Quality Analysis of the Radiology Department in a

NABH Accretidated Hospital

BY
Sakshi Sapru

A Project Report Submitted in Partial

Fulfillment of the Requirements for the Degree
of Masters in Hospital Administration School

School of Health Systems Studies (SHSS)

Tata Institute of Social Sciences
Mumbai
2013-2015

1
 DECLARATION

I, SakshiSapru, do hereby declare that this dissertation entitled

“Quality Analysis of Radiology department in a NABH
Accretidated Hospital” is the outcome of my own study
undertaken under the guidance of Mr. Joy Chakrobarty,
Chief Operating Officer, PD Hinduja hospital Mumbai. It has
not previously formed the basis for the award of any degree,
diploma or certificate of this or any other university. I have
duly acknowledged all the sources used by me in the
preparation of this dissertation.

28 January 2015 SakshiSapru

2
 Acknowledgement

Itgives me immense pleasure in acknowledging those who

helped and motivated me to undertake this study and helped me
in successfully completing the same.
Firstly I would like to thank my guide Mr. Joy Chakrobarty,
Chief Operating Officer PD Hinduja Hospital,Mumbai for
helping me to develop an insight on the project. I am grateful
to him for his constant comments, feedbacks and suggestion
throughout my dissertation.
I would like to thank our Dean, Dr. C.A.K. Yesudian and
course Coordinator Dr.M. Marriappan for giving me an
opportunity to undertake this study as my research project for
partial fulfillment of my degree.
I would like to thank the staff of Sir Dorabji Tata Memorial
Library for their help and support.
I would also thank my family and family for always being
supportive.
The chain of my gratitude would be definitely incomplete if I
would forget to thank almighty god for inspiring and guiding
me.

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 CERTIFICATE
This is to certify that the dissertation entitled, “Quality
Analysis of radiology department in an NABH
accretidated hospital is the record of original work done
by Sakshisapru under my guidance. The results of the
research presented in this dissertation have not
previously formed the basis for the award of any degree,
diploma or certificate of this or any other university.

Mr. Joy Chakrobarty

Chief Operating Officer
PD Hinduja Hospital, Mahim, Mumbai

4
 Table of contents

Content Page no

1.Declaration 2
2.Aknowledgement 3
3.Certificate 4
4.Table of contents 5
5. list of tables 6
6. Abstract 7
7. Introduction 8
8. Literature review 24
9. Methodology 38
10. Results 35
11. Recommendations 53
12. References 55

5
 Table of contents

Table no Content

1. 3.1 Objective and

methodology used for
data collection
2. 4.1 Categorical analysis of
patient satisfaction
questionnaire
3. 4.2 Various categories of
the checklist
4. 4.3 Assessment of the
criteria’s on the basis of
structure
5. 4.4 Assessment of the
criteria’s on the basis of
process

6
 Abstract
Quality is an integral part of accreditation, so most of the hospitals go
for it but the quality expected to be maintained and improved, not able
to do so due to various reasons. So, in this study researcher tried to find
out the gaps and suggested measures for the same.
The study “Quality Analysis of the Radiology department in an NABH
accretidated Hospital” was done to know to what extent a hospital
maintains standard after getting accreditation. The objective of the
study was to assess the policies of the radiology department with
standard protocols of NABH and to assess measures taken by the
management to maintain the standards. Data was collected from 300
bedded NABH Accredited hospitals by means of non participatory
observation, semi structured interview. Data collection was also
collected by HMIS (Hospital Management Information System),
questionnaire on satisfaction was filled by 50 patients, who had visited
department for twice or more than twice for more than a week.
Department staff was interviewed to know the perception of the
management’s perception towards quality and accreditation. To know
the compliance of the staff to the NABH standard a surprise check was
done in the radiology department of hospital.
Data analysis showed that the organization was not able to maintain
some of the standards, as it was having at the time for accreditation.
The quality team strongly accepted that accreditation helps in maintain
and improving quality, whereas the data showed a little variation in
compliance. The patient satisfaction questionnaire also shows that the
patient’s were not satisfied with the some of the services given.
Recommendations were given according to gap detected while
conducting study and data analysis.

7
 Chapter-1(Introduction)

Quality of care:
The degree to which health services for individuals and populations
increase the likelihood of desired health outcomes and are consistent
with the current professional knowledge. [5]
As compelling the definition might look but it does not provide much
guidance in developing a measure or set of measures subsequent IQM
report specified seven aims of a medical care system that are more
specific:Safe- avoiding injuries to the patients from the care that is
supposed to be given to them.Effective- providing services based on
scientific knowledge to all that could benefit from refraining from
providing services to those not likely to benefit. Patient centric-
providing care that is, respectful of and responsive to the individual
patient preferences, needs, and values and ensuring that the patient
values guide all clinical decisions.
1. Timely- reducing waits and sometimes the harmful delays for
both those who receive and those who give care.Efficient-
avoiding waste, in particular waste of equipment, supplies, ideas
and energy.

2. Equitable- Providing care that does not vary in quality because of

personal characteristics, such as gender, ethnicity, geographic;
location, and socioeconomic status.
8
These aims describe two related, but distinct types of excellence:
technical and interpersonal.
Interpersonal excellence refers to care that meets information,
emotional, and physical needs of patients in a way that is consistent
with their preferences and expectations. Another term that can be used
for such akind of care is patient centric care. One more important
aspect of patient centric care is involvement in decision making.It is
important to distinguish between excellence of interpersonal care and
patient satisfaction. Patient satisfaction is commonly measured and
may consider it an indicator of medical care quality. However, patients
might be satisfied with poor quality of care.
Thus, it is important to specify the interpersonal aspects of high quality
of care and ask patients to report about their experiences. It may also
be useful to rate the extent to which care met patients expectations, but
it is important to recognize that high satisfaction does not necessarily
imply high quality of care. Although the aims above suggest how one
might measure quality, there are multiple approaches to measuring
different aspects of quality. Donabedian proposed that one could assess
whether high quality care is provided by examining the structure of the
setting in which care is provided, by measuring the actual process of
care, and/or by assessing what the outcomes of care are.

