Has Accreditation made a difference in Healthcare Delivery in India by Dr.Mahboob Khan Phd

1
Has Accreditation Made a Difference in Healthcare Delivery?
AN INDIAN PRESPECTIVE ON QUALITY AND COST OF
HEALTHCARE
Dr.Mahboob ali khan,MHAPhd Harvard, Professor, Healthcare Management, and a leading healthcare
Consultant
ABSTRACT: With recent advances in healthcare, quality has become a pertinent issue. As the demand for healthcare
is rapidly rising with increasing population base and increasing levels of affordability, so is the demand for quality healthcare
services. Superior quality of medical care is often associated with higher costs of hospitalization. This paper attempts to
explore the relationship between quality of medical care services and the cost of hospitalization across hospitals in India. The
findings have indicated a strong positive association between the cost of hospitalization and infrastructure, while a negative
association was observed between staff to patient ratios. Though both these parameters affect and contribute to superior
quality of care their impact of cost of hospitalization differs significantly.
Key Words: Quality of Medical Care, Cost of healthcare, Average cost of hospitalization, Quality indicators
1. PRELUDE
Rapidly rising cost in healthcare is an increasing cause of concern across the world. Indian healthcare is also
experiencing a change, with increasing focus on better quality of medical care services. With a large section of
healthcare practitioners in the private sector, the government has realized the need to improve medical care services
and has stepped in to regulate the quality of medical care services by introduction of various quality accreditation
norms like the JCI ,NABH,JCI,NABL and NABL.
As per available information the healthcare spending per capita per annum in India was about $109, with total
healthcare spending in the range of 4.9% of the country's GDP [1]. Most of the spending occurs from the private
sector with public sector contributing to a mere $ 19 per capita per annum. Concurrently, the average spending per
capita per annum in the United States during the same time frame was approximately $4271 whilst United Kingdom
the spending was $ 1675. These figures clearly indicate that healthcare in India is fairly cheaper, a strong reason for
a growing medical tourism market in the country. However, when compared with paying power parity and
affordability, the cost of medical care is escalating. It is worthwhile to note that as per World Bank estimates more
than 44% of Indian population earns less than one dollar a day.
As per the Finance Ministry, the overall inflation rate in India was about 9.4 percent during April- December
2010, while inflation in medical expenses was in excess of 10 percent for the fourth year in a row [2]. There
are several other factors that have been contributing to the escalation in cost of medical care. These factors
include increasing demand for medical care services with consistently limited supply, increased penetration of
health insurance, improvement in medical technology with new innovations improving diagnostic capabilities
and increasing dependence of doctors on diagnostic procedures. Increasing demand for quality in medical care
services plays a critical role in increasing the overall cost of medical care services.
While empirical evidence suggests that there is an increasing demand for healthcare services across India,
affordability remains a pertinent issue. This has resulted in market segmentation where on one hand there is an
increasing demand for quality medical care services while on the other hand there is a demand for medical care
services at affordable cost [3]. The demand for the latter has inevitably resulted in poor quality of medical care
services with poor health outcomes.

