Pillars of Quality : An Overview of NABH - Dr. A.M Joglekar at Knowledge Series Seminar-Pune


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  • Quality is defined as the power or ability of a product or services, to meet the expectations of the consumers and othersPatients: Get well soon at affordable prices, judge by outcome and costLegal: not only getting licenses, but meeting the compliances. Internal customers: Doctor, nurses and staff, good working condition, appropriate returns. Owners: depending on type of hospital, follow the vision and purposeThird parties: Nabh, Iso, Others: Community members, environment, etc
  • 2nd edition was in practice for 4 yrs – 2008-12, recently upgraded in Nov 2011 to the 3rd edition by obtaining feedback from all stakeholders.
  • Crisis management: after a negative event has happened, fire fighting approach, eg. Wrong medication or effects of blood transfusion, wrong operative procedures, wrong documentation, process bashing instead of person bashing
  • Pillars of Quality : An Overview of NABH - Dr. A.M Joglekar at Knowledge Series Seminar-Pune

    1. 1. Dr. A. M. Joglekar
    2. 2. Quality Quality in Hospitals is all about meeting expectations of:  Patients  Statutory / Legal bodies  Internal Customers  Owners / Trust  Others  Third parties (NABH) NABH has simplified matters by laying down accreditation standards for Hospitals and Healthcare providers
    3. 3. NABH 3rd Edition (Nov. 2011) Accreditation standards for Hospitals and healthcare providers
    4. 4. NABH – 3rd edition 636 (514) Objective Elements 102 (100) Standards 10 Chapters“Patient safety” and “Continuous Quality improvement” have been given emphasis Standards are non-prescriptive Guidance (remarks, interpretations) is integrated Shall/should vs. can/could Intent of each chapter explained
    5. 5. Key issues addressed NABH 3rd edition Regulatory Organization NABHPatient Employee related policies Standardrelated related related related
    6. 6. NABH Multi disciplinary approach at Hosmac  Doctors  MHAs (Administrators)  Bio medical Engineers  Civil Engineers  Architects  Technical experts
    7. 7. References MTP Act  Critical Care guidelines PNDT Act  Clinical Audit guidelines NACO policies on HIV/AIDS  ICMR guidelines for research SOPs by NACO and research related WHO Guidelines  FDA Act CDC guidelines  National list of essential Control of Hospital infection medicines guidelines (CDC)  Code of Medical ethics by MCI NABH guidelines for OTs  Organ Transplantation Act NABL guidelines  BIS Standards AERB for Radiology  Clinical establishment Act
    8. 8. NABH Standards - Recap Patient centered Standards Access, Assessment and Continuity of Care (AAC) Care of patients (COP) Management of Medication (MOM) Patient’s rights and education (PRE) Hospital Infection Control (HIC)
    9. 9. NABH Standards - Recap Organization centered Standards Continuous Quality improvement (CQI) Responsibility of Management (ROM) Facility management and safety (FMS) Human Resource Management (HRM) Information management system (IMS)
    10. 10. Impact of improvement Patient centered AAC 15/14 ; 78/86 UID, Std. reports, DAR, OPD follow up, etc. COP 18/20 ; 105/136 Nursing care std, Blood transfusion, Special groups, etc. MOM 61/73 Rational use of drugs, Audit of prescriptions, patient counseling on prosthesis/devices, etc. PRE 5/7 ; 30/46 Info to patients, consents, complaint redressal, etc. HIC 46/51 IC officer, Hand hygiene, safe inj and inf practices, reprocessing, etc.
    11. 11. Impact of improvement Organization centered CQI 6/8 ; 39/57 Analyzing complains, feedback and incidences, regular audits, review of nursing care, patient safety program, etc. ROM 5/6 ; 25/38 Senior leaders and committee performance, service standards, outsourced services, etc. FMS 9/8 ; 43/54 Disaster management, Alt sources for gases, vacuum and comp. air, etc. HRM 13/10 ; 47/52 Recruitment procedure, manpower planning, etc. IMS 41/43 24 hr access to medical records, records to contain test results
    12. 12. NABH Accreditation ProcessApplication for Accreditation (By Healthcare organizations)Acknowledgement & Scrutiny of the Application (By NABH Secretariat) Feedback to HealthcareSelf assessments by Healthcare organizations (Toolkit provided by NABH) Organizations Pre-Assessment visits (By Assessment Team) And Final Assessment of Hospital (By Assessment Team) Necessary CorrectiveReview of Assessment Report (By NABH Secretariat) Actions Taken Recommendation for Accreditation (By Accreditation Committee) By Healthcare Organizations Approval for Accreditation (By Chairman, NABH)Issue of Accreditation Certificates (By NABH Secretariat)
    13. 13. Surveillance and Re assessment Accreditation to a hospital shall be valid for a period of three years. NABH conducts one surveillance of the accredited hospitals in one accreditation cycle of three years. The surveillance visit will be planned during the 2nd year i.e. after 18 months of accreditation. The hospitals may apply for renewal of accreditation at least six months before the expiry of validity of accreditation for which reassessment shall be conducted. NABH may call for un-announced visit, based on any concern or any serious incident reported upon by an individual or organization or media.
