JCI, NABH

1. Accreditation of Health care
organization
Dr. Harpreet Kaur
PG student
Community Medicine
Guru Gobind Singh Medical College, Faridkot

2. Learning Objective
• To know the basic structure of accreditation of health care
organization

3. Lesson Plan
• Definition of accreditation
• Components of accreditation
• Purpose of accreditation
• Accreditation procedure
• Advantages of accreditation
• Different types of accreditation

4. Definition
• Accreditation may be defined as a formal process by which a
recognized body, usually a non-governmental organization (NGO),
assesses and recognizes that a healthcare organization meets pre-
determined standards.
• It can also be defined as a system of external peer review of an
organization for determining compliance against predetermined
standards.

5. • Accreditation standards are usually regarded as optimal and
achievable and are designed to encourage continuous improvement
in delivery of healthcare within accredited organizations.
• An accreditation decision about a specific healthcare organization is
made following a periodic on-site evaluation by a team of peer
reviewers, typically conducted every two to three years.
• It is usually a voluntary process in which organizations choose to
participate, rather than one required by law and regulation.

6. Components of accreditation
a) It is based on written and published standards.
b) Reviews are conducted by professional peers.
c) The accreditation process is administered by an independent body.
d) The aim of accreditation is to encourage organizational
development.

7. Purpose of Accreditation
a) Improve the quality of healthcare by establishing optimal
achievement goals in meeting standards for healthcare
organizations.
b) Stimulate and improve the integration and management of health
services.
c) Establish a comparative database of healthcare organizations able
to meet selected structure, process and outcome standards or
criteria.
d) Reduce healthcare costs by focusing on increased efficiency and
effectiveness of services.

8. e) Provide education and consultation to healthcare organizations,
managers and health professionals on quality improvement
strategies and “best practices” in healthcare.
f) Strengthen the public’s confidence in the quality of healthcare and
reduce risks associated with injury and infections for patients and
staff.
g) Accountability to professional bodies.

9. Accreditation Procedure
• There are many recognized bodies providing Accreditation to
Healthcare Institutions.
• These have diverse policies and procedures.
• However, the common elements in a typical Accreditation procedure
are:

10. Resurvey after a fixed period
Accreditation report and award of Accreditation
Resurvey, if the Institution is found deficient in certain areas of delivery of care
Survey by the multidisciplinary team of Accreditation Body
Pre-survey activities
Payment of fees
a)Application for registration by the healthcare institution
a)Setting and publication of standards and elements of performance by a recognized body

11. Health care accrediting bodies use a variety of evaluation approaches
during the on-site survey in order to determine the healthcare
organization’s performance with predetermined standards.

12. These methods include any combination of the following:
a) Interviews of the top level Administrators or the Managers of the
organization
b) Clinical and support staff interviews.
c) Patient and family interviews.
d) Observation of patient care and services provided.
e) Tour of the building facilities, observation of patient care areas,
equipment management and diagnostic testing services.
f) Review of written documents such as policies and procedures, training
documents, financial documents and quality assurance plans.
g) Evaluation of the organization’s achievement of specific outcome
measures (e.g. Immunization rates, hospital acquired infection rates,
patient satisfaction).
h) Evaluation of patients’ medical records.

13. Advantages of Accreditation
Benefits to the Hospital
a) It Improves delivery of medical care and enhances the image of the
hospital. Thus, for private healthcare organizations it also results in
more business.
b) It stimulates a process of continuous improvement in delivery of
medical care.
c) Demonstrates commitment to quality care.
d) Raises community confidence.
e) Opportunity to benchmark with the best.

14. Advantages of Accreditation
Benefits for the employees
a) It helps in education, training and development of professional
staff.
b) Provides leadership for quality improvement within medical
profession and nursing.
c) Increases satisfaction of employees with working conditions and
leadership.
d) It aims for improved employee safety and security.
e) It promotes team work.

15. Advantages of Accreditation
Benefits for Patients
a) Provides access to organizations providing quality medical care.
b) Patient’s rights are respected and protected.
c) It increases patient’s Involvement in medical care decisions.
d) Focuses on patient safety.

16. Accreditation System in USA
There are a number of organizations in US performing the function of
accreditation of healthcare institutions:
1. The Joint Commission on Accreditation of Healthcare Organizations
(JCAHO).
2. The National Committee for Quality Assurance (NCQA).
3. The American Medical Accreditation Program (AMAP).
4. The American Accreditation Health Care Commission / Utilization
Review Accreditation Commission (AAHC/ URAC).
5. Accreditation Association for Ambulatory Health Care (AAAHC).

17. JCAHO/JCI
• JCAHO is the largest and oldest accrediting body of USA.
• It is now more usually known as The Joint Commission.
• It is an independent, non government and not-for-profit organization.
• It has provided accreditation to more than 20,000 healthcare
organizations both in US and outside.

18. The constitution of the JCI board includes :
(a) Administrators, Physicians, Medical directors and Nurses
(b) Consumers
(c) Providers of care
(d) Employers, Human Resource and quality expert
(e) Health Insurance expert and expert in Ethics
(f) Corporate and Public Members.

