10 Years of our journey in Quality Improvement and Patient Safety
Quality at Apollo: The Never Ending Story
The Group's tryst with quality and excellence has been as long as its existence. It is a well endorsed fact that Apollo Hospitals was the pioneer in setting the highest standards in quality in the nation, and actually introducing clinical excellence into the Indian healthcare lexicon.
Joint Commission International
In early 2003, our journey of quality took a definitive turn. We decided to embark on a highly structured approach to clinical excellence and decided to benchmark ourselves against the very best. We took on the ambitious goal of getting an accreditation with the Joint Commission International (JCI) – the undisputed gold standard of quality in global healthcare. In the early 2000s this was an audacious dream; not many had even heard of JCI in India, and among the few who did know, it was considered a bridge too far!
The leadership decided that Apollo Hospitals should be the first in India to achieve JCI accreditation and Indraprastha Apollo Hospitals, New Delhi was chosen for the honour.
They say the first step is always the hardest, and it was no different with our first JCI accreditation. We left nothing to chance and ensured no stone was left unturned in the hospital's transformation. The JCI Standards Manual was dissected and broken down into crisp, detailed policies. Comprehensive documentation was introduced by way of plans, medical records, standard operating procedures, etc. Infrastructure was another area of great intervention - slab to slab fire compartmentalization of the buildings, a first for Indian hospitals, was carried out using large numbers of fire and smoke doors. Signage was reinforced, and access to the hospital was ensured for the disabled. Every possible expectation by JCI standards was analyzed and covered.
On 13th June 2005, the process reached fruition – a team of three from JCI reached New Delhi to carry out the first JCI survey for any hospital in India. The excitement and anticipation were palpable, an intense agenda was set in place for the next five days. The JCI team was meticulous in their approach; every bit of the facility was covered! All our systems and processes were evaluated, our medical records were scanned in detail and infrastructure was put to great scrutiny. Finally, on the 18th of June 2005, a preliminary report was handed over to the Apollo Hospitals, New Delhi, with a recommendation for the hospital to be accredited. It was one of the proudest milestones in Apollo's history.\
New Delhi was just the start. By now the leadership's dream encompassed a much wider canvas. Starting with Delhi, the other hospitals of the Apollo Group underwent JCI accreditation.
Apollo Hospitals, Chennai, Hyderabad, Kolkata, Ludhiana, Bangalore, Dhaka and finally Apollo Hospitals, Mauritius got accredited. The Stroke Program at Apollo Hospitals, Hyderabad became the first JCI accredited Stroke Program in the world. A host of other hospitals beyond the Apollo Group also saw the opportunity and went in for JCI accreditation. Today more than 23 organizations are accredited by JCI in India.
Our Chairman believed that India needed a bespoke accreditation platform, a system for India by India. The idea was put forth and discussed with the Quality Council of India and other hospital groups. We were delighted when the National Accreditation Board for Hospitals & Healthcare Providers (NABH) was established. A think tank was assembled from within the healthcare landscape, comprising of the brightest minds which got together in the boardroom at Apollo Hospitals, New Delhi for early meetings. The think tank finalized the standards for the NABH and laid out the survey process. This gave the opportunity to the hundreds of hospitals in India to prove themselves by reaching a level where they could receive accreditation by NABH. Chacha Nehru Hospital became the first public hospital in India to be accredited by the NABH. The government of Gujarat made a policy decision to get all its public hospitals accredited by NABH. One by one the Apollo Hospitals in the tier two and tier three cities also started their journey towards NABH accreditation. Today fourteen of the Apollo Hospitals are accredited by NABH – Madurai, Chennai (Nandanam), Ahmedabad, Secunderabad, Noida, Mysore, Bilaspur, Bhubaneswar, Pune, Ranchi, Bhilai, Hyderguda, Kakinada and Vanagaram.
Apollo Clinical Excellence (ACE @ 25)
In 2007, our quality paradigm received another shot in the arm. Our Chairman wanted a scientific system to be developed to quantify Apollo Groups’ excellent outcomes. This lead to the genesis of ACE@25, and various other initiatives that Apollo undertook to monitor quality and clinical outcomes subsequently. ACE@25 comprises of 25 indicators benchmarked against the best-published outcomes in various specialties. The benchmarks looked challenging and needed complete support of our network of CEOs, Medical Directors, clinicians, nurses and support staff across the Group.
The Apollo Medical Director's Conference was held in 2008 where the details of the tool were shared. The aim of the scorecard was to measure clinical outcomes objectively, benchmark them with the best international institutions and strive to achieve those benchmarks, thus ensuring clinical excellence for the patients. This balanced scorecard focused on providing evidence-based quality care and a safe environment to our patients. It had, in addition, strengthened the functional efficiency of our hospitals, stimulating quality improvement while reducing variations.
