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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
5
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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