Structure refers to the characteristics of the setting in which care takes

place. Measures of the setting used might include characteristics of:

9
• Physicians and hospitals (e.g., a physician's specialty or the
ownership of a hospital);
• Personnel; and/or
• Policies related to care delivery.
Increasingly, we view structure as not just the way clinics and hospitals
are organized and operated, but by the policies they have in place that
affect care quality. For example, processes for monitoring and
promoting quality, incentives for high quality care, etc. can have an
influence on how well care is delivered. A motivation for focusing on
structure is the premise that the setting can be a strong determinant of
care quality and given the proper system, good care will follow. For
example, one would expect care to be of higher quality when all staff
are clear about their roles and responsibilities, when there are strategies
for monitoring adherence to recommended procedures, and there are
systematic approaches to continuously improving care quality.

Process measures assess whether a patient received what is known to

be good care. They can refer to anything that is done as part of the
encounter between a physician or another healthcare professional and a
patient, including interpersonal processes, such as providing
information and emotional support, as well as involving patients in
decisions in a way that is consistent with their preferences, etc.
Outcomes refer to a patient's health status or change in health status
(e.g., an improvement in symptoms or mobility) resulting from the
medical care received. This includes intended outcomes, such as the
10
relief of pain and unintended outcomes, such as complications. There is
also a category of measurement called intermediate outcomes. This
includes measures like Hemoglobin A1c levels for people with diabetes
and blood pressure measurements. These intermediate outcomes are
often closely related to other health outcomes.
If quality of care criteria based on structural, process or intermediate
outcomes are to be credible, it must be demonstrated that variations in
the attribute they measure lead to differences in health status
outcomes.For outcomes to be used as quality of care measures, they
must reflect, or be responsive. For example, we know that taking blood
pressures is necessary for monitoring how well blood pressure is
controlled and that controlling blood pressure reduces the probability
of heart attacks, strokes and other bad outcomes.
Outcome measures:
Outcomes now have been incorporated into a broad range of health
care activities. Physicians providing clinical care routinely ask patients
about outcomes to guide their therapy.In clinical research, patients'
outcomes provide a measure of the effectiveness of different medical
interventions. Outcome measures also have been used in health care
organizations and systems to assess quality and guide efforts to
improve it. Most of the efforts to monitor and/or report outcomes
systematically have focused on mortality or other outcomes such as in-
hospital complications, and physiologic function. However, such
measures do not adequately reflect the full range of variations in health
affected by care that are important to individuals. It is also important to
measure the impact of medical and surgical care on symptoms,
functioning, and emotional well-being. These types of outcomes often
are referred to collectively as health-related quality of life.

11
Links between outcome and process are more likely when the patient
group is well defined by medical condition and/or demographic
characteristics, when there is a well accepted physiologic, biochemical,
or psychological mechanism that links medical intervention with
outcome, and when the outcomes are targeted for the medical
condition.Often we lack information on the natural history of illnesses
that are not treated. This would provide an important comparison
against which outcomes for treated patients could be compared. In the
case of procedures, measuring outcomes can have an unintended and
perverse consequence: performing the procedure on healthier patients
may give the appearance of better technical quality because the
patients’ outcomes are better if the case-mix models do not adequately
adjust for such differences. If a procedure was not indicated for the
patient in the first place, the good outcome may not be attributable to
the procedure and the patient may have being exposed to unnecessary
risk since the procedure may not have been necessary.
Other limitations of outcome measures are that in many situations the
most relevant outcome takes a substantial amount of time to become
manifest. For example, one of the outcomes of a hip replacement might
be how long the replacement lasts and it may take many years to have a
good sense of that. A limitation of outcome measures for quality
improvement purposes is that even when outcomes are less than
optimal, they may not provide insights into why there were poor
outcomes and what needs to be changed to yield better outcomes.

12
There are other practical difficulties in assessing outcomes. The data
collection systems required to collect such data are not routinely
available in clinical settings. When one does develop data collection
systems there can be biases in the data. Specifically, for some
measures, particularly patient reported ones, patients with worse
outcomes may be less likely to respond to surveys. Thus, bias can
result if response rates differ across settings.
Process measures:
Process measures attempt to answer the question”Did this patient
receive the right care,” or “what percent of the time did patients of this
type receive the right care?” Such measures are typically developed
based on the known relationship between a process and outcomes. For
example if one was examining the quality of care received by a patient
with diabetes, one might assess whether the patient had undergone an
annual funduscopic examination by an ophthalmologist or whether the
patient's feet were professionally examined annually. Such measures
are used because research has demonstrated a link between those
processes and important outcomes, such as retinopathy or foot
amputations. A nurse or medical-record technician trained in quality
assessment could compare what was done to what should have been
done, and the result would be expressed as the proportion of times that
the criteria were met. Such measures or criteria are typically developed
by first identifying the condition of interest, and then synthesizing
research evidence to create evidence-based guidelines for clinical care.

13
Once one has identified the part of the medical care process that will be
used, one defines patients who are eligible to receive care on the basis
of guideline, create criterion to determine which patients received care
in accordance with guideline, and divide number who received care in
compliance with guideline by number of patients eligible to receive
care.
It is not adequate to simply assess individual processes of care, but
rather groups or processes, or “bundles” of activities that need to occur
to lead to a better outcome. For example, researchers attempting to
prevent catheter related bloodstream infections learned from prior
research that multiple activities, such as hand washing, full barrier
precautions, and skin antisepsis with chlorhexidine, avoiding the
femoral site during catheter insertion, and removing unnecessary
catheters are all necessary to achieve the best outcomes.
Even when there are data supporting the appropriateness and
effectiveness of a process or procedure, there often is more than one
evidence-supported way to treat a condition. Frequently, for example,
different approaches to treatment (e.g. radiation, versus surgery for
prostate cancer) are developed and thought to be best by physicians in
different specialties. This situation has given rise to a field of research
referred to as comparative effectivenessresearch.
It is also important to recognize that for many treatments that are
“preference sensitive”whether or not a particular treatment or
procedure is appropriate depends on patient preferences.Sometimes,
processes of care are too complicated for completely explicit criteria.
For example,determining when a problem occurred or when an adverse
event was preventable, may require some clinical judgment [5].