2
It is simple to compute the direct costs for various medical services, however to compute the cost of quality is
not only difficult but rather elusive, which has resulted in over dependence on subjective criterions [4].
Various modalities like manpower ratios, infrastructure, medical technological capabilities, accreditation and
quality assurance policies and mortality rates, have been considered as quality indicators and have been used to
evaluate the quality of healthcare services. The paper attempts to explore the implication of these quality
indicators on the direct expenses incurred by patients whilst seek healthcare services across India.
2. UNDERSTANDING QUALITY IN HEALTHCARE: COMPONENTS OF QUALITY
Quality in healthcare may comprise of newer technology, newer and effective medication, and higher staff to
patient ratios, affordability, efficiency and effectiveness of healthcare delivery. Quality as defined by the
Institute of Medicine, USA, is 'The degree to which health services for individuals and populations increase
the likelihood of desired health outcomes and are consistent with current professional knowledge.'
Conceptually, Quality refers to any intervention made to improve the health outcome in totality. At a macro-
level, quality for health systems comprises of six building blocks namely healthcare services, healthcare
workforce, Healthcare Information System, Technology and Medications, Healthcare financing and Leadership
and Governance [5].
Though the sequence in terms of priorities may change, these building blocks are also essential at micro-level to
have a pertinent impact on the overall healthcare outcomes.
For a hospital or a healthcare institution, it is imperative to understand the components which can influence the
overall quality of medical care services. Quality hence can be understood based on their overall implication on
health outcomes of the patients. The various components that impact the health outcomes and thereby
influence quality include,
1. Comprehensive and integrated services, based on the demand, with adequate infrastructure and
logistics. Building, equipments, water supply, sanitation, power, etc play a crucial role and
considerably influence quality of medical care.
2. Manpower skills, knowledge, qualification, technical knowhow, training and their availability is also
critical for improving the healthcare outcomes and hence enhancing quality.
3. An information system helps retrieve data and information easily and also aids in planning for
expansion and need based requirement of the population. Quality is affected by the nature and
comprehensiveness of the information system, which helps identify existing lacunae and take
corrective action.
4. Availability of safe and effective drugs, technology and medications directly impact on the health
outcome and should be considered as an integral part of quality
5. Accountability improves health outcomes and hence enhances quality. Effective and efficient
governance is a cornerstone to ensure quality medical care services
6. Finally, cost effectiveness plays a crucial role. Quality can be acceptable only if it affordable for the
general population.
Though the aforementioned parameters have direct impact on health outcomes, it is difficult to measure their
influence on quality of medical care. It is vital to convert these parameters into specific indicators, which can
be used to define and measure quality more rationally.
3. DEFINING THE QUALITY INDICATORS: LITERATURE REVIEW
In healthcare, health outcomes play a crucial role in determining quality. However, the importance of customer
experience and customer delight can't be underestimated. Hospitals and Healthcare institutions have
consistently focused on improving the patients experience and providing services in timely and orderly
fashion. However it is often difficult to rate the quality of services (both clinical and non clinical), using
similar indicators.

