Last week I wrote about the importance of co-existence of regulations and accreditation in the healthcare system. This week I want to talk a little bit about ICHA and its mission.

I have had the opportunity to work in and witness first hand, at close quarters, nearly all the systems and stakeholders in healthcare both in India and abroad. What once looked like a “rolling stone” career, in retrospect looks like ‘fate’ endowed me with a fairly comprehensive and holistic view of healthcare. Like a helicopter, on the one hand, was able to observe the canvas, while on the other, able to swoop down to study the details and nuances. The following are my learnings and observations. I have tried to distil my thoughts, avoiding the detailed narrative of the experiences leading to the same, for the sake of brevity.

Against the backdrop above, an opportunity arose that led to the conceptualisation and establishment of ICHA. ICHA, basically, was envisaged, inter-alia, to restore professionalism and ethics in healthcare to address the prevailing dismal scenario. In taking ICHA forward, and based on my learning, experience and extensive research, a few fundamentals became apparent:-

1. The need for excellence in healthcare: Non-management of various factors like complexity, information explosion, societal changes and expectations of all stakeholders, just to name a few, have led to a situation of gross mistrust among stakeholders – a disastrous situation for something almost totally based on trust, thereby endowing it with the nobility that healthcare and its providers enjoyed. Accreditation, as the name implies, could be the appropriate tool to achieve excellence and restore credibility.

2. Analysis of accreditation and excellence lent definition to its three pillars viz.
   1. Technical expertise
   2. Perceptions and expectations of different stakeholders, and
   3. Societal structure and legal framework

Whilst technical expertise is a common factor the world over; perceptions and expectations are variable; the major differences are in the societal structure and legal framework – impacting both, access and delivery in each country. This necessitates a separate system for each country.

3. The structure: Such a system had to be comprehensive and multi-stakeholder. It cannot be individual based, to avoid politicking and finding “10 wise men” to whom everybody would defer to – an impossible task. It needed a dedicated not-for-profit organisation for this sole purpose. An organisation run and owned professionally by professionals.

4. A platform like United Nations where each constituent upholds its own sovereignty without being subsumed in or subservient to others and being able to hold on to their ‘turfs’ or expertise. At the same time, share and contribute for achieving excellence in a collaborative manner.

Based on the above, a set of core values and operative mechanisms were evolved democratically with lots of deliberations:-

1. Moving to ‘interdependence’ from ‘independence’.
2. Trust – transparency – transaction (communication)
3. From adversarial to collaborative relations

In just 2-3 years a feat was achieved that took 50 years or more in “advanced” systems of being able to bring seemingly diverse stakeholders together. The purpose of ICHA is to achieve all round excellence in healthcare delivery. Through endeavoring safer healthcare for all, build trustworthy healthcare delivery institutions. ICHA has also grown in size and numbers since. ICHA is the National multi-stakeholder Confederation of National Associations/ Institutions for establishing validated excellence in healthcare in line with similar bodies in all developed countries. Today all the major National associations (40) of Medical (Clinical, Lab, Admin), Nursing, Pharmacy, Therapy, Consumers, Management and Architects comprise ICHA. All the constituent associations are well established and respective apex bodies.  Please visit www.icha.in for details. Funding which was thought to be the easiest, as against bringing together of all stakeholders, emerged as the biggest challenge.

Professionalism and Ethics – a closer look

While there are multiple factors e.g. political, social, environmental and economical for the current scenario, I believe, the healthcare providers can contribute maximally to address the issues of professionalism and ethics. Setting the premises and my assessment thereof, Professionalism, to me means being:

1. Knowledgeable – technically sound
2. Autonomous or freedom to pursue the practice. However, it brings with it a great amount responsibility and accountability.
3. A fiduciary trustee especially in healthcare since the receivers may not be able to judge the ministrations fully.
4. Being Proactive: To be able to visualise near and distant future and take appropriate steps to be ready for the changes. The greatest challenge lies here. Most seem to be on a ‘treadmill’ running faster and faster to stay where they are. The short term expediency relegates the vision to the background and results in being reactive or ‘fire-fighting’. I believe that much of it is a direct result of the political and societal environment. This sways a majority to swim along with the current commercialisation despite their best intentions. They are even led to believe that they are doing the right things.
5. And a by-product – Intellectual Arrogance, is fairly universal. Greater the intellect and/or power, greater is the arrogance. Dealing with this arrogance is the biggest challenge and also the barrier, to my mind to collaborate with resultant slowing of progress.