ACE @ 25 incorporated parameters involving complication rates, mortality rates, one year survival rates and average length of stay after major procedures like liver and renal transplant, CABG, TKR, THR, endoscopy, large bowel resection and MRM covering all major specialties. Also included were hospital acquired infection rates, satisfaction levels with pain relief and medication errors. The numerators, denominators, inclusions and exclusions for all indicators were defined lucidly and methodology of data collection was standardized.
All Medical Directors committed to forging a new ecosystem of excellence across the Group. The tool was then put online and a trial period of three months was initiated in Oct 2008. Data poured in from across the Group. The tool was launched formally by Chairman on the 1st of January 2009 and Apollo has never looked back since then.
ACE @25 was chosen for presentation at the ISQua conference in September 2011, has been published as a case study by the Richard Ivey School of Business, and has won the FICCI Healthcare Excellence Award 2011 in the category of "Best Initiatives Addressing Healthcare Industry Issues".
The Apollo Standards of Clinical Care
Apollo Hospitals then went on to develop The Apollo Standards of Clinical Care (TASCC) to establish standards of clinical care to ensure that all its hospitals deliver safe and quality clinical care to all its patients, irrespective of location and size of the hospital. TASCC embodies sets of process requirements and sets of outcome measures that underlie, Apollo Hospitals' approach to clinical care.
TASCC was an extensively planned program which objectively monitored and evaluated special indicators and the clinical and internal processes involved in patient care. Besides this, it helped in identifying opportunities for improvement and provided a mechanism through which action was taken to make and sustain those improvements. In addition, TASCC sought to improve patient care and outcomes through systematic review of care against clearly defined criteria. This evaluation helped in achieving a better quality of patient care and service delivery leading to better utilization of resources and lowering of costs in the long run. In this manner, TASCC makes up the double helix of the Apollo Group's clinical fabric.
TASCC comprises of the six components including Apollo Clinical Excellence @ 25 (ACE@25), Rocket ACE (RACE), Apollo Quality Plan (AQP), Apollo Mortality Review (AMR), Apollo Incident Reporting System (AIRS) and Apollo Critical Policies, Plans and Procedures (ACPPP). Project Rocket 14 was a mission under the leadership of the Chairman to create clinically advanced, operationally lean and service oriented Centers of Excellence.
A dashboard was created to assess the outcomes of clinical parameters under RACE so that when the volumes increased the quality should not be compromised.
Apollo Hospitals also developed a comprehensive set of best practices by way of the Apollo Quality Program; a plan for the Group wide implementation of standardized methodologies for clinical handovers, International Patient Safety Goals, surgical care improvement, zero medication errors, standardization of medical records, diagnosis and procedure codes and promoting innovation in quality improvement.
Apollo critical policies, plans and procedures were developed into 25 policies covering clinical care, nursing care, managerial processes and utility systems and infrastructural requirements. All Apollo Hospitals have established and implemented policies to address these processes. Prototype policies were provided to all hospitals which could customize these policies as per their own procedures and processes.
Apollo Hospitals endeavored to establish clear systems for reporting of information related to specific patient and staff incidents/near misses, along with certain other serious health care errors and all sentinel events to the central leadership and to provide a mechanism of tracking, trending, and follow-up of all such incidences that posed an actual or potential safety risk to patients, families, visitors and staff. These included patient fall rates, needle stick injury rates, patient pressure ulcers, missing patient records and legal cases. Hospitals with higher rates were advised on improvement measures and to follow best practices being adopted by other hospitals.
Triggers were identified for mortality reviews to be conducted by every Apollo Hospital; the deaths qualifying as triggers were peer reviewed as per a predefined peer review checklist, presented in a mortality review meeting and categorized into defined categories. Sequential monitoring using statistical process control methods were useful in the early identification of unfavorable trends. Formal, structured review of all deaths (not just ‘unexpected' deaths) helped detect quality issues that would otherwise remain hidden, particularly around every day processes of care. By concentrating on the events actually experienced by patients, our hospitals helped to foster a culture of safety that shifts from individual blame for errors to comprehensive system redesign that reduces the chances of patient suffering and harm.
Apollo Clinical Audit Team
To authenticate and validate data, an audit team comprising of members from Apollo Group Hospitals was developed to audit the records of each hospital.
The Apollo Clinical Audit Team (ACAT) went through extensive training in the audit methodology, and audited all the Group Hospitals for accuracy of ACE @ 25, RACE parameters, Apollo Quality Plan parameters, the process of the Apollo Mortality Review and the identification of triggers and category 4 and 5 deaths, the process of collection and reporting of incidents data, and compliance to the Apollo Critical Policies, Plans and Procedures. The auditors also provided guidance for effective implementation of all clinical processes wherever required. An audit guide covering the audit methodology was made available to the auditors for reference. The audit is done twice a year at each of the Apollo Hospitals.