3
Healthcare providers often use patient satisfaction surveys to understand the lacunae in quality of care
provided and identify critical areas of improvement. Patient satisfaction surveys can be used to measure the
quality of services from the prospective of subjective opinion of the patients/beneficiaries. As per a study
conducted in Taiwan, it was concluded that patients lack the ability to judge the quality of care in healthcare
institutions are in general lack awareness regarding the various quality indicators (6). The study indicated that
patients are not able to rate the infrastructural and technological capabilities of the institution or the technical
competences of their physicians or medical staff.
A healthcare institution hence has to depend on various objective parameters to ascertain quality. For the
purpose of this research, some quality indicators have been identified, which have been presumed to be
directly linked with the ability of the institution to provide quality medical care services. Relevant literature
review to support these views has also been provided.
Asset value: Asset value is indicative of the medical technology along with the other infrastructural
amenities like elevators, air conditioning units, fire fighting services, etc. These services will implicate the
overall quality of medical care as it directly impacts on patient safety, infection control rates and ability of
the institution to provide critical care services, etc. In a study conducted in Mexico, it was observed that
the infrastructure of the hospital determines the mortality rate among its beneficiaries (7). In another study
conducted across 87 hospitals in Massachusetts a clear positive correlation between the investment in
plant, machinery and property was observed with the quality of care and patient outcomes [8].
Manpower ratios: Hospitals and healthcare institutions are human resource intensive units. Higher nurse to
bed and higher staff to bed ratio are indicative of reduced burden on the staff, which in turn directly
enhances their ability to pay greater attention to details of patient care. In a study conducted it was
observed that the educational qualification, attitude and behavior of the staff impacted their overall ability
to provide medical services and fulfilling patient expectations [9]. The Joint Commission on Accreditation
of Healthcare Organizations (JCAHO) found that staffing levels have been a factor in 24% of sentinel
adverse events that resulted in death, injury, or permanent loss of function [10]. Another research study
conducted in the United States indicated that a ratio of 8 patients to one nurse was least expensive but
associated with highest patient mortality and the effectiveness of the staff increased with improvement in
the ratio [11]. These studies reiterate the importance of better staff to patient ratios and their significance
in enhancing quality of medical care.
Accreditations and quality assurance systems: There are various accreditations and quality assurance
systems presently available. These accreditation and quality assurance systems help organizations to
streamline their processes, provide timely services and thereby enhance patient outcomes. Evidence from
JCI has indicated that accreditation tends to help enhance the overall quality of patient care services, based
on select case studies from across the globe [10]. Unfortunately there is little documented evidence about
the effectiveness of NABH,JCI,NABL in improving patient outcomes and quality.
Mortality Rate: Though this research study has not been able to evaluate the quality of medical care based
on this parameter due to ethical issues, standardized mortality rates are used as a parameter to evaluate
quality by many. However, there is considerable opposition to this concept and standardized mortality rate
is considered a bad parameter to judge quality of medical care [12]. Though risk adjustment is aimed at
standardizing the mortality rate and identifies the preventable deaths, it still has several limitations.
Patient Experience: In the era of consumerism, the role of patient experience is undisputed and impacts the
assessment of total quality of medical care. Timely service provision, promptly addressing patient
grievances, etc play a crucial role in the impression the hospital management creates on patients and
thereby influences the perception of the patient about the overall healthcare services provided by the
institution [13]. However the use of patient satisfaction should be ideally limited to a few parameters
aimed at enhancing patient experience.
4. EXPENDITURE ON MEDICAL CARE: DOES QUALITY IMPACT COST?
A hospital which rates high in its performance of the quality indicators can be improve patient outcomes,
which would explicitly affect the quality of healthcare services. Evidence from across the globe indicates that
improvement in healthcare has direct relationship with the resources diverted for healthcare

4
services. Table.1. Per capita Expenditure on Healthcare Vs Key Health Indicators,provides an overview
of the performance of various health systems across the globe.
Table 1. Per capita Expenditure on Healthcare Vs Key Health Indicators
Country Per Capita
Expense on
Healthcare per
annum (in US$)
Infant
Mortality Rate
(per 1000 live
births)
Life
Expectancy
(in years)
United States 6096 6.1 78.2
United
Kingdom
2560 4.7 79.9
Australia 3123 4.7 81.7
Kenya 86 53.5 58.8
Sudan 54 68.07 55.42
Table.1. indicates that the expenditure on healthcare has a direct impact on the outcomes, using life expectancy and
infant mortality rates, as a measure of quality of a health system. However this doesn't imply that quality comes at a
cost.
Figure.1. Life Expectancy Vs Spending on Healthcare Globally, explains why?
It can be observed in Figure.1. that with a life expectancy of 76.9 years, Cuba ranks 28th
in the world, just
behind the US. However, its spending per person on health care is one of the lowest in the world, at $186, or
about 1/25 the spending of the United States. The countries ability to utilize its resources optimally determines
its ability to improve its health outcomes.
Figure 1. Life Expectancy Vs Spending on Healthcare Globally

