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Guidelines on Ayushman Bharat Pradhan Mantri -Jan Arogya Yojana (AB PM-JAY) Quality Indicators for

Quality of Care

AYUSHMAN BHARAT – PRADHAN MANTRI JAN AROGYA YOJANA (AB PM-JAY), NATIONAL HEALTH AUTHORITY – GOVT. OF INDIA

(AUGUST 2020)

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Table of Contents

Background ---------------------------------------------------------------------- 3

Need-------------------------------------------------------------------------------- 3

Proposed Approach------------------------------------------------------------- 4

Proposed Quality Indicators for Hospitals--------------------------------- 4

Implementation Plan and Roll Out----------------------------------------- 6

Dashboard at Hospital Level------------------------------------------------- 7

Dashboard at National/ State Level--------------------------------------- 7

Monitoring Survey------------------------------------------------------------- 8

Conclusion----------------------------------------------------------------------- 8

Annexure------------------------------------------------------------------------ 8

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Background

Ayushman Bharat PM-JAY is the largest health assurance scheme in the world which aims at

providing a health cover of Rs. 5 lakhs per family per year for secondary and tertiary care

hospitalization to over 10.74 crores poor and vulnerable families (approximately 50 crore

beneficiaries) that form the bottom 40% of the Indian population.

Prime moto of AB PM-JAY is to provide quality healthcare to its beneficiaries. To ensure the

quality services in empanelled hospitals NHA has developed -

• Monthly Audit Checklist - Monthly quality audit checklist for its empanelled hospitals.

The checklist helps the empanelled hospital to monthly monitor the quality of services

provided.

• AB PM-JAY Quality Certificate - National Health Authority (NHA) and Quality Council of

India (QCI) have developed AB PM-JAY quality certifications which include

Bronze/Silver/Gold Quality Certification to deliver quality services to its beneficiaries.

o Bronze Quality Certification is basic level of certification. Hospitals that are

empaneled with AB PM-JAY scheme and which do not possess any accreditation

or certification from any other recognized certification body (NQAS, NABH & JCI)

can apply for this certificate.

o Silver Quality Certification is for hospitals with NQAS and NABH Entry Level

certification. Hospitals with these certifications can directly apply for Silver Quality

Certification with simplified process.

o Gold Quality Certification is for hospitals with NABH and JCI accreditation.

Hospital with these certifications can directly apply for Gold Quality Certification

with simplified process.

Need

A detailed study on two quality indicators readmission rates and hospital mortality under PM-

JAY was conducted in November 2019 and the detailed document “PM-JAY Policy brief 7: Quality

of Care in PM-JAY: A first look at unplanned readmissions and mortality” was submitted in May

2020. It was suggested that there is need to improve data collection and data quality to help in

Quality of care in PM-JAY, also it was suggested to link quality with payment.

NHA through AB PM-JAY quality certification and Monthly Audit Checklist is trying to ensure the

quality services in AB PM-JAY empanelled hospitals. Since both initiatives are voluntary in nature

sustainable quality data is not received from all the health care facilities.

With increasing number of empaneled hospitals in AB PM-JAY ecosystem there is a need to

develop quantitative indicators for monitoring quality of services provided by empanelled

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hospitals. A quality matrix at National level/ State level can further be developed which will help

in grading the hospitals. The matrix can further be used for strategic decision making.

Proposed Approach

Study of National and International Systems:

As a first step to understand and create a framework

various system, both domestic and international were

studied through desktop research. Salient features of

the systems have been included in Annexure 1

A set of 8 quality indicators is proposed. The proposed

indicators need to be filled on monthly basis by each

empanelled hospital before 10th of each month. For

each indicator Goals are defined at State/National level.

Goals for each measure is named as “PMJAY Gold

Specification”. The goals will help in strategic decision

making at State/National Level.

Proposed Quality Indicators for Hospitals

Sr.N

o.

Quality Indicators Definition Data Source PMJAY Gold Specification

Remarks

1 Average Length

of Stay (ALOS)

Number of in-patient days in a

given month / Number of

discharges and death in that

month

Hospital Records/ TMS

ALOS = National average or less

2 Gross Mortality

Rate (MR)

Total number of deaths

happened in the hospital in a

month / Total number of deaths +

discharges during that month x

100

Hospital Records

MR= 25 Points below the national average

3 Hospital

Readmission

Percentage

Number of discharged patients

readmitted for the same

condition/complications of the

procedure undertaken to the

hospital within 30 days of their

discharge/Number of patients

discharged * 100

Hospital Records

30-day hospital readmission = 4.49% or less

• Whole System Measures

(WSM) - Institute for

Healthcare Improvement

(IHI)

• National Accreditation

Board for Hospitals and

Healthcare providers

(NABH)

• Institute of Medicine

(IoM) Report – Crossing

the Quality Chasm

SYSYEMS STUDIED

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4 Rate of Adverse

Events (AE)

AEs per 1,000 Patient Days =

Total number of AEs/Total

Length of stay for all patient

records reviewed * 1,000

Hospital Records

5 or less Adverse Events per 1,000 Patient Days

An adverse event is any undesirable experience associated with the use of a medical product in a patient. It can lead to death, life-threatening, hospitalization, disability or permanent damage etc.

