Lecture: Quality for Me

[Phanindra] Hello, good evening, everyone. I’m Phanindra from Vision 2020 India. On behalf of Vision 2020 India and the LV Prasad Eye Institute, let me welcome you to this webinar on Quality for Me. Today’s session focuses on understanding the parameters of how one can improve the quality of care continuously, set up cooperation and resource sharing among members interested in creating quality care modules for their own hospitals. Today the resource persons will discuss various case scenarios that are on quality with ample time for interaction.

[Anshu] Good afternoon, everyone. And a warm welcome to the session. Let’s get started with a small scenario. It’s a normal Sunday afternoon for 54-year-old Asha until she experiences a sudden vision loss. Her husband is not home so she calls for an ambulance to drive her to the nearest health care facility. She’s suffering from an eye stroke. Let’s imagine that the nearest health care facility is ours and we are working there. And the call comes to our casualty. For her, the phone is ringing. But actually, the phone in the casualty is dead. It has been dead for a couple of days, we have put out a complaint but we are not followed up. So while she is frantically waiting for a response from our side, our instrument has failed us.
Another scenario. Let us understand, maybe the phone is ringing, we have been successful in picking it up and we assured her not to worry, the ambulance is one its way. We put the phone down, we ask for the ambulance, ask for the ambulance driver, and we get to know that the ambulance driver has been on ad hoc leave. No idea when he took leave, when he’s going to come back, no one else to drive the ambulance. Once again, Asha is waiting there frantically for our response. And from our side we have administratively again had a challenge and failure.

Let’s understand another situation. The call has been received, we have assured for ambulance, the driver is very much there, but there is no fuel in the ambulance, the ambulance has no fuel, we don’t have a reserve, there’s a strike outside, the ambulance cannot move. What I’m trying to say in all this, imagine a situation we’re fine. All this works, we get Asha comfortably to the health care facility, but we are short of beds. Or the equipment which is necessary, the critical equipment, that’s broken down and we’ve not had a substitute or alternative arranged as a back up.

In all this, what’s reflected or what I would like to bring to your notice is that there’s many touch points that can influence a patient’s perspective on the overall patient experience. The challenges we all know as part of help of healthcare are many. Improving the throughput and capacity is always a challenge but what we need to understand most is the variability cannot be eliminated. That is inevitable. The warning signs for us when we talk of patient experience. From a patient and family’s perspective, in all these questions the most recurring question is are they on top of things? For the healthcare organization or the healthcare provider. Are they on priority? From the care provider’s perspective Including physicians, nurses, and ancillary staff, from all the questions that they do have and face as a challenge, most recurring question is will I as a caregiver be efficient when providing the best care possible? And yes, from the executive and management perspective, the recurring question always is, are we actually putting our resources to the best and optimal use?

Given all of this, there are several key symptoms that reflect poor performance. It could vary or range from the poor capacity management, to intra-stary challenges, and we cannot ignore the kind of challenge that is faced when we have our staff and physicians dissatisfied in the organization. In all of this, our typical hospital, while it may comprise many islands of excellence. Each department may say they excell and they are the best. The challenge is when the efforts of one department is not synchronized with that of the other. So the overall patient flow and experience remains a challenge.

What is needed is a commitment to system-wide process improvement and integrating these islands of excellence. We all use or we try to use quality indicators, executive dashboards to enhance the economic impact of performance improvement. Also we cannot deny that it actually helps us enhance employee engagement in terms of retention, safety, and performance.

When I talk of it all and I’m talking of patient experience, patient flow, the one question that may be coming back to us is, what does quality have to do with all of this? And that’s where we stay for a moment. Quality can mean different things to different people. But centrally when we are talking about quality, we are talking about meeting a standard. And at LVPEI, it always is doing something tomorrow better than what we do today. Wherein each one of us comes back and is responsible to enhance quality in our own small way, administrative or clinical.

Challenges, once again, are many. We are all very familiar with it. But what I’d like to bring to light is the unfortunate aspect that even today, quality is taken as a separate entity rather than being woven into the very fabric of the organization and that is what needs more focus.

When we talk of quality there are different dimensions and aspects to it. Ranging from technical performance, to access of services, how effective we are our terms of care, what is our efficient service delivery all about? Interpersonal relations definitely, continuity of services, continuity of care which remains an important challenge. Safety, the degree to which the risk of injury, infection, or any other harmful side effect can be minimized or mitigated. Physical infrastructure and comfort, of course. And most importantly, what is the choice that we provide to the patient or customer in terms of provider, insurance plan, or treatment?

When we talk about safe patient care, a comprehensive approach to creating effective outcomes becomes critical. And that’s only possible through staff training, continuing training, and process Improvement. The key ingredients from all of the experience we’ve had over these many years, boils down to this. A person-centered service, open and transparent learning culture, a very strong clear leadership and governance, effective team working and communication, and fit-for-purpose workforce. Effective information management and measure is always the way we can define and close the gaps. And of course, internal and external robust quality assurance cannot be denied.

The irony is that even as of today fully knowing it’s all, the current practice as part of healthcare especially is that we rely on memory. Excessive number of handovers is always a challenge, our processes are not really standardized. Long work hours, excessive workloads remain a constant challenge and liability for all of us. Spotty feedback does not help us with effective decision-making. And yes, variable information availability is something that we keep facing at every level of patient care.
Having said all this, one of the best practices we would be, of course, familiar with is adopting the International Patient Safety Goals. This has been jointly promoted by WHO and JCI. And it includes goals like identifying the patient correctly, improving effective communication, and this means verbal and telephone communication as well, where read back policy, incident reporting becomes a mandate. Improving safety of high-alert medications. How we train our people and how we store them, including the look-alike/sound-alike drugs. And, of course, ensuring correct site, correct procedure, and correct patient surgery using the all well-known WHO surgical checklist. Where I should not miss out saying that time out has become a critical need, which is where we are forever trying to comply with it across our procedures.

Reducing the risk of healthcare-associated infections is the fifth goal, where hand hygiene, NSI/endophthalmitis protocol compliance, biomedical waste management and the use of PPE, which we have seen over the COVID pandemic, becomes very critical for us to overcome any challenges in respect to that. Lastly, as part of the sixth goal, we talk about reducing the risk of patient harm resulting from falls we’re signage brings about a lot of safety precaution and comfort, risk mitigation, with respect to safety.
AT LVPEI, our focus is, and has always been, on vulnerable patients. Patients who are not able to protect or take care of himself/herself and therefore can be prone to various risks within the hospital such as falls, injury, neglect, et cetera. We have it integrated with our manual and digital services. We will be demonstrating that a bit later.

