Hospitals find Fine Line to Walk when it comes to Transparency

By Team HE

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Whether they are nostalgic reveries of patients who came years ago or the brutal nightmares of those who lost their loved ones due to medical negligence, the trust of patients matter. Earning trust and improving transparency seems more critical than ever and many organisations are adopting policies to help doctors with this challenging task.

If the first thing that comes to mind when you hear “private hospital” is lack of transparency, you’re not alone. According to a KPMG report, India is at second place from the bottom, in a health system transparency index, which means that the sector is still way behind regarding healthcare infrastructure.

In fact, on the trust index, the report based on data collated over a year from 200,000 subscribers of GOQii both male and female found that 92.3% don’t trust the healthcare system in India including doctors, hospitals, Pharma companies, Insurance companies and Diagnostic labs.

Anant Bhan, Researcher, Global Health, Policy and Bioethics, points out that he likes the Institute of Medicine definition of transparency, modified to suit healthcare sector’s needs: “Transparency in healthcare is making available to the public, including internal stakeholders within the organization, in a reliable, and understandable, easy to obtain manner, information on the health care system’s quality, efficiency and patient/consumer experience with care, which includes price, outcomes, quality data, so as to influence the behavior of patients, providers, payers, and others to achieve better outcomes (quality and cost of care), and enhance trust in the system.” He notes that it has usually not been a priority, except in smaller discussion groups such as morbidity/mortality meetings in departments. “But with pressures increasing to focus on quality, accreditation, outcomes, increasing expectations of disclosure from patients—it’s becoming imperative that organizations respond by focusing on enhancing transparency—not just to external stakeholders, even their own. This can have beneficial effects on efficiency, productivity, key stakeholder engagement, and service improvement,” he says.

Many experts think that the challenge is primarily one of culture. Most organizations are inward-looking and focused on the protection of their interests. They believe that transparency and openness, especially about mistakes, and negative outcomes will be harmful to their interests. But this often backfires on the institution. A culture of transparency encourages openness, disclosure, honesty with relevant stakeholders (e.g. patients) and lessens the chances of controversy and antagonism. It also serves as a learning platform for Quality Improvement.

Nandakumar Jairam, CEO of Columbia Asia Hospital, points out that transparency in health care has been debated upon for a long time. “India’s healthcare industry is one of the fastest growing sectors, and it is expected to reach $280 billion by 2020. With this projected growth, it has become imperative to ensure greater transparency in healthcare service delivery.”

He points out that transparency in the healthcare sector may mean different things to different people. “Transparency builds trust within and outside the organisation. For a consumer, access to appropriate information about the costs and procedures, including alternatives and likely complications, leads to building trust with the healthcare provider. Some of the fundamental questions consumers have are the exact costs for the procedures with possible escalation, where is the best care available for the money spent, what happens if the prices shoot up as affordability is an issue, how appropriate are the tests and medicines that have been ordered by the clinician and insurance coverage, etc.” says Jairam.

Further, transparency about the tests and medicines and getting the patient and their attendant involved in the treatment plan helps in mapping the expectation from the planned treatment. It creates an enabling environment to seek clarifications on alternative treatment options and second opinions.

So how does Columbia Asia handle this issue? “The outcome of a procedure is extremely critical for an organisation as this is the base for the building trust in the community. At Columbia Asia, we practise internationally benchmarked protocols and also evidence-based medicine. This practice helps in easy explanation to the patient on the diagnostics, treatment plan, and expected outcomes of the procedure. One must keep in mind that outcomes can only be to the extent of medical science permitting and cannot be guaranteed for all,” he explains.

Today, there is no denying the fact that there is a nexus between doctors and pharmaceutical firms. In fact, corruption, kickbacks and the link between doctors and pharmaceutical firms are so rampant that BMJ, in June 2014, launched a campaign called Corruption in Medicine, specific to India.

But, with a high attrition rate in the healthcare sector, organisations struggle to understand how or what initiatives to improve transparency within the organisation. 

And many use creative solutions to improve transparency at the organisation level and address these issues.

“For external consumers, at Columbia Asia, we have in place a charter of patient rights, a clear financial counselling and clarity, doctor-patient conferences at periodic intervals, especially in critical care. Encouraging patient complaint and early redressal is also another aspect of quality and transparency. For external vendors: set guidelines and openness in the selection of vendors is mandated. We have an objective selection criterion based on specifications, performance and adherence to good manufacturing practices,” concludes Jairam.

Dr Harish Pillai of Aster DM Healthcare seconds his view and says that transparency is an accurate reflection of excellent governance systems. “It encompasses the entire values and culture of the organisation whose bedrock rests on the strength and faith of its entire clinical and non-clinical teams in the provision of care. Increasingly with the growing change in information disequilibrium between providers and consumers in favour of the latter, it has empowered them to seek alternatives in care plans and search for the track record in clinical and service excellence. More than accreditation norms, it will be clinical outcomes that will shine like a ray of light to distinguish one provider versus another. The main challenges that a few providers face in being transparent are the lack of an inspiring vision and effective leadership; improper culture; lack of robust staff credentialing; non-adherence to quality systems; not following clinical pathways and evidence-based medicine; and lastly systems skewed in favour of financial gains rather than clinical outcomes.”

Some of the initiatives taken by Aster DM Healthcare are robust governance systems, strong monitoring mechanisms, periodic monthly reviews, internal whistleblower policy, national and international accreditation, external and internal audits, staff training, consumer empowerment, open display of patient and family rights, robust grievance redressal mechanism, benchmarking with best-in-class national and international organizations, customer feedbacks for clinical and service excellence and continuous staff training.

While healthcare organisations are driving transparency initiatives within the organisation, the government is also not leaving any stone unturned. Delhi government, known for its pro-poor policy, has announced a plan to bring down the cost for patients admitted at private hospitals. It announced that it would cap the profit margin on medicines and consumables at a maximum of 50 percent over their procurement cost.

What does the law say?

The Clinical Establishments (Registration and Regulation) Act 2010 (CEA), the law that is currently used to regulate the private sector in healthcare, prescribes minimum standards for personnel and gives standard operating protocols.