5 Health Care Cost

per Capita

Sum of all health care

expenditures for a group of

people who live in a defined

geographical area / Number of

people in the defined

geographical area

TMS $3,150 per Capita per Year $5,026 per Enrollee per Year

6 Surgical Site Infection (SSI)

Surgical Site Infection (SSI) (for month) = Number of surgical site infections/ Number of patients operated *100

Hospital Records

Infection Rate = 25 points below National Average

7 Urinary Tract Infection (UTI)

Urinary Tract Infection (UTI) (for month) = Sum of Urinary Tract Infection Complaints/ Total Number of patients admitted *100

Hospital Records

Infection Rate = 25 points below National Average

Catheter related, occurrence of a catheter-related urinary tract infection (UTI) in patients with indwelling urethral catheters, suprapubic catheters, or undergoing intermittent catheterization (documented by a positive urine specimen)

8 Blood Stream Infection (BSI)

Blood Stream Infection (BSI) (for month) = Number of Catheter related BSI/ Number of patients on IV line * 100

Hospital Records

Infection Rate = 25 points below National Average

The occurrence of bacteremia or fungemia (documented by positive blood culture samples) following placement of a central venous catheter device with no other apparent source for bloodstream infection

If any indicator is not reported it will be taken as NIL and will not be included in average count

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Implementation Plan and Roll Out

1. Stakeholder Consultation – Consultation of Quality Experts from Industry and advisor

on the formed indicators. Also, consultation of top empanelled hospitals to look at the

feasibility of implementation of indicators.

2. Indicators Finalization – Once the review from different stakeholders is collected,

indicators will be finalized by NHA.

3. Dashboard Development – After finalization of indicators a dashboard will be

developed which can be used at Hospital, District and National level

• Web based dashboard includes all the Quality indicators on a single screen at

different levels:

o Hospital

o State

o National

• The hospitals will use the dashboard to fill the indicators

• At State/National level the dashboard will reflect each indicator with PM-JAY

Gold specification

• The dashboard enables data visualization by aggregating, analyzing and making

sense of all forms of data.

• Provides international benchmarking, gender, nationality and age group split for

each indicator

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Note:

This will be mandatory requirement and message will pop up on TMS regularly that you have 3 days to fill in the details

These indicators will be reviewed from time to time and may be revised if the need is felt.

Dashboard at Hospital Level

Dashboard at National/ State Level

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4. Capacity Building – Detailed training plan on State level training of hospitals. Training will

include details on Quality indicators, ways to capture it on monthly basis at hospital level.

Refresher trainings and on-premise handholding support is provided when required.

5. Roll out of Indicators- After training of States, Indicators will be rolled out and

empanelled hospitals will capture the data on indicators monthly basis.

6. Monitoring of Indicators - Regular Monitoring of indicators at State and National Level as

compared to Toyota Specification.

Twice a year Survey - Cross sectional survey based on sample size from geographical, type

of care and bed strength

Monitoring Survey

Twice a year survey cross sectional survey will be panned based on random size from different

geographical locations.

Hospitals will be surveyed on the validity of 8 Quality indicators submitted by hospital in last year

with help of third party.

Records will be reviewed and detailed report with recommendations based on observations will

be submitted.

Conclusion

There is a need to define quality indicators for continuous monitoring of quality of care in each

empaneled hospital. The defined quality indicators will be updated on developed dashboard at

each hospital before 10th of each month. Field surveys needs to be conducted twice a year for

validity of data collected on dashboards. Compliance to Quality indicators can further be linked

to Star rating of hospitals.

Annexure

1. “Whole System Measures” Indicators:

Institute for Healthcare Improvement (IHI) Cambridge, Massachusetts and colleagues developed

the Whole System Measures.

These are balanced set of system-level measures which measures the overall quality of a

hospital system and aligns improvement work across a hospital, group practice or large

healthcare system. It evaluates the patient journey from the first point of contact with the health

system till the actual health outcome achieved after the patient is discharged.

This is done with the help of comprehensive set of 13 Whole systems Measure (WSM) Indicators

developed and recommended by IHI (Institute for Healthcare Improvement)

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Key Features of WSM Implementations:

• Enables strategic decision making at the National/ Regional/ Sub-regional level after

identifying areas of improvement

• Enables hospitals reach international benchmarks of quality of care for patients

• Measures the periodic progress of hospitals system to achieve the excellence in patient

care

• Counters “indicators fatigue” by focusing on a smaller set of 13 indicators

• Can be implemented at 1 hospital, sample of hospitals or across all hospitals

• Can be used to roll out performance-based incentives, develop rankings etc.

2. Accreditation Standards for Hospitals and Healthcare providers – NABH

The following key domains to measure hospital quality are assessed:

Access, Assessment and Continuity of Care (AAC)

• Care of Patients (COP)

• Management of medication (MOM)

• Patient Rights and Education (PRE)

• Hospital Infection Control (HIC)

• Continuous Quality Improvement (CQI)

• Responsibilities of Management (ROM)

• Facilities, Management and Safety (FMS)

• Human Resource Management (HRM)

• Information management system (IMS)

The orientation for assessment is truly patient-centered and provides a great reference

for a vision for improving healthcare quality in India at the facility level.

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3. Institute of Medicine (IoM) Report – Crossing the Quality Chasm

The initial motivation for the report was to counter the alarmingly high rate of

preventable medical errors in the United States. It is now referenced as a basis for

measuring quality care as the US shifts from a fee-for-service model to a value-based

system > for Affordable Care and Patient Protection Act (ACA) 2010

Six quality aspects that are key to healthcare have been identified

• Safety

• Effectiveness

• Timeliness

• Efficiency

• Personalization

• Equity

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