Apart from that, patient safety rounds becomes a very critical initiative for us. And it has helped us establish a culture of safety within the organization. Emergency codes, we are all familiar with it. We have also tried to define that and we have tried doing a lot of modules, and that has definitely helped us overcome some very risky situations in the last many years, a reflection of which we will share with you shortly.
All said and done, if I have to summarize, when we talk about quality and where we can contribute or make a little difference, these are the possible enablers. Right from incident reporting, reporting every incident without feeling insecure but actually trying to be proactive in terms of ensuring CAPA define so that it doesn’t happen again. To training, repetitive continual process of training in various aspects, digital or in person. Defining codes, driving mock drills. Defining MOUs with organizations for services that we don’t provide, defining communities, their scope and function that helps us in terms of how proactively we can prevent any incident from happening.

Discussing incidents across these committees like your safety committees, CPR, HICOM, you’re all familiar with that. But how do we use these committees and make that particular difference in terms of quality is what we need to look at. Checklist like we have of hand hygiene, surgical checklist, et cetera. And of course, we should not forget the need for measure in terms of audits and use of quality indicators.

That’s what will help us drive this promising change. We would have our patients most satisfied that they are on top of our care. The physician extremely pleased how efficient the process had helped him in delivering that care. And the management, of course, very comfortable and rest assured that all of the resources that they have invested and committed for this particular requirement has been used optimally and reassuringly for the performance of the organization.
So my friends, I conclude by saying that quality starts with each one of us. And that’s what we need to realize if we need to take quality and performance in the organization this way forward. I now hand it over to Sidhartha and he will try to reflect and share with us the experiences we have in respect to this at our own hospital at LVPEI. Thank you.

[Sidhartha] Good afternoon, all of you. Ms. Anshu has already explained about the various things about the quality that starts with me at our hospitals. I will go into the practical examples correlating to the International Patient Safety Goals. I’ll give an example for each of the goals and what was our learnings and what we did about it. So these are some of the real incidents which has happened in our hospital from which we learned and we are still learning. So we’ll go to the presentation.
I have categorized the incidents which has happened into two parts. One is the International Patient Safety Goals and the emergency codes. I will not give examples of each one of the emergency codes. We have six codes, but I’ll give examples of only three because those three only has happened in the recent past. With a focus on learnings from the incidents and closures done in terms of corrective action and preventive action.

These are the six goals which are already explained. So we’ll directly go to the first one that is identify patients correctly. This is one of the examples where there was a patient who came to our operation theater whose initial was K. And the person had a surgery on the right eye. Whereas, there was another patient who also had a similar name and started with K but the operation was in a different specialty, and also with a different surgeon, and a different eye. But the patient identification wristband was exchanged between them and the wrong patient with the wrong wristband was sent to the OR. Although we have all types of checklists like pre-surgery checklist, patient wristband, and all those things verbally, cross-checking with the file, but due to assumptions and human error sometimes these things happen. And we keep on reiterating the training part of it so that they are not in a hurry and they do the right thing in the correct way and send the correct patient to the OR.

Most of you will be familiar with all of these things like a surgical patient checklist, the patient and attendant wristbands that we use, and the patient identification wristband that is used for this patient specifically. So the color determines which eye and all the patient’s details are imprinted in the label.

Coming to the next goal that is improve effective communication. Here you can see another incident which happened where the patient was moved to the emergency room, the patient was an admitted patient. The patient went to the emergency room for some treatment. The patient came back and the patient was under the supervision of the senior nurse. And she was assisted by a student nurse. Just after the care was done in the emergency room and the patient was shifted back to the original ward room, the senior nurse just asked the student nurse, “Do you know how to load insulin in the syringe?” To which the student said, “Yes,” and started loading the insulin and also happened to inject the insulin to the patient when this was not advised or not asked for.

Again, here there was a communication gap which culminated into giving a drug or the insulin to a patient which was not supposed to. She just asked, “Do you know the process?” Here the learnings are that always cross-check patient identity,drug dose site while administering any medication. The senior nurse shall not give any activity to a student nurse which is not under her scope. So the scope has to be defined very clearly. Always give clear and complete instruction about medication administration, and not to leave it halfway through. Do you know how to load insulin? So please load and keep it aside that should have been the complete instruction not otherwise. Also if possible, most of the time if it is possible, to give the instruction in writing and should not be left verbal so that there is confusion of interpreting what it said. The action taken was that we raised an incident report, the patient was given 25% dextrose, and training reintegration was done.

Coming to the third goal of patient safety that is improve the safety of high alert medication. Here you can see that a patient developed seizure after administration of local anesthesia. We call it local anesthesia because the patient is not fully anesthetized for most of our eye surgeries. So here you can see that the patient develops seizures. But how could we have avoided it? It could have been avoided because we could have done our pre anesthetic checkup better or the physician fitness much better where this could have been found out. And it is seen most of the times that the patient does not like to say or do not divulge they’re past illness or if they had a seizure or not. So that part was reiterated with the physicians and the anesthetist. Obviously the medical care was done for this patient so this ABC was checked, suction was done, these are all medication things which were done. The patient recovered fully. But to avoid such situations like that our kind of learning is that to do the PAC check up much better.

This is how we raise an incident report. This is a sample incident report of that patient which developed the seizure. So this is how we raised the incident report document and action is taken based on this.
Coming to the fourth goal, that is ensure correct site, correct procedure, correct patient surgery. Now here you can see, I’ll just read out because it has some medical terminology. A patient had left eye CRVO, right eye dense cataract. After checking the file, only right eye was dilated and as the patient also told us the same thing. Now here you can see that the patient had a problem in both eyes and the patient though, okay right eye I have cataract, so maybe right eye is the surgery. No, the patient was explained that it’s actually the left eye where the procedure has to be done. But everything was not checked and certain things were bypassed maybe. And the wrong eye, the right eye was done PRP laser. So once it is realized, then the correct eye was done the correct procedure.

