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Year : 2017  |  Volume : 55  |  Issue : 3  |  Page : 187-191

Quality healthcare and clinical processes: An amalgamation needed to achieve clinical excellence

Department of Ophthalmology, Dr. Shroff's Charity Eye Hospital, New Delhi, India

Date of Web Publication9-Mar-2018

Correspondence Address:
Dr. Suneeta Dubey
5027, Kedarnath road, Dr. Shroff's Charity Eye Hospital, Daryaganj, New Delhi 110 - 002
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/tjosr.tjosr_30_17

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Quality improvement is an essential component of 21st-century medicine. Dr. Shroff's Charity Eye Hospital is National Accreditation Board for Hospitals and Healthcare Providers-accredited organization which firmly believes in amalgamating quality measures with clinical processes and bringing out the most effective clinical environment for best patient care, one of the values of the organization. Clinical excellence is achieved through a stepwise approach.

Keywords: Clinical excellence, National Accreditation Board for Hospitals and Healthcare Providers, quality healthcare

How to cite this article:
Dubey S, Verma D, Arora A K. Quality healthcare and clinical processes: An amalgamation needed to achieve clinical excellence. TNOA J Ophthalmic Sci Res 2017;55:187-91

How to cite this URL:
Dubey S, Verma D, Arora A K. Quality healthcare and clinical processes: An amalgamation needed to achieve clinical excellence. TNOA J Ophthalmic Sci Res [serial online] 2017 [cited 2018 Mar 17];55:187-91. Available from: http://www.tnoajosr.com/text.asp?2017/55/3/187/226863

  Introduction Top

Quality improvement (QI) is an essential component of 21st-century medicine.

According to Robert Johnson, “Clinical excellence has four key elements: delivering the promise of quality healthcare, providing a personal touch, doing a more than adequate job, and resolving problems well.” To effectuate these elements, healthcare institutions, in particular, must be cautious about reducing the drivers of dissatisfaction and providing exceptional and unprecedented healthcare.[1] In the current health care scenario, where quality health care is taking huge strides, clinical excellence goes hand in hand with quality initiatives. It is not an adjourn path to achieve clinical excellence but is a tedious path which involves mammoth amount of teamwork, leadership, dedication, continuous training, and monitoring. Hence, achieving clinical excellence is a sapling which blooms from the seeds of efficient quality management system in the hospital.

Dr. Shroff's Charity Eye Hospital (SCEH) is National Accreditation Board for Hospitals and Healthcare Providers (NABH)-accredited organization which firmly believes in amalgamating quality measures with clinical processes and bringing out the most effective clinical environment for best patient care, one of the values of the organization. Clinical excellence is achieved through a stepwise approach. At SCEH, we followed these steps to bring out the best clinical outcomes and hence ultimately sufficing our goal to have utmost patient satisfaction.

Step 1: Building internal structures to initiate, enable, and internalize quality management systems

Constitution of a quality core team and commitment by the top management for continuous QI in hospital was the key. Under the right circumstances, a team harnesses the knowledge, skills, experience, and perspectives of different individuals within the team to make lasting improvements.[2]

The core team was the backbone of all system-wide programs for clinical excellence. The team provides direction and support for accreditation, conducts and facilitates clinical audits, builds capacity for quality management, and develops, rolls out, and monitors clinical indicators. In addition, it worked closely with the departments for clinical protocols' development and deployment and provided training and development support. In addition to staff, a key component of a well-functioning QI team is an effective infrastructure, such as leadership and policies and procedures to organize and facilitate the work of the team. Infrastructure support facilitates the team with tools, resources, clear expectations, and a forum for communication. Other committees constituted were Hospital Infection Control Committee, Medical Records Committee, Safety Committee, Drug and Therapeutics Committee, Clinical Audits Committee, and Internal Enquiry Committee. The first five committees contributed a lot toward achieving clinical excellence.

Step 2: Defining quality standards

A standard is an expected level of quality or an acceptable level of performance that can be written and explicitly documented including clinical protocols, procedures, or ethical rules. Where explicit standards are not available, standards agreed by all and based on the experience of professionals (implicit) can be defined.[3] Many quality standards already exist in the health industry with varied levels of recognition at international (e.g., ISO, JCI), national (NABH), and state levels.

