Importance of accreditation of lions eye hospitals


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Importance of accreditation of lions eye hospitals

  1. 1. P. K. Roy Chairman, Lions Seva Eye Hospital
  2. 2. Importance of Accreditation for Lions Eye Hospitals • Lions Eye Hospitals mostly engaged in Free cataract Surgery • Economy of the hospitals dependent on Cataract Surgery re-imbursement grant by LCIF or DBCS • LCIF stopped financing against cataract surgery and DBCS funding is uncertain • Economy of the Lions Eye Hospitals are at stake.
  3. 3. Threats  A good number of Private hospitals have started operation recently posing threats to Lions Eye Hospitals  Technical Infrastructure of the Pvt. Hospitals are better than Lions Eye Hospitals.  Pvt. Hospitals have provided better service.
  4. 4. Threats  Priority of these Pvt. hospitals are patient satisfaction.  Professional approach and corporate style of functioning develop patient confidence.  But the cost of service of Pvt. Hospitals are much higher than Lions Eye Hospitals
  5. 5. Steps necessary for Lions Eye Hospitals  Lions Eye Hospitals has to find out avenues to overcome these imminent threats.  Measures need to be taken: i) Improve technical infrastructure for attracting patients ii) Improve quality of service to develop confidence of the patient
  6. 6. Steps necessary for Lions Eye Hospitals iii. Attract patients(other than free) who are agree to pay the cost of service. iv. Utilize the low overhead cost and comparatively cheap price of service in Lions Hospitals. v. To compete with Pvt. Hospitals and for sustainable growth Lions Eye Hospitals has to go for Accreditation
  7. 7. What is Accreditation Accreditation means Certification of competence in a specified subject or areas of expertise by external agencies. Accreditation is an external review of quality .There are four principal component  It is based on written and published standards  Reviews are conducted by professional peers  The accreditation process is administered by an independent body  The aim of accreditation is to encourage organizational development.
  8. 8. Focus of standards  Patient Safety  Staff and employee safety  Environment and community safety  Information Education and Communication
  9. 9. Patient Centered Standards Section I  Access, Assessment and Continuity of Care  Patients Rights and Education  Care of Patients  Management of Medications  Hospital Infection Control
  10. 10. Health Care Organization Management Standard, Section - II  Continuous Quality Improvement (CQI)  Responsibilities of Management (ROM)  Facility Management & Safety (FMS)  Human Resource Management (HRM)  Information Management Systems (IMS)
  11. 11. Accreditation - Procedure  First step : Self-evaluation by unit seeking accreditation  Second step : External evaluation / on-site visit by independent experts  Third step : Decision, based on assessment of predetermined quality standards
  12. 12. WHO CAN APPLY Any Health Care Organization Requirements  Currently in operation as a HCO  Preferably registered or licensed  Willing to assume responsibility for improving quality of care  Should be able to meet the prescribed standards of the accrediting organization
  13. 13. HOW CAN ONE APPLY Basic Ingredients  Organizations apply on prescribed format giving details as required  Submission of a self assessment form indicating the outcomes of its own survey and Internal Audits  Extent of adherence to the laid down standards
  14. 14. WHERE TO APPLY Several quality accreditation agencies are available.  These are : i. Joint Commission International (JCI) is an International body working for maintaining standard in the HCO), ii. National Accreditation Board for Hospitals (NABH), a constituent board of Quality Council of India iii. ISO 9001-2000- is an international quality management system iv. Malcolm Baldridge, - Baldrige Program is dedicated to performance excellence. The most common one being ISO and NABH.
  15. 15. DOCUMENT REVIEW • Quality Manual • Various Policies and Procedures • Minutes of Meetings of various committees • Medical Records • Medical / Nursing Audit • Adverse Events • Action Taken Reports • Personal Records of Staff
  16. 16. Accreditation Process  Applications  Screening of the Applications  Pre-assessment survey  Assessment Survey  Review of the recommendations of the assessing body by the Accreditation Committee  Recommendations to the board  Accreditation decision
  17. 17. ACCREDITATION  These May Look Difficult ,  But Nothing Is Impossible  Impossible Means - I’ M Possible ACCREDITATION IS A JOURNEY AND NOT A DESTINATION.
  18. 18. THANK YOU For your patience…