Proposal
For
Establishing Quality Management System
Leading to JCI, NABH, CBAHI
Accreditation
CLIENT -
PREPARED BY
MAHBOOB...
Contents
Re
f
1
2
3
4
5
6
8
Title
Pag
e
Profile: Mahboob ali khan
Competitive advantage
Accreditation & Healthcare Quality...
Profile:
MAHBOOB ALI KHAN
Bsc,MHA,CPHQ (Masters in Hospital Administration)
I guide and facilitate healthcare organization...
Experience as a Healthcare Quality and accreditation consultant-
Planning and executing accreditation activities for clien...
Core Competencies-
 Advocate, develop and implement quality management systems
for continual quality improvement and accr...
provide them to the required department.7.Ensure Customer
Satisfaction of the highest level
8.Lead general administrative ...
Competitive Advantage:
Accreditation from the Joint Commission International is regarded as the
Highest Achievement in Hea...
intend to leave absolutely no stone unturned.
Mahboob ali khan
Accreditation & Healthcare Quality:
Accreditation as a means for implementing Quality consciousness in he...
Management System, based on Accreditation Standards, helps the
health care organizations in not only meeting patient’s exp...
All these have direct or indirect effects towards reducing the cost of
healthcare delivery, differentiation in the market ...
the formulation of process for data collection, aggregation and
analysis of various quality indicator(both clinical and
no...
b. Development of formats(clinical and non clinical) wherever
required
c. Operationalising of Monitoring system
13. Assist...
c. Organising refresher training programmes as per need identified
16. Assistance during JCI Survey Period
a. Organising M...
would require continuing and evolving support for maturing.
Both of us would provide guidance in organising and
implementa...
brought forth by both of us.
6. Arranging for delivery of lectures or other services from external
resources, where requir...
Consultancy charges:
Based on our understanding of the organisation the consultancy charges
for implementing Quality Manag...
Total
100
%
11
Time lines for the project:
We propose that the project be taken up on the defined time lines of 12
months. A concrete tim...
12
Mahboob ali khan
Healthcare facility Quality and Operational proposal by Mahboob ali khan MHA,CPHQ.
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Healthcare facility Quality and Operational proposal by Mahboob ali khan MHA,CPHQ.

  1. 1. Proposal For Establishing Quality Management System Leading to JCI, NABH, CBAHI Accreditation CLIENT - PREPARED BY MAHBOOB ALI KHAN MHA,CPHQ Healthcare Consultant
  2. 2. Contents Re f 1 2 3 4 5 6 8 Title Pag e Profile: Mahboob ali khan Competitive advantage Accreditation & Healthcare Quality Scope of consultancy services in quality and Accreditation Support required from the Hospital Consultancy charges Time lines for the project 3 5 6 7 8 1 0 1 1 1 2
  3. 3. Profile: MAHBOOB ALI KHAN Bsc,MHA,CPHQ (Masters in Hospital Administration) I guide and facilitate healthcare organizations (hospitals, clinics, polyclinics or health care professionals)to define, document, implement and continually improve their working systems based on Quality principles and International standards like JCIA,NABH,CBAHI.i am Masters in healthcare management and CPHQ USA and has 10 years of experience in CBAHI,NABH, JCIA accreditation in operations management. 1) Initial Review 2) Training Programs for staff 3) Complete documentation as per standards with forms and formats 4) Implementation Support 5) Readiness Audit & support till hospital is NABH,CBAHI or JCIA accredited In order to strengthen the competitiveness of hospitals, clinics & Healthcare Industries ,i am presently in india my mobile number 918790309122.my email is mahboob804@yahoo.co.in. Over 9 Years experience in Healthcare Expertise in implementing Accreditation standards, Training and continuous professional Development Continuous quality improvement and patient safety Mr.Mahboob ali khan has worked in the field of Healthcare Consultancy since, 2004 after obtaining his Masters in Hospital Administration, Osmania University, Hyderabad. Currently Mr.Mahboob ali khan is working in the one of the leading Healthcare Consultancy firm in India, Astron Healthcare Consultants Private Limited as Manager South consulting JCI accreditation and NABH accreditation program in various hospitals. Mr.Mahboob ali khan is also associated with Federation of Indian Chambers of commerce and Industry as a Jury member for the annual evaluation on “Excellence in healthcare award for quality improvement and patient safety” for the Hospitals and laboratories in India.