14
Such measures tend to be less reliable and usually provide less
compelling evidence than measures with a strong research base,
however.
Some of the advantages of process measures are that they are very
specific, understandable to patients and providers, and in many cases
can be easier than outcomes to measure. Disadvantages of process
measures include the fact that we do not know how many processes of
care are related to outcomes. Another shortcoming is related to the fact
that sometimes hundreds, if not thousands of things are done in the
course of caring for a patient with a complicated condition and it is
difficult to develop and use enough measures to form a comprehensive
assessment.
Structure measures:
Probably the main advantage and attractiveness of structure measures
is that they are concrete and usually easy to assess. For example, it is
relatively easy to determine whether an intensive care unit has a
specialty physician available 24 hours a day or if a health plan provides
incentives to physicians who meet high standards of care, the training
of physicians.[6]Measures based on explicit criteria derived from
strong evidence are more reliable and valid. After the scientific
literature has been reviewed, specific criteria of the quality of care are
enumerated and categorized by the level of evidence (randomized
controlled trials, observational studies, or expert opinion) supporting
them. A comprehensive internal analysis of a department should cover
the three categories above.

15
In the study analysis of the radiology department has been done which
includes a review and analysis of the quality of all the elements involve
in the practices of staff, equipment and procedures, patient protection
and safety and overall performance of the diagnostic radiology facility.
Any gap in technology, human resources and procedures should be
identified so that the institution can plan for the same.
NABH is a constituent body of quality council of India, which has the
mission to help India, achieve and sustain total quality and relialilbility
in all areas of life, work, environment, product and services at
individual, organizational, community and social levels.NABH
Technical committee for medical imaging services establishes and
maintains accreditation standards for medical imaging services with the
main goal to improve diagnostic accuracy and safety. These standards
are applicable to all medical imaging centers regardless of type of
Medical imaging services setup i.e. single modality service, double
modality service or medical imaging service as a part of Health care
organization. Hence, to assess the quality and safety of the medical
imaging services and to represent a method for monitoring of quality
standards, these have been formulated.

Accreditation:
Accreditation is a process in which an entity, usually non-
governmental assesses the health care organization to determine if it
meets a set of requirements designed to improve the safety and quality
of care.[7]Standards for NABH accreditation for Medical Imaging
services have been developed and formulated. They are divided into 6
chapters containing 23 standards and 96 objective elements. These

16
standards provide general guidelines pertaining to all diagnostic
imaging services.

Standards:
1. Control of services
2. Control of imaging processes and procedures
3. Control of personnel
4. Control of equipment
5. Control of documents and records
6. Risk control and safety
The above standards are:

 Patient focused
 Cover the functions and systems of medical imaging ,
interventional and nuclear medicine services
 Address the dimension of quality and support quality
improvement
Standards for Medical imaging services comprises of the standards and
objective elements.Objective elements under each standard indicate the
structures and processes necessary to deliver the standard.

Quality Management in hospital includes accreditation, infection

control, patient safety etc. With the help of accreditation an
organization knows where it stands on quality parameters. A number
of assessment mechanisms are available to assess quality in health
care organization.
17
 The most commonly used tools are certification, accreditation and
licensure. Accreditation has been known as most attractive and
reliable tool for external quality Assessment for any health care
organization.

The four most important principle of accreditation are:

 It is based on written standards

 Reviews are conducted by professional peers.
 The accreditation process is administered by an independent
body.
 The aim of the accreditation is to encourage organizational
development.

Accreditation involves measuring organization quality standards and

comparing with the same organization and giving feedback to fulfill
the gap, this is known as benchmarking.
The concept of accreditation first came in USA in 1910, to determine
the effectiveness of treatment provided to patients. In 1919 the hospital
standardization program came in existence, which was set up by
American college of surgeons. In 1953 JCAHO came in existence
which later became JCI in 2007.[7]

Most of the health services are provided by private sector whereas very
less portion of this is provided by public sector. So the competition
rises in the industry. To prove that one organization is best, it has to do
something different from others. At this point the role of accreditation
comes. Accreditation gives assurance of quality of care provided. So
the health care organizations widely go for accreditation because the 12
18
agency assesses on various indicators and inform the organization
where they lack.

The accreditation agency ensures that the standards set by the hospital
at the time of organization are not only maintained but also continuous
improvement is done with time. The vital need of accreditation is for
benefit of the patient.As illustrated quality is integral part of
accreditation, so most of the hospital goes for it but after the
accreditation the quality need to be maintained and should be
improved (CQI) but the organization is not able to do so. In today’s
scenario health care sector is concerned about Accessibility,
Affordability and Assurance. Assurance is the area about which NABH
is more concerned. The aim of accreditation is not only award,
certificate or merely compliance with minimum acceptable standard
but also on continuous quality improvement. It is necessary for any
organization to maintain and improve the standards even after getting
accreditation.

Rationale of the Study:

The hospital Industry is growing at very fast rate in India. New hospital
with very new technology is growing in second and third tier cities too.
The industry is growing with 15% rate year on year, becoming one of
the largest service sectors in the economy. Each health care
organization wants to be on top and want to survive in this throat
cutting competition. Whereas every customer wants equal or more
satisfaction for the services he is paying, which is subjective matter.
Patient satisfaction with minimum cost is the key for growth in sector.

The image of the hospital depends upon the services provided by the
organization, and one can provide better services when the
19
organization strictly follows the set of standard and by setting
benchmark and following them. As described above image of the
hospital depends upon the quality of care provided, so maintaining
quality and continuous improvement is important aspect in improving
the image of any health care organization. It is mandatory for an
organization to monitor quality parameters and compare them with
standard rates. This will improve the quality of care provided to the
patient by standardizing the process and other protocols. In various
hospitals the quality indicators are not monitored once accreditation
done, therefore the graph for quality of care declines which affects the
image of the hospital and in this competition one cannot afford this. To
help in maintaining quality worldwide accreditation agency were
established. Set of standards were given by these accreditation agency
which not only help one to know where an organization stands in term
of quality but also help to maintain and continuous improve the
standard.
Today in India various accreditation agency are active which are non-
governmental, nonprofit organization. Among which National Board of
Accreditation is one of important organization. It has given
accreditation to approximately 200 hospital and 600 hospitals have
applied for it.
So accreditation is an important part of maintaining and improving
quality. But just getting done the accreditation is not enough, it has to
be maintained and continuous improvement is necessary. So that there
can be improvement in quality of care provided to the patient.
The study was done to check whether an organization is able to
maintain the standard set by at the time of getting accreditation or it
was only one time process.

