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Accriditation of Healthcare Facilities - Dr J L Meena
1. 3rd International Public Health Management Development Program
20-25 March, 2017
School of Public Health
PGIMER, Chandigarh, India
ACCREDITATION OF
HEALTH CARE FACILITIES.
3rd International Public Health Management Development Program
20-25 March, 2017
School of Public Health
PGIMER, Chandigarh, India
Dr J L Meena
State Quality Assurance Medical Officer
Department of Health & Family Welfare
Government of Gujarat - India
Member of NABH Accreditation Committee, QCI
Member of Quality Expert Group, Govt of India.
Email:- drjlmeena@gmail.com
2. 3rd International Public Health Management Development Program
20-25 March, 2017
School of Public Health
PGIMER, Chandigarh, India
"A self-assessment and external peer
assessment process used by health care
organizations to accurately assess their
level of performance in relation to
established standards and to implement
ways to continuously improve"
What is Accreditation:-
3. 3rd International Public Health Management Development Program
20-25 March, 2017
School of Public Health
PGIMER, Chandigarh, India
Regulation Accreditation
An instrument mandated by the
Government to impose set of
conditions, which a healthcare
organization must comply with,
before and after it is permitted to
operate in the country.
A voluntary process by which an authorized
agency or organization evaluates and
recognizes health services according to a
set of standards describing the structure
and processes that contributes to desirable
patient outcomes.
It is based on minimum standards,
inspection, enforcement and
public accountability.
Compliance to documented Policies and
guidelines. Review by an authorized
external agency.
Regulation is mandatory Accreditation is voluntary. Accreditation is
promoted by way of
incentives and market forces
4. 3rd International Public Health Management Development Program
20-25 March, 2017
School of Public Health
PGIMER, Chandigarh, India
⢠Joint Commission International - JCI
⢠Joint Commission of Taiwan â JCT
⢠Council for Health Service Accreditation of Southern Africa -
COHSASA
⢠Danish Institute for Quality and Accreditation in Health Care -
IKAS
⢠Diagnostic Accreditation Programme, British Columbia
⢠Health and Disability Auditing Australia Pty Ltd - HDAA
⢠Malaysian Society for Quality in Health - MSQH
⢠Quality Improvement Council, Australia - QIC
⢠National Accreditation Board for Hospitals & Health Care
Providers, India - NABH
⢠Designated Auditing Agencies (DAA) Group Limited, New
Zealand
⢠American Association of Blood Banks (AABB), USA
⢠Netherlands Institute for Accreditation in Healthcare - NIAZ
⢠Instituto Colombiano De Normas Tecnicas Y Certification
(ICONTEC) Health Accreditation Service, Columbia
ď° California Health Kids Survey - CHKS Accreditation Unit,
UK
ď° Canadian Accreditation Council of Human Services -
CAC
ď° Global-Mark Pty Ltd, Australia
ď° Health and Disability Auditing New Zealand - HDANZ
ď° Australian Aged Care Quality Agency - AACQA
ď° The Healthcare Accreditation Institute (Public
Organization), Thailand - HAI
ď° Australian General Practice Accreditation Ltd / Quality
in Practice Pty Ltd â AGPAL/QIP
ď° Japan Council for Quality Health Care - JCQHC
ď° The Australian Council on Health Care Standards - ACHS
ď° Health Care Accreditation Council, Jordan - HCAC
ď° DNV GL Business Assurance, Norway
ď° Associacao Brasileira de Acreditacao De Sistemas e
Servicos de Saude, Brazil â CBA
ď° Haute AutoritĂŠ de SantĂŠ â DAQSS, France
ď° Accreditation Canada International (ACI) Canada
Accredited Organisations
5. 3rd International Public Health Management Development Program
20-25 March, 2017
School of Public Health
PGIMER, Chandigarh, India
What is common?
6. 3rd International Public Health Management Development Program
20-25 March, 2017
School of Public Health
PGIMER, Chandigarh, India
â˘Patient safety and
â˘quality of care âŚâŚâŚ..