  4. 4. Experience as a Healthcare Quality and accreditation consultant- Planning and executing accreditation activities for client hospitals with project management, vetting documentation, organizational capacity building, and trend analysis. Successfully conducted gap assessments and implemented for JCI,NABH ,CBAHI accreditation program in various hospitals in India and abroad such as CARE Hospital, Hyderabad (Year-2008) ,AR rawdha general hospital (JCIA)Dammam Kingdom of saudi Arabia,Al sadiq Hospital Saudi arabia (CBAHI) Durdans Hospital Colombo (year-2014), Ministry of Health Hospital PSBJH (CBAHI) KSA. Currently consulting various Hospitals for JCI ,CBAHI,NABH,accreditation under Astron Health Care Consultancy Development of a “Hospital management Information software” compatible to JCI standards as a domain expert 3
  5. 5. Core Competencies-  Advocate, develop and implement quality management systems for continual quality improvement and accreditation (both International accreditation-JCI and National accreditation - NABH)  Comprehensive understanding of medical and services processes, workflows, best practices and standards to advocate, co-ordinate and ensure standardised and consistency of practices.  Competence to develop the monitoring and analysis system for quality improvement activities in the hospital  Hospital planning, Budgetting, setup, infrastructure, administration set up, operational setup and management. 1.Manage and handle overall hospital administration and operations 2.Maintain optimum stock levels of consumables at various departments. 3.Identify and execute regular maintenance works with regard to building and infrastructure, equipment, vehicles and service connections. 4.Maintain the cost centre of various departments to take an estimation of the revenue earned, profits generated and expenses incurred. 5.Taking care of day to day admin and operational activities, trouble shooting and business performances to achieve customer satisfaction and financial targets.6.Generate required reports and
  6. 6. provide them to the required department.7.Ensure Customer Satisfaction of the highest level 8.Lead general administrative matters for the division while liaising with HR, accounting, legal, insurance etc. Professional affiliations- Indian Healthcare Quality Forum, Technical Committee Member Indian Journal of healthcare quality and Management, Domain expert Academy of Hospital Administrators, Member JCI Standards and Consulting Methodology, Certificate of Completion Medical Audit & ICD organized by ASCI, Certificate of Participation Revenue Cycle Management, Certificate of Participation Epidemiology & Study Design, Certificate of Completion
  7. 7. Competitive Advantage: Accreditation from the Joint Commission International is regarded as the Highest Achievement in Healthcare Standards around the Globe. It is the most sought after and the most rigorous accreditation process which encompasses each and every hospital processes and is restricted not only to clinical but also the non clinical and support services. Over the years, I have understood and interpreted the intent of the standards, I tailor-made its implementation, not only to suit Indian Hospitals but also in this part of the world and making sure that I comply with the standards at the same time. I have improvised, failed, learned and improvised further to achieve success and I assisted the first hospital in south asia to face the JCI,NABH,CBAHI survey (first time conducted in this country) which came out with an excellent result of 96% compliance of the measurable elements. My biggest advantage as resident consultants or advisors is that I can not only see the latent hurdles but can provide an apt solution beforehand. During the course of 2 years, consulting one of the major hospital in south east Asia, I have gained an in-depth knowledge regarding the systemic problems and thereafter tailoring solutions for some of the key issues in the private healthcare industry of the country such as Credentialing & Privileging of the Visiting consultants, implementation of JCI standards in the channeling chambers, complete BHT documentation .etc. As this is going to be the first venture where I will be responsible I
  8. 8. intend to leave absolutely no stone unturned.