The decision to choose NABH standards was very strategic because an NABH accreditation is a widely accepted measure of standard among private- and public-sector payers in India and an essential requirement to be empanelled on several payer networks as a preferred provider.

NABH has clearly defined patient- and organization-centric standards of performance for a hospital [Table 1]. To achieve an NABH accreditation, a hospital has to provide evidence, through a rigorous external assessment, of having achieved an acceptable level of performance against each of the defined standards. However, these standards do not provide support, information, or tools to help hospitals achieve them. It is upon hospitals to identify their approach for achieving and sustaining compliance with the required standards. NABH accreditation is time limited and needs reassessment every 3 years. Loss of accreditation has significant implication on hospital's brand image and business positioning. Hence, any quality management system will have to be sustainable and internalized so that accreditation is achieved and sustained [Table 2].
Table 1: Areas of standards defined by NABH

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Table 2: Indicators to achieve clinical excellence

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Step 3: Articulating a quality vision and describing key performance dimensions

A quality vision statement by SCEH was developed to communicate management's vision for quality to all staff members.

The quality vision statement clearly defined high-priority goals and ensured that the priority areas for improvement identified through the baseline assessment were addressed.

  • Leadership

  • Communicate leadership's vision and priorities throughout the hospital

  • Strategic planning

  • Establish clear channels of communication and reporting lines and use them for continuous feedback, improvement, and dissemination of actions taken

  • Customer focus

  • Improve customer satisfaction by enhancing customer experience

  • Operating focus

  • Increase the efficiency of all operating units

  • Measurement, analysis, and knowledge management

  • Strengthen the medical records department and management information system

  • Workforce focus

  • Develop and implement an orientation and induction training program for new employees and a system to assess and communicate the performance of all employees on a periodic basis.

Step 4: Documentation – standard operating procedures, forms, formats, manuals, and medical records

Importance of documentation and recordkeeping is unsurpassable. Documentation and recordkeeping are crucial to ensure continuity of care, accountability, and improvement of services. The significance of documentation and recordkeeping may be overshadowed by the convergence on direct services to client, i.e., patients. Consequently, proper documentation and recordkeeping may lie in the bucket of negligence. The following points elaborate the significance of documentation and recordkeeping:

  • Continuity of care: Records provide a case history and a more holistic picture to have an ease on following up or approaching to assist patients. This is especially for patients with long-term/chronic or complex needs, or who need several multiple services. Accuracy and timeliness in recording the information is significant, especially when there is an emergency and the responsible staff is not present (due to sickness, vacation, or any other reason). Excellent records and documentation will facilitate communication among service providers to ensure coordinated service rather than fragmented
  • Accountability: It is crucial to be able to provide relevant information to the patients at any given point of time and the organization's response to their needs. The information may be required to respond to queries from other stakeholders, for instance, insurance companies, patient's family, funders, or donors. One important source of information is the medical records of the patient. Documentation forms the nature of the professional relationship with the client. In the event of investigations or crisis, information on problems encountered and the agency's response would lay much help
  • Service improvement: Well-documented records can also lead to improvisation in service delivery to the patients by helping the staff members organize their thoughts. Aggregated and concrete information can also assist in planning, development, and reviews of services. It can also be a source of primary data to conduct evidence-based research.

At SCEH, standard operating procedures (SOPs) were drafted for each department (clinical and nonclinical), illustrating the activities performed in a department and responsibilities along with references. The SOPs help in increasing efficiency of tasks, forming consistency in system, reducing errors in the processes, evaluating performance, conducting audits, and promoting teamwork in the organization. Continuous training is provided to the clinicians to be in pace with the SOPs. SOPs are reviewed biannually. Moreover, they are made by the process owners and their team members; so, their active involvement leads to higher accountability.

At SCEH, regular capacity building of the clinicians is done on writing SOPs and manuals.

