We have subsequently witnessed more similar idiotic acts, the most recent being ‘The Ki Ki Challenge’ (where one dances on the road keeping pace with the music played in a moving car) that gained widespread notoriety because of the potential danger it exposed people to. While I do not advocate such gimmicks, however good be the cause, the phenomenon itself is revealing for the way in which people are willing to go to extreme lengths, provided they are sufficiently inspired by an imaginative idea. This makes me wonder how can we tap and use the hidden reservoirs of human nature to achieve excellence, innovation and superlative performance from members of our own profession.

This issue of Indian Pediatrics is dedicated to the subject of ‘Better healthcare through quality improvement.’As we can see from the way the world operates, the quest for quality is a constant theme of modern times. Today, every aspect of life demand ‘quality’ but it is a term that is very difficult to define. Does it mean better products? More reliable processes? Improved results? Lesser cost? … Or does it mean much more than that?

The term ‘quality’ is less of a technical issue and more of a management challenge. This subject has emerged as an entire branch of study in management science and many experts have made a lifetime reputation in pursuing this field. If we study various management concepts, we learn that quality has no specific benchmark; it is a dynamic target. A continuous process-driven approach is required to define, redefine and achieve goals in a constantly changing work environment.

So how can we achieve good results in such dynamic conditions? This is precisely the question that this issue of Indian Pediatrics aims to address. In this context, I find it relevant to share a few thoughts from Dr. Atul Gawande, who is a best selling author of several books [1]. He is also a doctor (surgeon) and an American of Indian origin. In one of his books ‘The Checklist Manifesto,’ the doctor-cum-author tries to address the issue of quality in the medical profession, especially in the surgery, intensive care unit and emergency care. He makes very interesting comparisons between healthcare and airline industry that is famous for using checklists in order to improve flight safety. A checklist is a simple tool that we all use in our personal lives. Almost all of us carry a ‘to do’ list in our pocket comprising various small tasks that we might forget. We doctors routinely use similar step-by-step procedures in our practice. Our protocol manuals outline a clear cut road map defining the way forward in administering treatment procedures taking into consideration various case scenarios.

But Dr. Atul Gawande’s goal was to achieve surefire results on a much bigger scale in the medical profession (in community medicine contexts). He tells about how simple measures like washing hands before and after attending to a patient can dramatically reduce spread of infection. He presents many cases where even very experienced doctors would have made fatal errors just because they oversaw or forgot something so basic. He was eager to overcome such faux pas and come up with a method of making the doctor’s checklist virtually fool proof. Illustrating his project with actual case studies, he shows how the very act of formatting checklists (or protocols, as we call them) presents huge design challenges. He finally concludes that most of the problems that we encounter in quality issues can be solved only if we try to achieve change in mindset, change in attitude and change in human behavior.

Today we live in a world where everybody is complaining about the high cost of healthcare. Everyone wants good healthcare at the cheapest cost. Therefore, apart from my first assertion that quality is a human issue and a process issue, I also wish to make my second proposition that one of the objectives of quality orientation should be to bring down the cost of healthcare. It is a common perception that all good things should cost more money. On the other hand, if we build on my first assertion that quality is a human issue and a process issue, it follows that a little application of mind in the right direction can result in greatly reduced costs.

As an example, I wish to highlight the tiny Indian car ‘Tata Nano.’ At a time when people thought that it was impossible to build a good car for less than Rs. 5 lakhs (7000 USD approx.), Ratan Tata called his engineers and gave them an impossible target – to build a new car that was affordable to the common man at Rs. 1 Lakh (1400 USD approx.). This challenge pushed his team of engineers into a new mindset focused on building a good car at a low cost. After some time, they succeeded in achieving the impossible by coming up with a small car for Rs. 1 Lakh, and made India proud.

Though this car did not become as big a commercial success as desired, its failure is attributed more to faulty marketing, wrong product positioning and other psychological factors rather than the merit of the product itself. Hence, we can all take inspiration from this example and recognize cost reduction as one of the important goals of continuous quality strategy. However, the issue of cost vs quality is yet unsettled. As Hussey, et al. [2] observe: "Although there is broad policy consensus that both cost containment and quality improvement are critical, the association between healthcare costs and quality is one of the more controversial topics in health policy." There is certainly a great need for more thinking to go into this sphere. We need a breakthrough to harmonize cost and quality.

The third and last point I wish to make is also best illustrated by an example. Today’s world is an extremely dangerous place. The most threatened people are our national leaders who always live under the threat of terrorist attack. For this reason, after the assassination of Mrs. Indira Gandhi, a special team called Special Protection Group (SPG) was formed by the Government of India in 1985 to protect the Prime Minister of India.

After the SPG was formed, there has been no serious attack on an Indian prime minister for the last 33 years despite increasing threats. When Mr Rajiv Gandhi was assassinated, he was not under cover of SPG as he was not the prime minister at that time. His assassination prompted the government to bring ex-prime ministers and their families also under SPG cover. Recently I read an interview with a former SPG officer. When the fact of SPG’s incredible success was pointed out to him, he very coolly said: "For us at the SPG, it is always a ‘Zero Error’ job." That’s right – theirs is a ‘Zero Error’ job as they recognize that even one error can be very costly. Hence, they have to be very thorough on the job.

Being doctors we too are in a similarly challenging situation. The babies who come under our care are the little VIPs who deserve our zero-error service. It should be our continuous endeavor to deliver this kind of service by coming up with continuous strategies to achieve optimum quality. I am sure this issue of Indian Pediatrics will shed more light on the subject, and provide you with some concrete ideas and sound evidence base on how to respond to the challenge.

I wish you a zero-error career in the future.

1. Gawande A. The Checklist Manifesto: How to Get Things Right. New York: Metropolitan Books; 2009.