  9. 9. Mahboob ali khan Accreditation & Healthcare Quality: Accreditation as a means for implementing Quality consciousness in health care is fast gaining acclaim as a critical input. The improved efficiency and efficacy of health care delivery as a result of improved quality has a direct positive impact on health outcomes with derived consequences of greater patient satisfaction. The basic premise for implementing standards as per Accreditation norms in health care management is to provide a framework for implementing quality initiatives with the tenet of improving resource utilization and gaining improved health outcomes. Accreditation establishes Quality Management System in health care through a set of policies, processes and procedures in compatible physical structure for planning and executing patient care services. It integrates various internal processes within the organization. Thus Accreditation focuses on process approach for improved service delivery. It enables the organization to identify, measure, and improve the various processes and instituting control mechanisms for improved performance. Accreditation benefits all stake holders. Patients are undoubtedly the biggest beneficiaries as it results in high quality of care and patient safety. The staff in an accredited hospital is also more satisfied professionally, as accreditation provides for continuous learning, good working environment, leadership and above all ownership of clinical processes. An important role for any health care system is to ensure the quality of its services and to improve the efficiency and effectiveness of the service delivery at all level. The Benefits of implementing Accreditation standards in healthcare may be summarized as below: Today’s hospitals and health care organizations are facing the rising expectations of people for better healthcare and to meet the needs for patient and community satisfaction. A well structured Quality
  10. 10. Management System, based on Accreditation Standards, helps the health care organizations in not only meeting patient’s expectations but also modulating these expectations. It brings about uniformity in processes of health care delivery through establishment of standards and practice guidelines, ensuring patient and staff safety while minimizing risk and adverse outcomes. Reduce waste due to repetition or reworking as a result of wrong or inappropriate process or techniques Safeguarding the organization against litigation. Enables hospital to demonstrate its commitment to quality care. Accreditation is increasingly being used as a stimulus for continuous improvement It also provides opportunity to healthcare unit to benchmark with the best. It raises community confidence in the services provided by the hospital. 7 Mahboob ali khan
  11. 11. All these have direct or indirect effects towards reducing the cost of healthcare delivery, differentiation in the market and greater profitability. Scope of consultancy services in quality and accreditation: 1. Gap assessment and analysis programme Assessment of infrastructure, human resources, biomedical equipment management programs, various clinical and non clinical processes, documentation (Policies, procedures, Plans and Programs), orientation of staff (both clinical and non clinical staff), Quality improvement monitoring mechanism and other features with respect to the JCI accreditation norms. Assisting on developing Action plans towards fulfilment of the gaps in association with Managers and other leaders of the Hospital 2. Assistance in developing and reviewing the hospital action plan periodically for JCI Accreditation 3. Assistance in formulation and coordination of various committees and teams(Hospital facility safety team, patient safety team, infection control team, Quality champions team.etc) 4. Guidance on the Development of Quality Assurance Programme for radiology, laboratory, critical care services and surgical services of the Hospital 5. Assistance in the Development of Documents, (Policies, Plans, Programs, Manuals and departmental SOPs.etc) modulating the existing system and suggesting changes to support JCI accreditation norms. Where required documents will be developed in collaboration with the hospital staff. It will be our endeavour to guide the development of documents in a manner such that the feeling of ownership of the system facilitates compliance. Mr.Mahboob ali khan would not develop the documents on behalf of the organisation as it would defeat the purpose of sustainability and compliance. 6. Assistance the Quality Assurance department of the Hospital in
  12. 12. the formulation of process for data collection, aggregation and analysis of various quality indicator(both clinical and nonclinical) 7. Assistance in formulation of clinical pathways and clinical protocols guidelines and monitoring of adherence of the same as per JCI accreditation norms. 8. Assistance in development of process for data collection, aggregation analysis of the International Library measures 9. Guide on the development of the Incident report mechanism to identify near miss events, adverse events and sentinel events ,Medication error, Adverse reactions .etc 10. Assistance in conducting FMEA (Failure Mode Effect Analysis) on the various process of the Hospital as per the JCI standard requirement. 11. Guidance on the various auditing process to monitor the quality improvement activities(IPSG Tracer Audits, Fire safety Audits, Hand hygiene audits, Prescription audits, Open BHT audits, Closed BHT audits, Department quality assurance audits.etc) 12. Assistance in the Development of Record Keeping Programme of the healthcare facility through guidance on the a. Organising of records(BHts and Others) as per JCI standards 8 Mahboob ali khan