Regular training classes are also held to capacitate the clinicians on proper filling of medical records. [Figure 1] elicits the points which are checked and monitored in medical record files every month in SCEH. The results are presented in front of clinicians, and this approach of monitor and feedback makes them more accountable toward following the documentation process stringently.
Figure 1: Medical record completion

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The meeting minutes of committees are also documented and proper follow-up is done to check whether the issues have been closed through required actions or not.

The audit reports and closure reports of internal audits are submitted by the auditors, and their log is maintained annually.

Hence, documentation plays a vital role in achieving clinical excellence remarkably.

Step 4: Defining indicators and benchmarks

Assessment of quality of care has become rapidly crucial to service providers, regulators, and consumers of care. In recent scenarios, service providers have shown their interest in evidence-based medicine and consumers have started to converge on the cost-effectiveness of healthcare in achieving suitable health outcomes. Performance and outcome indicators allow the quality of care and services to be assessed and measured. This assessment can be accomplished by forming quality indicators that illustrate the performance that should occur for patients or the respective health outcomes, and then evaluating whether patients' care is in line with the indicators based on evidence-based standards of care.[4]

Quality indicators are defined as, “Measures that assess a particular healthcare process or outcome.” Quality indicators are quantitative in nature that can be used to monitor and evaluate the quality of clinical, support, and management functions. They are used to monitor, evaluate, and revamp the quality of patient care hence improvising patient satisfaction.

Indicators provide a quantitative basis for clinicians, organizations, and planners aiming to achieve improvement in the processes by which patient care is provided. Measurement and monitoring of indicators serve various purposes. They make it possible to document the quality of care given to patients; make comparisons (benchmarking); make appropriate judgments and elicit accountability, regulation, and accreditation; support continuous QI; and support patient choice of providers.

Indicators measure the extent to which set targets are achieved and are expressed as numbers, rates, or averages that can provide a basis for clinicians, organizations, and planners aiming to achieve improvement in patient care processes. They can be measures of structure, process, and outcome. Outcomes may be of major interest to the patients or payers of care, while providers who are receiving data for QI purposes need detailed data about the process of care to make the information credible and possible to act upon.[5]

Use of relevant quantitative indicators aids in the surveillance of healthcare quality, supplementing other approaches that may include qualitative analyses of specific events or processes.

At SCEH, a list of indicators was developed to track progress on patient experience outcomes and process measures related to quality of care and clinical excellence. Quality-of-care measures included indicators on patient safety and clinical effectiveness. Indicators which are essential to achieve clinical excellence are monitored at SCEH regularly as shown in [Table 2].

With effective interventions, we try to improve the compliance of quality indicators to bring clinical effectiveness into the system and processes. For instance, we monitor interoperative time, the benchmark of which is 95% (<10 min), the representation of which is shown in [Figure 2].
Figure 2: Interoperative time

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As said by various quality experts, to sustain improvement, control is required; hence, regular monitoring of quality indicators is an apportionment of continuous QI. In SCEH, monthly meeting is held with the key stakeholders where the data are presented in front of them. The improvements, gaps, and interventions are discussed in the meetings, and crucial decisions are made to make continuous improvement.

Step 5: Implementation and execution

Healthcare as an industry is known for resistance toward change. Workforce engagement and accountability has been identified as a key principle to ensure successful implementation of QI initiatives.[6] Evidence suggests that building a sense of ownership is a key factor in attenuating resistance and driving change toward improvement. Therefore, SCEH's total quality management implementation strategy was built around three principal approaches.

Empowering process owners by building a strong sense of ownership and control over the improvement process

The management facilitated the formation of independent Quality Assurance Committees in each unit (or department) which comprised of staff members under the leadership of the head of unit/department or a representative appointed by them. Unit Quality Committee was responsible for the overall performance of their unit. The role of the unit committee was to

  • Identify all critical processes in their unit
  • Define the standard operating protocols for each critical process in consultation with the core Quality Assurance Committee
  • Define their target/benchmark for quality indicators
  • Conduct regular audits and identify specific areas of improvement.

