NABH has become a FARCE
National Accreditation Board for Hospitals and Healthcare (NABH) was started with the noble intention of bringing quality into Indian Healthcare. For the first 10 years of its existence the board was doing all the right things by motivating the top healthcare organizations for taking NABH accreditation. Top hospitals in the country were working hard to get the coveted Certification by adopting NABH standards with full honesty and dedication. Standard Operating Procedures (SOPs) were not only made but also implemented and non-conformity to these standards were being rectified. By 2015 there were 267 hospitals in the country which got the NABH certification. Not all of them were in full compliance of the NABH standards but most of them were.
By this time, NABH had created a pool of Assessors who wanted business. Since NABH was not known amongst the patients so there was no advantage for most of the hospitals to go for the Certification. Instead of creating a Brand pull for the NABH certificate, the board decided to go the `sarkari’ way. It convinced the Insurance Regulatory and Development Authority (IRDA) to pass a circular that only those hospitals which will have NABH certificate will be entitled for Cashless empanelment with the TPA’s and Health Insurance companies. At that point of time there were close to 9000 hospitals on the cashless panels of various insurance companies. The time given to these hospitals was 2 years which passed without any kind of movement on the part of the hospitals to go for NABH. Now IRDA had no choice but to extend the timeline for another year till July 2019. The game was very obvious – minting money for NABH. Which certification body will charge a hospital Rs. 1.65 – 4.40 lacs per year for getting such a certificate. When you give your Secondary, Higher Secondary or any other exam do you pay one time fee for getting that degree or you keep paying every year for the rest of your life. The logic behind annual fee for NABH Certification is beyond comprehension. You pay annual fee to an organization which provides you services every year but NABH is not providing any kind of annual service to the member hospitals. I have never seen any kind of TV commercial or a magazine advertisement to promote the brand value of this certification amongst the general population. NABH then managed to get the CGHS, ECHS and other Public Sector undertakings to link the payment with the NABH certification. Here also no extra money was being given to the hospitals which had this certificate but the hospitals which did not possess the certificate were docked 10% of the service fee.
The number of full NABH hospitals increased from 267 in 2015 to 968 by April 2020 and consequently the annual fee from these hospitals jumped from 4 Crores to 15 Crores. This was a windfall for Quality Council of India which owns the Healthcare Accreditation Board.
Now came the big move which has turned NABH Certification into a complete farce. Another level of certification called `Pre Entry Level’ was introduced with reduced standards and almost one-fifth objective elements. This is the golden goose for the Assessors and the Board which they can milk for several years in the future. The NABH Assessors who now number close to 2000 went to these hospitals masquerading as `Quality Consultants’ and promised the remedy for the removal of the Damocles Sword hanging over the head of these hospitals. This sword was the removal from the Cashless Empanelment of the insurance companies if the hospitals fail to achieve `Pre Entry Level’ by July 2019. The consultants were charging 2-2.5 lacs for getting you the certifcate. Yes they did manage to get the entry level certificate for more than 8000 healthcare organizations which is now being boasted by NABH on its website. So how was this feat achieved in just one year. The quality consultants copied the SOP’s and forms from one hospital to the other by just changing the hospital names using `Control F’ command in Microsoft Word. The hospital staff was assigned the task of filling up the forms and completing the files. The `Assessor’ came on the due date with flight tickets which were also booked by the hospital and in some cases returned home with fancy gifts. The certificates were issued in hordes and within no time the entire healthcare industry in India had the coveted NABH Certificate hanging on their walls. Most of these hospitals never had a nursing superintendant or an infection control nurse but hired these professionals for the day of the inspection. The farce was played out beautifully and everybody was aware of the reality. The hospital owners were paying fee to NABH for a certificate which is not even worth the paper on which it is printed. The only objective of getting the certificate was to avoid getting de-empanelled by the insurance companies. The golden goose is ready to be cooked and the hospitals will be milked by NABH for years to come. Once all these 8000 healthcare organizations get full NABH, the fee of the board will be in excess of a whopping Rs. 200 crore year after year. For an organization which has 29 employees as per their website this is a windfall.
So who is paying the price. It is not the patients because they can’t care less about the NABH status of a particular hospital despite of what the hospital administrators wish to think. It is actually the hospital owners who are paying the price for this mockery of the Quality Standards. They are paying money to the `Consultants’ and to NABH for no real improvement in the Quality of their services. If you go to any of these hospitals, not even 10% of the staff would have an idea about the relevant standards and the objective elements. The wise heads who created these standards did a wonderful job but those who are milking the product are doing grave injustice to the hard work of these enlightened people.
If the NABH standards are implemented in letter and spirit then real quality would be achieved and it would show in the outcomes of the treatment at the hospital. However for that to happen, the owners will first have to make a commitment towards quality rather than just paying lip service. Most of the hospital owners believe that implementing the NABH standards increases their cost by 10%. I would disagree with them in the sense that real implementation of these standards would increase the cost by more than 20%. However these higher costs should be recovered through higher pricing.
How can the quality payback – The investment on quality begins at the time of setting up of the hospital. A good quality cathlab costs Rs. 2.5 crores while a bad quality machine will cost only 1.25 crores. The same holds true for every medical equipment be it the hospital beds, monitors, ventilators or diagnostic equipments. A low quality ventilator in Russia took the lives of several people due to a blast in the equipment just a few days back. Similarly the implementation of the NABH standards would mean higher operational cost. Once a hospital has installed good quality equipments then the next step is to make processes which ensure quality. Hiring good quality staff and providing intensive training to the staff members is the next step. The role of training is the most important in the entire process. Once the staff is thoroughly trained in the processes then implementation of these processes becomes a cakewalk. So if a hospital has made genuine SOP’s, provided intensive training and rigorously implemented the standards then no power on earth can prevent them from getting any kind of Quality Certificate. This can be done without the services of these `Quality Consultants’ who can do things only on paper and not bring real quality into the organization.
The hospitals which introduce real quality into their services must showcase these quality initiatives in their communication so that the discerning patients would understand the value of quality and would be happy to pay a higher price for such services. The people who buy an i-phone from Apple do not wish to pay for the services of the hospital not because they do not appreciate quality but because we have not been able to convince them about our quality. NABH Certificate will not do the job as no patient knows anything about this certification. It makes no sense for any hospital to flaunt their NABH status as every other hospital also has the same. The solution for the hospitals is to create their own brand image associated with high quality service by showcasing their processes and quality initiatives. China is known for its low quality but still there are companies which have been able to buck this trend and establish manufacturing facilities in China. Similarly India is known for its shoddy certifications and `managed things’. However hospitals which truly want to bring quality into their services will get adequate compensation for their efforts. Despite all the fancy hospitals in the National Capital Region, the common refrain amongst the medically literate people is that – If you want to save the life of the patient then rush to `Gangaram Hospital’. This is called `Brand Value’ which has been created due to quality outcomes for several decades.