Here again, you can see the surgical checklist at different points. This is our surgical checklist as part of WHO guidelines we have made. The time out is there. Different stages you can see 1,2,3 if you can see, that is right from that we should now face the IPW pre-op, operating surgeon, pre-op nurse, anesthetist, PCA nurse who’s shifting the patient, the time out by the surgical team. Every stage it was missed and that’s why this wrong procedure in the wrong site had happened. This is our learning that documentation is very important and it should not be just give and take like that, and it should be diligently done, and be confirmed at every stage. It is not that the second stage is done correctly by somebody so third stage need not be done, I’ll just put a tick and go on. It should not be like that. This was our learning and we continuously try to redirect that time out is very important. Time out is the last stage where you can find a mistake and correct it.
Coming to the fifth goal that is reducing the risk of health care-associated infections. To reduce health care-associated infection we have a lot of tools and a lot of things. Everything cannot be told in this presentation, but I’ll give some examples of what we do in our hospital. This is an example of the WHO recommended hand hygiene checklist that is done by our HIC team. We have a big HIC team who goes in different areas. Like I, myself, go to the OR to do this surveillance in OR. We have hand hygiene. This is one of the things that we use to pick up any mistakes or any area of improvements that can be corrected on the spot. And also this is documented and presented in our HIC committee. I’ll come to the next slide and show you.
This is our hand hygiene checklist and this is our surveillance checklist. I’m showing the surveillance checklist for OR. And on the right hand side you can see an extract of the minutes that all the surveillance rounds were discussed, like OR surveillance here, then inpatient surveillance, and then OPD surveillance. These are all discussed as a part of our hospital infection control meeting. So that is documented, we know what are the findings, and how it is closed. And all the high risk areas like labs and all.
We also have a very good monitoring system and documentation of each and every endoph and surgical site infections that happens. Other than what we do normally with documentations, I’ll highlight the three of them. That is CCTV footage review is done so that we can pick out any breach in sterile protocol has happened or not. Then mandatory recording of ringer lactate and viscomet serial numbers are in the EMR, so that nobody can skip it, and we can do the sterilization recall properly if any endoph case is reported. And other mandatory documentation you can see here, like form one, for two, summary report, these are our LVPEI protocol. These documentations are filled out by the primary surgeon, microbiology report, sterilization recall list, recall we do. We also see the CCTV footage, as I said, and the surgery we do is also reviewed. After all this is done, we meet and we find out what is the root cause for the endoph and we take necessary action. And it is reiterated.

And these are some of the non-negotiables that we put as a declaration to the OR and OPD staff who is performing their duties in those respective areas. These are certain things which where we cannot negotiate, we have to do this. And these are the policies of the institute. And they sign it before they get on to their duties. This we are still a process in reiterating again and again, whenever any new staff comes, we get this done.

Coming to the sixth goal, that is reduce the risk of patient harm resulting from falls. I’ll just go to the definition. That it is an event which results in a person coming to rest inadvertently on the ground or floor or other lower level. It is from one level to another level if the patient falls and if the patient goes we consider it as a fall. It can be same level, it can be ground level, so different definitions are there.

This is one of the examples which has happened in our Institute. In the diagnostics area, one patient who was supposed to undergo a diagnostic test, was trying to sit on the patient stool which had wheels on it. So when the patient tried to take support of the stool and tried to sit on it, the stool rolled on them, and the patient fell down. And that’s a very major event for us. For us, it was fortunate that this particular patient which I’m referring to did not have a major injury, but it could have been a major fracture or injury. And the patient can raise a medical legal case against the hospital and compensation for injury because we did not provide a proper safe facility for the patient.

This was learning for us so we changed all of our wheeled stools or wheeled seating facility you can sit, to a static one which does not have a wheel below it and has a rubber cushion below it so that it gets a good friction. This is a medical management like DOLO was given and not much treatment was required, fortunately. But this happened and we also documented it.

Coming to the emergency codes. As Anshu has already said that we had around six, actually seven codes that we have. Out of that I’ll give an example of three which has happened with us. First one is code red. Here you can see that there was a refrigerator which had snacks and it was under outsourced vendor management. And you can see the time over here, 4 a.m. in the morning, when the very minimal, bare, skeletal staff remains in the hospital, for our eye hospital, you can see. But we had a fire alarm in place. We had the night duty security team in place who are well-trained, and they took the fire under control when it happened.

So the learnings is that the importance of having fire installations properly serviced under AMC so that they function at the time of need, as in this incident. At 4 a.m. who will be near the refrigerator if it caught fire, nobody would have known. Only the fire alarm did its job and we got to know. Not to overload or make connection for power supply which is not recommended. And the third one which is very important is that the outsourced staff should also be included as a part of hospital generic training. We call it generic training, where they’re also taught about Fire & Safety, CPR, basic things that they should know so that they’re not alienated from the other staff. So action taken is that I’ll just read out, that faulty appliance repaired and circuit breakers were put in place. Outsourced staff were trained and also made a part of the contract. This is very important, so that they’re bound by it.

Coming to code yellow, this was a very unfortunate event which happened in our hospital because of which code yellow was introduced. Fortunately, after the introduction, we did not have any incident where such thing happened again. I’ll read out that our patient attendant, this was a case of an attendant. The patient attendant was missing from the floor while our patient was waiting in a wheelchair, our patient was a wheelchair patient. We tried to contact the attendant but no response was received. Finally called the patient’s home and her relatives came and picked her up from the hospital. We also asked the people who came from the home that do you know about this attendant where he actually might have gone? So they said that he might have left the institute or may have gone somewhere. And that was kind of an expected kind of behavior of what we could find out initially. So we thought that might be the case.

But next day, the attendant was still missing. The next day when our housekeeping person opened the gents toilet we saw that the attendant was there lying dead. The attendant was lying dead in our washroom for more than 10 hours and nobody knew about it. The learnings were that no washrooms should be left unchecked during and at the end of the day. The door shall be openable above from outside if any emergency occurs. This is the kind of door latch we have put in many of the washrooms where you can open it from outside if emergency occurs.

And these are the washroom stalls which are done for the new washrooms where you can see that there is a gap from where the person can be rescued in case of any emergency. These are the actions taken that our washroom and blind spots can be regularly checked where the concerned housekeeping and security staff. All washrooms to be checked and closed at the end of the day to avoid any misuse or accidents. In the night if anybody gets stuck in the washroom, nobody will know so it has to be closed after checking at the end of the day. Most of them, except one or two for use. Doors openable from the outside were installed to cater for during any emergency. CCTV cameras were repositioned to cover all the areas. We could find from our CCTV footage where this attendant has gone initially. But we could not trace him properly because we did not have a good coverage of all areas. This was repositioned in certain areas.

As I said, our washroom stalls were with door which have a gap underneath to cover for any emergency. And the last one, very important, which was something new for our hospital and this happened in 2017. The code yellow was introduced. We had an SOP we have conducted, we are conducting, actually, more drills for code yellow where any adult is missing with a patient or staff, we can readily act on it. If we are not able to find the person by traditional method like calling or asking others. If that fails, then we announce code yellow. We have a trained code yellow team in place who takes care of us.

And the last one is code blue. This is the most common incident, that’s why I put it over here. This happens whenever the patient is having hyperglycemia or syncope. Here we have a trained code blue team who is regularly under training by code blue mock drills which happens in a periodic interval and they’re all in place. Immediately, whenever there is a medical emergency we announce code blue. And the patient was resuscitated, given a Trendelenburg position, and given some oral glucose, and the patient recovered. But we also have certain incidents where the CPR has to be given where this code blue and BLS training and SLES training staff. Trained staffs are very much useful and they do a pretty good job. That incident I could not put unfortunately, but this is what it is. This is most commonly what happens.