Apollo Innovation and Quality Awards
To spread the culture of quality at the grass roots, the Apollo Innovation and Quality Awards were launched in 2010. The aim of the Apollo Innovation and Quality Awards was to promote performance excellence through innovation and sharing of successful innovative performance strategies and the benefits derived from their implementation. Nominations for Apollo Innovation and Quality Awards were invited from all locations in six categories every year including excellence in operations, community service, clinical services, environmental conservation, HR practices and financial practices. The awards are given away on the Founder's Day.
New in Medicine
In the month of October 2011, Apollo initiated the compilation of the latest advances in medicine into a single report every month to be disseminated to all our clinicians and administrators. The report is compiled under four heads, namely, drugs, devices, research and treatment guidelines, after studying leading high impact medical journals, major medical news sites, and numerous web resources.
Apollo Accreditation Program
In 2011, the Apollo Accreditation Program (AAP) was created, which was formally launched on 1st January 2012. AAP is a web-based tool designed to review compliance with JCI standards across all the JCI accredited Hospitals within the Apollo Group. AAP comprises of all standards and measurable elements, within each chapter of the JCI standards manual, with provision for each location to report compliance on a periodic basis. Finally, a single dashboard summarizes the overall compliance at each location and indicates compliance levels for the entire Apollo Group as a single entity. The aim was to provide a comprehensive tool to each hospital which can be used to help maintain the same high standard of care throughout the year rather than when gearing up for a survey.
AAP, at a later stage, was also extended to cover all NABH standards for hospitals accredited by NABH across the Group.
The year 2013 saw the launch of the Safe Surgery Checklist across hospitals. Surgical safety was ensured through preoperative site marking, preoperative checklists and a final verification check before the start of the surgery by the whole operating team, called the ‘time out'. At the same time, we developed in consultation with intensivists and anesthetists, a unique checklist which is to be used in all the ICUs for each and every patient admitted. The ICU checklist of care comprised of issues that were addressed daily for every patient in an intensive care unit and helped deter omissions and mistakes wherever possible. It helped with memory recall, especially with routine matters that were easily overlooked in patients undergoing more drastic events. It made explicit the minimum, expected steps in complex processes. The checklist augments the daily, multidisciplinary team rounds and alerts the doctor when important items have been missed. In addition, the ICU team's collegiality and team bonding were enhanced by using an evidence-based tool to achieve care goals. Both the Safe Surgery Checklist and the ICU Checklist implementation across the Apollo Group were closely monitored using defined indicators.
Apollo Clinical Excellence Platform
Apollo has always been acutely conscious of India's widespread healthcare dichotomy and is committed to finding solutions to remedy the situation. The Group took up an initiative intended to contribute to the enhancement of quality of healthcare delivered across smaller hospitals and nursing homes in India. This initiative aimed at sharing the best practices for clinical excellence and quality improvement implemented by Apollo Hospitals with other healthcare providers to enhance the safety and quality of care provided to patients and community at large through the Apollo Clinical Excellence Platform (ACEP). ACEP is a standardized tool which can be used by any hospital across the country to drive quality improvement, improvement in patient safety, and better clinical outcomes. ACEP comprises of important indicator sets for monitoring quality and clinical excellence along with policies which would deal with the core processes in patient care.
The Apollo Standards of Clinical Care 2.0
In 2015, we raised the bar and took The Apollo Standards of Clinical Care to the next level and framed the new TASCC 2.0. The ACE@25 indicators were revised in keeping with the current trends in the procedures being carried out at our Hospitals within the Apollo Group and are now called ACE 1.
The indicators used to monitor the specialties under the Centers of Excellence were regrouped under ACE 2 with the number of indicators increasing from 25 to 50 considering the increase in certain types of surgeries. Annual reports are being planned for each of our Hospitals. A web-based "TASCC 2 Knowledge Repository" portal is being developed where all the award entries, "Share your Story" documents etc. shall be posted for quick referrals.
A revised format for the Annual Departmental Review has been created with the aim to get an insight into the COE / thrust area specialties.
Apollo Clinical Innovation Group
In 2015, Apollo Hospitals set up the Apollo Clinical Innovation Group (ACIG) to strengthen leadership in the adoption of new technology and procedures. A structured decision-making process for adoption of new technology/procedures involving stakeholders at all levels has been developed. The inputs for new technology, procedures and surgeries come from the Clinical Advisory Groups and the Specialty Advisory Groups and are coordinated by the ACIG.
Today, with a 32 years rich experience in healthcare in the country and overseas, Apollo has the wherewithal to provide the highest levels of patient safety and best in class services for provision of quality care for our patients. The greatest testimony to this fact is the faith reposed in us. The Apollo Group has touched the lives of over 42 million people, who have come to us from more than 121 countries.
JCI Accredited Hospitals
NABH Accredited Hospitals