5
Then can better health outcomes (and overall quality of medical care) be improved without increasing the
healthcare expenditure? For a nation, the answer lies in its ability to optimally utilize its resources and
maximize the outcomes. The role of public sector and government in enhancing health outcomes of its
population is crucial. Provisions for safe drinking water, health awareness, sanitation, availability of essential
drugs, etc are public goods, which need to be provided by the government.
Private sector in India has evolved primarily due to lack of the State to provide some of the basic services to its
population. Quality has often been considered to be one of the crucial aspects governing the higher utilization
of private sector institution; however it is not always the case [3]. Private Sector is often driven by profit
orientation and hence, over utilization of private sector in India can be assumed to be one of the reasons for
increasing cost of medical care services in India. Role of quality in escalating medical cost remains debatable.
5. METHODOLOGY AND STUDY DESIGN
This research paper aims at understanding the implication of the quality (as derived from the various quality
indicators identified above) on the direct cost incurred to purchase medical care services. This paper compares
the data from various hospitals across India, to appreciate and ascertain if higher quality of care is associated
with higher patient bills.
A review of discrete primary data collected between 2009-2011, from twelve different private sector hospitals
from across India, was used to understand the implication of quality on cost of medical care. The hospitals
were categories as Tertiary care hospitals (n=3), Multispecialty Hospitals (n=4) and secondary care hospitals
(n= 5), depending upon the service mix and focus areas. The focus areas of the various categories of hospitals
included,
Tertiary care Hospitals- Cardiac care, Neurology, Gastro-entrology, Oncology and Advanced Trauma
rehabilitation.
Multi Specialty Hospitals- Ophthalmology, Orthopedics, Nephrology, ENT, Respiratory Medicine, etc.
Secondary care hospitals and Nursing Homes primarily focusing on Gynecology, Obstetrics, General
Medicine, General Surgery, General Medicine and Pediatrics
It should be noted that the list of services provided above was not exclusive, but indicative of the level of
advanced specialty services provided by the hospital. Tertiary care hospitals and Multi-specialty hospitals,
surveyed in the study, provided the secondary care services, in addition to the aforementioned services.
5.1 Analysis Considerations
The average cost of hospitalization, for these institutions was evaluated against the various quality indicators,
to identify an association between cost of medical care services and quality standards. The average cost of
hospitalization only included the direct expenditure incurred by the patient and didn't include other tangible
and non tangible costs like income lost due to sickness, travel expenditures, etc.
The average cost of hospitalization was computed based on the revenue generated by the hospital, over a
period of preceding six months, since individual patient bills could not be evaluated. Revenue generated by the
hospital is indicative of the expenditure made by the patients; however the components of total hospital
revenue were different in different hospitals. Some hospitals (in the survey sample), provided support services
like canteen and pharmacy in-house while others have outsourced the services and don't reflect in the direct
revenue of the hospital. In such situations, the pharmacy and canteen sales were incorporated separately to
provide a comparative estimate
No separate patient satisfaction surveys were conducted. Already existing data from the same time frame was
collected, codified and the comments were categories to reflect patient opinion about specific parameters.
5.2 Limitations of the Study design
1. Fifteen different hospitals of different bed capacities, different facility and service mix were
evaluated. It should be noted that perception of quality is affected by a wide range of factors including

