Patient safety & universal health coverage in India.

The World Patient Safety Day (WPSD) was approved by the Seventy Second World Health Assembly (WHA) in May 20191. The WHA resolution 72.6 recognized patient safety as a global health priority and endorsed to observe September 17 annually as WPSD, to raise awareness and understanding about patient safety and to galvanize global actions for safer systems, services, procedures and practices in healthcare to eliminate harms to patients and mitigate any risk of harm to patients and health workers. The first ever WPSD was observed on September 17, 2019 with theme of 'Patient Safety: A global health priority'2.

Patient safety is the reduction of unnecessary harm associated with healthcare to an acceptable minimum3. Unsafe health services are increasingly being recognized amongst the classical barriers to access to healthcare, i, e., physical, financial and information access. There are many compelling reasons to increase investments and scale up intervention for reducing patient safety incidents. Unsafe care erodes the trust (of people) in healthcare system; alters their health seeking behaviour; costs nearly 15 per cent of total health expenditure; demotivates healthcare providers and poses serious risk of advancing health goals4. Unarguably, patient safety is a fundamental element of quality health services, which are needed to advance and achieve Universal Health Coverage, another agreed global goal. The WPSD has been designated in times, when there is better than ever understanding of evidence on patient harms as well as on the effectiveness of interventions to improve patient safety1.

The designation of WPSD which is the eighth and the most recent World Health Organization (WHO) approved international day, places patient safety at a new level of priority and an opportunity to make healthcare safer2. Starting this year, the WPSD is an opportunity to bring all stakeholders: policy makers, programme managers, academia, patients, communities, patient groups and non-governmental organizations to raise awareness about reducing patient harms and making healthcare safe.

Patient safety and initiatives for improving quality of healthcare services in India

In the last one and half decade several initiatives have been taken by the Government of India to improve quality of healthcare services and strengthen patient safety (Box)567. The release of National Patient Safety Implementation Framework (NPSIF, 2018-2025) is a major development, which with six objectives, 21 priorities and 81 interventions intends to integrate key patient safety initiatives in India5. The six strategic objectives of NPSIF are establishing institutional framework/mechanisms; assessment and reporting of adverse events; competent health workforce; infection prevention and control; safety in programmatic and clinical domains and patient safety research567. India's NPSIF is fully aligned with 'Regional Strategy for Patient Safety in the WHO South-East Asia Region (2016-2025)' endorsed by the 68th Regional Committee of WHO South-East Asia Region8.

Box

Key initiatives to improve patient safety and quality of healthcare in India (2005-2019)

2019: India joined as one of 4 countries at global level to the WHO led GPSC

2019: Meeting of expert group to develop operational document for NPSIF of India

2018: Government of India meeting on high quality healthcare system

2018: Second National Quality Conclave

2018: NPSIF (2018-2025) of India

2017: National Action Plan for Antimicrobial Resistance (2017-2021)

2017: LaQshya: Labour Room Quality improvement initiative

2016: Formation of N-TEG on injection safety in India (reconstituted in 2019)

2016: Mera Aspataal (My Hospital) initiative for patient feedback on quality of health services

2015: Kayakalp Awards, for cleaner healthcare facilities in government sector

2014: First National Quality Conclave

2013: NQAS for public health facilities

2010: The Clinical Establishment (registration and regulation) Act, 2010

2007: IPHS (revised in 2012 and being revised again in 2019)

2005: Quality of care described as integral part of NRHM

In addition, the patient safety and quality control committees have been formed at both State and district levels; capacity building of various category of staff in patient safety has been conducted under NQAS and National Health Mission; accreditation of public and private facilities under various accreditation standards and implementation of Biomedical Waste Management Rules are other ongoing initiatives for quality care and patient safety. Many Indian States have taken other initiatives such as transition to re-use prevention syringes instead of traditional auto-disable syringes for therapeutic care. Injection safety has been included as an integral part of National Viral Hepatitis Control Programme of India, launched in 2018.