  13. 13. b. Development of formats(clinical and non clinical) wherever required c. Operationalising of Monitoring system 13. Assisting in Training programs throughout the JCI accreditation preparation process. Guidance on the formulation of training need analysis across the organisation (yearly and monthly), training calendars, Training evaluation process and refresher Training courses .etc. These training programmes would be consisted of various training modules such as: a. JCI sensitization Module for Leaders b. JCI Sensitization Module for Doctors c. JCI Sensitization Module for Nurses d. JCI Sensitization Module for Other staff e. JCI policy Training for Doctors f. JCI policy Training for Nurses g. JCI policy Training for Other staff h. Other Training programs as per the specific requirement to meet the JCI standard. 14. Facilitation on the development of an facility assessment programme through a. Assistance in the conducting various mock drills to address the emergencies(internal& external) b. Training of facility staff (Engineering depart. staff) to conduct assessments c. Assistance in organising for internal assessments d. Facilitation in the Conduction of internal assessments e. Assistance in evaluating the results of internal assessment 15. Monitoring of accreditation compliances a. Internal Mock Survey b. Monitoring of effectiveness of training programmes
  14. 14. c. Organising refresher training programmes as per need identified 16. Assistance during JCI Survey Period a. Organising Mock Group sessions as per survey agenda of JCI. b. Organising specific Mock group sessions for leaders/senior managers regarding GLD Chapter (Governance and leadership) c. Sensitization of the Quality assurance executives/survey coordinator regarding the Survey Presentation/document review session, Daily briefing sessions.etc d. Guidance for smooth and effective conduct of all survey activities during the survey period. 17. Development of niche hospital programmes. Certain activities of the hospitals have multiple arenas of operations and representation. These specific activities need to be addressed as programmes and which 9 Mahboob ali khan
  15. 15. would require continuing and evolving support for maturing. Both of us would provide guidance in organising and implementation of these programmes depending upon the maturation level of the organisation achieved during this project. Certain aspects form the soft part when implementing Quality Management System and accreditation programme and would be beneficial for progress. Towards this end we would assist in organising a change management system with representation from expertise available in-house, discussions and developing an action plan so that the process of change is accomplished smoothly. This would also help reduce the impact of accidental adversarial interactions Support required from the Hospital: We would be expecting the following support from the Client hospital for implementing Quality Management System leading to JCI Accreditation. 1. Commitment of top management 2. Designation of a nodal person to interact with both of us. 3. A dedicated Quality Assurance Team consisting of at least one Quality Assurance Manager suitably versed in ‘Quality in Healthcare’ supported by three executives. 4. Providing proactive support in i. Formulation of teams and committees, ii.Conduct of meetings in a scheduled manner, iii. Compilation of Documents with suitable secretarial assistance, iv. Organisation of trainings, audits, performance measurements and assessments. 5. Timely fulfilment of gaps and accreditation compliances as
  16. 16. brought forth by both of us. 6. Arranging for delivery of lectures or other services from external resources, where required, when undertaking activities related to development of Niche hospital programmes, study on optimisation of services, soft aspects for developing quality management systems and any special audits if the management desires. 7. Any other support that may be required in organisation and implementation of Quality Management System including contractual arrangements. 8. Access to records and documents for undertaking historical and concurrent data analysis. 9. Arranging for interview with various staff members and management personnel. 10. Deputing Executives and other staff to assist in undertaking surveys and collecting data – primary and secondary, based on templates developed by both of us. 10 Mahboob Ali Khan
  17. 17. Consultancy charges: Based on our understanding of the organisation the consultancy charges for implementing Quality Management System leading to JCI Accreditation is 40,000 USD- for the above scope of services rendered to the hospital. This fee is exclusive of service tax or any other tax mandated by the government and that the same would be paid by the Client hospital as per existing levels and from time to time. The fee is also exclusive of charges to be paid for specialised surveys for system optimisation or other programmes that may be required to be conducted through external agencies as deemed necessary in concurrence with the management apart from the above scope of works. This fee is also exclusive of the residential visa charges as per government and client Hospital shall provide individual accommodation facility to Mr.Mahboob ali khan throughout the project period. We propose below a fee payment structure which we would appreciate to meet your concurrence. 1. On Initiation of job 25 % 2. Completion of Documentation 25 % 3. On application of the facility for JCI 15 % 4. On first Mock Survey 15 % 5. On second Mock Survey 10 % 6. On Accreditation 10 %
  18. 18. Total 100 % 11
  19. 19. Time lines for the project: We propose that the project be taken up on the defined time lines of 12 months. A concrete time line would be developed upon completion of gap assessment/initial study, which would provide us greater information of the work to be undertaken. We would appreciate the modulation and finalisation of this in consultation with the management of the Client hospital, keeping in view the deeper understanding of the organisational capabilities by them. The time lines would also be open for review at suitable intervals, to be decided mutually from time to time, depending upon the prevailing or special circumstances. THANK YOU For any queries feel free to contact for healthcare consultancy mahboob804@yahoo.co.in 00918790309122 00914064502081
  20. 20. 12 Mahboob ali khan

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