6
purchasing power parity, educational status and awareness of the population and general healthcare
trends in the region. The selected hospitals were located in different regions (Mumbai, Kolkotta and
Delhi). These inherent differences in the population dynamics could have acted as confounding
variables in the analysis of the study.
2. Internal comparison was made to provide a realistic picture; but considering the small sample size for
internal comparison, the findings could not be substantiated.
3. No data regarding the mortality rates was shared and hence it could not be used to evaluate the quality
of healthcare services with specific reference to patient outcomes.
6. FINDINGS OF THE STUDY
The direct cost of healthcare services (in terms of average cost of hospitalization per bed per day) was
evaluated against the various quality indicators described in section.3, which have been associated with quality
of medical care services. This was aimed at understanding the overall implication of cost of quality of
healthcare services.
6.1 Asset Value and Impact on Direct Cost of Hospitalization
Literature Review shows that the Asset value of a healthcare institution is directly related to the healthcare
outcomes, which higher asset value associated with better quality of care.
The asset value in terms of medical equipment technology varies primarily due to variation in the installed
infrastructure capacity of the healthcare institution. A secondary care hospital has limited diagnostic and
imaging services (like CT scan, MRI, Immunoassay, etc), which in turn affects the ability of the physician to
diagnose and treat the patient appropriately. Further, equipments and technology, like a well equipped
Intensive care unit improved the chances of patient survival (14). This directly impacts the overall outcome
and thereby has an implication on quality of medical care. The cost of infrastructure includes various aspects
like evidenced based design of the hospital, hospital ambiance, furniture and finishing of the facility. It also is
indicative in terms of availability of various amenities like clean drinking water, toilet facilities, etc.
Also operating costs for these institutions may vary considerably depending upon the infrastructure. In institutions
with a centralized chiller plant the average consumption of energy per bed per day was observed to be
approximately 80 units, whereas in institutions without a centralized unit, the average energy consumption per bed
per day was as low as 25 units. A centralized unit plays a crucial role in enhancing patient experience and
providing comfort but also plays a crucial role in controlling the infection rates (15), which in turn have a
direct impact on the outcome and quality of care.
Table.2. Indicative Asset Value Vs Av Revenue per bed (n=12) provides average estimates for the cost of
infrastructure and the average cost per hospitalization in the hospitals. While considering the estimated cost of
medical technology, estimates were based on the audited financial sheets of the hospital, which included
deprecation of older equipments. Pearson Liner correlation coefficient for the cost of infrastructure verses the
average cost of hospitalization was R=0.975. Figure.2. Relation of Asset Value with Cost of Hospitalization
(n=12), shows that higher asset values were linked with higher cost of hospitalization.
Table2. Indicative Asset Value Vs Av Revenue per bed (n=12)
Type of
Hospital
Cost of
Infrastructure/bed
in million INR
(Std. Deviation)
Cost of Medical
Technology/ bed
in million INR (
Std. Deviation)
Av Cost of hospitalization
per day in INR ( Std.
Deviation)
Tertiary care 4.6 (0.3) 0.44 ( 0.054) 14,167 (1527.5)
Multi Specialty 3.225 (0.263) 1 (0.141) 9,075 (1281.6)

7
Secondary Care 1.36 (0.114) 1.7 (0.1) 1,680 (238.7)
Figure 2. Relation of Asset Value with Cost of Hospitalization (n=12)
Asset value of a healthcare institution is considered as a quality indicator and higher asset value is strongly
associated with better quality of care. The findings of this study indicate that cost of hospitalization increases
with the overall asset value of the healthcare institution.
6.2 Manpower Ratios and Direct Cost of Hospitalization
The deployed manpower at different facilities varies depending upon the complexity of the medical care
services provided. Though some studies in the United States (16) have shown that staffing can't be considered
as a measure of quality of care, evidence for other studies indicates staffing affects morbidity patterns of
hospitals and hence is crucial measure of quality. For the purpose of this study, we have assumed that staffing
plays a strong role in quality of medical care, however comparing staffing parameters across different hospitals
with different facility matrix may not provide a rational and realistic picture. Hence this assessment has to be
based on internal comparison of the three categories of hospitals covered in the survey. The relationship in
presented in the Figure.3. Nurse to bed ratio versus average cost of hospitalization per bed per day
Figure 3. Nurse to bed ratio versus average cost of hospitalization per bed per day

8
The figure clearly depicts that the average cost of hospitalization per bed per day is related to Nurse to bed
ratio. Pearson Liner correlation coefficient for secondary care hospitals was -0.15, for multispecialty hospitals
was -0.19 and for tertiary care hospitals was -0.5.
Different studies have indicated that higher Nurse to patient ratios reduce hospitalization stay, which impact
the cost of care (17&18). Though these studies have computed cost of hospitalization in terms of reduction of
average length of stay, the reduced requirement for intensive care also reduces the cost of hospitalization
significantly. This reiterates the findings of this study which observed a negative correlation between nurse to
bed ratio and the average cost of hospitalization. Negative correlation was also observed when staffs to patient
ratios were compared with cost of hospitalization. This implies that higher patient to nurse/staff ratio, tend to
reduce the hospitalization cost, while enhancing quality of medical care services.
While evaluating the manpower deployed in healthcare institutions, the other basic parameters that need to be
evaluated is the basic training and qualification of the deployed staff. In the Indian context, hospitals may have
designated nurses in its staff, but most of them lack formal degree or qualifications. Higher the proportion of
qualified staff is an indication of better quality of medical services provided and the proportions are depicted
in Figure.4. Percentage of Qualified Nursing Staff Vs the Average Cost of hospitalization per day per
bed of the hospital.
Figure 4. Percentage of Qualified Nursing Staff Vs the Average Cost of hospitalization per day per bed of
the hospital.