19. • In 1997, Joint Commission initiated first step in establishing a link
between accreditation and the outcomes of patient care, treatment
and service issues.
• During on site survey, the Joint Commission team assesses
performance improvement in conditions related to selected core
measures with the help of data from the hospital.
• The JCI expects home health agencies to establish their own
performance measures, which gives these organizations the freedom
to develop their own quality assurance programs and outcome
measures.

20. Accreditation system in INDIA
Quality Council of India (QCI)
• QCI is an autonomous body set up jointly by Government of India and
Industry to establish and operate accreditation structure in the
country.
• It offers services like certification, inspection, testing, calibration and
registration.
• Initially it started with product certification and inspection under ISO
9001 series.

21. • Objectives of QCI include:
• Establish & operate accreditation structure in the country.
• Provide right & unbiased information on quality & related standards.
• Spread quality movement in India.
• Represent India’s interest in international platform.
• Help establish brand equity of Indian products.
• QCI developed standards for accreditation of laboratories and the
Hospital as different boards-
• National Accreditation Board for Testing and Calibration Laboratories (NABL)
• National Accreditation Board for Hospitals and Healthcare providers (NABH)

22. National Accreditation Board for Testing
and Calibration Laboratories (NABL)
• NABL is an autonomous body under the aegis of Department of
Science & Technology, Government of India and is registered under
the Societies Act.
• Government of India has authorized NABL as the sole accreditation
body for Testing and Calibration laboratories.

23. • NABL provides laboratory accreditation services to laboratories that
are performing tests / calibrations.
• These services are offered in a non-discriminatory manner and are
accessible to all testing and calibration laboratories in India and
abroad, regardless of their ownership, legal status, size and degree of
independence.
• The accreditation granted to a laboratory is valid for a period of 3
years subject to satisfactory annual surveillance.

24. National Accreditation Board for Hospitals
and Healthcare providers (NABH)
• NABH is a constituent board of QCI set up with cooperation of the
Ministry of Health and Family Welfare, Government of India and the
health Industry.
• The board while being supported by all stakeholders including
industry, consumers, government, but board have full autonomy in its
operation.
• The Technical Committee of NABH had formulated first edition of
standards for hospitals in 2005 which have been revised and in
November 2007 second edition of standards have been published.

25. • Vision of NABH
To be the apex national healthcare accreditation and quality
improvement body, functioning at par with global benchmarks.
• Mission of NABH
To operate accreditation and allied programs in collaboration with
stakeholders focusing on patient safety and quality of healthcare
based upon national/international standards, through process of
self and external evaluation.

26. • Values of NABH
Credibility:
Provide credible and value addition services
Responsiveness:
Willingness to listen and continuously improving service
Transparency:
Openness in communication and freedom of information to its
stakeholders
Innovation:
Incorporating change, creativity, continuous learning and new
ideas to improve the services being provided

27. • NABH is a member of International Society for Quality in healthcare
(ISQua).
• ISQua is an international body which grants approval to Accreditation
bodies in the area of healthcare as mark of equivalence of
accreditation programme member countries.
• So far hospital standards of 11 countries viz. Australia, Canada, Egypt,
Hong Kong, Ireland, Japan, Jordan, Kyrgyz Republic, South Africa,
Taiwan, United Kingdom.
• India becomes the 12th country to join in this group.
• The hospitals accredited by NABH will have international recognition.

28. Standards of NABH
• There are 10 chapters in NABH document including 100 standards.
• The standards can be classified as :
(a) Patient Centered standards : These include :
(i) Access, Assessment and Continuity of Care (AAC)
(ii) Care of patients (COP)
(iii) Management of medication (MOM)
(iv) Patient Rights and Education (PRE)
(v) Hospital Infection Control (HIC)

29. (b) Organization Centered Standards : These include :
(i) Continuous Quality Improvement (CQI)
(ii) Responsibilities of Management (ROM)
(iii) Facility Management and Safety (FMS)
(iv) Human Resource Management (HRM)
(v) Information management System (IMS)
• Each standard is further divided into variable number of objective
elements.
• Objective elements frame the guidelines for achieving a particular
standard.

30. SUMMARY
Accreditation can be regarded as one of the most attractive form of
tool for External Quality Assessment of healthcare organizations. Joint
Commission Resources now provides consultation by Joint Commission
worldwide on healthcare issues and Joint Commission International is
the largest Accreditation body, concerned with global accreditation.
One of the chief purposes of Accreditation is to Improve the quality of
healthcare by establishing optimal achievement goals in meeting
standards for healthcare organizations. Health care accrediting bodies
use a variety of evaluation approaches during the on-site survey in
order to determine the healthcare organization’s performance with
predetermined standards.

31. References
• Bhalwar R, Health Policy & Health Care Systems, Textbook of Public
Health and Community Medicine, 1st ed. Department of community
medicine, AFMC, Pune in collaboration with WHO, India office, New
delhi; 2009. p.420-26.
• Kishore J, Health care delivery system in India, J. Kishore’s National
Health Programs of India, 12th ed. Century Publications; 2017.p.108-
09.

32. THANK YOU