This structure allowed the core quality team to function as an “enabler” supporting the unit committees in the process of quality management, while the agenda for quality, standards, benchmarks, and interventions was developed and implemented by the unit committees and process owners. Thus, its role was essentially to

  • Supporting development and review of quality standards with units/departments
  • Supporting critical review of processes and identification of potential areas for improvement
  • Disseminating policies, guidelines, and QI learning materials
  • Coordinating, guiding, and coaching HODs, Unit Quality Committees, and process owners.
  • Organizing process and compliance training programs
  • Promoting best practices in quality management
  • Facilitating monitoring exercises and supporting data collection and analysis.

When a potential area for improvement was identified by a Unit Quality Committee, Qualifications Registration Committee (QRC) supported the committee in

  • Building a QI team of 4–6 people with the focused objective of solving a specific problem. Team comprised of people who participated regularly in the processes involved with identified area, understood it well, and worked together
  • This team would be supported by QRC team in framing the problem, collecting and analyzing data, and developing a solution
  • The team would then pilot test and evaluate the solution with support from the QRC team.

Supporting development of explicit standards for processes, providing easy access and training support for those expected to the standards

The core quality team partnered with the Unit Quality Committees to identify critical and noncritical processes undertaken within their units and worked with each Unit Quality Committee to standardize their processes in line with the adopted NABH standards and supported drafting of standard operating protocols. These protocols were made accessible to all through the hospital intranet. The core team then supported the Unit Quality Committee members to schedule and conduct coaching of staff members to adopt the standards of care.

Building accountability through regular internal auditing

The core quality team appointed an Audit Committee and supported it with training and monitoring tools to track progress on compliance with adopted standards (NABH) and predefined performance indicators and ensured audits are conducted at least twice a year.

Step 6: Audit and review

SCEH has a separate Clinical Audit Committee as mentioned before, which is responsible for conducting regular clinical audits in the organization. Various clinical audits have been conducted, for instance, audit to see if the guidelines for management of postsurgical infection are followed in patients postsurgery, audit to examine if the protocol for management of angle-closure glaucoma is followed, audit to examine if the protocol for examination of infective keratitis is followed, and prescription error audits.

Postdata collection interventions were made as per the needs, and reaudits were conducted to analyze the postintervention situation.

The audit reports and findings are shared with the key stakeholders and unit committees.

Hence, audit and review are important tools which assist in achieving clinical excellence.

  Conclusion Top

Clinical excellence is performing at a level well above satisfactory — both qualitatively and decisively. When physicians achieve a level of mastery in serving the patients and organizations, they give their best to the healthcare in efficient and effective ways.

The quality measures as mentioned if implemented and executed in the organizations effectively can propel clinical excellence prodigiously. In the present scenario of healthcare, quality and clinical excellence remain in symbiotic relation.

The clinicians at SCEH are exemplary, having demonstrated leadership in the delivery of clinical service and in the development of new ideas and improvements. These clinicians are able to quickly diagnose and treat clinical problems and adhere to a scholarly approach to medicine. They exhibit a passion for patient care, and they explicitly model all of the above to medical trainees, thereby earning an exceptional reputation in healthcare in India and abroad.

SCEH will continue to maintain the decorum and breaking stereotypes in terms of achieving clinical excellence.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Kapur N. On the Pursuit of Clinical Excellence. University of Southampton, UK: Addenbrooke's Hospital, Cambridge, and Department of Psychology; 2009.  Back to cited text no. 1
Marley KA, Collier DA. The role of clinical and process quality in achieving patient satisfaction in hospitals. Decis Sci 2004;19:128-9.  Back to cited text no. 2
Ferlie EB, Shortell SM. Improving the quality of health care in the United Kingdom and the United States: A framework for change. Milbank Q 2001;79:281-315.  Back to cited text no. 3
Mainz J. Defining and classifying clinical indicators for quality improvement. Int J Qual Health Care 2003;15:523-30.  Back to cited text no. 4
Freeman T, Walshe K. Achieving progress through clinical governance? A national study of health care managers' perceptions in the NHS in England. Qual Saf Health Care 2004;13:335-43.  Back to cited text no. 5
Quality Improvement – U. S. Department of Health and Human Services Health Resources and Services Administration 2011.  Back to cited text no. 6


  [Figure 1], [Figure 2]

  [Table 1], [Table 2]


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