Reasons for selection of Radiology:

Radiology has been distinct,medical specialty with unique technical
challenges from its inception.The origins of specialization can be

20
traced back to the technical nature of X-ray image capture and perhaps
more significantly the difficulty of exposing, transporting and
developing images.Despite pressure in early 1900sto define radiology
as a technical service, radiologicimage interpretation and reporting
required medically trained specialists.

Therefore, radiologists have been clinical specialists, who have been

obliged to also become experts in image capture technology, broad
based advances in engineering and more recently, applications of
information technology for healthcare, which continues to drive and be
driven by radiology.Radiology is now the key diagnostic tool for many
diseases and has an important role in monitoring treating and
producing outcomes.
This is from patient point of view, but other than this Radiology also
generates major part of revenue for a hospital so it can’t be ignored. If
an organization maintains the quality and follow the rule of continuous
quality improvement, no doubt it will grow and can sustain in the race
of providing best to the patients.

Radiology was chosen to study quality indicators because:

 Radiology helps in generating major portion of revenue in
hospital
 Radiology has major portion of expenses
 The reports of these diagnostic tests form the initial step of any
treatment process

 It is very important to follow the policy and procedure as the

patient care is directly related to patient satisfaction and image
of the hospital.

Scope of the study:

21
The study was conducted in NABH accredited corporate hospital in
Mumbai, having a wide range of imaging modalities in the imaging
department. Approaches to clinical assessment were classified under
three categories: structure, process and outcome.

Quality indicators were discussed with the quality team and

observation checklists were prepared from the NABH standards for the
imaging department, dividing into above three categories.These were
then compared to the hospital standards to find the loopholes. Data was
specifically collected for three modalities, plain X- ray, mammography
and CT scan.Patients were given questionnaire to fill, to know their
perception, expectations and satisfaction who visited the radiology
department. All the findings from data collected helped to draw the
conclusion at the end of the study. The study helped to find out at what
extent the hospital maintain the quality standards and what all
measures are taken to improve. The study also helped to know the
attitude of staff and management toward accreditation and quality and
need of continuous quality improvement.

Objectives of the study:

1. To assess the policies with standard protocols of NABH in

Radiology.
2. To assessthe quality of the patient care, resources and clinical
services.

3. To identify the gap in technology, human resources and procedures

so that the hospital such that it is able to plan for improvement.

22
Chapter-2 (Review of Literature)
Accreditation is an external assessment of any organization’s
performance against a pre-determined set of standards which are
measurable to the extent possible. Before the study was started done a
detailed review of literature was done to know the status of
accreditation in India as well as outside. The review of literature also
helped in knowing the need of the accreditation in today’s scenario.
A study done under the control of world health care organization
describes structure and activities at national and international level
around the world to promote quality in health care, quality tools used
in various countries, and initiatives in health services accreditation.

To describe the structure and activities by countries, various secondary

data was used which include journals, information from government
records, different websites of government agencies.

All journals and data reviewed were specific to quality in health care
and various accreditation programs in various countries and
accreditation agencies whole over the world. The summaries stated the
status of accreditation in various countries at present. The data helped
in knowing the natural history of accreditation in various countries.The
Survey was done in 47 countries. The survey shows that there are 33
accreditation programs in 29 countries, ¼ of them are still in
development and 30 % of them are in Europe. No program in Eastern
Mediator Ranean Region. Further this study also revealed that

23
accreditation of all health care services is mandatory only in France
and Italy.

The major finding was that accreditation is used by government as a

means of regulation and public accountability rather than for voluntary
self-development in some of the countries.
The study showed the variation of different accreditation program in
different program but could not locate the success factor. This wide
study by WHO shows the need and importance of the accreditation in
world and need of traditional accreditation agency to adapt to demands
and needs in order to survive. (5) Jafaret. all did a systemic review of
Medline, Pub Med with keywords of accreditation model and hospital.
The articles were searched from Jan 1985 to December 2010.Which
resulted in 2369 articles.Further 826 articles were excluded due to
inconsistency with the study and 42 articles were common in Medline
& Pub Med. In second stage 1501 articles were studied and 16747
articles excluded.

In third stage 754 were assessed for reference to attributes and

advantage and disadvantage of any accreditation model. This resulted
in exclusion of 681 articles and remaining 73 articles were most
relevant to the topic. The result of the study showed that most cited
program is the US based JCAHO/JCI, which was referred in 91% of
articles reviewed in the study.

JCAHO meets all the attributes at the highest level with main focus on
quality and emphasis on best practice. The reviewed articles shows the
list of attributes which can assist in choosing an accreditation model.

24
According to the study results JCAHO is the most comprehensive for
reference purpose. (6)

25
Above two case studies shows the need of accreditation worldwide and
its importance. The study done by WHO reveal every country’s
accreditation system and structure and improvement necessary in an
accreditation program? The second study shows the advantage and
disadvantage of various accreditation models and a reference for
accreditation model.
SubhalakshmiGopinathan conducted a study over the period of a
month in 2010.Data collection was done primarily by interviews and
direct observation. Secondary data was collected from the registers of
the hospitals. The result showed that hospital only satisfies 3 standard
of AAC and 2 standards of care of patients. This study documented the
gap between actual standards of NABH and existing standard in the
hospital. Removing this gap will help to improve the quality care and
image of the hospital. (7)

J. Warren conducted a study in South Africa in October 2003 to know

the impact of Accreditation on quality of hospital care. The Kwa Zulu-
Natal (KZN) provenance randomly selected 20 public hospitals; ten of
these were accredited in 1998 and ten hospital served as control.
The accreditation program used was COHSASA on various indicators.
Data was collected on eight hospital quality indicator with hospital
structure and processes. The indicators were, nurse’s perception on
quality, client satisfaction, client medication education accessibility
and availability of medical records, quality of peri-operative notes,
hospital sanitation and labeling of ward stocks. The study design was
prospective, randomized control trial with hospital as unit of analysis.