7. 3rd International Public Health Management Development Program
20-25 March, 2017
School of Public Health
PGIMER, Chandigarh, India
International Society for Quality in Health Care (ISQua )
is an international body which grants approval to
Accreditation Bodies in the area of healthcare as mark of
equivalence of accreditation program of member
countries.
So far hospital standards of only 12 countries viz.
Australia , Canada , Egypt , Hong Kong , Ireland , Japan ,
Jordan , Kyrgyz Republic , South Africa , Taiwan , United
Kingdom & India were accredited by ISQua.
8. 3rd International Public Health Management Development Program
20-25 March, 2017
School of Public Health
PGIMER, Chandigarh, India
⢠Critical path issued
⢠Technical review
⢠Final Submission of Self Assessment
⢠Surveyor Assessment (survey)
⢠Factual Review
⢠Report Validated by Panel
⢠Accreditation Decision
⢠Award Pack to Organisation
⢠Continuous Assessment â 12 and 30 months post survey
International Accreditation Programme by ISQua - 4 year cycle
9. 3rd International Public Health Management Development Program
20-25 March, 2017
School of Public Health
PGIMER, Chandigarh, India
ď The Joint Commission (TJC) : Body for
accreditation of HCOs across USA which forms the
basis for licensure and Medicaid reimbursement
ď Joint commission International: For International
Accreditation, publication and education
International Scenario on Accreditation
in Healthcare services - USA
10. 3rd International Public Health Management Development Program
20-25 March, 2017
School of Public Health
PGIMER, Chandigarh, India
JCI is the recognized leader in international health care accreditation.
JCI maintain ISQua membership in the following categories:-
ď Accreditation survey
ď Surveyor education program
ď Ambulatory Care Standards
ď Clinical Laboratory Standards
ď Care Continuum Standards
ď Hospital Standards
ď Primary Care Standards
ď Clinical Care Program Certification Standards
ď Home Care Standards
ď Long Term Care Standards
11. 3rd International Public Health Management Development Program
20-25 March, 2017
School of Public Health
PGIMER, Chandigarh, India
800+ Accredited
Organizations.
100+ Countries
Served by JCI.
12. 3rd International Public Health Management Development Program
20-25 March, 2017
School of Public Health
PGIMER, Chandigarh, India
⢠360 Standards
⢠1240 Measurable Elements
Section I : Patient Centered Standards
Section II : Health Care Organization
Management Standards
Joint Commission International Accreditation
Standards for Hospitals
13. 3rd International Public Health Management Development Program
20-25 March, 2017
School of Public Health
PGIMER, Chandigarh, India
Each applicable measurable elements is scored
Met (10)
Partially Met (5)
Not Met (0)
14. 3rd International Public Health Management Development Program
20-25 March, 2017
School of Public Health
PGIMER, Chandigarh, India
International Scenario on Accreditation
in Healthcare services - AUSTRALIA
The Australian Council of Healthcare
Standards
ď (ACHS): Pioneer in accreditation of HCOs
in Australia
ď ACHSI : for overseas accreditation
15. 3rd International Public Health Management Development Program
20-25 March, 2017
School of Public Health
PGIMER, Chandigarh, India
The Australian Council of Healthcare
Standards (ACHS) International delivers
education / consultancy services as well as
quality improvement and accreditation
programs throughout New Zealand, Hong
Kong, India, Saudi Arabia, Sri Lanka, Bahrain,
the United Arab Emirates and Malaysia etc.
16. 3rd International Public Health Management Development Program
20-25 March, 2017
School of Public Health
PGIMER, Chandigarh, India
A proven pathway to accreditation
10 steps that hospitals and academic medical centers typically follow toward accreditation
success. (Average duration 18-24 months).
