Unprecedented levels of discontent among all stakeholders in healthcare have overshadowed the achievements and leapfrogging technological progress in this arena. The crying need for succor is a clarion call for a total overhaul and paradigm shift. The chasm, between what exists and what is desired is too vast for piecemeal solutions to suffice. A critique of various strategic mechanisms (In view of the topic only two – regulation and accreditation) and some solutions as a way forward are suggested.

Regulation: A necessary mechanism planned or resorted to, to address the distortions in the healthcare systems and society. However, while it is necessary, it is neither sufficient nor enough.

The perceived advantages being the authoritative legitimacy and power it bestows. It also provides a tangible benchmark and basic structure for the society and systems to operate.

The limitations are equally significant as follows:-

1. By its very nature, regulation is minimalistic thus falling short of sufficiency and desirability parameters.
2. Creates adversarial relationships due to the compliance / conformance paradigm. It blocks progress by creating a ‘treadmill’ on which one runs faster and faster to stay at the same place.
3. Enforcement is the biggest limiting factor. The experience and evidence is large enough to preclude reiteration.
4. Relatively static (given the long time it takes to be changed) and too slow to respond to a situation as dynamic as healthcare.

Accreditation: The true form and purpose of accreditation is to attain and sustain trustworthy delivery mechanisms. This necessarily entails continuous improvement to meet, preferably lead, the ever rising expectations of all stakeholders. On the face of it accreditation appears to be an ideal mechanism, but the beast lurks in its execution.

Trust and its pillar, comprehensive excellence, needs commitment, buy-in and ownership. It has to be nurtured to create a sustained culture. It cannot be, howsoever one may wish, administered as a remedial medicine – forcefully if necessary, to accrue desirable benefits even at the cost of acceptable side-effects.

Thus the limitations are as follows:-

1. Usually mixed up with licensing, certification and regulation virtually making them synonymous.
2. Not perceived as milestone in an ongoing journey but as a badge of attainment and achievement.
3. ‘Syllabus’ vs. ‘Curriculum’: While it is easy to have a syllabus like frame work of ‘what should be’, it is futile without the content based curriculum to address the ‘how’ through consensus based guidelines that are relevant and contextual.

A case for disseminated excellence: The islands of excellence become victims of their own good by attracting disproportionate crowds and attention. The overwhelming loads result in a breakdown and loss of excellence. The ongoing battle to maintain their status only perpetuates the vicious circle. This also adds tremendous costs and inconvenience to users while unnecessarily burdening the overstretched systems and infrastructure ending in a zero-sum game.

It is therefore imperative to expand and disseminate excellence not only to sustain it but also save costs and strains.

Solutions: A suggested list is as follows:-

1. A deliberate and concerted investment in excellence attainment strategies in healthcare  e.g.health quality education, guidelines, patient and persistent nurturing, safer healthcare etc.

2. Realise, appreciate and capitalise on existing mechanisms (like ICHA – Please see icha.in for details of the multi-stakeholder not for profit confederation) and even create, as necessary, mechanisms for the above. The need for facilitation role by the government is far greater than the regulatory role. The latter should be an outcome of the former and to prevent / control reckless, criminal neglect. It is more desirable to use market forces and peer-pressure to drive excellence than top-down regulation.

3. Invest in ‘curriculum’: By actively and financially supporting the development of consensus based guidelines that are dynamically updated.

4. A ‘Mixed approach’: The approach to quality or excellence in healthcare is different. The traditional mechanical approach is to set rigid and stringent specifications. The goods and providers meeting these are said to be ‘up to the mark’ or conforming. This is the “Outside – In” approach. This works well where the variables are mechanical and predictable, but can be counterproductive where uncertainty is high as in healthcare. “Inside – Out” approach on the other hand is beginning with the patient’s (in Healthcare) needs and requirements. Optimum quality of healthcare delivery is ensured by working backwards to align processes in tandem to meet these requirements. Healthcare comprises both, as most processes have some predictable and many uncertain variables, thus a mixed need based customised approach is desirable.

Thus there is need for co-existence of regulation and accreditation or the other way round.

About the author

Dr. Akhil K. Sangal is the Chief Executive Officer and Director ICHA. He  is a practicing Medical doctor in addition to being an Accredited Management teacher in General Management & Quality Management Systems .

He conceptualized and established ICHA and also spearheaded the Patient Safety initiative with global partners.

Over the last 40 years approx. he has acquired in-depth experience in all Healthcare systems and Sectors, both in India and abroad. He has worked in primary, Secondary and tertiary care facilities and received initial training in Medicine and Gastroenterology and has published research papers in these areas. He was Country Head – Healthcare Accreditation & Quality Management Systems with a German Multinational Health Consultancy Company, during which tenure this project was initiated in 2002. Dr. Sangal has always been a keen practitioner of research based Continuous Quality Improvement in all his activities and endeavors. He loves to work in areas of individual / Organisational Development.