I’ll show a glimpse of our code blue mock drill which we do regularly. You can see the code blue team over here. This patient is our own staff orderly who volunteered to be a dummy and participate in the code blue mock drill so that all the staffs are ready and they can act immediately when such real emergencies occur.

So with that I conclude my examples and our learnings from LVPEI goals.

[Subhadra] We are trying to show real world scenarios and I will continue that. I’m Dr. Jalali. All I want to say is that clinical cases and the quality improvement basically reflects the care that we want to give to our patient. And that is the underlying process which defines why we want to give quality care. It’s not about any of it, it’s not about exaltation, it’s about compassionate care.

So when we said that we want to create a culture of safety, I think that’s the most difficult thing, that’s the most challenging thing, and that’s the most fun thing that you want to create a culture. It’s like in your house, as a mom, I want to create culture in my children. In my society I want to have a very cultured society. And same way in my staff and the people here, we want to create this culture of safety, which unfortunately, is a lot of missing because it’s not taught in our regular college curriculum or school curriculum and we’re not a very safe thinking society overall. I’m going to share how we build this culture.

Here is a photograph of our center which was newly opened a few years ago at Kothur, Telangana. This is a secondary center, one of the 20 odd centers that we have across the states. And what you see here is that there is a marking on the floor. This is a center which is a remote part, it’s not in Hyderabad. What we are trying to do is that we want to have the best place for our patients. And we want to have an inbuilt care for our visually impaired clients. So many of the eye hospitals, the patients who come there are visually challenged, they’re poor vision or they’re blind, but hardly we see any hospital which is catering to a real good infrastructure for these visually-impaired people. And they have to hand hold somebody else and they always need an attendant to help them. And why not we have a culture where we have very good visually disabled markings, whether that’s Braille on the lift or if it’s on the floor as you see here.
And this change was suggested to us by our director of rehabilitation when we were building the new core campus a few years ago. And immediately the management thought this is such a good idea, let us put it in all the new buildings. What we learned in one place, it was not that it was a big building in Hyderabad so why don’t we have it elsewhere, why should we showcase this in smaller buildings? But we’ve decided that it’s going to be in all the buildings that LV Prasad Eye Institute makes. This is what is culture.
These two things, how these foot markings came up, that there’s a creativity and ownership by every employee, that’s the culture we want. That everybody should think and create something new. In fact, our appraisal system asked what did you do new this year? That is asked to all the categories of staff. The empowerment to speak out. That the person should not feel inhibited that I cannot speak out because somebody bigger, the doctors are there and I am a rehab person. How can I tell them what should come into the hospital? There should be a platform to share the ideas and for this we need team building, they can share it with their own team, they can share it vertical across the network, they can share it horizontally across the departments. So there should be a seamless platform to share ideas and this platform come because you can do it in your tea room, you can do it in your monthly meeting, you can do it in your leisure time, you can do it over WhatsApp, whatever works. But there has to be a give-and-take of ideas and there should be platforms available for that.
There should be responsive management. What’s the point if they keep on telling something and the management doesn’t take care or doesn’t get back and say why it was done or why it was not done. Especially if it was not done, there should be feedback, otherwise the enthusiasm will decrease. So the management has to be responsive. They will take it up and then they will make a decision and that will be conveyed back to the person who gave the idea, and to their teams, and it will be very open and transparent as far as possible.
Then after one decision has been made it has to be operationalized. There’s no point in keeping those things hidden in the files and then they go round and round and round and it doesn’t happen. So here we can say that yes this idea came from the rehab person, it was operationalized, and it was scaled up.
The buy-in of the users is also very important. There is no point in having this on the floor if you don’t train our visually-challenged people how to utilize this facility. That is very important. It has to go to the next level where people actually use the thing that has been put there, and then we need to have surveillance data. We need to measure was it really happening or is it in our mind that it is happening? So before and after did more visually-challenged people fall before we put this in place, are the people more happy, is the patient are very happy to see this? How is it looking to our International visitors to see that our hospital is up to the standards of international level? Various data one can collect depending on what one wants to use it for.
And then the feedback, is it really good? Can there be better things? This is somebody who has put in the words and we’ve copied and pasted it here, but is this something for our patients, our footwear, our sari-wearing population, does it work for them or not? This is just what I’m trying to say is the culture of continuous improvement and giving of our feeling to your patient.

The one thing which I didn’t notice, but we recently had an assessment and they pointed out that they are very happy that all your committees are headed by doctors. I didn’t know that this is unique. I thought this is something very natural that all the committees should be run by doctors because it is we who are different face that patients come to us and it is our ownership of giving the best to our patients. We are very proud that almost all the committees, as you see, are headed by the doctors. Except for the internal complaints committee which is part of the harassment committee, which is not headed by the doctor. Because there it’s the public who wants to talk to someone who’s not a doctor. Although we have doctor member there, but almost everybody is a non-doctor in that harassment committee. But otherwise we have doctors who take ownership and they take the lead.

Let’s look at some of the things that we said and then I’ll go to the six patient safety goals. The challenges in India have been that when we want to identify the patient correctly and this is the learning over the last 20 years, is that language is a big problem because we have so many languages. And obviously many of us are out speaking three, four, five languages but we can’t speak all the languages. But yes, we can speak the language of care and we can speak the language of love. That does not require any value, that doesn’t have any value. So we do have these very popular names coming to our OPS. On a given day, you may have 10 Lakshmis in your OPD or may have five Satyanarayanas and that, so it’s very common in our busy OPD to have patients with the same name. And when you call out, and especially if they’re from a different language, it may be the wrong patient that you’re seeing.

Also we have this unique problem in India that patients are intimidated by a big place. They are not used to speaking up, many of the patient staff have been culturally taught don’t speak up, don’t speak to the doctor, don’t speak out if you notice something wrong, just be quiet otherwise you may get punishment. People are scared, they are not forthcoming to speak up if they notice something.

And then hearing and cognitive disabilities. Again, people hide them. They are not very comfortable telling that my mother has a little cognitive difficulty and please talk to her because she will not understand, or my mother or my father is hearing impaired or I’m hearing impaired. We are not very open, we don’t have badges. One has to pick up those clues and so the staff and the attendants need to be sensitized in the training programs that there can be vulnerable patients and you may not even know that they’re vulnerable patients unless you look out for the red herrings.

