13 vikram kashyap-quality-management-systems_ncas_2011

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13 vikram kashyap-quality-management-systems_ncas_2011

  1. 1. Ambulatory Surgical Centres Quality Management Systems Accreditation to NABH SHCO Standards
  2. 2. Managing Quality• START a Quality Dept.: Team, Resources, Authority, Competence, Internal Audits •Structure •Process •Outcome
  3. 3. COMPLIANCE• Legal, statutory, regulatory requirements• Patients requirements: stated and implied• Employees requirements, especially safety• Hospitals own policies and procedures• Start preparing for N A B H Accreditation
  4. 4. NABH organisation Quality Council of India National Accreditation Board for Hospital & Health Care Providers Appeals CommitteeAccreditation Technical Committee Panel of Committee Assessors Secretariat
  5. 5. N A B H Accreditation Programmes• Hospitals : 51 + beds• Small Health Care Organisations• Ayurveda, Yoga, Unani, Siddha, Homoepathy• Wellness• Imaging• Blood Banking• Clinical Laboratories
  6. 6. S H C O Standards• Small Health Care Organisations• 20 – 50 beds, & Day care and ambulatory surgical centres• 10 chapters, 258 requirements• Exclusions clamed must be justified• Apex Quality Manual, Documented Policies, Standard Operating Procedures, System of maintaining patient records
  7. 7. Patient Centred• Access, Assessment & Continuity of Care• Care of Patients• Management of Medication• Patients’ Rights & Responsibilities• Hospital infection Control
  8. 8. Organisation Centred• Continuous Quality Improvement• Responsibilities of Management• Facilities Management and Safety• Human Resources Management• Information Management System
  9. 9. Top Management• Identify and follow all applicable laws• Establish & support the Quality Dept• Identify & monitor key indicators of volume, quality and performance• Standard billing practices• Conduct mock drills: Fire, CPR, disaster• Conduct internal quality audits
  10. 10. Take Home Messages• Quality Management Team > integral to the practice of medicine and surgery today• Compliances: Legal, Patient requirements, Employee related, Hospital policies• Management: Material, Medicines, Methods, Manpower (their motivation), Machines, Milieu, MONEY !• Visit the website: www.nabh.co
  11. 11. Patient satisfactionis the best accreditation Thank you very much

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