Here’s what health ministry advises to improve quality at government hospitals

New Delhi: The Centre has issued guidelines to all government-run hospitals, recommending a minimum number of doctors and nurses based on bed count, and adequate security, among other things, to improve the quality of services as complaints about mismanagement rise.

The hospitals must also earmark at least a fifth of their beds for daycare services, set up Janaushadhi stores (generic drug stores) for affordable medicines, promote e-prescriptions, and set up grievance committees to address patients’ complaints, according to the communication sent by the Union health and family welfare ministry to hospitals, reviewed by Mint. The number of registration counters should be in proportion to the size of the hospital.

While the new guidelines apply to all central-run hospitals, states can modify these based on their needs for their facilities.

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Inadequate manpower, including doctors and nurses, is a common complaint from patients. Poor basic facilities such as no proper waiting area, insufficient wheelchairs and trollies, no canteens, dirty toilets, lack of receptions to get queries resolved and no breastfeeding rooms only add to poor experience. Moreover, frequent violence against doctors has become a major concern. 

The Clinical Establishments (Registration and Regulation) Act 2011 regulates both private and government hospitals and prescribes minimum basic standards for medical institutions. However, hospitals fail to implement all provisions, and some states have not even implemented CEA yet. The new guidelines are aimed at ensuring that public-run medical institutions improve their services. 

“The government hospitals operate under limitations. There is huge patient load and fewer staff. Nursing ratio is half as compared to private sector and in most cases even that is not filled fully," said Dr Girdhar Gyani, president, Association of Health Care Providers of India. “There is no accountability per se in government hospitals.”

State governments may consider outsourcing the process of meeting the guidelines to conformity assessment agencies through Quality Council of India, said Gyani. The government is also encouraging government hospitals to go for National Quality Assurance Standards accreditation, which will cover most of these guidelines, he said.

The health ministry has asked All India Institutes of Medical Sciences, institutes of national Importance and hospitals under its purview to take up the guidelines for implementation.

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Queries emailed to the health ministry spokesperson remained unanswered.

The guidelines follow a report on improving patient care across hospitals submitted by a committee set up by the ministry under the chairpersonship of Dr Pratima Murthy, director of the National Institute of Mental Health and Neuro-Sciences or Nimhans. The panel also comprised experts from All India Institute of Medical Sciences (Delhi & Patna), Directorate General of Health Services, and North Eastern Indira Gandhi Regional Institute of Health & Medical Science, Shillong.

The report, approved by the health ministry, has been circulated to key government hospitals, including AIIMS, for quick implementation.

The report's observations have been classified into three categories: vital, essential, and desirable. These pertain to staffing medical and security personnel, patient infrastructure, digitization of health records, telehealth services, proper disposal of biomedical waste, and addressing complaints.

Medical staff based on capacity

The report suggests a minimum number of medical staff based on the number of beds in a hospital:

100 beds: 29 doctors, 45 nurses and 31 paramedics

200 beds: 34 doctors, 90 nurses, and 42 paramedics.

300 beds: 50 doctors, 135 nurses and 66 paramedics.

400 beds: 58 doctors, 180 nurses and 81 paramedics.

500 beds: 100 doctors, 270 nurses and 111 paramedics.

According to the government, till March last year, the country had 169,615 health sub-centres, 31,882 primary health centres, 6,359 community health centres, 1,340 sub-divisional/district hospitals, 714 district hospitals, and 362 medical colleges serving both rural and urban areas.

More registration counters

The report suggests a comprehensive human resource policy at the state level. The government said hospitals with 1,000 beds need to have at least nine registration counters, with the minimum number coming down to seven, five and four for hospitals with 800, 500 and 400, respectively.

Four to five hospital managers are needed in facilities with over 600 beds, and three in a 500-bed hospital. At least two managers must be posted in 300- and 400-bed hospitals, while one manager is a must in facilities with 200 beds.

Faster clinical assessment

The report recommends centres for brief intervention and adequate private wards, with 20% beds earmarked for daycare.

While patients in the emergency centres should be treated immediately, for indoor patients admitted to hospitals, medical assessment by clinicians should be conducted within 24 hours and by nurses within 2 hours.

Hospitals should not take more than four hours to discharge patients covered by insurance, and those making cash payments must be discharged within two hours.

Discharge time must be monitored, and a summary should be provided and explained to the patient. In case of death, the cause should be mentioned in the summary, the report said.

Robust safety, data security

The report suggests 24/7 availability of security personnel in all areas with CCTV surveillance. The Central Industrial Security Force (CISF) personnel can be deployed in hospitals to ensure stringent and vigilant monitoring around the clock, it said.

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The suggestion comes at a time the rape and murder of a young female doctor in Kolkata’s KG Kar hospital sparked nationwide protests across the country by medical professionals seeking adequate security.

Medical institutions must also maintain data security, confidentiality, and integrity of the information.

For bio-medical waste management, the guidelines recommend that hospitals should tie up with an authorized outsourced agency for safe and hygienic collection and treatment of waste.