26
The main question addressed by this study was, whether there is any
improvement after a hospital goes through accreditation. After two
years the intervention hospital’s performance increased from 38 % to
76%, whereas control hospital did not show any remarkable progress
(37 % to 38 %). This was the first study done to access the impact of
hospital accreditation.(8)
A similar study was conducted in Lebanon, to know the impact of
accreditation on quality of care. The objective of the study was to know
the view of health care professionals, especially nurses on quality and
accreditation. All the hospitals that passed the national accreditation
survey were included. Total 1048 registered nurses from 59 hospitals
were selected. The result showed that improvement in quality has been
noted by nurses after accreditation, and felt that accreditation is a good
tool for improving quality of care. (9)

27
 Chapter-3(Methodology)

Till 2014 there are 259 hospitals all over country which are accredited
among which 10 are in Mumbai and 21 in Maharashtra. This shows the
competition present in the area. If the standards are not maintained by
the organization, then an organization cannot survive in the market. So,
among these according to availability, a hospital was selected and was
compared with its own benchmark set at the time of accreditation to
know whether organization is maintaining the standards or improving
them or not.The objective of this chapter is to explain in depth the
methodological details undertaken while conducting the study.

3.1. Research Design

3.1.1. Type of the study:

A mixed study (quantitative and qualitative) was done. Emphasis was
given on current practices followed by hospital under quality
management procedures and infrastructure patient related procedures
as well as the technical procedures. Patient expectations towards the
care received were also assessed. NABH checklist was used and
questionnaire was given to the patients.

28
3.3.1. Frame of the Study:
A corporate NABH accredited hospital with good number of radio
diagnostic modalities was selected for the study purpose. The
department was assessed for infrastructure, procedures and policies
followed, for a period of time. Data was collected from three
modalities of the department in the hospital. A sample size of 30 was
taken for each modality. Data was collected in three phases. In first
phase the patients was interviewed, in second phase a surprise check
was done on staff of radiology with the help of check list which
included NABH standards, in third phase the data related to quality
indicators was collected for one year (Jan 2013 to Dec 2013).

3.2.1. Area of Study:

Mumbai is the capital of the India with population of 20.7 million in
2011, world’s eight most populated and India’s most populous
metropolitan area [10]. Total number of hospital in Mumbai is 253
among which 10 are accredited [4]. Maximum population of Mumbai
is served by KEM, TMH,Sion,Niar and JJ Hospital in public sector and
Fortis,Apollo, Jupiter,Kohinoor,kokilaben DA Hospital are corporate
hospital which cater the maximum population of this region.

3.2. Sampling Design

3.2.1. Sample Selection:
Mumbai has 10 accredited hospitals, list of all these hospital were
prepared and all the corporate hospital were selected among these
hospitals which are NABH accredited. Further these hospitals were
shortlisted on the availability.
The hospital with good variety of imaging facility was selected. As
quality related data is very confidential subject to a hospital so after
getting permission from one of these hospital data collection was
started by researcher.

29
3.2.2. Setting for the Study:
Hospital was a corporate hospital established in 1954. Today it has
strength of 300 beds. The hospital was NABH accretidated for which
continuous renewal was done. In the recent renewal it successfully met
all the criteria. It’s the first hospital to win IMC RamakrishnaBajaj
national quality award for the year 2007.The hospital serves not only
the population of Mumbai but also from the country and foreign
patients.

3.2.3. Data collection:

Data was collected over a period of a month (April to May 2014),
which included primary as well as secondary data. Primary data was
collected by mean of direct non participatory observation. A random
sample of 50 patients visiting the radiology department was taken to
know the patient expectations, so, a close ended questioner was used.
All the data was collected on the basis of maintaining the
confidentiality of the respondent and hospital. A written statement was
given regarding maintaining the confidentiality, and using the data only
for academic purpose. Confidentially was maintained throughout the
study

30
3.2.3.1. Quantitative Data:
The quantitative data was collected on-

Observation checklistparameters
Structure Process Outcome

1.Quality management Patient related: Patient satisfaction

system 1..Referral of the survey
2.Structure of the patient for
diagnostic radiology examination
facility 2.Identification of the
3. Equipment patient
4.Documentation 3.Examination
control 4.The imaging report
5.Patient 5.Report
confidentiality, feed communication
back and complaints 6.Continuity of
6.Communication clinical care
7.Accident and
incident reporting
8.Record and image
retention

Technical procedures:
1.Infrastructure
2.Radiation safety
3.Instrumentation and
calibration

31
  Questionnaire was filled by 50 respondents. Questionnaire was
given to only patients / relatives who had visited the department twice
or more. Data was collected in the one month period.

A checklist was prepared for surprise check of the department to
check whether staff is following the criteria or not. The checklist was
based on NABH standards which are related to Radiology. The criteria
applicable in Radiology were selected

The standards on which the check list was made:

 CS (Control of service): Documented policies and procedures for
deliveringappropriate imaging pathways
 CPP (Control of imaging processes and procedures): Documented
policies and procedures to ensure the images are acquired in
accordance with the agreed protocols
 CP (Control of personnel): Documented policies and procedures
to ensure that the management of staff is effective, fair, consistent
and supportive
 CE (Care of Equipment): Documented policies and procedure to
ensure appropriate procurement, installation, operation,
maintenance, quality assurance and replacement of all equipment
 CDR (Control of documents and record): Documented policies
and procedures such that information for staff and patients is
properly maintained
 RCS (Risk control and safety): Documented policies and
procedures to ensure that the organization has arrangements and
general protection measures for staff, patients and others to
restrict exposure to the ionizing radiation.

32
3.2.3.2. Qualitative Data:

Primary data was collected in the form face to face interview. Semi
structured Interviews were taken on availability. Before taking the
interview verbal consent were taken from the respondent’s.
Patients / Relatives – 50 Patients / Relatives who are had been visiting
the Radiology department for two or more than two times were asked
to fill the questionnaire, to know the satisfaction level.

Serial Objective Methodology

no
1. To assess the policies with Checklist, policy.
standard protocols of NABH in
Radiology.

2. To assess the quality of the Semi structured interview,

patient care, resources and observation.
clinical services.

3. To identify the gap in Observation checklist

technology, human resources
and procedures so that the
hospital such that it is able to
plan for improvement.
Table No. 3.1: Objective and Methodology used for Data
Collection

33
3.3. Experience of Data Collection

By calling to the concerned person of shortlisted hospital, permission

was asked to do study in the organization. But after assuring the
confidentiality hospital X gave permission to conduct the study in the
hospital. After giving permission and consent for confidentiality the
hospital was so reluctant to some data on quality indicator but after
assuring the organization shared the necessary information. The
interviewee answered 23 the question in vague/ superficial way, but
getting filled the questionnaire was comparatively easier task.