What are the solution? What we have started doing is to change this culture of identifying people with language vulnerability. We put a tag on them and whenever there is a person with a language vulnerability we try to get another person who’s tagged with that patient throughout their OPD or their OT, one of the staff, or the patient will come. We’ll find out who the Bengali person is on the floor. Everything that we have to communicate to them that person will come. They’re working in some other area. When I have to talk, I will call that person for the day and then he will explain. The same person will keep on explaining and then the patient also feels very happy and rushes back to that same person to ask more questions.
Whenever we had a miss, we run retrainings. The very important thing is to make the patient and the attendant partners in the care. Many times, we, in the organization, we keep on doing many things like putting bands on patients or bringing a checklist. But we don’t tell the patient or attendant why we are doing this or this is being done. It’s like at the airport, people are doing many things and we don’t know why they are doing it, so we just go along and cover it and cover it. This is very important. When I put the band, I should tell the patient, “I am putting this band on your arm and this will tell which side the surgery has to be done. Is this okay?” Get acknowledgement from that. Same way if you’re doing something by putting them on a stool, then explain to them why this is being done. All the safety measures, all the checklists, so that they’re alert.

Recently we had an instance where the name was being called of the patient, the patient “AB” and the mother was telling, “I am A but I’m not B. I am A I am not B.” But they didn’t listen to the mother, they thought that she’s saying something, and they’re in a hurry, they have to finish the list. They took the patient and only after the patient was put on the bed, it was realized, yeah, he’s actually AC, he’s not AB. And the mother was telling he was not AB. We know that there’s something wrong the name that you’re calling or it’s my name but it’s not the correct name. I think it’s very important to put the patient and attendant as partners in their care especially with the safety checklist are going on.
And as I said, we enable the family that there is nothing wrong if you have a hearing or a cognitive disability patient we are going to take care. And you are with us and we bring them to the theater. Many times they bring them right up to the table so that they are there and vulnerability can be mitigated.

The next one which is, why is it not moving? Okay, so we go to goal two. And that is the improving the effective communication. (speaking Urdu) For people who do not understand Urdu, it’s like, “Oh Lord! They have not understood me and they never will! Give them some more heart rather than give me some more words!” Yes, it’s the heart, which as I said, is the care which decides whether you have the culture or not.

What did they say, and what did they hear? As you heard in the previous instance, the sister said, “Load the insulin.” But what did she hear? She heard, “Load the insulin and go ahead and give it off to that patient whom we were just now handling.” It’s very important to do drills. To do wet labs and workshops where actually this is being done so I’m handing over something and I’m telling them what do I mean when I say, “Go and give saline to this patient.” Go and give this saline to this patient could mean that go and wash that chemical injury eye with saline, or it could be go and give the saline wash mouth to that patient, or it could be give IV saline to that patient. What I said was, “Go and give saline to the patient.” What did the assistant understand and which saline she gave to which part of the body are two very different things. Unless we do these repeated drills and workshops and handing over and talking, because everybody sometimes uses some abbreviation, they do some gestures. Those should be verbalized and those should be told very clearly in complete sentence.

After some time when the team works together, two people, then they know okay, then you don’t even have to… It’s like the couple, husband and wife, then you just have to raise your eyebrow and you know the husband knows what’s happening. But until that level of communication happens, I think it’s very important to speak. And you train to speak the same sentence again and again every time by everyone. Give it in writing.

For example, to the telephone operator, to the front desk staff. So we have this example, I’ll put it here. We have a sight savers reception and there’s a non-paying reception. At the non-paying reception we don’t want the patient to have the feeling that you’re a charity patient, you’re an excess patient, you are a patient whom we are doing some charity to you. No, we want to have a very dignified welcome to that patient. We are very thankful that you’ve come to our facility and giving us the opportunity to treat you. Unless the front desk staff has been trained of exactly what to tell a patient when we are shifting from paying to non-paying, the patient will feel that they have been downgraded. I was a paying patient, I don’t have money and now I’ve been downgraded into a non-paying patient so now I will not get the same service which I got when I was paying. This is a common perception patients feel when they are shifted from paying to non-paying.

And same thing for the sight savers. For sight savers, we don’t want them to have a perception that if you pay more the doctor will see you faster or you’ll get better treatment than if you don’t pay. Then they end up paying. The concept of sight savers in our institute is different, it’s like the patient pays for themselves and they’re also giving some charity for others. How to convey this? Every person cannot convey this. We have a written format which every person has to say the same thing.
And then the most important thing is the daily team huddle. We keep on telling the staff to do daily team huddles so the supervisor will be there and they will tell them. Yet again, they should not say whatever they want to say, there has to be a point where a speech which daily they have to tell. Today in our team, we have five surgeries to be done, everybody will wash hands, everybody will use Thilium, everybody will cut nails. This has to be told every day, every day, every day. So this is very important to have a daily team huddle. And the supervisor and team keep on reiterating the point wise things. These are the things which help effective communication.

Then it’s about improving safety of high alert medications. And that told you that you can have higher dangerous medications and people are very careful about that. The same sounding medication. But I want to tell that even ordinary medicines, even ordinary medicines can become very dangerous. To my mind, any and every medication we administer to a patient can become dangerous. And again, this is not something which is taught to us, we are taught pharmacology separately, we are told all these danger signs, what has to be done, what doesn’t have to be done. But when it comes to the wards, we just write those medications. Especially in pediatric populations.

I want to bring to notice that there are no eye drops which are formulated for babies. Every eye drop in a baby is danger because their eye drops have been formulated for an adult 60 kg man. When I’m putting an eye drop in a 1 kg baby, I’m really putting that baby to a very high risk. It could be just homatropine or just tobramycin, or just anilaphrine, but we are actually overloading babies and we don’t have any formulations. We have to be very, very careful in how to administer how many drops before it should not spill out, the nasolacrimal duct should be blocked, and train the mothers, and see which is the safest drug for the child. Because it goes into the system, they get feed intolerance, they will vomit, they’ll become lethargic and nobody will notice or note that it is because of the eye drop that this is happening to the baby.

We had an instance here, and I was not aware that Crocin comes in various doses. I used to write syrup Crocin for six drops or eight drops for the baby. And then one baby came back after a single dose very lethargic and actually was very sick. And that is the time I tried to Google and then I found that actually Crocin comes in various doses. And when I went to the pharmacist and I asked him, “Which Crocin did you give?” The pharmacist was also not very clear that there are different doses. You can see where it says the first one says peppermint flavor 100 milligram per mL, and the next one is 120 milligram per five mL, and the next one is 240 milligram per five mL. If somebody doesn’t know that their Crocin which are mL and per five mL then you will have very off doses and there’s lot of literature available of see the side effects of Crocin. Crocin is something we give left and right to everybody.