1. Become familiar with Accreditation Standards and Survey Process (2-3 Months)
2. Conduct Gap Analysis and Build Action Plan. (2-3 Months)
3. Update Policies and Procedure. (2 Months)
4. Target Improvement where Needed. (2-3 Months)
5. Work with Staff to overcome obstacles. (2-3 Months)
6. Assess your readiness at midpoint. (2-3 Months)
7. Continues Training for Sustainable Change. (2-3 Months)
8. Evaluate and Refine Process. (2-3 Months)
9. Use a Mock Survey to assess your readiness. (2-3 Months)
10. Make Final Modification (Process for 3rd Party Assessment by Accreditation organization
e.g.-JCI or NABH etc, Fulfill gaps, review in board and Accreditation). (6-7 Months)
17. 3rd International Public Health Management Development Program
20-25 March, 2017
School of Public Health
PGIMER, Chandigarh, India
Accreditation Agencies in India:-
Quality Council of India (QCI):-
ďź ďNational Accreditation Board for Hospital
and Health care Providers (NABH)
ďź ďNational Accreditation Board for Testing
and Calibration of Laboratories (NABL)
18. 3rd International Public Health Management Development Program
20-25 March, 2017
School of Public Health
PGIMER, Chandigarh, India
Certification and Grading Agencies in
India:-
ďISO 9001 â 2008 as amended by recently
issued ISO 9001 â 2015 standards
ďNational Quality Assurance Certification
ďIndian Public Health Standards 2012
19. 3rd International Public Health Management Development Program
20-25 March, 2017
School of Public Health
PGIMER, Chandigarh, India
Quality Council of India:-
QCI is an autonomous body set up
by Govt. of India to establish and
operate accreditation structure in
the country.
20. 3rd International Public Health Management Development Program
20-25 March, 2017
School of Public Health
PGIMER, Chandigarh, India
21. 3rd International Public Health Management Development Program
20-25 March, 2017
School of Public Health
PGIMER, Chandigarh, India
22. 3rd International Public Health Management Development Program
20-25 March, 2017
School of Public Health
PGIMER, Chandigarh, India
⢠NABH is an institutional member of the International
Society for Quality in Health Care (ISQua)
⢠NABH is also a member of ISQua Accreditation
Council
⢠NABH is founder Member of Asian Society for Quality
in Health care (ASQua)
⢠NABH is also represented on WHO International
Patient Safety Committee.
NABH Global Recognition
23. 3rd International Public Health Management Development Program
20-25 March, 2017
School of Public Health
PGIMER, Chandigarh, India
â˘Creation of NABHI was approved by Board in
July 2010
â˘Started work in Philippines
â˘Qatar
â˘Nepal
â˘Bangladesh
NABH International
24. 3rd International Public Health Management Development Program
20-25 March, 2017
School of Public Health
PGIMER, Chandigarh, India
â˘Autonomous Body under the aegis of Dept of Science
and Technology, GoI but now itâs under QCI
â˘Sole Accreditation Body for Testing and Calibration Labs
⢠Accessible to all Labs irrespective to their Status
â˘Maintains International linkages
⢠International Lab Accreditation Cooperation
⢠Asia Pacific Lab Accreditation Cooperation
National Accreditation Board for Testing and
calibration Laboratories
25. 3rd International Public Health Management Development Program
20-25 March, 2017
School of Public Health
PGIMER, Chandigarh, India
Chapters : 10
Standards : 105 (102)
Objective Elements : 683 (636)
NABH Standards for the Hospitals:
4th Edition
26. 3rd International Public Health Management Development Program
20-25 March, 2017
School of Public Health
PGIMER, Chandigarh, India
27. 3rd International Public Health Management Development Program
20-25 March, 2017
School of Public Health
PGIMER, Chandigarh, India
28. 3rd International Public Health Management Development Program
20-25 March, 2017
School of Public Health
PGIMER, Chandigarh, India
⢠Assessment is based on the scoring on a scale of 0, 5 and 10
as per the following details:
â Compliance to the requirement:10
â Partial compliance to the requirement: 5 (if any of the
sample is found to be non complying out of total samples
selected)
â Non-compliance to the requirement:0
⢠Not Applicable: NA
Scoring Pattern
29. 3rd International Public Health Management Development Program
20-25 March, 2017
School of Public Health
PGIMER, Chandigarh, India
Outcome
⢠Pre-accreditation entry level
⢠Pre-accreditation progressive level
⢠Accredited
30. 3rd International Public Health Management Development Program
20-25 March, 2017
School of Public Health
PGIMER, Chandigarh, India
Pre-accreditation entry level
⢠Conditions for qualifying to this award are:
â All the regulatory legal requirements should be fully met.