3.4. Limitation of the study:

tudy was conducted in Radiology only, not in whole hospital.

ata (secondary) was only for one year.

34
 Chapter -4 (Result and Findings)

4.1 Quantitative Methods

4.1.1Patient Satisfaction Questionnaire Analysis

The Questionnaire contained 19 questions related to satisfaction of

services. Questionnaires were filled by the 50 patient who had visited
department twice or more than twice. The questions are further
classified for the ease of the analysis in three categories.
Satisfaction related to
Services
Hygiene
Information

Services include care provided by staff, attendants, attitude of staff

towards patients, charges of services provided. In hygiene category
question were asked related to sanitation facilities in the hospital.
Information include whether patient were given all the necessary
information regarding procedure, charges and duration of treatment.

Responsiveness is displayed by staff as:

 Patient treated with dignity and respect.
 Privacy is provided during treatment.
 Affordable charges for services rendered.
 Are you satisfied with the services provided?
 Are you satisfied with the continuity of care (followup) provided
by the organization

35
Hygiene:
 Clean and comfortable environment
 Staff is professional and neat in appearance
 Are you satisfied with the cleanliness of the hospital

Information:
 Consent form is filled and explained before any procedure done
 Information is provided regarding services available.
 Thoroughness of explanation of medical condition of patient
 Every procedure done is explained well
 You were given chance to ask questions and make choice of
treatment and obtain feed back

Analysis of questionnaire:
Categories Yes No Sometimes
Services 180(64.5%) 56(21.65%) 35(14.76%)
Hygiene 100(100%) 0 0
Information 114(54.6%) 73(37.12%) 21(8.92%)
Table 4.1: Categorical Analysis of Patient Satisfaction Questionnaire

The categorical analysis of the patient questionnaire shows the patient

satisfaction level in different categories. Patients were highly satisfied
with hygiene and cleanliness, whereas satisfaction level were very low
for services (64.50 %) and information (56.65%) provided to patient.

Percentage of respondents satisfied with services provided in the

hospital was 64.50%, where as 21.65% patients were not satisfied with
36
the services provided in the hospital, (14.76%) people were sometimes
satisfied. Respondents were highly unsatisfied with information
provided to them regarding services available to them, like treatment
available, information regarding best treatment available. Only 54.60%
respondents said that they were given proper information regarding
treatment available, patient’s condition and best possible treatment for
patient.

The area for dissatisfaction was different for every patient. For instance
14 out of 50 patients said they were not sometimes given information
regarding services available in the hospital and the last choice of
treatment was decided by the doctors. Information regarding procedure
performed was given to 20 patients, whereas 20 patients said it was not
explained. In case of explaining the patient’s medical condition only 16
relatives said it was explained well, 28 relatives were not informed
about patient’s condition. The major area where patient was not
satisfied with services was following up care. Among 30 respondents,6
said they were not given proper care while doing follow up. Only 22
patient/relatives said they were given full attention at the time of follow
up. Out of 50 patient 32 patients said they were satisfied with services
provided to them. On the other side 37 patients said they are satisfied
with technology available in the hospital. Most of the patient / relatives
accepted that they were given chance to ask question regarding
treatment.

37
4.1.2 Analysis of the checklist:

The checklist made up of NABH standards was categorized into:

 CS (Control of service)
 CPP (Control of imaging processes and procedures)
 CP (Control of personnel)
 CE (Care of Equipment)
 CDR (Control of documents and record)
 RCS ( Risk control and safety)

The checklist was analyzed on the basis of responses recorded by non-

participatory observation.The checklist is included in Annexure.
The surprise check was done in the Radiology department of hospital,
on the basis of checklist the results were as follows:
Serial Component A NI N
no Categories analyzed NA
1. Control of Structure yes
2. service yes
3. Control of
4. personnel yes
Control of
yes
equipment Care
of documents
and records
5. Control of Process yes
processes and
6. procedures yes
Risk control and
safety
Table 4.2;various categories of the checklist
A – (adequate); NI – Needs improvement; N – No ( not adequate); NA – Not applicable

38
Categorical analysis of the Checklist:
To assess the structure of the department following were analyzed:

 Quality management system-

A quality management system is a framework to support the operation
of a facility/service, with the objective of continuous quality
improvement.
A quality management system involves:
 Documented procedures consistent with these objectives and
policies
 Written practice instructions for staff
 Monitoring, recording and auditing of practice

 Structure of the diagnostic facility

 Personnel
The personnel of a radiology facility form a multidisciplinary
team that typically includes: radiological medical practitioners,
radiographers, technical assistants, sonographers, nurses, medical
physicists, service engineers, information technology (IT)
specialists and administrative staff. The facility staffing levels
and the professional competence of the staff should be sufficient
to provide safe imaging examinations of good quality, and to
meet the specified objectives of the institution for radiological
services.
 Procedures
Processes should be documented, preferably in the quality
manual.

 Premises
39
 The premises of the radiological facility should be adequate to
safely meet the specified objectives and operations of the
institution. The premises should be clean and designed to
optimize patient access, comfort, privacy and special needs.
Radiation protection of the patient, staff and general public
should be addressed. For a detailed review of the processes in
radiation protection see Section 5.1. Note that this audit process
is intended to avoid overlap with regulatory requirements.
The location of the facilities should take into consideration the
other services necessary for good patient care, as well as effective
patient movement and access.
Appropriate space should be available for:
-Imaging examination rooms
-Control rooms
-processing
-Patient changing rooms
-Recovery/post-procedural areas
-Waiting areas
-Patient movement within the facility;
-Administration
-Storage
-Record filing rooms
-Staff accommodation

 Equipment
The types and numbers of items of equipment should correspond
to theobjectives and scope of the facility’s operations as
specified in the institution’squality manual.

40
 -Policies and procedures should be documented and
monitoredwith regard to equipment, as follows:
-Purchase, usage and replacement
-An inventory;
-Appropriate checks before use;
-Quality control;
-Maintenance, particularly with respect to safety and infection
control;
-Data protection and backup.