I’m just trying to raise that drill and the training and the drugs that we give, it has to be part of our culture that everybody has to look at the drug, even if it is a common drug. What is the dosage I am giving, what is the formulation of that? It could be a different thing. And we should not just memorize something that we know all these drugs and we know the dosage. This was a big learning for me, this happened only a few months ago.

Then about the correct site, and this is a nightmare. This is the most difficult to achieve, if you Google search, you will find that thousands of patients, hundreds, thousands of patients throughout the world, they get wrong side surgery. And as far as ophthalmology is concerned, the most common inaccuracy is the wrong IOL. And this is the NHS data reported from London and Wales. In seven years they had 164 cases. That can happen, okay, something happened. But the thing that was not good was that in 62 of these reported cases with NHS, no learning was there and no causal data was reported. It was just reported to the NHS that the wrong IOL has been put. And only in the rest of the 40 odd cases was the reason given that there was an inaccurate biometry, or there was a wrong IOL selection, or there were transcription errors, what was written and what was copied on the file was wrong, and handwriting misinterpretations. This is what was published.

And something similar, our data is there. This is data from two of the campuses. And you can just see how we look at these patients. Whenever there’s a wrong IOL, we have a detailed assessment, we try to find the cause, we nail down exactly what happened, who did what. And the good thing is that there’s a lot of transparency in this, there’s no punishment, “why did you do this,” because then people will not come out and tell exactly what happened. And they’ll keep saying, “No, I went for breakfast and I don’t know who put the IOL there,” or somebody will say, “No, no, I didn’t do it. No, somebody else did it.”

It’s very important to have a transparent procedure process. So you can see here the whole detailed description is given, this is across two different campuses. The root cause is analyzed and the corrective action is taken and then the preventive action is taken.

But the heartening thing was, if you read the last line in one of our campuses at MTC, there has been not a single wrong IOL in three years. This is so good. It means that it can be achieved, it means it can be done. And in other two, we had two and, of course, in another campus we had seven or eight, because there were a lot of trainees there, a lot of complicated processes. When we said, that okay, there’s a lot of complicated process in one of the centers, whereas one center is having no wrong IOLs then one not to have very few, let us look at the whole process So that is the time we compile all the data, sat with the IOL surgeons, and now we’ve not had any wrong IOLs. I think this is something that we have to do. This is just an example. If something happens then we have to do a detailed analysis, transparency, and analyze it very thoroughly, very ruthlessly and then you will come to that level where you want to be.

Coming to the infection control, yes, there is an active approach. We’ll do checklist and these checklists are dynamic, they are not static ones. We have something which is consistently okay on the checklist, then we change the parameter and go with something which is new, which needs to be checked again. But we should also have a lot of non-checklist observations and this was pointed out in one of our assessments here. You do a lot of checklists and you’re doing it thoroughly but you should also have non-checklist observations where a person just stands there and just observes what is happening around so that they can pick up some things which may not be in the checklist. And then whenever, of course, the things happen, Sidhartha has shown that we go over the incidents. Sometimes we go over and over again.

I just wanted to highlight that there were 200 cases of surgical site infection reported in South India before it was traced to topical anesthetic drops. This was a huge epidemic. And it’s very strange that so many cases happened and not so much analysis must have been happening, and this was across multiple doctors, multiple hospitals. But more than 200 cases happened before we could find out that it was the topical anesthetic eye drop which was contaminated. Sometimes it’s not very easy to find, we have to really persist.

So we had 11 cases between September 6th to 29 in 2010 and this was published. So what happened is that we had 11 cases and then we stopped the OR, we closed the OR, we did everything thoroughly, we did a meeting. We did everything that was possible, we changed everything, tubing, this, that we couldn’t find any cause so everything was okay. Then we opened the OR. And one or two days it was okay and then again we had four or five cases. Then we were like okay let’s close the OR again. We were just not able to trace what happened. Then somebody really analyzed, sat day and night on that data, and then realized it was only one particular group of patients who were getting infected. And then finally we could trace it to a particular brand of IOL. Normally we would not think the IOLs are contaminated. We use so many IOLs from so many different companies. There’s so many mix ups, so many types. But really to get down and say that this is the common factor where we’ve got the thing. But the learning curve is that we have to persist and then we might find something very, very unusual from where the infection was coming. It is very important to keep on tracing and have all the data there.

Does it help? This is my last to say that yes, it helps. You can see here that our endoph data and our surgical site infections, they’ve come down, down, down, down and now we are very good at it and hopefully it will be less. Of course, the year 2020 we did less surgeries because of the pandemic, so that may not be a real data, but we are close to .03 or something. These are all the cases that we have done and our attempt is to keep on reducing that.

When we come to reducing risk a patient from falls and it’s all not only just falls but I would say any other hazard. What happened is we found that the workers when our new building was open, after almost a year, something fell on a patient. And then we found that the workers, one year back when they had handed over the building, they had forgotten to remove some spacers which they had put in the ceiling. And this almost fell and hurt on a patient. This is something very, very serious.
After that, what we did was we did something called an Oktoberfest. I know those who are beer drinkers, they just love this Oktoberfest, okay let’s drink around our place. So we said just look around you and take photos of any problem in your area in the month of October. And let’s just find out if there’s something hanging, is there something loose, is there something which can cause problem?

We also recently saw that there were handrails and some of the toilets and when we went to our secondary centers we suddenly realized that those toilets did not have handrails. And then we said okay, all the toilets in all of the secondary centers please put handrails. You observe something and you take it to the next level and put it across the network. It should not be at one place. And of course we do look at the vulnerable points. This is the poster we had put for the Oktoberfest. It was distributed to everybody that look around, if you find anything in your area of work, just report to us. And also this was good so these were multiple things which came up. I’ll just show some pictures of that. This is what somebody noticed, so before and then we could repair it, and after. There was some leakage and here we had some place. This was a part which had been laid out and many people, especially those who were wearing heels and all, they used to just skid on the area. There was no fall in that area, but multiple people, we could see that they would just skid a little bit. But we don’t have to wait for the fall to occur to correct it, it was a vulnerable area and it was picked up and photographed and then we could do so.
Same here, you don’t have to wait for somebody to fall. You notice that the tape is missing, so we need to correct that. I think that is the ownership that every person on the campus must report if they notice something wrong. Just to say again that we are going to give all the care to our patients and that is what drives up our quality and our strive to improvement. I stop here.

[Phanindra] Somebody said that when you talk about the yellow code that you produce, when the patient is missing, how more drill is performed? Please highlight.

[Sidhartha] Whenever we conduct mock drill, we create a scenario that a certain known person is missing. That’s why we call it as a mock. We know which person was present and then that person goes missing. That does not mean that the person is really in a blind spot or really suffering somewhere not like that. They’re in a secluded place, and all of us know that, but we act like the person is missing and what has to be done, which areas has to be searched, and then we find that person in that place. So that’s how we go about with the drill.

