HOSPITAL ACCREDITATION … A tool for quality improvement
What is Hospital Accreditation? 14-Jun-09 Accreditation of Hospitals
Accreditation is a voluntary process. Its standards are usually regarded as optimal and achievable.
It provides a visible commitment by an organization to improve the quality of patient care, to ensure a safe environment and to continually work to reduce risks to patients and staff.
Accreditation has gained worldwide attention as an effective quality evaluation and management tool.
The focus of accreditation is on continuous improvement in the organizational and clinical performance of health services, not just the achievement of a certificate or award or merely assuring compliance with minimum acceptable standards.
Accreditation focuses on learning, self development, improved performance and reducing risk.
Definition - “A self-assessment and external peer assessment process used by health care organizations to accurately assess their level of performance in relation to established standard and then to implement ways to continuously improve it”. 2
Ensures a Quality Index for Health Consumers. A growing number of hospitals in India are turning to accreditation agencies worldwide to both standardize their protocols and project their international quality of health care delivery.
It is a Public Recognition of the achievement of accreditation standards by a healthcare organization, demonstrated through an independent external peer assessment of that organization's level of performance in relation to the standards.
Attract foreign patients.
The process of accreditation is envisaged to result in a process of fundamental change in the technical procedures of service delivery, in the appropriate use of available technologies, in the integration of relevant knowledge, in the way the resources are used, and in the efforts to ensure social participation.
Quality Assurance helps improve effectiveness, efficiency and in cost containment, and accountability and the need to reduce errors and increase safety in the system.
Driving Factors for Accreditation
Consumer Protection Act
Clinical Establishment Act
Insurance Companies regulation
Empanelment by CGHS, ECHS, Corporate etc.
Community Awareness & Response
Benefits of Accreditation The accreditation process is designed to create a culture of safety and quality within an organization that strives to continually improve patient care processes and results. In doing so, organizations:
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 patients and their families, respect their rights, and involve them in the care process as partners
create a culture that is open to learning from the timely reporting of adverse events and safety concerns
establish collaborative leadership that sets priorities for and continuous leadership for quality and patient safety levels
…contd. 14-Jun-09 5
Benefits of Accreditation
Identify systemic break-downs and close gaps or loopholes
Define key interfaces between processes, departments and staff
Streamline work flow and maximize resource utilization
Proactively prevent problems from occurring
Provide ways to detect and correct errors and problems
Ensure conformance to and effectiveness of documented processes
Focus on patient and provider needs and expectations
Maximize customer satisfaction
Accreditation Authority 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.
Since its inception, NABH has received nearly 87 applications from various hospitals for accreditation, out of which 20 hospitals have been granted accreditation and others are in different stages of processing.
Ref:- www.nabh.org 14-Jun-09 7
NABH Accreditation Hospitals B.M. Birla Heart Research Centre, Kolkata MIMS Hospital (MIMS Ltd.), Calicut Kerala Institute of Medical Science, Thiruvananthapuram Max Super Speciality Hospital, New Delhi Max Devki Devi Heart & Vascular Institute, New Delhi Moolchand Hospital, New Delhi NarayanaHrudayalaya, Bangalore Dr. L. H. Hiranandani Hospital, Mumbai Fortis Hospital, Noida Sagar Apollo Hospital, Bangalore Columbia Asia Medical Centre – Hebbal, Bangalore Ref:- www.nabh.org 14-Jun-09 8
NABH Standards for Hospitals 14-Jun-09 9
NABH Standards for Hospitals 14-Jun-09 10
Service profile of Trinity 14-Jun-09 11
Trinity Methodology 14-Jun-09 12
Why Trinity Consulting Services?
Modest size company working in Management Systems domain for the past 3 years.
Our consultants have decades of cumulative experience in the design and implementations of Management Systems (MS) in various industries (Dairy, Meat, Fish, Agro- Processing, Healthcare, Engineering, etc.);
Established work execution & delivery process.
Speed and agility (response time).
Local language, local culture, local responsibility, but global quality.
Proven capability of working with large corporate organizations.