The Basic Essentials for Quality Health Care

Rao G. Nanduri
Professor& Consultant, Computer Aided Medicine,
International Advisor on Quality Health Care,
Director, Millennium Medical Information Systems (UK & India)
Secunderabad-500009, India

1. Introduction
India is progressing well towards Quality Health Care to match with the standards of developed countries. Establishing corporate hospitals with well qualified and experienced and introduction of cheap health checkup and treatment schemes and health insurance policies to suit every common citizen in our country are contributing lot for heralding soon a new era in health care delivery of international standards. WHO and ISO have been playing their parts very well in this regard. The central government and the governments of most of the states in India are encouraging adequately by improving medical and health education including hospital administration, allowing import of latest gadgets, material and drugs, allowing many doctors to visit or study in developed countries and learn more and gain the best experience in all fields of health care, allowing corporate level multi specialty hospitals to boom in all the parts of the country, implementing steps to provide quick health care to the rural masses by experts in all medical subjects .through Telemedicine projects and Remote Health Care Projects and encouraging ISO Companies to operate efficiently in our country. Health Awareness and demands of high quality health care among most of the common citizens in India are two most important factors which are forcing the health care providers in all the three sectors, government, public and private to improve their standards in health care delivery. Most of the corporate hospitals and some of the government hospitals are now giving the best patient care that was possible until recently only in the developed countries and are making their best efforts to get ISO certification for their services. This is a fact which can be substantiated by many citizens of nearby countries are choosing to come to India for their treatment.

Recently, a National Accreditation Body for a Comprehensive Health Care Accreditation in India has been formed with a view to establish VALIDATED EXCELLENCE IN HEALTH CARE DELIVERY with the objectives of ensuring international quality health care at all the three levels of health care delivery (Primary, secondary and tertiary) by all the health care providers, belonging to both the government and private sectors, to involve both the health care providers and health care receivers in framing guidelines and constant updating of these guidelines based on consensus to make clinical audits compulsory for all hospitals, to frame the processes for internal and external audits, to frame generic standards on common issues in Health Care delivery, to frame professional ethics for each specialty, to make all the health care providers accountable and answerable for every thing that happens within their jurisdiction, to recognize the Excellence in Quality Health Care Delivery among the health care providers, to institute awards for those health care providers for achieving excellence and to involve all the Heads of Medical and Health Organizations and the governments in the centre and states in strict implementation of the directives issued by this body and in making it a law to follow them. In future, only those hospitals and nursing homes that take a oath to implement these directives will be issued licenses to function. 

In spite of all these developments, I have observed through my many and frequent visits to developed countries as well as to many parts of India, that the basic essential elements that are obligatory and which make lot of difference in the quality of Health Care Delivery are either neglected or paid inadequate attention in implementation of these by most of the health care providers in India in their day-to-day functioning. Though, we can not expect much in this regard from the government and public sector hospitals, we definitely expect them from the corporate hospitals, private nursing homes and private polyclinics. These basic and essential elements are:- 

(a) Electronic Medical Records that are complete, accurate and easily transportable and transferable across not only the country, but also the whole world. 

(b) Clinical Records processed by Automatic Validation Techniques to make them error free and complete. 

(c) Clinical Records that suit Telemedicine Consultations and Remote Health Care Delivery. 

(d) Routine Health Education and complete guidance every day to all the patients seeking health care free of cost. 

(e) Keeping pamphlets and booklets on most of the common illnesses freely available to the patients and their relatives. 

(f) Framing and implementation of Hospital Orders (Permanent and Periodic) by the hospital administrators for all categories of employees working under them. 

(g) Conduction of periodic clinical audits (Minimum three quarterly internal audits and one annual external audit) and making the employees especially, those involved in the patient care accountable and answerable for every thing they do. 

(h) Explaining and detailed description of all the procedures and treatment to the patients and taking their consent before starting except in emergencies and while dealing with semiconscious and unconscious patients. 

(i) Keeping ready the equipment and medications for all the emergency procedures even though the specialists for those emergencies are not employed by a health care provider.. 

(j) Provision of books, literature and charts readily available to the doctors, nurses and paramedicos for dealing with any kind of emergency and Continuing Medical Education in collaboration with all the nearby hospitals. . 

