PRESENTED BY: SANA SAIYED

Seminar on Accreditation

Hospital accreditation

Hospital accreditation has been defined as “A self-assessment and external peer assessment process used by health care organizations to accurately assess their level of performance in relation to established standards and to implement ways to continuously improve”

Driving factors for accreditation

Consumer protection ActClinical Establishment ActInsurance companies regulation Empanelment by CGHS, ECHS, Corporate etc.Community Awareness & Response

Why accreditation???

Ensure a quality index for health consumer. A growing number of hospital in india are turning to accreditation agencies worldwide to both standardize their protocol and project their international quality of health care delivery.

Attract foreign patients.Quality Assurance helps improve effectiveness, efficiency and in cost

containment, and accountability and the need to reduce error and increase safety in the system.

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The process of accreditation is envisaged to result in a process of fundamental change in technical procedures of service delivery, in the appropriate use of available technologies, in the integration of relevant knowledge, in the recourses are used and in the efforts to ensure social participation.

Benefits of accreditation

Improve public trust that the organization is concerned for patient safety and quality of care.

Provide a safe and efficient work environment that contributes to worker satisfaction.

Listen to patient and their families, respect their rights, and involving them in the care process as partners.

Create a culture that is open to learning from the timely reporting of adverse events and safety concerned.

Established collaborative leadership that sets priorities for and continues leadership for quality and patient safety levels.

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Identify systemic break-down and close gaps or loopholesProvide ways to detect and correct error and problemsEnsure conformance to and effectiveness of documented processes Focus on patient and provider needs and expectationStreamline work flow and maximize resource utilization Maximize customer satisfaction

Accreditation authority in India

NABH (national accreditation board for hospitals & healthcare provider)QCI (quality council of india)

NABH(National Accreditation Board for Hospitals & Healthcare Providers )NABH is a constituent board of Quality Council of India, set up to

establish and operate accreditation programmed for healthcare organizations.

The board is structured to cater to much desired needs of the consumers and to set benchmarks for progress of health industry.

NABH is an institutional member of the International Society for Quality in Health Care (ISQUA).

ISQUA is an international body which grants approval to Accreditation Bodies in the area of healthcare as mark of equivalence of accreditation program of member countries.

NABH Standards

10chapters100 standards514 objective elementsEach accreditation standards is a statement of an expectation or

requirement which makes it possible to deliver quality care.Objective element are sub components of slandered.

Standard (patient centered )

1.Access, assessment and continuity of care (AAC) Standards for ‘Registration’, ‘Admission’, ‘Discharge 'Transfer’ &

‘Referral’ processes are covered in this group and are properly taken care of using the Patient Administration System [PAS] module of an HMIS

2.Patient Rights and Education (PRE) Standards related to ‘Consent Recording/Archiving’ are an important

constituent of this group the Application too, making them available across time and space.

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3.Care of Patients (COP) By using specialty specific ‘Clinical Form sets’, ICT ensures

standardized delivery of clinical care across all locations & departments of a Hospital. Ex. workflow template

4. Management of Medication (MOM) Health care professionals need assistance while choosing a medication

from a large list of medications available with respect to Drug Interaction and ‘Individual Sensitivity’. Develop electronic medication administration reconciliation module.

5. Hospital Infection control (HIC)

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8. Facilities Management and Safety (FMS) A ‘Materials Management System’, which includes Stores Management,

takes care of all the processes related to Equipments and Devices life cycle.

9. Human Resource Management (HRM) A standard functionality mapping to a HRM module in a HMIS is

necessary to meet these standards10. Information Management System (IMS) A modern HMIS takes care of the information needs of the care

providers, management of the organization as well as other agencies that require data and information from the organization.

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Two important HMIS modules which cover the standards covered in this section are ‘Central Sterilization & Store Department’ [CSSD] module and ‘Bio Medical Waste management’ Module.

6.Continuous Quality Improvement (CQI) An intelligent HMIS, which is capable of reporting ‘Key Performance

Indicators’ assists in achieving the standards mentioned in this section.7.Responsibilities of Management (ROM) A modern HMIS is capable of creating a hierarchy of ‘Roles’ with robust

‘Role Based Security Rules’ thereby ensuring proper accountable Hospital Management.

Benefits of NABH Accreditation

• Benefits to the Clients:• Good health outcomes • Clint satisfaction • Value for money • Less frustration

Benefits to health care provider

Health staff become more satisfied with their work.Health workers understand patients better.Information flow among staff is improved.Health staff who perform well are reworded.

Benefits to health institution

Patient become more satisfied with the services.More patients may use a good services.The environment will become clean and beautiful.The facility will have a good reputation.

NABH Accreditation hospitals

B.M. Birla Heart Research Center, KolkataMoolchand hospital, New Delhi Fortis hospital, Noida Dr. L.H. Hiranandani hospital, MumbaiColumbia Asia medical center, bangalore

QCI (quality council of india)

Quality Council of India (QCI) was set up in 1997 by Government of India jointly with Indian Industry

Establish and operate the National Accreditation Structure for conformity assessment bodies; providing accreditation in the field of education, health and quality promotion.

It also promotes the adoption of quality standards relating to Quality Management Systems (ISO 14001 Series)

To realize the objective of improving quality competitiveness of Indian products and services, QCI provides strategic direction to the quality movement in the country by establishing conformity assessment system which is recognized at the international level

Evidence based management

1. Health sector accreditation research: a systematic review

Author : DAVID GREENFIELD Purpose: The purpose of this study was to

identify and analyze research into accreditation and accreditation processes.

Method : Systematic review Result : 1. In two categories consistent findings were recorded: promote change

and professional development.

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2.Inconsistent findings were identified in five categories: professions’ attitudes to accreditation, organizational impact, financial impact, quality measures and program assessment.

3.The remaining three categories—consumer views or patient satisfaction, public disclosure and surveyor issues—did not have sufficient studies to draw any conclusion.

Conclusion. The health care accreditation industry appears to be purposefully moving towards constructing the evidence to ground our understanding of accreditation.

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2. The standard of healthcare accreditation standards: a review of empirical research underpinning their development and impact

Objective: Healthcare accreditation standards are advocated as an important means of improving clinical practice and organizational performance

Method : Empirical researchResult : 1.Three interventional studies were identified, with the remaining 10

studies having research designs to investigate clinical or organizational impacts.

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2.Only one study noted implementation issues, identifying several enablers and barriers. Standards were reported to improve organizational efficiency and staff circumstances. However, the impact on clinical quality was mixed, with both improvements and a lack of measurable effects recorded.

Conclusion: Standards are ubiquitous within healthcare and are generally considered to be an important means by which to improve clinical practice and organizational performance.

Keywords: Healthcare, Accreditation, Standards

Thank you