Ethics, to me simply put, can mean to “do good” and being “morally right”. However, both are subjective, perceptual and thus nebulous. Since they are relative, changing with time and societal evolution, are a subject of much debate.

Despite the above some least common denominators are still available and agreed upon. However, they are also under constant threat of changing roles and affecting the provider–receiver relationship from mutual trust to gross mistrust, perpetuated by increasing litigation and violence, escalating into a vicious cycle.

Another dimension and challenge is to answer the question “what is in it for me?”  In real life it boils down to ‘material’ or ‘power’ gains. Given the current scenario it has been difficult to sell the moral gains or the mental peace and restoration of trust as sufficient reasons to do what is necessary.

The short term expediencies and vision or non-vision threw up the biggest challenge i.e. deliberate non-funding, on the one hand and on the other, a perception of having the “badge” as more important than excellence. What is lost sight of are the long term effects, because the discovery of truth may be delayed but cannot be done away with. This is amply evident from global experiences as well – both positive and negative. The worst casualty has been the pushing back of the agenda and discredit “accreditation“(Credibility being the hallmark of accreditation) making it synonymous with licensing and/or certification.

Metamorphosing from Accreditation to Patient Safety

Excellence having been the prime objective of ICHA, it was decided to strategically shift from accreditation and quality to “Patient Safety” as the right mechanism to pursue.

Patient safety is non controversial and acceptable to all – patients to politicians. It encompasses within it, of necessity, the provider safety since only safe providers can deliver safe care. It is also the same as excellence when delved into in-depth. Semantic debates do tend to differentiate it from quality.

The crowning achievement was the nationwide sensitisation about patient safety in a short span of few months and bringing together virtually all stakeholders from within India and even neighbouring countries to the Patient Safety Convention. A wide array of international partners, including WHO, coupled with Indian experience sharing resulted, in a mass of knowledge to determine a way forward. This is what is being pursued currently under the following broad heads:

1. Patient safety in education and curriculum to ensure double gains of immediate benefits and long term investment in future.
2. Focused initiatives for priority areas like maternal and neonatal safety.
3. Implementations in hospitals and health systems.

While a lot of progress has been made, but it is still miles to go and funding remains the biggest challenge followed by the ‘buy-in’ commitment to invest and seeing it as a non-productive expense.

Current final observations

Since learning is unending, I refrain from “conclusions”. I therefore submit my observations at this point of time on the state of healthcare and the needed steps.

1. I have been fortunate in rallying around numerous stakeholders and ignite interest and willingness to address the dismal scenario. It gives me the optimism of “can happen”.

2. There is no dearth of technical expertise and desire for professional freedom per se. However, as is expected, there is paucity on other parameters above. Managing ‘arrogance’ is a huge challenge too. The way forward is to channelize, the vast majority who will swim along the current, in the right direction.

3. Preventing demoralisation of ethics remains a big challenge in the current scenario of commercialisation seeking “exorbitant” returns on investment rather than appropriate returns. Increasing mistrust resulting in violence and litigation is propelling us to unforeseen disaster. The only solution, I feel, is the right political will and governance to course correct. The time is now or it may be too late!

4. We have to be willing to contribute. It is a “Mahayagna” whose “Prasad” is wanted and desired by everybody. However, for prasad it is necessary to complete the mahayagna for which “aahuti” has to be put in. This aahuti is our contribution – let us do it!

About the author

Dr Akhil Sangal is the Chief Executive Officer and Director ICHA, is a practising 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, 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 endeavours. He loves to work in areas of individual / Organisational Development.