Dr Vasundhra Atre, Director – Medical Operations, Medical Strategy & Operations Group, Fortis Healthcare
Over the years, newer and more exciting technologies have been introduced and continue to evolve, with the aim of increasing safety and efficiency in hospitals. Improved hospital design to better cladding materials, self-disinfecting surfaces to newer cleaning agents, ‘no-touch’ decontamination technologies and robots are some examples of the same. But many hospitals can ill-afford to invest in these, explains Dr Vasundhra Atre, Director – Medical Operations, Medical Strategy & Operations Group, Fortis Healthcare
Healthcare is changing
The importance of maintaining hygiene in the hospital environment is undisputed. However, both the hospital environment and the nature of those availing healthcare services has changed. Hospitals are handling older patients, a more at-risk population with multiple comorbidities and higher expectations, and providing more ambulatory care. In parallel, medical practices and care pathways are changing with regular knowledge updates and rapidly changing technology.
The challenges thus arise at the level of defining and maintaining quality standards, defining procedures, embracing developments and new technology, ensuring training and most importantly, doing it in a manner that is both economical and keeps the patient safe.
Good hygiene practices means maintaining a healthy and safe environment at all locations in the hospital at all times. These include not just the basics of hand hygiene and cleanliness of the patient areas but also encompasses safe food, air, water, laundry management, medical equipment & machines, and medication management among others.
Valid licenses need to be procured and renewed in a timely manner, qualified personnel need to be employed as laid down by law, best practices and audits need to be done and faced and documentation needs to be done in a timely and appropriate manner. In the event of non-compliance or an untoward incident, the authorities need to be informed, not to mention the medicolegal implications.
Considering that all hygiene practices have the potential to affect the health of the patient, stringent quality checks at predefined intervals are mandatory; some for the purposes of accreditation while others are statutory requirements.
Who will pay?
Everything comes with a price tag; so do hygiene-related practices in hospitals. Given that payments for healthcare services are either out of pocket or covered by insurance or schemes, the questions one is forced to ask are: “Who will pay for the costs other than those relating to the actual medical costs?” “Out of pocket payments put a strain on the patient and their family’s finances; what about insurance?”
A Google search threw up the following facts in reply to the question, ‘which cost is not covered in medical insurance?’: The Insurance Regulatory and Development Authority of India (IRDAI) has allowed insurance providers to exclude certain charges incurred during hospitalisation, called ‘non-medical expenses’. These are generally categorised into non-medical expenses in room charges, non-medical expenses in the treatment costs, non-medical costs in procedure costs and other non-payable medical expenses. Interestingly, these categories include items like hand wash, tissue papers, disinfectant lotions, housekeeping charges, gown, slippers, blankets, antiseptic mouthwash, disinfectant, hydrogen peroxide, urine container, vaccination charges, disposable razors, washing charges, digestion gels, paper gloves, barber charges, to name a few that would impact hygiene practises and patient safety in the hospital environment.
Cost-benefit analyis
The exclusion of the cost of non-medical expenses should possibly also be reconsidered by the insurance companies as should the remuneration offered by various schemes. E.g. A surgical site infection in an operated patient would prolong their stay in the hospital, require more resources in terms of medication, repeat procedures, investigations and manpower hours of care; while for the patient, it increases the morbidity and chances of mortality.
A higher average length of stay in hospital or the cost of infection is thus more expensive than payment towards maintaining a safe and clean hospital environment. It will prevent hospitals trying to cut costs on non-medical items, which in turn will help reduce infection rates, antibiotic abuse and overall morbidity and mortality due to infection.
Paucity favours compromise
Knowing that certain items are not covered under the medical costs, and knowing that there will be issues in realising the non-medical costs from the patient and their family, may contribute to cost cutting measures. Opinions may sway in favour of selecting the cheapest rather than best materials and technologies as well as the cheapest manpower.
In the meanwhile, it is important that the insured and those paying out of pocket become aware that the charges being incurred under the non-medical charges are actually important to maintain infection control practices and safety, both of the patients and their caregivers.
The way forward
Diverse types of healthcare facilities and services are available to patients, ranging from a PHC to a seven-star hospital; from basic care to quaternary care. Everything from planning the hospital building to the choice of the construction material, floorings, cladding materials used and workflow supported, affect the hospital environment, infection rates and clinical outcomes.
However, typically, the choice of materials or the technologies to be adopted, whether in the clinical or ‘non-clinical’ areas, is governed by economies of cost. The comparisons often are not based on scientific data, especially when it comes to planning construction, choosing materials, technology, cleaning agents or hygiene practices. The decision makers at times may be non-medical personnel or medical personnel without an understanding of the level of disinfection or the cleaning processes and the requirements thereof.
Selection of the cleaning crews and those who lead the teams may not be based on their knowledge or practise methods. If one has the best trained staff but an ineffective product or an effective product but a team that does not know how to apply it correctly, the pathogen that is being targeted will continue to flourish. Choosing the right materials, methods, technology and training people in safe hygiene practices are critical for instituting robust practices on the ground and requires a multipronged approach.