9
A similar negative correlation was observed when hospitalization costs were compared with the percentage of
qualified nursing staff deployed at the hospital.
6.3 Accreditation and Quality Assurance and Direct Cost of Hospitalization
National Accreditation Board for Hospitals and Healthcare institution is the nonprofit organization that
provides accreditation to Indian hospitals that comply with certain quality standards. The process of
accreditation is voluntary and lack of certification doesn't imply that the overall quality of services of the
healthcare institution are poor, however accreditation standardizes certain quality protocols which impacts the
quality of medical care. Some hospitals, in India opt for Joint Commission International (JCI) accreditation to
attract medical tourists. The NABH,JCI,NABL guidelines are similar to JCI with a basic difference in cost and
overall flexibility.
Similar, certain hospitals also opt for ISO certification, which unlike accreditation is a quality assurance
system. Though, similar to accreditation, lack of ISO certification doesn't imply poor quality, but it points
towards the organizations commitment to provide quality services to its beneficiaries.
Analysis of data with hospitals with and without accreditation pointed out towards marginal variation in cost of
medical care services. The Figure.5 Accreditation and cost of Healthcare depicts the impact of accreditation
on cost of medical care.
Figure 5. Accreditation and cost of Healthcare

10
The analysis of the findings was two dimensional. For secondary care hospitals, accreditation resulted in
increase in cost of medical care services, which was due to the need to comply with various mandatory
requirements. On the other extreme, accreditation for tertiary care hospitals actually helped in reducing the cost
of medical care to a considerable extent, due to standardized procedures and policies. Hence the role of
accreditation, especially for larger hospitals has been proven beneficial in improving quality of care and
relatively affordable costs.
6.4 Patient Experience and Direct Cost of Hospitalization
Data from Patient satisfaction surveys conducted internally by the twelve surveyed hospital, was codified and
integrated to evaluate patient satisfaction across three basic categories including the quality of medical staff,
infrastructure and cost effectiveness. Figure.6. Average cost of hospitalization Vs Overall patient
perception suggests the relationship between average cost of hospitalization against the overall patient
experience (using the patient satisfaction survey).
Figure 6. Average cost of hospitalization Vs Overall patient perception

11
The analysis suggests a clear association between patient satisfaction index and the average cost of
hospitalization. It should be noted that patient satisfaction is a subjective evaluation of the quality of care, but
is crucial in understanding the deficiencies in service provision. On comparing data internally, a positive
correlation was observed for secondary care services with R= 0.656 while a strong positive correlation was
observed for multispecialty hospitals and territory care hospitals at R= 0. 0.97 and 0.923 respectively.
7. CONCLUSION AND DISCUSSION
Cost of healthcare depends upon a host of modalities including the disease condition, insurance coverage, age
of the individual, etc. In addition, cost of healthcare is influenced by other institutional factors namely the
service mix, the treatment modalities, brand image of the institution, etc. Whilst defining quality of care is
difficult and subjective, quality parameters can be used to assess the overall quality of medical care services.
Studies have shown that there is a non linear U shaped association between quality and hospital charges. This
implies that for the lowest quality will have the lowest price and as quality improves the hospitalization
charges are bound to increase [19]. However, to generalize the findings of this study to all contexts may lead to
misinterpretations, as the methodology used was purely exit interviews and patient opinions. In another study
conducted in the United States, it was observed that there was no relation between patient satisfaction levels
and the expenditure made on healthcare services [20]. Taking lessons from the United States and Cuba
example, optimum utilization of resources plays a crucial role in controlling costs in a healthcare institution.
Quality indicators namely manpower ratios, infrastructure and asset value, accreditation and quality control
procedures can be used to ascertain of the quality of healthcare services. Patient satisfaction surveys also play a
crucial role in assessing the quality of care provided by the healthcare institutions Patients appreciate better
quality of medical care services [21]. Though several organizations use patient satisfaction reports to evaluate
the quality of medical care services, the findings are often not very compelling. Patients are often considerably
biased towards reporting satisfaction depending upon various factors including their underlying condition,
ethnicity, age, improvement in the condition, etc (22). However, careful and appropriate evaluation of patient
satisfaction surveys could also act as a vital quality indicator can provide insights into areas of improvement.
Though other factors like disease standardized mortality rates may be used, their application is constrained due
to technical issues and statistical limitations.

