Bommakanti Girish Babu

In my short stint of twenty years in healthcare, I have had the chance to work with a variety of healthcare setups. These include some of the top corporate hospitals in India, rural healthcare programs, and corporate social responsibility organizations among others. Across these different healthcare organizations, what has struck me as being a common problem is the perpetual shortage of resources. This shortage of resources is seen in almost every department of hospital management right from security and housekeeping up to the top management. Attrition is high and retention methods are few and traditional.

Hospital-based healthcare moved from being largely unorganized during the ninetiesto slightly better and organized ways of functioning in the years that followed. And yet,till as late as the early 2000s, the processes and systems in most organizationswere yet to be standardized.Staff members functioned without being fully oriented with and aligned to the values and mission of the organization. If excellence in services is to be delivered through superior patient experience and high quality clinical care, a systematic approach to deliver those results is of paramount importance.

During the early 2000s, larger hospitals started developing their own training unitsto undertake continuous training in order to deliver quality and to build a committed workforce acrossthe frontline, middle management, and senior management levels. In addition to the training, the organizations provided incentives for career development and progression within the groups. Despite these initiatives,it is often observed how organizations struggled to get people trained on and off the job with an established system of training and evaluation. Staff retention was not achieved as a result. It did, however, serve the purpose of orienting the staff towards better practices and systems.

On my visitsto different cities such as Hyderabad, Vishakhapatnam, Surat, Chennai,Pune, Nagpur, Raipur, Mumbai, Indore, Bhubaneswar, Kolkata, andDelhi among others, I have had the chance to interact with various stakeholders about the issues faced by both larger hospitalsas well as small and medium hospitals in terms of resources and training. Smaller hospitals neither have the scale of operations of larger hospitals, nor the resources needed for continuous internal training. Despite the relatively low costs incurred in staff training, most hospitals tend do away with this expenditure component intheir efforts to cut costs. During this time, there has been an emergence of pharmaceutical companiesoffering to support institutionswith their training requirements for some of the common training modules required for the hospitals. This is largely being undertaken by the pharma companies to build a relationship with the hospitals and doctors.

It is safe to assume that for a large part, the training component is not well organized across the different levels and sizes of healthcare organizations, right from nursing homes and smaller hospitals to medium hospitals, trust hospitals and larger hospitals. So, how are the capacity building challenges in these organizations being addressed? Typically, a senior professional is identified to champion the trainingof the nursing and paramedical staffunder the stewardship of a clinician. These training sessions are meant to help the staff in maintaining good patient care and outcomes and in managing the processes well.Standard practices and systems approach are largely missing in these organizations, most of which are run as per the discretion of the promoter or owner of the facility.

In the above context,the NABH has tried to establish an outlook and culture towards quality, standardized systems, and processes among healthcare organizations. While patient care has been marginally improved with the introduction of NABH guidelines, there has also been an increased awareness around the quality of care. Some smaller hospitals also tend to send some of their staff for short term training to larger, more established hospitals or clinicians. Another way to train staff is to send them to a professional organization for short term certification programs.But the uptake of these programs is low as they come at a cost. On the whole, organized learning systems are missing in the system.Only the continuous medical education mandate for clinicians and nurses are in place, which solves the problems albeit only to a certain extent.

It is also worthwhile to look at the other end of the spectrum, moving away from largely urbanized and centralized healthcare towards rural areas wich see an acute shortage of resources in healthcare. In tier two and three towns and villages, healthcare delivery is largely delivered by clinician promoted or clinician owned facilities with most of the clinical work being supported by nurses. The latter is a trend common to the urban facilities too.With dwindling duty doctors and physicians, the middle level of medical staff, needed toexamine patients and the floor rounds is largely missing or being supported by professionals from alternative medical systems such as Ayurveda and Homeopathy. 

It is important to understand the capacity building needs of these players in the system and to what extent are these needs being met.It is not uncommon for nurses in rural areas to require training on a continuous basis in terms of ICU management, OT management , and ward Management etc. Even a pharmacist needs to be trained for maintaining a formulary and supplies and towards effective management of logistics.

Given the complexity of the running a hospital, delivering good quality care will always be a challenge and remain an ongoing process. In the late 2000s, the shortage of resources was looked at from the deskilling perspective as a strategy. This is because there still exists a huge demand and supply gap in the market. The nursing stream would have nursing aides, pharmacist would also have an aide, and clinicians would have aides such as physician assistant or nursing assistant. Similarly,floor management has been largely looked by floor nursing heads. The shortage of clinicians is addressed through DNB programs and certificate programs among others. There has been an effort by IGNOU to start a few course to help in this direction and towards the later end of 2000s there has been a movement towards having skill development training centres / institutions to help bridge the gap in the availability of the healthcare resources.

A look at the developments over these past years point to a growing trendof addressing the shortage of resources.However, with the simultaneous and rapid growthin demand, the gap between demand and supply is much higher today than ever before. In the past five to seven years, we have witnessed a growth of digital healthcare platforms to improve the reach for underserved populations which do not have access to healthcare. Concepts like the e-ICU have helped deliver intensive care to some of the most remote places. Even asmarket-based response has been evolving,Ihave not noticed any significant trends around capacity building.  An exception to this isthe emergence of digital learning tools designed to meet some of these requirements.

Today, healthcare organizations require training programs which are conducted in an organized manner and are customized to their specific training requirements. A common learning center (online / offline) for all hospitals in a city, incentives to build training organizations or to repurpose existing organizations much more effectively are some potential solutions that we must work towards.  Private healthcare delivery is the most widely used type of healthcare by the people of India.It is not only befitting therefore, toprioritize and focus on capacity building and develop solutions towards the growing demand of high-quality healthcare among citizens.

Bommakanti Girish Babu