[Subhadra] No, I think the question I think he has written mock there, I think what he meant is what actually when a patient was missing what all did you do? We will call out the number and we’ll say, “Code yellow, code yellow, what floor?” Who also has reported, it will be the patient’s attendant may have reported or the doctor may report that this patient was here and then suddenly he’s not there. Then we try to immediately look at the CCTV footage, we try to ask the people around so that’s what they want to know. Tell what we do in yellow.

[Sidhartha] Okay, first thing that we do, even before announcing a code yellow, if a real incident happens, then we try to find whether the patient is available on the phone or the reachable methods, whether their attendant know about the patient or not. If it is the attendant, then does the patient know about it or not? And the nearest areas, suppose the patient is missing from an OPD corridor, then we try to search in the area first.

After we are sure that the person could not be found in that area and all the principle method has failed, then we announce code yellow and that should not take too much of our time, we wait for one hour and then we announce code yellow. No, not like that. It is a very short exercise within two to three or five minutes maximum, we try to find out not found. Immediately we call code yellow through our public address system. We have a common number for all the codes. So we dial that number from any of our house phones and through the public address system in our hospital the code is announced. It is like code yellow, code yellow. And maybe the details of the person will be given so that everybody in each area of the hospital is alert. And they hear the identification and they also try to find out whether anybody presenting the same description is there in their area or not. If they are there, they immediately inform.

Maybe the security may see that person near the gate, maybe the person has moved out or try to move out, maybe the person is mentially not well that they are just left without telling anyone. Such scenarios may offer. Whoever has heard that announcement, they will try to find out and they will get back. Not only that, it does not stop there, we also have a code yellow team which is headed by our security chief who comes at the scene of the event, inquires about the details, and makes a search throughout the building. When there is a team, the team is divided into two and they do a thorough search in the building. Another part of the team goes into the premises and outside the hospital perimeter and does a search. And then they try to find the person which covers the blind spots like minus one parking, maybe the sewage treatment area. Those areas are also covered so that no blind spots are missed out. And definitely we will find a person. If we do not find them, then we go to the next level that we inform the police and raise a formal complaint.

[Subhadra] I want to say that we saved a life because we were doing this code yellow and actually we found one of the visually-challenged person who was going to our terrance and was trying to commit suicide and we could save that person. I think it’s very important to do these drills and you may save a life.

The person who was found lying dead in the toilet, what happened is that he wanted to make a payment because some payment was pending. And he went to the bank, to the ATM, it was evening, six, seven. He told the patient who was in the wheelchair that I’m going to the ATM outside. So he went to the ATM and then he didn’t return from the ATM. So we didn’t know that he had returned and had gone to the toilet. So that is why there was a difficulty in finding where he was. So we kept on searching for him around the ATM area and outside and then calling his family. Maybe he went to some friend’s house to get some money. So we were let off track. But of course, once we learned that, now we’ve improved our systems.

The other question which is here is that the front desk staff may not be with all patients properly and they may look at their dress or their jewelry, and then they decide how to speak to them. I think this is where the culture is very, very important. How does the management make sure that the staff becomes sensitized that our center is going to treat everybody equally? I think the buck stops at the senior doctors and if I don’t do that then then they will also not do that. What have we done? First of all we have made sure that whenever a VIP comes, nobody will stand. If you are doing your work, if you’re typing a report, if you are entering the data, and just because some minister has walked in you are not supposed to stand up. You continue your work. Say, “Good morning,” continue your work, don’t stand. That is not the culture of this place. Because you are not going to stand when the non-paying patient came.

A couple of times we had issues. Some people they complained, they were high flight people. They thought it was below dignity that why this person didn’t leave their job and come running to them and prostrate in front of them. They left our Institute and we are fine with that. But our culture is that everybody will do their work and nobody will leave their work just to get up and give extra respect to somebody. If you do that for one patient then you have to do it for everybody, you better do it for everybody. That is the rule, if you’re going to stand up for ABCD then you will stand up for EFG also.

The other thing is that the first person, the first doctor-student was actually terminated from her hospital and this is a history that we keep on telling all the new people who join. Was terminated because they did not give respect to the non-paying patient and I’ll tell you exactly what happened. The patient, the doctor was in the OPD, very busy and the patient was keeping on coming with some query and then he went and then again came back with some query. So maybe the doctor was busy and got a little irritated. And the only mistake she did what she told the patient that you are a non-paying patient and you are asking so many questions. That’s all she said. “You’re a non-paying patient and you are asking so many questions.” The patient was very smart, he was educated, he wrote a letter to the management: “I came to your hospital for treatment of my eye. I did not come for getting insulted.” The doctor was terminated.

Once you know that your doctor will be terminated because she did not speak well to the patient or they did not speak well to the family, the whole staff, everybody from top to bottom, will be alert that I have to speak very nicely with dignity to the non-paying patients. So our non-paying patients don’t sit on benches; they have individual chairs just like the paying patients. The only difference will be maybe the chair may be less padded, maybe there is a cooler, there’s not an AC, there may be minor comfort differences. But the dignity of the place and then the non-paying patient will get the same care as the paying patient, comes from the way you set up your things and how you demonstrate it.

Once you demonstrate the same way. Our OPD’s, they’re not having different paying and non-paying rooms. All of the patients, paying and non-paying, they are seen together. All of the staff eats together. I went to one hospital here in Hyderabad, a very good hospital, and they served us food in a separate lunch to the faculty. And I said, “Why are you serving food here, can’t we go to the canteen?” They said, “How can doctors eat in the canteen where all the staff eats?” But in our hospital all the doctors and all the other, I could be eating my food here and my security guard would be sitting in front of me. And look around, maybe doctor sitting there and the housekeeping may be sitting on the same table. Once you demonstrate the culture then I think the staff also becomes culture. We cannot expect staff to get culture and we give some different signals.

[Phanindra] Thanks, Subhadra. I think another question related to yellow code again. Is it mandated with attendant? Yellow code mandatory for the attendant?

[Subhadra] No, so in our hospital, nowadays, especially after the COVID started, we started putting an arm band to the attendants also. Otherwise what was happening many people were walking in and it was very difficult to control the crowds. So we were not that diligent, initially, but once COVID started we got this idea that why not put a band on the attendant also. And if anybody’s found in the hospital without a band on their arm, that person is an intruder. That person should not be on the floor. Otherwise, no, previously we were giving slips. These these slips they would throw from some window and then somebody else will collect that attendant slip, and then they will share the slip. So it was quite unruly. But with the band, it has become absolutely good. We put a band on the attendant, we put the band on the patientm whoever walks into the institute.