12
Asset value of hospitals, implying the infrastructure, medical equipment technology, basic amenities and
additional services provided play a crucial role in cost of hospitalization. This study observes that with higher
asset value the average cost of hospitalization increases. Reports indicate that hospitals with centralized air
conditioning units are associated with higher cost of hospitalization [23].
Nurse to patient ratios and staff to bed ratios also influence quality of care. Though it may appear that higher
staff would increase the cost of medical care borne by the common man, the findings of the study indicate
otherwise. The rational for higher staff to bed ratio, results in provision of better quality of care, which in turn
reduces the average length of stay and hence average hospitalization cost. Higher staff to bed ratio reduce the
need for intensive care services and medical equipment support, which in turn reduce the cost of
hospitalization.
Accreditations and quality assurance systems have also been observed to reduce the average cost of
hospitalization. This clearly indicates that accreditations and quality assurance systems help hospitals to
streamline their functions and processes, minimize wastage and thereby aid in enhancing quality and reducing
cost of care.
Then, does higher quality of care imply higher costs? On considering the intangible cost including man days
lost due to morbidity or life years lost due to premature mortality, poor quality of services actually increase the
overall cost of medical care services (24).
As per the latest estimates by the Central Statistical Organization, the per capita income of Indian population
stands at INR 46,492 which is about 14.5% higher than the previous year estimates (25). As per the Human
Development Report, 2009 of the UNDP, the estimated income in US dollars was $ 2753 (adjusted by
purchasing power parity).
The public expenditure on healthcare was about $21/inhabitant (adjusted to Purchasing Power Parity), which
implied that the overall expenditure on healthcare was approximately $140/inhabitant (adjusted to PPP).
This paper attempts to answer this question by evaluating the various quality indicators and their association
with cost of hospitalization. The findings have indicated the role of each specific indicator in cost of
hospitalization, but fail to answer the pertinent question. The various quality indicators evaluated in the study
impact the overall quality of care, with varying degree of intensity. This makes it difficult to estimate the
contribution of each specific indicator to quality of care, which in turn results in failure to understand the
overall association of quality of care and cost of hospitalization.
8. ACKNOWLEGMENT
The author would like to acknowledge Healthcare Consultants, which provided most of the primary data to
conduct the aforementioned study.The data used for the study was part of assessment data collected for
specific clients.

