common cause for errors related to receiving test results or orders. Verbal orders should be limited to emergency situations when there is no time to appropriately write the order required. The staff receiving the order should acknowledge hearing the correct order by verbally repeating it to the ordering staff. The ordering staff should immediately write the order as soon as the emergency is over. Telephone orders should be repeated in a read back fashion, whereby the receiving staff immediately writes the order in the file and reads it back to the ordering staff.

Credentialing and privileging

The credentials of each and every healthcare giver should be carefully studied by a group of experts to ensure that the staff has the right qualification and experience necessary to carry on the job description of the desired post. It is of utmost important to check on the authenticity of the evidence of qualifications and experience by contacting the source where the certificate originated from. Physicians are assigned what their qualifications and experience allows them to perform in clinical practice (privileging). This could be further categorised to include what is allowed to be performed with and without supervision to enhance their training. All privileges has to be available to all ancillary staff in areas where procedures are performed, in order to ensure that the physician is performing what he/she is allowed to only. The process of credentialing and privileging should be periodic to cover the initial assignment period and any further contract renewals and it also has to be flexible to allow for revision of a physician’s privilege or credentials when the need arises (recent morbidity, new certification in a procedure or a new qualification).

Development, use and monitoring of clinical practice guidelines and clinical protocols

Evidence-based guidelines and protocols, targeting the management of high risk diagnoses, the high volume or the problem prone cases, have proven to improve clinical outcomes. It also serves as a legal back up in a court case.

Accountability of the attending physician

It is important for attending physicians to review all consultative orders and plans requested by other physicians and healthcare givers to ensure uniformity of care and avoid conflicts in plans. Coordination of care, for example by case managers, does not substitute the accountability of the attending physician.

Professional development

This is an integral part of any human resource plans. Organisations should always encourage the staff to seek higher degrees and training by providing them with time and opportunities for learning.


Standardised assessment and re-assessment forms

To ensure that all information required for patient management is available at any time for all healthcare givers.

Electronic medical records

In addition to its great value in standardising the process of documentation, it also provides a safer platform for medication management as it eliminates transcribing errors, alerts physicians of possible interactions, maintains a drug profile for each patient and helps in administering the right drug to the right patient in the right dose and format and at the right time and saves a confirmatory document.

Ongoing monitoring and evaluation of staff performance

It is very important to have an objective assessment tool that highlights areas of weakness in the staff members for further improvement. This tool includes, but not limited to, personal interactions, reports on clinical outcomes (length of stay patterns, ordering of blood and blood products, operating times and patients’ returns to operating room, significant morbidity, preventable mortality, compliance with patient safety goals), self-professional development and quality of medical records documentation.

Patient safety goals

Implementation and monitoring of patient safety goals has proven to reduce errors related to patient identification, communication, the use of high alert medications, wrong site, wrong procedure, wrong patient surgery, patient falls and healthcare acquired infections.

Structure and process design

It is very important to realise that patient outcomes are very much linked to the way a procedure was designed to be executed or the design of the place where the procedure takes place. Therefore, any new procedure to be modified or introduced to the organisation or a modification to an existing area or constructing a new procedure area has to be studied carefully by a multidisciplinary group that have the skills and knowledge to reach a safe procedure or design.

Active patient and family education and participation in the care process

A well-informed patient and family can rarely complain about outcomes, especially with effective documentation.

Reactive Risk Management

Healthcare organisations must track all incidents, morbidities and mortalities. Risk management team should be involved in analysing all such events and putting together corrective system recommendations to prevent it from recurring. Hospital staff should receive a periodic feedback on the events and a summary of the recommended corrective actions. Examples of the possible tracking methods include:

  • Compulsory reporting of accidents, variances, sharp injuries, medication errors, adverse drug reactions, blood transfusion reactions and patient falls
  • Audits, targeting a specific procedure, diagnosis or staff member
  • Open and closed medical records review
  • Trigger tools
  • Reporting of sentinel events and near misses
  • Morbidity and mortality reviews.

Finally, it is obvious that all this requires a change in the culture of organisations and individuals to move from a physician oriented and controlled practice into a team work within the borders of an evidence based system of patient and staff safety. A system where transparency is the rule and information is shared in order to establish further improvements and actively prevent errors from happening.

QCI urges hospital managements not to compromise with patients safety

December 31, 2011 by · Leave a Comment
Filed under: Hospital 

QCI urges hospital managements not to compromise with patients safety
December 30, 2011, 0800 IST – Source : Pharmabiz News

Quality Council of India (QCI) has urged all the healthcare providers in the country to ensure that they follow all quality standard guidelines recommended by the government to avoid any complications that may compromise patients safety in the hospitals. This demand comes in the wake of the devastating fire at Amri Hospital that claimed lives of 190 people due negligence on the part of the hospital.

With a view to ensure that all the hospitals in the country are sensitised about the importance of following all the quality and safety regulations, QCI had recently organised its first national quality conclave for the healthcare sector in Bangalore. The conclave focused on enhancing the quality in healthcare system of the country and deliberate on the issues that hinder in deliverance of quality service.

According to Rajendra Pratap Gupta, member, Healthcare-Quality Council of India, “It is not possible to provide accreditation to all the hospitals at once since its takes a lot of time as well as man power to do that. However it does not mean that the hospitals that are not under National Accreditation Board for Hospitals and Healthcare Providers (NABH) should fall behind. We want the healthcare providers to understand that accreditation is important but at the same time it is not beyond quality. We want to ensure and change the way things are perceived today by stressing on keeping up with our motto to ensure quality healthcare in the country.”

He informed that as on date NABH, which is a constituent board of QCI has accredited nearly 140 hospitals and another 500 plus hospitals are preparing for accreditation in the country. The accreditation programme by NABH covers all the facets of patient safety including surgical safety, medication management, hospital infection and patient communication. The primary goal of accreditation is to ensure that the hospitals not only perform evidence based practices but also give importance to access, affordability, efficiency, quality and effectiveness of healthcare. However, he stressed that though approval is essential steps must be taken to look beyond accreditation to address and deal with quality issues in the present healthcare system.

The conclave that was co-organised by Bronze Certification of Lean by Simpler UK at M S Ramaiah Medical College & Hospital in Bangalore provided critical inputs pertaining to various facets of quality in healthcare.

“Quality in healthcare is of paramount importance as it directly impacts human lives and unlike quality in other sectors, quality in healthcare relates to a hospital monitoring and measuring clinical outcome on a continuous basis. Through this conclave, which will be a quarterly event, we want to bring in all the healthcare providers under the same roof so that we can exchange new ideas and deliberate on issues and challenges that will have a far reaching effect on the way healthcare system is dealt in the country,” Gupta said.

He further informed that looking at the quality issues in the East zone, QCI has decided to organise the second conclave in Kolkata in March next year followed by west and north zones respectively.

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