The details of some of these are described below:

2. Clinical Records
The medical Record (complete with clinical data, family history data, past and present health information, information on allergies, occupational health data, family planning data, immunization data, special therapies data, alternative medical treatment, treatment in foreign countries etc) is the basic element for any thing to do in medical profession; be it a simple OPD consultation, or a complicated surgery, or a telemedicine consultation in an emergency, or an emergent treatment in a foreign country, every doctor needs complete and accurate medical record of past illnesses for quick and accurate diagnosis and proper treatment. In other words, the doctor's efficiency in diagnosis and treatment how qualified and experienced one may be, is dependant to a great extent on the medical record of the patient available to him or her at the time of examination. 

It is a fact that the specialist doctors of every specialty in medical profession are keeping their own format of case notes for keeping the records of patients coming to them. In most of the hospitals, these are still manual records. Some hospitals do maintain computerized medical records, but these are not of an uniform format in all hospitals in the town, let alone in hospitals of other cities in the same country and hospitals of all other countries in the world. International Standardization and uniformity of the medical records are very essential to make them accessible and usable any where in the world. This is possible only through computerization and only through the intervention of an International Authority on healthcare like WHO. The International Standards Organization insists on HIPAA and HL7 standards. We all should demand for such internationally acceptable and uniform medical records for each specialty so that communications between one hospital and the other and between one department and the other in the same hospital are smooth, quick and easily understood. This uniformity is also essential for records meant for use in Telemedicine. Let us see the other essential aspects of medical records.

2.1 Autovalidation of Clinical Records
The medical records are very well known for errors. Especially, the clinical data is very much prone to grave errors. In spite of so many advances in medical field, it is not uncommon to find medical records with incomplete information and many types of errors. Either due to callousness on the part of healthcare people or data entry personnel, or due to data handling by non-medical professionals, blanks are seen in many important fields and many errors do take place in creating medical records. Though, most of the errors are simple typographical errors (wrong characters, wrong units and wrong placement of decimals etc), about 15% of the case notes with errors do contain logical type of errors (doubtful data, impossible information, mismatches between complaints, findings, lab reports, diagnosis etc) which are very serious errors.

The importance of completeness and accuracy in medical records do not need any further elaboration. These are the causes for failures in diagnosis in most of the cases whose diagnosis was either wrong or delayed considerably resulting in incorrect or delayed treatment.. Incomplete history taking and inadequate investigations are the main causes for the clinician's inefficiency in detecting atypical and rare disorders also. 

Therefore, medical records of both in-patients and out-patients that are validated for their completeness and accuracy are the most essential items of all the basic necessities to deliver health care at WHO and ISO standards of quality. It is very essential to detect blank data in important fields and all types of errors in clinical records while doing data entry itself so that the user will become aware of these errors, note them and take necessary action to correct the data and fill up the missing data so that only error free and complete medical records are saved in the concerned file. 

(a) An automatic HELP WINDOW facility if provided for every important field without specially asking for help, to tell the user how and what data exactly is to be entered in that field giving examples, would definitely prevent 90 to 95 % of the typographical errors .in important fields. 

(b) Another very simple feature in the data entry software like, cursor halt and prevention of moving forward or backward when an important and essential field in the medical records is left blank and the user tries to go to the next field or when a wrong character is typed in it (like alphabet character for numeric and vice versa and unknown character and abbreviation) would prevent all the blanks and the remaining typographical errors.

(c) Yet, another very unique validation feature for detecting any data which is very doubtful or erroneous (not conforming to given normal ranges and descriptions, misplaced decimal points, wrong units of measure etc) or when any wrong prescription is entered (like incorrect dosages, incompatible medications, wrong route of administration, wrong frequency etc), if implemented in the data entry software, would reduce the occurrence of most of the logical errors to a large extent. 

(d) A complete medical dictionary would prevent many spelling mistakes in the clinical terminology.

(e) The other features for validation of clinical data should focus on detection of complex logical errors like wrong or impossible reports on investigations, impossible diagnoses, missed points in past history, missed investigations, 

2.2 Telemedicine Consultations
The clinical data if not complete in all aspects and accurate without errors would not be suitable for Telemedicine consultation. Hence, the whole data of the patient after the data entry should be subjected to a validation check. This check should be obligatory, otherwise, the whole exercise and effort to obtain an expert's advice for the seriously ill cases, complex cases, individuals with multiple ailments, difficult to diagnose cases due to rare types of disorders and atypical variations in a known disease, diseases that are endemic or epidemic in other parts of the world etc would be futile. 