13
References
1. Care Continuum Alliance (Home Page on the Internet). USA. India Healthcare Spending; 2009 (updated 2009 December 6;
cited 2011 May 21) available from: http://dmaa.pbworks.com/w/page/17960771/India%20-
%20Health%20Care%20Financing%20and%20Expenditure)
2. Medical bills rising faster than inflation. Business Today, 2010, March 31: Sect 2
3. Shah U, Mohanty R. Private Sector in Indian Healthcare Delivery: Consumer Perspective and Government Policies to
promote private Sector. Information Management and Business Review. 2010. 1(2): 79-87
4. Klint R, Long H. Towards a definition of Quality-Healthcare. Physician Executive.1(5)
5. WHO Publications: World Health Organization. Strengthening Health Systems to Improve Health Outcomes, WHO
framework for Action, 2005 Geneva (Switzerland)
6. Cheng S, Ho Y, Chung K. Hospital quality information for patients in Taiwan: Can they understand it?. International
Journal for Quality in Health Care. 2001: 14 (2), 155-160
7. Aguilera N, Marrufo G. Can better infrastructure and quality reduce hospital infant mortality rates in Mexico? Health
Policy. 2007;80(2),239-252.
8. Levitt S. Quality of Care and Investment in Property, Plant and Equipments in Hospitals. Health Services Research. 1994;
28(1):6.
9. Grujic S, O'Sullivan D, Wehrmachur W. Organizational Control of Hospital Infrastructure Determines the Quality of Care.
American Journal of Medical Quality.1989; 4(1),19-24
10. Joint Commission International (Homepage on the Internet). USA: JCI Success Stories;2011 ( cited 2011 May 26)
11. Rothberg M, Abraham I, Lindenauer P, Rose D. Improving Nurse to Patient Staffing Ratios as a Cost Effective Safety
Intervention. Medical Care. 2005;43(8):785-791
12. Pronovost.J. Using Hospital Mortality Rates to Judge Hospital Performance: A bad idea that just won't go away. British
Medical Journal. 2010; 340:C2016
13. Cleary P. The Increasing Importance of patient Surveys. British Medical Journal. 1999; 319 (7212):720-721
14. Lee J. The inter hospital variation of intensive care unit mortality in Korea: What's the problem and what do we do to solve
it?. Korean Journal of Anesthesiology. 2009; 56(7): 691-92
15. Desai V. Planning HVAC systems in Hospitals in India. Air-conditioning and Refrigeration Journal. 2002: 11(3)
16. Needleman J, Buerhaus P, Mattke S, Stewart M., Zelevinsky K. Nurse staffing and quality of care in hospitals in the United
States. New England Journal of Medicine. 2002; 346(22):1715-1722.
17. Amaravadi R, Dimick J, Pronovost P, Lipsett P. ICU nurse-to-patient ratio is associated with complications and resource
use after Esophagectomy. Intensive Care Medicine.2000. 26, 1857-1862
18. Cho S, Ketefian S, Barkauskas V, Smith D. The effects of nurse staffing on adverse events, morbidity, mortality, and
medical costs. Nursing Research. 2003; 52, 71-79.
19. Peabody J, Florentino J, Shimkhada R, et al. Quality variation and its impact on costs and satisfaction: Evidence from the
QIDS study. Med Care. 2010; 48 (1): 25-30
20. Fu A, Wang N. Healthcare expenditures and patient satisfaction: cost and quality from the consumer's perspective in the
US. Curr Med Res Opin. 2008; 24 (5):1385-94
21. Quality is what patients expect: Hosman 2007. Express Healthcare. 2007: November. Available
from: http://www.expresshealthcare.in/200711/market17.shtml
22. Thiedke C .What Do We Really Know about Patient Satisfaction?. Family Practice Management. 2004; 14(1):33-36
23. Rising healthcare cost enough to make you sick. Times of India. 2011 March 1st
; Sect.3
24. Kaiser Family Foundation .Healthcare Cost: A Premier, Key information on healthcare costs and their impact. 2009. The
Henry J. Kaiser Family Foundation.
25. Indians get richer: Per capita income at Rs 46,492.Times of India. 2011 January 31; Sect.1

Has Accreditation made a difference in Healthcare Delivery in India by Dr.Mahboob Khan Phd

More Related Content

What's hot (20)

Viewers also liked (13)

Similar to Has Accreditation made a difference in Healthcare Delivery in India by Dr.Mahboob Khan Phd (20)

More from Healthcare consultant (20)

Recently uploaded (20)

Has Accreditation made a difference in Healthcare Delivery in India by Dr.Mahboob Khan Phd