 Documentation controlAll facility documentation, such as policy

and procedure manuals and
Inventories, requires proper control to ensure that it is current,
regularly updated&distributed. A master list of controlled
documents should be maintained.

 Patient confidentiality
To ensure that patient personal information is protected, the
confidentiality policies and procedures should be documented,
and each staff member in contact 22with patient data should have
agreed to abide by the facility and institution rulesin regard to
confidentiality.

 Feedback and complaints

To ensure that patient personal information is protected, the
confidentialitypolicies and procedures should be documented,
and each staff member in contact with patient data should have
agreed to abide by the facility and institution rulesin regard to
confidentiality.

41
As a measure of how well the service provided meets the expectations
andneeds of patients, the facility should actively seek patient feedback.
There shouldbe policies and procedures in place to address complaints
from patients. Recordsshould be maintained of patient complaints, the
results of their investigation, andactions taken to rectify problems
identified.

Serial no Criteria A NI N NA
1. Quality manual yes
2. Quality manager roles and responsibilities yes
3. Range of employed/contracted personnel
4. Trainee and supervisory staff yes
5. Staff qualification and training yes
6. Professional supervision yes
7. Policy and procedures for staff management, yes
recruitment, job description.
8. Cleanliness yes
9. Staff comfort, privacy and special needs yes
10. Policies for staff ,patient ,general public
radiation safety
11. Patient care, movement and access yes
12. Internet, library access yes
13. Policy and procedures for equipment quality
assurance before use
14. Quality control, maintenance, and safety yes
15. Staff authorization and training yes
16. Policy and procedure for equipment purchase, yes
usage and replacement.
17. Master list documentation coverage yes
18. Policy and procedure for patient yes
confidentiality
19. Policy and procedures for patients compliant yes
20. Complaint records, analysis and response yes
21. Intrafacility communication mechanisms, yes
Access to documentation.

Table 4.3:Checklist assessing the criteria’s on the basis of structure

A – (adequate); NI – Needs improvement; N – No ( not adequate); NA – Not applicable

42
 To assess the process, following were analyzed:

 Referral of the patient for examination

The radiology consultation begins with the critical task of
selection of theexamination required.Justification of an
examination requires evidence that the diagnosticbenefits of the
examination outweigh the risks for the patient, particularly if
thepatient is pregnant or potentially pregnant, breastfeeding or
pediatric, and is based on knowledge of the:
-Indications for available examinations
-Advantages and limitations of examination options
-Complementary nature of other examinations
-Results of prior examinations
-Risk–benefit considerations including adverse effects
-Contraindications
Appropriate clinical information is essential for good quality
radiologypractice.A radiological medical practitioner (or
delegate) should review the requestand determine if the
examination requested is appropriate given the
clinicalinformation provided, and, as appropriate, contact the
referring medicalpractitioner for further discussion of the clinical
findings and imagingexamination options.

 Patient education and consent:

Information regarding the potential benefits and risks (such as
contrastagent and radiation risks) associated with the relevant
examination/s should be 30made available to the patient prior to the
examination.

43
 The patient should begiven the opportunity and adequate time to ask
questions about the examinationand its risks, including radiation
exposure in pregnancy, and what otherexaminations are available. The
patient should be aware that they have the option
refuse the examination or to withdraw their consent at any time.They
consent of the patient to undergo examination should be obtained
anddocumented as appropriate.

 Policies and procedures

These should be in place to identify the clinical
conditionsrelevant to the hazards of specific radiological
examinations, such as:
-Contrast media contraindications (e.g. netforium)
-Latex and food allergies
-Renal impairment
-Pacemakers and aneurismal clips
-Anti-coagulant therapy
-Pregnancy status

Scheduling and patient preparation should be modified in

response to theseclinical conditions.There should also be
processes in place to ensure that examination-specificpreparation
processes (e.g. fasting) are communicated accurately to patients
and/or their carers, and that the facility has procedures for
managing patients who areinappropriately prepared.
 Scheduling
Timely scheduling is the next step. Staff with appropriate clinical
trainingshould be responsible for prioritizing examinations.Once
examination scheduling has been confirmed, there should be
amechanism to ensure recall of prior imaging examination images and
reports,which should be available to the reporting radiological medical
practitioner assoon as practicable.

44
 Identification of the patient

It is crucial that fail-safe mechanisms be in place to ensure that

the patient is correctly identified, that the correct examination is
performed and that the correct anatomical region is studied. There
should be a documented protocol to ensure accurate identification
of the patient and the examination performed. In view of the
complexity of patient communications, multiple checks and
balances should be in place. Constant vigilance is vital to protect
patient safety.

 Examinations

Patient confidentiality and physical privacy it is the responsibility

of the facility to have policies and procedures in place to ensure
that security and confidentiality of patient information and patient
physical privacy are respected throughout the patient’s stay in the
radiology facility. All staff should be aware of their
responsibilities and obligations with regard to patient information
and privacy.

Patient information includes:

-Biographical data
-Clinical information;
-Medical images.

The physical environment encompasses:

-Waiting rooms;
-Changing rooms;
-Examination rooms;

45
Imaging technique
Protocols and procedures for all imaging examinations should be
documented and regularly updated, and they should be readily
accessible to imaging staff at all times.

Image report:
The imaging report is integral with radiology practice, and all
examinations should be reported by qualified and trained radiological
medical practitioners/ physicians, or trainee radiological medical
practitioners/physicians under appropriate supervision.

Report communication
Communication of the imaging report to the referring medical
practitioners is also integral to radiology practice.
For this to be effective, mechanisms need to be in place to ensure that
there is
-Reporting and authentication of reports for all completed
examinations;
-Completion of reporting within agreed time-frames;
-Communication of the final report to the referring medical
practitioner.

Policies and procedures should be in place in regard to communication

of reports and specifically of urgent results. A method for identifying
urgent results and for ensuring an appropriate response is required.
Policies and procedures should be regularly monitored.