GPSC, Global Patient Safety Collaborative; WHO, World Health Organization; NPSIF, National Patient Safety Implementation Framework; N-TEG, National Technical Expert Group; NQAS, National Quality Assurance Standards; IPHS, Indian Public Health Standards; NRHM, National Rural Health Mission Source: Refs 567

In 2019, there is renewed attention to converge multiple initiatives to strengthen patient safety and integrate with overall efforts to improve quality of health services in both public and private sectors. The Directorate General of Health Services in the Ministry of Health & Family Welfare, Government of India, in collaboration with the WHO, is developing an implementation document for operationalization of NPSIF (2018-2025)5. In addition, the operational research has been completed to understand the training need on patient safety for graduate curriculum for various cadres of health staff including doctors, nurses, laboratory technicians and pharmacists9. The recommendations from this evidence-based work are expected to guide the next step in curriculum revision and modification. The Government of India has joined hands with the Global Patient Safety Collaborative (GPSC)7. As part of this international collaborative work which includes WHO, the Government of United Kingdom and Imperial College, London as academic partner, India is the only country in WHO's South-East Asia Region and one of the four countries globally, which would receive technical support to strengthen leadership; education and training capacity as well as research for accelerated improvements in patient safety9.

Converge policy proposals with facility-level interventions

The patient safety in India has evolved rapidly yet the need for more is recognized. The top-level/policy initiatives need to be supplemented with interventions at the facility levels. WPSD 2019 is an opportunity to 'Recognize, Talk and Take actions' for patient safety. It is widely acknowledged that health services and facilities have a few preventable errors. Recognizing the issues of preventable errors at the level of every facility in non-blame shifting style can contribute to safe care. Once the problem is recognized, it needs to be talked and discussed amongst the stakeholders: doctors, nurses, operation theatre technicians, facility-level infection prevention and control committee as well as the staff at all levels in a health facility up to the cleaners. The solutions are likely to emerge from these sustained communications and dialogues. Taking actions at every facility level would contribute to make healthcare safe in all facilities. The approach is applicable to both public and private sectors. The need for research in patient safety, as well as capacity building for research in this area, is increasingly being recognized and needs to be supported financially and augmented through collaborative work.

There are generic and yet concrete actions, which each health facility can take to provide safer healthcare. A few indicative approaches could be as follows: One, having a clean and safer environment contributes to patient safety. For example, if there are no wet floors and spill of water on the floor, it can prevent falls of the patient (or relatives), which is emerging as a major patient safety issue. Similarly, the provision of running water and soap for hand washing closer to patient wards can reduce infections. Second, simplify and standardize the treatment. The treatment protocols and standard treatment guidelines need to be widely made available and implementation facilitated. Third, every facility should develop plan for training of staff with provision of regular in-service training in patient safety. Fourth, involve patients in their own care, which could be innovative such as patients marking their body part which needs to be operated and seeking their regular feedback before discharge. Fifth, a culture of reporting, discuss and learn from mistake needs to be developed at facilities. The slogan of WPSD 2019 is 'Speak up for Patient Safety'2, which is to be interpreted in the spirit of speak up what is right and what is needed for making health services safe.

Health is a State subject in India; therefore, in addition to policy initiatives of the Union Government, the States need to take additional and concrete measures to improve patient safety. The patient safety and quality of care interventions need to be harmonized in the country and supported with increased government financial allocation and spending. The use of digital health technology can contribute to evidence generation and for accelerating interventions, including strengthening recording and reporting system9. Both components of Ayushman Bharat Programme: Health and Wellness Centres and Pradhan Mantri Jan Arogya Yojana have potential to improve patient safety at all three levels of care, through mechanisms such as implementation of standard treatment guidelines and treatment flows as well as accreditation of healthcare facilities10.

Conclusion

WPSD 2019 is an opportunity for all countries to build upon ongoing initiatives and accelerate patient safety in their settings. It is an opportunity for India, amongst other, to converge multiple ongoing initiatives and linkage with efforts to improve quality of healthcare services at both policy and facility levels. Safe healthcare would help in breaking one of the access barriers and encourage people for early access to healthcare. Improved patient safety is integral to improved quality of healthcare, which would help India (and the world) to achieve the goal of universal health coverage, as envisaged in National Health Policy 201711 and as in the Sustainable Development Goals.