2.3 Knowledge Bases
To achieve this type of validation checks, it is essential to provide the following information (Knowledge Bases) to the system: 

(a) A complete list of medical terminologies and words with accurate spellings. 

(b) A complete list of all the commonly used medical abbreviations and their expansions. 

(c) A complete list of essential information fields for each category (group) of diseases without which, the medical record would be incomplete. This would pause the cursor move and would not allow the user to proceed to the next field or next record or another screen. This would also reduce the chances of missing information. 

(d) A complete list of clinical laboratory tests with normal ranges, warning ranges and error ranges. This will be used by the system to flash warning and error messages and logical errors. 

(e) A complete list of special investigations for each category of diseases with their normal values or reports. This will be utilized by the system to output error messages and inconsistencies in medical records after making a decision on the illogical relationships between one and the other information within the clinical data. .

(f) A list of commonly occurring inconsistencies among past medical history, present medical history, clinical findings, results and reports of various investigations and diagnosis for each group of diseases (falling in same category). This list will be the guidelines for making a decision on the inconsistencies in clinical data and to detect atypical variations in a disease. 

(g) A complete list of very important medications with details of type, dosages, routes of administration, frequencies, normal durations, incompatibilities with other drugs etc. This prevents prescription of wrong medications by mistake. 

(h) A list of brand names of each drug available in the market in the country of use would be an added facility to augment the utility of the validation software by young doctors. 

2.4 Record of Health Education and Guidance Programmes
Now, it has become the responsibility of the healthcare provider to educate the patients on all aspects of their illness, the necessity of various investigations and medical and surgical procedures, the details of the treatment including drug over dosage problems and toxic reactions, preventive measures if any, supportive measures which help in enhancing the speed of recovery, reducing the seriousness of the ailment, preventing complications, etc. WHO and ISO specify the details of information to be provided to the patients through brochures, lectures, audio-video tapes, other visual presentations, demonstrations, counseling etc. It has become very easy with the introduction of computer presentations through touch screens. This would enhance the quality of patient care by any healthcare provider to a great extent and minimize many of the complaints and legal actions by the patients and their kin. 

Another very important aspect of Health Education is Counseling on Health Insurance Policies, Medical Benefit Schemes, Free Medical Camps, Annual Health Check-up Schemes etc. Majority of the patients are found to be totally ignorant of these. A good hospital of repute should not aim to earn money through ignorance of its patients and instead, it should educate the patients on all aspects of investigation and treatment costs involved, alternative procedures and their costs, available medical benefit schemes and health insurance policies etc and give a true option to the patient in choosing the investigations and treatment. A record to this effect should be maintained in the HIS and the patient's individual medical record. Depending on his/her economic situation and other conditions and situations, the patient will be able to choose one of the options. The hospital should try to avoid unnecessary, unwanted and non-indicated procedures. In case of clinical trials of new drugs and new procedures, the patients and their kin should be made aware of all the possible complications before starting them. The hospital should give them or arrange adequate compensation to any victims of such clinical trials; a written undertaking by the hospital authorities should be handed over to the patients or their kin. 

2.5 Record of Hospital Orders
It is now imperative that a Record of both PERMANENT HOSPITAL ORDERS (PHO) & ROUTINE HOSPITAL ORDERS (RHO) are to be kept in the hospital for viewing by all the hospital staff and the medical auditors at any time A hospital, if interested in rendering a good standard quality healthcare to its clients, should make it clear to all its staff, their duties and responsibilities. It should also communicate to all its staff on medico-legal matters and other legal matters, their position and status in such matters versus the legal responsibility of the hospital and the patients' legal rights. This is very essential to run the hospital not only smoothly but also, to maintain the desired quality in healthcare. There are many instances where the administrators of some hospitals were so much preoccupied with legal proceedings all the time throughout the year, they could not pay due attention to the patient care aspect finally resulting in closure of the hospital. The legal proceedings consume so much of time and money, it would be much better to prevent their occurrence and remain free from such matters. Most of the legal suits occur from deficiency of service to the patients where as, few arise from its own employees. Hence, a very efficient hospital administrator takes care of every aspect of administrative services, clinical services and supportive services present in the hospital and prevents most of the legal problems both from the patients and employees. It is also better, if the hospital could afford to employ a part time legal consultant to save some of the precious time of the hospital administrators and clinicians.