Continuity of clinical care

The responsibility of the radiological medical practitioner does not end
when the patient leaves the radiology facility. The contributions of the
radiological medical practitioner to continue clinical management of
patients should include involvement in documented:
-Multidisciplinary clinico-pathologic correlation meetings

46
 -Tumour boards
-Morbidity and mortality conferences

Accident and incident reporting untoward incidents involving patients

should be documented promptly.
In accordance with written policies, serious patient safety incidents6
and patterns of events should be:
-Recorded;
-Systematically evaluated;
-Acted upon.
Critical incidents (e.g. sentinel events such as a wrong sided
interventional procedure) should, in addition, be reported to the
institution and the regulatory authorities
 Retention of records and images
All records and images from imaging examinations should be retained
for a period in accordance with local/national regulatory
requirements. The radiology facility should have documented policies
and procedures on retention of records and images.

 Radiation protection and safety

The department should ensure that it has made all the efforts to
implement radiation protection measures for staff, patients and
other visiting personnel in order to minimize the ionizing exposure.
- Safety manual
-Signage and restricted area access

47
Serial Criteria A NI N NA
no
1. Referral of patients for yes
examination
2. Quality of the referral yes
3. Information of the referrer yes
4. Patients education and yes
consent
5. Preprocedure screening and yes
examination
6. Scheduling of the yes
appointment
7. Identification of the patient yes
8. Patient confidentiality and yes
physical privacy
9. Protocols for the imaging yes
techniques
10. Availability and yes
completeness of the report at
the time of reporting
11. Policies and procedures for yes
the report communication
12. Continuity of care yes
13. Accident and incident yes
reporting
14. Protocols for imaging yes
equipment QC tests
15. Procedures and policies for yes
radiation protection and
safety
Table 4.5:table shows the crirerea’s for assessing the processes
A – (adequate); NI – Needs improvement; N – No ( not adequate); NA – Not applicable.

48
Analysis of the checklists:

Surprise visit to the department showed that the staff was not
following the standard procedures as in the manual. They lacked
proper training and supervision. There was less awareness in the staff
about their rights such as comfort, privacy and needs. They also had
less access to the internet and library as the department is located in
separate building. Little more stress on the intra department
communication is also required. Moreover, the records of the
complaints of the patients could be maintained that would also lead
to scope of improvement in patient satisfaction and a proper protocol
should be followed for the same. There should also be a proper policy
and procedure for patient compliant.The information of the referrer
also needs some improvement as it lacked on some of the referral
forms that were checked. Also when a patient is taken inside the lab
for a test, there is no pre- examination of the patient. There should be
proper procedure for that and staff should be educated for the same.
In some of the modalities scheduling of the appointment was really a
task as the patients were taken into the lab late because of the delays
created by taking in emergency patients and also in patients. So, there
should a proper procedure to deal with the inadequacy of the
equipment and staff members while handling such issues, thereby
keeping a leeway between two consecutive appointments; as patients
become really impatient while waiting.

49
Qualitative Methods
The HR head, staff members and the assistants were interviewed for
achieving the objective 1 and 2. All the members of team were
interviewed on quality and accreditation. The interview was semi
structured, summary of each question is written below.

Meaning of Quality in Health Care

The interview data analyzed and the answer were very common among
quality team, which can summarized as achieving excellent standard of
care, and patient satisfaction. Quality in health care is more than a
concept which is very essential for any health care organization. It’s42
is standard of excellence and offering reliable services and facilities.
Quality in health care is about improving efficiency. The degree to
which the desired outcomes for patients are achieved and the patient
expectations are met.This is the important part of hospitals competitive
strategy. Quality is providing better and safe health care at affordable
cost. Quality is the corner stone for staff to act in a health care setting.
It guides for streamlining the process, channelizes responsibilities,
minimizes waste and cut the unnecessary cost, ultimately adding to the
delight of the patient.

Accreditation and Quality

Accreditation process gives an opportunity to access the existing set

up, processes and activities to turn them around as process maps,
SOP’s, Standards and norms as defined by different accreditation
agencies.

50
Accreditation works as framework for quality care given in a
hospital.Accreditation sets standard for organization to follow. Below
that standard is not accepted by accreditation board.It gives a set of
objective and goals which helps the organization to achieve quality
care, which if not followed the certification is cancelled by the agency.

Necessity of maintaining Quality after Accreditation

Post accreditation period is very crucial as for all the time that an
organization has strived to attain the accreditation should not go in
vain, once the structure has been made and function and activities
finalized and optimized, it should go on as quality is something very
dynamic and one has to be on his toes to match up. Again maintaining
the standards keeps a check on them.

Quality and Image of the Hospital

A hospital image depends on the perception of the customer, who is

vigilant and aware of the current scenario of health care. So if the
organization performs and delivers as per the likes of the patient it
reflects on the patient’s feedback and recommendation. The quality
norms if met gives boost to the hospital’s brand value and goodwill.
In other words the relation between giving quality care and image of
the hospital is directly proportional.Health care is now an industry and
survival is difficult, so as to survive in this throat cutting competition,
maintaining image is very necessary.

51


Suggestion to Improve Quality in ICU

The answers were very different from members. For instance the
human resource manager insisted on Continuous Medical Education,
where as head of radiology department insisted to keep an eye on
safety of the radiology. Continuous medical education, team work,staff
involvement is basic things which were narrated by them. Other than
this, protocols and policies for radiology should be made mandatory to
read by the staff and to follow them. Patient feedback was one common
answer given by all the members. Patient feedback on services will
improve the quality of care given. Regular internal audits, Surprise
checks, maintaining records of all NABH indicators, and
documentation will be of great help.

52
Chapter-6(Recommendations)

As there were gaps in standards illustrated in policy and followed in

radiology of hospital studied, so after analyzing the reasons,
recommendation were given to the organization which were
organization specific.

1. Common Measures should be taken:-

aff: - CME should be done o
staff .Staff should be updated about recent development in required
areas.
ion to policy of the
hospitals
ard operating procedure for every radiology

strict adherence to the standards should be done by staff

ement to be given to the staffs
ation so that the organization
don’t have to go for the training process again and again
Radiology incentives for the staff working in the department, for
talent retention.

findings to the staff.

Liaison between radiology department and Quality control team.

53
protocols.

department.
isfaction checkup and feedback on services
should be taken.

1. Patient Satisfaction

the services should be patient centered, patient should be at the

centre while planning any activity, which is directly or indirectly
related to patient.

treatment available and condition of the patient should be

communicated to the patient/relatives.
back on patient/relatives complain should be given either by
mail, text or in person.

with the consequences.

checkups etc.

would like to improve.

54
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