Along with a distinguished career in the Army Medical Corps (AMC), Air Marshal (Dr) Pawan Kapoor has also been one of the strongest voices in India’s Healthcare Quality movement. He has been a founder member of the NABH and continues to serve as a mentor to the NABH. He retired in December 2017 as Director-General, Medical Services of the Indian Air Force. During his years in the armed forces, he served as HOD for Hospital Administration in AFMC, Pune, and has been instrumental in setting up the Army College of Medical Sciences near Naraina, New Delhi. At present, he is vice-chairman, Ruseducation, which facilitates Indian students wishing to study medicine in Russian universities. In an exhaustive interview he discusses his long and distinguished journey in the field of Healthcare Quality. Edited Excerpts:
More than 10 years have passed since NABH’s formation. Are hospital managements showing greater interest in health quality and accreditation?
Prior to 2005, there was no system of accreditation and no consciousness of quality. The emphasis was on concealment rather than improvement. The Consumer Protection Act, applicable from 1989 onwards, provided an impetus, and concealment was no longer an option. After Indian standards were established in 2005-06, some hospitals began to show interest. At present, about 600 healthcare organisations (HCOs) and 218 small HCOs have been granted full accreditation while another 2,100 or so have received entry-level accreditation. Approximately 400 others have applied to NABH for accreditation. In terms of tangible impact, we find that many more hospitals are discussing quality-related issues and regular conferences are being held. Still, there is a long way to go – the number of HCOs in India is much larger than these modest numbers.
But have the improvements in healthcare quality been documented in the form of better clinical outcomes or fewer instances of Medical Adverse Events (MAE)?
Yes, they have. A 2016 study published in Asian Journal of Blood Transfusion Science reported that NABH accreditation resulted in reducing wastage of whole blood and blood components, as well as a lower frequency of transfusion reactions.
In both private and public hospitals, only 30 percent of incidents of medication errors were being reported before NABH assessment, and this rose to nearly 100 percent by the time it was completed. The corresponding figures for reporting hospital admissions due to adverse drug reactions or unplanned return to OT after surgery showed similar trends.
Some experts feel that financial incentives offered by CGHS or PMJAY for accredited HCOs have resulted in the distortion of the system, that HCO managements are trying to obtain the NABH certification for its own sake. Do you agree with this view?
I do agree that some distortions must have crept in over the years, because every system has certain loopholes. However, those who manage to game the system would be caught out during the post-accreditation surveillance and the renewal assessment after two-three years. They would then suffer a loss of reputation, and the gains of accreditation would be lost over time.
What was the origin of your personal interest in healthcare quality? Was it inspired by your experiences in the armed forces?
During my residency in AIIMS in 1992-94, I noticed that the emergency room was a very busy area with a continuous flow of patients. The doctors were brilliant but there was very little concern for the safety of patients. Consequently, we would find, for example, that a patient whose surgery went on perfectly later succumbed to a hospital-acquired infection! Hence, I developed my thesis on the topic “Planning and Design of Accident and Emergency Services in Delhi Metropolitan Area.” One of the consequences of my thesis was the setting up of the J P Narayan Trauma Care Centre in Delhi. That was the start of my involvement with healthcare quality.
What was your personal contribution as head of the Technical Committee and Accreditation Committee of the NABH? Who were your closest colleagues in the quality movement during those early stages?
In the beginning, I was requested to help create some standards for healthcare quality, but when the document was ready, it was rejected for being “too difficult to implement.” Even the corporate hospitals threw up their hands. Then the Quality Council of India (QCI), an autonomous body operating under the Government of India, put together a team headed by Mr Girdhar Gyani. Each of us had some special expertise: one was a clinician, another was a senior surgeon and I represented HR and support services, and so on. Our target was to put together a set of standards that would be implementable by Indian hospitals. We also had to sensitise the leaders of healthcare organizations, train the assessors for accreditation, etc. It was a humongous task. We consulted all kinds of medical and non-medical stakeholders and were soon able to get recognized by ISQua (International Society for Quality).
You mentioned that you had helped to lead a transformation in the armed forces medical corps. Could you please elaborate?
For the AMC, we had to initiate a lot of changes in infrastructure, Combat Medical Support, Information Technology training and many other facets. An important issue was cadre restructuring so that people from combat units would not be pulled out for super-specialty training. I am glad that most of the points in the blueprint got implemented and remains in effect even today.
What were the salient features of the project report for Army College of Medical Sciences?
This arose out of an observation that children of armed forces personnel were required to change their schools frequently because of transfers and posting of the parents. Hence, they were unable to compete in selection exams for regular medical colleges. The solution was for the military to set up its own medical college where children of military personnel were competing only against other similar students, giving them a level playing field.
After your retirement from the Indian air force, are you still associated with the healthcare quality movement in India and with NABH in particular? If yes, in what capacity?
When I retired from the IAF, I became even more closely associated with NABH. Thus, I have served in several capacities – Mentor for the Technical Committee, Chairman for Accreditation of Hospital Ethical Committees (that approve and supervise clinical trials) and so on.
During the early years of NABH, the top managements of many hospitals were skeptical of the value of accreditation. What was the reason?
Prior to 2005, there wasn’t much interest in healthcare quality among managements and hospital owners. They would point to resource constraints and heavy patient loads to justify this. Even then, the corporate hospitals sat up and took notice in 2005, when the first Apollo Hospital received accreditation from JCI (Joint Commission International), which is the international wing of the US JCAHO (Joint Commission for Accreditation of Healthcare Organisations). The main interest of the corporate hospitals was in facilitating medical tourism business. But JCI proved too expensive and too difficult under Indian circumstances. NABH was formed soon afterward and some hospitals turned towards it.
NABH has expanded its services to deal with small HCOs such as nursing homes, blood banks, Eye Care centers, etc and instituted a system of entry-level certification. Do you think this approach would result in the dilution of quality standards? Or would it help to spread the culture of quality among Indian HCOs?
Multi-level certification indicates an attempt by hospital managements to improve their quality performance. It is a journey with several steps. Hence a system that accords full accreditation or nothing at all discourages many organisations from even making the attempt. Likewise, NABH has separate standards for nursing homes, blood banks, eye care centres and others, because the full standards document may not be implementable. Thus, they may not need to meet the infrastructure and HR requirements of big hospitals, and still be able to offer excellent quality of services. This system enables a wide variety of HCOs to join the accreditation system.