As a first step, every hospital should draw its own PHO which ought to be approved and ratified by a STANDING COMMITTEE of the hospital. The members of the committee usually consist of the senior most hospital administrator, one senior most staff from each department of the hospital covering all the 3 services mentioned above and an experienced legal advisor. The standing orders of the hospital should cover all aspects of the duties and responsibilities of every employee of the hospital including the part time employees and honorary consultants if any, the services provided by the hospital (both routine and emergency services) and all administrative instructions. It should clearly specify what to do and what not to do for each category of the employees and it should cover all situations such as routine daily hospital services, emergency conditions, large natural and man made calamities etc. If the hospital is capable of undertaking telemedical consultations and has remote health care facilities in it, these are to be clearly specified in these orders. The PHO are made once only to stay permanently like a constitution and not tbe changed or modified except in exceptional circumstances. Hence, is the necessity to pay utmost care in drafting these. These are kept in the hospital computer server as a READ ONLY file for viewing and referring by any of the hospital staff. These are also required to be made in a book form and one copy of it should be kept in each department for ready reference by the employees at any time. Every employee of the hospital, at the time of joining employment in the hospital, should declare that he/she has read the hospital's standing orders in detail and would obey and follow these orders strictly in its true sense by taking an oath of allegiance and signing an acceptance deed. The International Standards Organization has formed guidelines on this issue and these are one of the most essential things to be fulfilled by the hospital to qualify for an ISO certification. The recently formed National Accreditation Body of India is also drawing similar guidelines for all hospitals in the country falling in any of the three cateories (Primary Healthcare, Secondary Healthcare and Tertiary Healthcare ). The Armed Forces Medical Services of India have these permanent hospital orders named STANDING ORDERS for the last 5 decades and they follow them very strictly like their working bible. 

The periodic RHO are published in most of the hospitals world over, once a week. The hospitals belonging to the Armed Forces Medical Services in India do publish them every day except Sundays and holidays and call them Daily Orders. Some of the European Hospitals publish them once a month. In some of the hospitals in USA, Canada, Australia and other East Asian Countries, they do not publish them in a fixed periodicity and do so as and when there are some important announcements to be made, when some important changes occur, event happenings, engagements, VIP visits, duty rosters and other instructions to their staff. Some of the hospitals do not name them as Routine Hospital Orders, but circulate them among all the employees as a Circulation Letter covering all important points in the day to day happenings and any instructions to be followed. Like the Permanent Hospital Orders, these are useful to the staff of the hospital for their daily routine work. Both the Permanent Hospital Orders and Routine Hospital Orders do contribute to the discipline of its employees and prevent many of the unwanted things from happening due to ignorance and indirectly enhance the quality of its services. 

2.6 Record of Clinical Audits
A good clinical audit speaks of the facts that happened and gives scope and directions to the healthcare provider for corrections and improvement if any in future. The medical audit is a mirror to see one's own image. Medical audits do develop competitive spirit among different health care providers and should be viewed in pure professional spirit and not in punitive way as some people view them. These audits will be very useful in hospital administration for giving a rise to an employee, to dispense with any one, to honor an individual, to give additional responsibilities, to depute persons for special training in India or abroad etc. Each medical record kept by the healthcare provider should have a space in a suitable place on the first page of the record preferably on one of the corners on the top to indicate whether a periodic or special internal or external medical audit was carried out on that record and if so, the date of the audit. It is mandatory that every healthcare provider should conduct periodical medical audits and keep a record of their findings, suggestions, actions taken etc for not less than 10 years. It is made quite easy and comprehensive with suitable software for medical audits. 