â No individual standard should have more than two zeros.
â The average score for individual standard must not be less than 5.
â The average score for individual chapter must be more than 5.
â The overall average score for all standards must exceed 5.
⢠The validity period for pre-accreditation entry level stage is
from a minimum 6 months to a maximum of 18 months.
31. 3rd International Public Health Management Development Program
20-25 March, 2017
School of Public Health
PGIMER, Chandigarh, India
Pre-accreditation progressive level
⢠Conditions for qualifying to this award are:
â All the regulatory legal requirements should be fully met.
â No individual standard should have more than two zeros.
â The average score for individual standard must not be less than 5.
â The average score for individual chapter must be more than 6.
â The overall average score for all standards must exceed 6.
⢠The validity period for pre-accreditation entry level stage is from a
minimum 3 months to a maximum of 12 months.
32. 3rd International Public Health Management Development Program
20-25 March, 2017
School of Public Health
PGIMER, Chandigarh, India
Accredited
⢠Conditions for qualifying to this award are:
â All the regulatory legal requirements should be fully met.
â No individual standard should have more than one zero to qualify.
â The average score for individual standard must not be less than 5.
â The average score for individual chapter must be more than 7.
â The overall average score for all standards must exceed 7.
⢠The validity period for accreditation is 3 years subject to terms
and conditions.
33. 3rd International Public Health Management Development Program
20-25 March, 2017
School of Public Health
PGIMER, Chandigarh, India
34. 3rd International Public Health Management Development Program
20-25 March, 2017
School of Public Health
PGIMER, Chandigarh, India
Feedback
To
Health care
Organization
And
Necessary
Corrective
Action
Taken
By
Health care
Organization
35. 3rd International Public Health Management Development Program
20-25 March, 2017
School of Public Health
PGIMER, Chandigarh, India
Feedback
To
Laboratory
And
Necessary
Corrective
Action
Taken
By
Laboratory
36. 3rd International Public Health Management Development Program
20-25 March, 2017
School of Public Health
PGIMER, Chandigarh, India
37. 3rd International Public Health Management Development Program
20-25 March, 2017
School of Public Health
PGIMER, Chandigarh, India
38. 3rd International Public Health Management Development Program
20-25 March, 2017
School of Public Health
PGIMER, Chandigarh, India
39. 3rd International Public Health Management Development Program
20-25 March, 2017
School of Public Health
PGIMER, Chandigarh, India
40. 3rd International Public Health Management Development Program
20-25 March, 2017
School of Public Health
PGIMER, Chandigarh, India
41. 3rd International Public Health Management Development Program
20-25 March, 2017
School of Public Health
PGIMER, Chandigarh, India
ďHigh quality of care
ďDedicated and sincere medical staff
ďAccess to a quality focused organization
ďRights respected and protected
ďPatient Satisfaction evaluated
ďInvolvement in care process
ďPatient safety
ďPain management
ďSafe transport
ďContinuity of care
Benefits of Accreditation for Patient
42. 3rd International Public Health Management Development Program
20-25 March, 2017
School of Public Health
PGIMER, Chandigarh, India
43. 3rd International Public Health Management Development Program
20-25 March, 2017
School of Public Health
PGIMER, Chandigarh, India
ďProfessional staff development
ďProvides education on laid down standards
ďProvides leadership for quality improvement
within medicine and nursing
ďIncreases satisfaction with continuous learning,
good working environment, leadership and
ownership
Benefits of Accreditation to Staff
44. 3rd International Public Health Management Development Program
20-25 March, 2017
School of Public Health
PGIMER, Chandigarh, India
45. 3rd International Public Health Management Development Program
20-25 March, 2017
School of Public Health
PGIMER, Chandigarh, India
ďImproves care
ďBrings in Corporate Governance
ďStimulates continuous improvement
ďDemonstrates commitment to quality care
ďRaises community confidence
ďOpportunity to benchmark with the best
Benefits of Accreditation to Hospital
46. 3rd International Public Health Management Development Program
20-25 March, 2017
School of Public Health
PGIMER, Chandigarh, India
47. 3rd International Public Health Management Development Program
20-25 March, 2017
School of Public Health
PGIMER, Chandigarh, India
48. 3rd International Public Health Management Development Program
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PGIMER, Chandigarh, India
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20-25 March, 2017
School of Public Health
PGIMER, Chandigarh, India
50. 3rd International Public Health Management Development Program
20-25 March, 2017
School of Public Health
PGIMER, Chandigarh, India
ďQuality revolution
ďDisaster preparedness
- Epidemics
- Physical
ďAccess to comparative database
Benefits of Accreditation for Community
51. 3rd International Public Health Management Development Program
20-25 March, 2017
School of Public Health
PGIMER, Chandigarh, India
52. 3rd International Public Health Management Development Program
20-25 March, 2017
School of Public Health
PGIMER, Chandigarh, India
ď Efficiency of Government hospitals as key contributors for
building trust and confidence for the hospitals in the hearts of
the citizens of the State through actively pursuing quality
improvement programme in various facilities.