    14. 14. Principles NABH system integrates the following for managing quality at HCOs: Hospital Quality Quality assurance assurance applications programs Quality Programs assurance assessment techniques and trends
    15. 15. Transition Quality NABH Improvement programs Crisis Management (Traditional) Process bashing in lieu of person bashing 
    16. 16. What NABH gives HCOs ?? Patient focused Support from Top Management (by personal examples) Quality is everyone’s business Process or system approach Rationality and logic in decision making Continuous improvement NABH – a journey…
    17. 17. Approach at GMH New hospital v/s Old hospital Quality “system” were focused Defined vision – Quality, affordability, rationality, ethics and focus on emergency care Framing policies in support of the vision Process and procedures defined Forms and formats designed and developed in accordance to above
    18. 18. Approach at GMH Hospital design validated according to BIS standards. Operation theatre according to ASHRAE standards. Biomedical equipments from standard reputed companies complying with quality standards. Support and auxiliary equipments also from firms complying quality standards. All statutory/legal authorizations obtained and complied with. All personnel deployed were appropriately qualified and experienced.
    19. 19. Approach at GMH Prepared policy and process/other manuals Installed processes as per process manuals Regular training to orient personnel Formulated committees (Medical/non medical) Designated medical departmental coordinators Instituted patient feedback and analysis system from Day 1 NABL accreditation for hospital lab obtained prior to NABH
    20. 20. Approach at GMH Senior management attended NABH Assessors course and assessed other HCOs. Conducted several self assessments. Middle management/Doctors/Staff attended various NABH workshops and participated in NABH sponsored projects. (Six Sigma)GMH was NABH accredited in June 2009, followed by a surveillancevisit.Re-accreditation was accorded in June 2012 .
    21. 21. Quality Concepts Quality was conceptualized, defined, implemented, monitored, measured, reinforced and constantly improved. Apex body (Think Tank) was for generating quality ideas, defining benchmarks and quality indicators. Hospital committees and others advised and gave feedback to the Apex body.
    22. 22. Quality Concepts
    23. 23. Approach to Assessment At assessment, non compliances/partial compliances were considered as opportunities to improve rather than a matter of dispute, maximizing benefits to the organization. NABH system is a continuous quality improvement journey
    24. 24. Assessment Experience Doctor interviews Medical Documentation Patient Interviews Hand Wash facility Registration of Staff Credentialing and privileging BMW Storage (bins) Safety (Grab bars) Fatal case analysis Infection Control Police verification Question of affordability ?? Question on Ethicality
    25. 25. Assessment Experience Fire Safety – Fire NOC, Fire alarms, expired extinguishers, Fire training and drills, Fire officer Medical Documentation – Illegible, Date and time, Name, designation of doctors, completeness Calibration of equipments – Balances, centrifuges and Bio Med equipments Testing – water, air, RO water Consents, time out and PA check Marking of Surgical sites Medical Audits Committee meeting and MOM MLC Reporting on discharge Discharge at request (DAR) Signage – Fire, emergency exits, scope of services, clinical protocols, etc. CPR Analysis Others Col. S. K. M. Rao has conducted a detailed scientific study of the deficient areas in Hospitals
    26. 26. Current scenario for NABH in India Accredited Hospitals Applicant Hospitals 138 471Huge improvementopportunity for hospitals
    27. 27. Benefits of Accreditation Patients : High quality of care & safety. Service by credentialed medical staff. Rights of patients are safeguarded. Patient satisfaction is the focused. Hospitals : Systemized approach rather than personalized approach. Process driven rather than person driven. Stimulates constant improvement in the healthcare organization. Demonstrates commitment to quality care. Raises community confidence in the healthcare organization. Opportunity for the healthcare organization to benchmark itself against the best.
    28. 28. Benefits of Accreditation Hospital Staff : Improves staff satisfaction due to continuous learning, good working environment, leadership and ownership of clinical processes. Improves overall development of medical & paramedical staff. Paying & regulatory bodies : Objective system of empanelment for insurance bodies and other third parties. Access to reliable and certified information on facilities, infrastructure and level of care.
    29. 29. NABH NABH encourages us to do, what we should be doing in the first place. Quality is “made to happen” via sincere efforts of a HCO. NABH makes the task easier. Being good is difficult enough, demonstrating goodness (by evidence) requires far more efforts.
    30. 30. NABH – a journey of continuousquality improvement….
    31. 31. THANK YOU