The most recommended practice is monthly (for very large hospitals) or quarterly (for small and medium size hospitals with less than 500 beds) internal audit by senior doctors of the same department in the hospital, quarterly internal audit by senior doctors of another department in the same hospital, half yearly or yearly external audits by a team of senior most doctors from another hospital not belonging to the same organization or group of hospitals and an urgent special medical audits whenever a serious mishap occurred in patient care. The latter two types of audits may be organized and supervised by the head of health and medical services of the district or state or central government or an autonomous body like Indian Medical Association or the National Accreditation Body for Health Care. The medical audit should cover all aspects of patient care supposed to be rendered by the health care provider such as hospital services and facilities, nursing care, doctors' care and supportive services. The auditors should pinpoint the deficiencies if any without identifying the individual concerned and suggest the remedial measures In many countries, the name of the patient is also deleted from the audit records removing the chances of identification leaving only the age, sex, nationality place, month and year of hospital stay and diagnosis.

2.7 Record of Emergency Procedures
A list of authorized and normally recommended emergency procedures done in different emergency situations in the hospital for which the facilities are available and the persons responsible to do them are required to be displayed in important and relevant places in the hospital besides keeping them in the Permanent Hospital Orders and the HIS for the knowledge and benefit of its staff along with their recommended indications. The correct and exact procedures to be followed by all the concerned staff of the hospital when an emergency patient arrives in the hospital should be readily available on the HIS to enable any staff of the hospital to carry out their responsibilities properly. The hospital should keep a record of all the emergency procedures carried out with indications for the purpose of clinical audit.. 

2.8 Record of Routine Hospital Procedures 
The routine hospital procedures other than the emergency procedures should also be displayed in all the departments and also included in the Permanent Hospital Orders. 
The record of patients', next of kins' and guardians' consents for every procedure done in the hospital especially those which carry any type of risk are essential not only for clinical audit, but also for helping the hospital administrators in any legal problems arising at any time. Any changes in these procedures should be published through the periodic RHO.

2.9 Record of Continuing Medical Education 
Knowledge has no limits and no end. There is none exempted from Continuing Medical Education (CME) programs; and even those whom we consider as the most experienced and senior most in medical profession do find them knowledgeable. It is the responsibility of the hospital to organize periodical updates in medical sciences to all its clinical and para-clinical staff. It is rather for its own good, as the enhanced professional efficiencies of its staff keep its own image clean and upright The junior doctors who mostly handle the emergencies first, carry out the instructions given by the consultants and advisors and provide 24 hour vigil on all their inpatients in the wards will be highly benefited from the continuing medical education. Besides them, the nursing staff too are the back bones of the hospital infrastructure on which the reputation of the hospital stands; and they too are required to undergo periodical CME. The CME is mainly of 3 types. (a) Periodical Guest Talks (b) Regular monthly Clinical Meetings and (c) Periodical seminars and workshops in different subjects A detailed record should be maintained by the hospital regarding all the activities and those given below. 

2.10 Other methods of CME
(a) Live Demos and Discussions on Surgical and Medical Procedures through Local and Wide Area Clinical Networking

(b) Participation in Live Telemedicine Consultations.

(c) Attending International and National Conferences, workshops, seminars and Pre-conference Tutorials.

(d) Attending Important Postmortem Examinations.

(e) Publishing articles in International and National journals.

(f) Self Improvement through various Medical Internet Sites

(g) Organizing Periodic Medical Quizzes

3. Summary
The quality in healthcare delivery is always kinetic, ever changing, relative and qualitative. Hence, every healthcare provider has to make own efforts to assess their weaknesses, compare their services with others and make continuous endeavors to excel the others. They should not be satisfied with their own assessment on their own performance and allow an external team of medical auditors to conduct yearly audits without bias. In healthcare, there is always a scope for further improvement. The patient satisfaction and the amount of gratitude the patients do express to their doctors and other hospital staff matters the most. The patients are the bread winners of doctors and hospitals and they have both moral and physical obligation to the patients to provide them the best quality healthcare. This paper is for the healthcare providers. It described the most important basic elements that are essential to achieve an international standard in quality healthcare. The computer based hospital administration will eliminate many of the drawbacks and loopholes in the day-to-day functioning in the hospital. Few of these basic essential elements are the medical records, their validation, clinical audits (both internal and external) and continuing medical education for all doctors and nurses make lot of difference in the quality of the healthcare provided by any hospital.