[Phanindra] Can you see the question there from Sumani Sumananandi? It is about how the assistant missed out to take out the IV channel after flushing FFA. What type of incident report we should raise?

[Subhadra] This happens, if the assistant did not take the IV. All incident reports are the same. What we want to highlight is that there’s no incident which is small and there’s no incident which is big. It should not be like this is a grave incident and this is a minor incident. Every incident is grave. If somebody had left the IV cannula there, in the same form they will write, the same incident point they will raise. Who will raise that to the person who saw that the cannula was not removed? Then they will raise that incident and they will say that such and such person’s cannula was found, it was not removed and the patient was leaving the hospital with the cannula on. Then we’ll have a meeting. We’ll find out, we’ll call the assistant there, we’ll discuss with her what happened. So maybe she will say I was too busy, there were 40 patients and I was the only assistant, the other assistant was on leave. Then we have to say that okay, should we have a checklist, should we have a thing, should the FFA person also say yes and you should also help? Find a system so it doesn’t happen again.

And it will go into a surveillance checklist. The next time the hospital committee is doing the rounds, they will check randomly. Are all the cannulas are all off the FFA patients being removed? Or are there near misses which are not being reported? Maybe we find some patients leaving and then say, “Oh, come, come, come, come, come, I forgot to remove your cannula!” That should not happen. So there will be a surveillance, there will be a checklist and only when we are sure that now it has become innate, it has become culture, then that point will be removed from the checklist.

[Phanindra] One more, I think they’re seeing reservation and quality points for organizing the eye camps where surgery is not happening but only the spectacles are dispensed. Are there any reservations that we can offer in terms of quality points that they should keep in mind for organizing the eye camps where surgery is not happening.

[Subhadra] We do this in school screening. Sometimes we have school screenings and all that thing. We do have quality checkpoints for the optometrist in the clinic. Most important, of course, will be the transcribing the glasses. What we did here was previously there used to be this problem that somebody writes -1 at 80 and then when they actually enter in the form they wrote -1 at 90. Or something like that. Instead of plus they wrote minus, the wrong glasses. Then some years ago, what we did was of course now in the EMR, the person’s signature will be there who has entered that data. But we made it mandatory that if the patient gets the wrong glass, which has been wrongly transcribed, the optometrist has to pay for it and buy for the patient. Irrespectable what he spent on his glasses. The optometrist will repay the glass if the wrong prescription was handed over to the patient. Fortunately after a year or so, we don’t have this problem.

But in the camp, I think this has to be reiterated: what is the system which is there of doing the refraction? Who does refraction, who writes it, enters in the recording and who actually hands over the prescription? Now it is automatic in our EMR system, but yeah, that could be a point of the wrong thing. The right eye refraction in the left eye and left eye refraction in the right eye. How is it checked again, and is it correct, and does it make sense? But still, there could be wrong glass given.
[Anshu] One of the things we need to emphasize here is and we felt it as a need is to report all these incidents as incident reports. What we have done is we have made the incident report available on our intranet. And we’re trying to also integrate down to the MR. We make everybody aware that whatever the episode, without any fear or level of insecurity, they should report. And such reports when they come as incidents, we look at the CAPA and we see how best we can reiterate that so it doesn’t happen again. Through your trainings, community, requirements, policy decisions, et cetera. That incident report finding and reporting it and bringing it to the notice. And it could be the first witness, it could be many people reporting the same incident, so be it.
But the idea is that you report and report without any fear. You want an anonymous report. It comes to QA, we look at it, we try then get back to the concerned department without any question, blame game. We ask them what is the kind of situation that brought about this concern and how can we address it? And our safety officer, with Dr. Subhadra is the quality lead, any of the campuses whoever is the quality lead, they can act together. And we have this frequent understanding, all of the CAPA understand where the situation is, can we overcome it, in terms of preventive aspect? That is where this incident reporting and translating all these situations brings about the quality and continuous improvement aspect.

[Subhadra] This is about the Oktoberfest, I know Oktoberfest. People who don’t know, this is the biggest beer festival which happens in Germany every October. What we did was it was just a name, we put up Oktoberfest because it was the month of October that we decided to do it as to make it a little fun. I think it’s very important to make quality a little fun. Because we put up some funny posters, some cartoons, it should not become very strict and very stale and make too formal. As I said it is culture, culture is always fun, culture is always colorful, culture is always something that people just love to do. It should not be something which is imposed on somebody that you have to do this. It should be something which people really love. So I think it’s really important for the quality team to bring in that fun into this thing. It should not become something which is very drab and dry and dull.

So what we did was we just sent out this poster to everybody on the email and put it up in a prominent place in the institute that we are celebrating a festival and what is the festival about? The festival is about reporting any abnormal infrastructure in your room.

One day I went to the municipal council office here in Hyderabad. I was also surprised the GMJC which is supposed to do our sewage and clean the city and clean the municipy. And that person was sitting on the table and on top of him, one spider net was just here. And the spider was hanging on his head. The housekeeping is sitting outside lounging around. And I was like this person is sitting in this office for every day for 12 hours or eight hours and he’s not going to remove these cobwebs from his hospital? I’m sure in his house he would have removed. That is the idea that you’re sitting if you’re sitting on a desk, at least look around your room and find out if there’s something which I need to correct.

One thing that my work, my job is just to enter something, so let’s have some fun. So that is what we did in that. And that we do other activities, sometimes we have a go green activity, sometimes we have let’s change something. That type of group activity, the little fun activities, I think, bring good flavor to the quality. I think we should do it more. Now, recently, Sidhartha started, maybe Sidhartha can talk about the quiz that you started.

[Sidhartha] Yeah. Previously, we used to teach our employees with a PPD kind of a set up. But gradually it came to so that it became very boring and it was very long. And also what we did was that we broke up that big PPD, all that content into small, small part and small video shout outs and then a curated question/answer session. Like that we made those sessions, just initiated that actually right now. Not all is completed. But we initiated that so that it becomes interesting and whatever is there in that capsule of three to four minutes or five minutes, that is registered in their minds rather than attending just another class and just another session for compliance sake. That is our idea so that it gets registered and also serves our purpose.

[Subhadra] Hopefully we will be able to do that type of session with many of you in the future. We are just evolving that. Different way to learn rather than just put up a PPD and tell certain points.

[Phanindra] Thank you so much.

[Subhadra] We are only an email away. We are only an email away. Any queries, any further questions in your hospital, any time anything is happening, you want immediate response, you don’t know what you do, just call us. Just write to us.

[Anshu] Thank you so much for this opportunity and it was a pleasure sharing these practices. As Dr. Subhadra has said, we are just an email or a call away. It’s good interacting in this session, thank you so much for this opportunity from our side.