ACCREDITATION STANDARD FOR

MEDICAL IMAGING SERVICES

ASHISH RANJAN

AASTHA SERVICE INTERNATIONALF-17, IIND FLLOR , SUBASH CHOWK , LAXMI NAGAR,

DELHI-110092

What is Accreditation?What is Accreditation?

Public recognition of the achievement of accreditation standards by a healthcare organization, demonstrated through an independent external assessment of that organization’s level of performance in relation to the standard.

(ISQua)

Hospital Accreditation in IndiaHospital Accreditation in India

Started in India in the year 2005 by National Accreditation Board for Hospitals & Healthcare Providers (NABH)

NABH is a constituent board of Quality Council of India (QCI) set up to establish and operate accreditation programme for healthcare organizations.

QCI is an Autonomous body jointly set up by the Government of India and Indian industries to establish and operate National Accreditation Structure.

The board while being supported by all stakeholders including industry, consumers, government, has full functional autonomy in its operations.

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A constituent board of Quality Council

of India (QCI)

To provide accreditation services to hospitals and healthcare providers

Structure of QCIStructure of QCI

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Quality Council of India

National Accreditation Board

for Certification Bodies (NABCB)

National Board for Quality Promotion

(NBQP)

National Accreditation Board for Testing and

Calibration Laboratories (NABL)

National Accreditation Board for Education and Training (NABET)

National Accreditation Board for Hospitals & Healthcare Providers

(NABH)

Quality Information and Enquiry Service

(QIES)

StructureStructure of of NABHNABH

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National Accreditation Board for Hospitals & Healthcare Providers

Technical Committee Panel of

Assessor/Expert

Accreditation Committee

Appeals Committee

Quality Council of India

Secretariat

NABH ActivitiesAccreditation of Hospitals

Accreditation of SHCO/ Nursing Homes

Accreditation of Dental Centers (Ready for launch)

Accreditation of Blood Banks

Accreditation of Wellness Centers

Accreditation of PHC/CHCs

Accreditation of OST Centers

Accreditation of AYUSH hospitals

Accreditation of Medical Imaging Services(Ready for launch)

International Recognition International Recognition

NABH is an institutional member NABH is an institutional member of the International Society for of the International Society for Quality in Health Care (ISQua) Quality in Health Care (ISQua) since 2006.since 2006.

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ISQua Board Member

Member of Accreditation Council

ASQua Board Member

International RecognitionInternational Recognition

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ISQua Accreditation of NABH Standards for Hospitals (April 2008 – March 2012)

International RecognitionInternational Recognition

Basic Principles of Basic Principles of AccreditationAccreditation

Statutory/ Regulatory/ Licensing – Compliance Must

It is based on structure, process and outcomes

Focused on Patient Care and Safety

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Accreditation Standards

Accreditation Standards for Medical Accreditation Standards for Medical Imaging ServiceImaging Service

1) Control of Service (CS)2) Control Of Imaging Processes And Procedures

(CPP) 3) Control Of Personnel(CP)4) Control Of Equipment (CE)5) Control Of Documents And Record (CDR) 6) Risk Control and Safety (RCS)7) Control Of Services(CS)8) Control Of Imaging Process And Procedures (CPP)9) Human Resource Management (HRM)

10 chapters,100 standards,514 objective elements.

Objective of the studyObjective of the study

To analyze the improvements in the quality of services rendered by different hospitals, accredited under the accreditation program of NABH, based on certain service and clinical standard indicators.

MethodologyMethodologyThe hospitals were provided with questionnaire related to some service and clinical standards. They were requested to provide information on benefits of accreditation in terms of improvement in performance under different standards provided.

The standards selected are:

Service standards: a) Registration desk b) Pharmacy c) IT and Billing

Clinical Standards: a) OPD standards b) Diagnostic (Laboratory and

Radiology) c) OT and Nursing

The data from hospitals accredited under NABH accreditation program

was collected, analyzed and following

observations were made

RESULTSRESULTS

SERVICE STANDARDSINDICATORS

Scope of services well defined and understood by staff

Job responsibilities of staff clearly

defined

Patients rights and responsibilities are identified and respected

Admission process streamlined, admission

counseling startedIncreased

patient satisfaction and quality

of care

Increase in staff strength in areas like enquiry, doctors

booking & console as per work load

Staff review meetings for discussion complaints & suggestions

REGISTRATION DESK

Procurement, storage & dispensing policies/procedures

for medications well defined

Special care taken in handling,storing and dispensing sound alike, look alike and high risk

medicines

Improved inventory practices as a result of

training of staff

Regular medical audits

Policies defined for handling of narcotic, radioactive& chemotherapeutic drugs.

Adverse drug reactions & medication error tracking & review has been reinforced

Lower incidents of medication related adverse events in care

PHARMACY

IT &BILLING

Auto stoppage of medication which have serious side effects unless reordered by the physician

New out patient and in patient billing counters to meet up additional workload.

Introduction of billing counseling

Auto log& limitation on viewing privileges

IT generated discharge summary

Schedule of charges displayed through kiosk and handouts

Safety of patient data & decrease in waiting time for billing

CLINICAL STANDARDSINDICATORS

Corrective steps taken to reduce OPD consultation waiting time

More emphasis on preventive care through patient education.

Protocols for preventive health checks, cardiac evaluation, pre operative anesthesia, angiography have been reinforced

Monthly review of statistics on mortality, code blue occurrence, capacity utilization, doctor’s performance etc.

Increased patient satisfaction

OPD Consultation

Procedures and policies for pathology & radiology depts. implemented with

standardized processes

Wastages identified and corrective actions

taken. Biomedical waste practices improved

Regular training of staff in

radiation safety

Continuous monitoring of clinical tests

results

Staff with requisite qualifications and

experience is employed

Increased patient safety and enhanced quality of

services provided

DIAGNOSTICS

Policy to prevent adverse events like wrong site, wrong patient &wrong surgery is defined and

implemented

Sterilization and disinfection practices are monitored and are in place

Infection and environmental surveillance carried out regularly

Rational use of blood and blood products in OT

Proper documentation of OT notes and sign offs by treating surgeons are in place

Improved practices in OT and reduced chances

of error

OT & Nursing

Registration: Staff awareness about various policies,

procedures and services improved considerably. Patient’s rights are now recognized and respected.Turn around time reducedPharmacy: Waiting time reducedReady stock of emergency drugs at all times Improved inventory practices.

CONCLUSION

IT and Billing: Security policy for the access of data and OPD

records.Restricted control and access to patient’s data.

OPD Consultations: Mandatory nutritional assessment .Patient rights regarding privacy and

confidentiality reinforced.

Diagnostics: Equipment calibration/preventive maintenance

schedule monitored regularly.Quality assurance programme implemented.Corrective actions identified & implemented.OT and Nursing: Fumigation policy and hands washing is

continuously monitored in OT.Better Infection controlContinuous training, incidental teaching and

supervision to ensure quality nursing service.Motivation to nursing staff to be a partner in

delivery of healthcare.