ď Given a sense of pride to the government for ensuring quality
services to the poorest of the poor.
ď Confidence has been restored of the community in Govt
hospitals
Benefits of Accreditation to the
Government
53. 3rd International Public Health Management Development Program
20-25 March, 2017
School of Public Health
PGIMER, Chandigarh, India
â˘Appreciation awarded by QCI to Ministry of Health and Family Welfare Government of Gujarat for establishing Quality
Assurance framework in providing quality healthcare to the people of Gujarat in 5th National Quality Conclave, New Delhi.
â˘Appreciation awarded to Department of Health and Family Welfare Government of Gujarat for their pioneering effort to
spearhead the Quality and Accreditation Programme in health care organization. In 3rd International Health Care Quality
Conclave on âRole of Quality in Globalization of Indian Healthcareâ. Place: - Gurgaon, Haryana Date: 30thAugust 2010.
â˘FICCI Health care Excellence Award to Dist Hospital Gandhinagar & PHC Gadboriad, Govt of Gujarat in FICCI Heal 2010, New
Delhi Date: 6th Sept 2010
â˘FICCI Health care Excellence Award to Dist Hospital Gandhinagar, Govt of Gujarat in FICCI Heal 2011, New Delhi Date: 8th Sept
2011
â˘FICCI Health care Excellence Award to Community Health Centre Bardoli, Govt of Gujarat in FICCI Heal 2013, New Delhi Date:
2nd Sept 2013
â˘Operational excellence award in IndiZen 2014 to Govt. of Gujarat-department of health and family welfare was achieved.
â˘FICCI Health care Excellence Award to Community Health Centre Bardoli, Govt of Gujarat in FICCI Heal
2014, New Delhi
Date: 1st Sept 2014
â˘FICCI Health care Excellence Award to Paraplegia Hospital- Ahmedabad, Govt of Gujarat in FICCI Heal
2014 New Delhi
Date: 1st Sept 2014
â˘FICCI Healthcare Excellence Award to Laboratory Information System, B J Medical College â Ahmedabad,
Govt of
Gujarat in FICCI Heal 2016 New Delhi Date: 31st August 2016.
54. 3rd International Public Health Management Development Program
20-25 March, 2017
School of Public Health
PGIMER, Chandigarh, India
Web:-
1. https://gujhealth.gujarat.gov.in/quality-assurance-
program.htm
2. http://www.facebook.com/drjitulal?ref=tn_tnmn
3. https://www.youtube.com/user/drjlmeena
Email:-
drjlmeena@gmail.com, sqipgujarat@gmail.com
Mobile No:- 09099075162
55. 3rd International Public Health Management Development Program
20-25 March, 2017
School of Public Health
PGIMER, Chandigarh, India
ThanksThanks
2nd International Public Health Management Development Program
20-25 March, 2017
School of Public Health
PGIMER, Chandigarh, India