1) Emergency departments in India are adopting quality accreditation standards to improve patient care, safety, and reduce mortality and morbidity. 2) In 2016, the National Accreditation Board for Hospitals (NABH) announced exclusive emergency room accreditation standards consisting of 256 standards across 8 chapters. 3) Aster DM Healthcare institutions have achieved NABH emergency room accreditation by establishing a roadmap that included forming task forces, implementing standards, conducting mock audits, and facilitating a final audit by NABH assessors.

1. Quality accreditation in
Emergency departments:
Sharing the experiences
Dr.Venugopalan P P
DA,DNB,MNAMS,MEM-GW
Director : Emergency Medicine
Aster DM healthcare

2. Need of
accreditation
EM is a new concept in India
EM is the real front office of a hospital
ER is the place where chances of error are more
Accreditations bring standards in care
Bring down ED related mortality and morbidity
Bring transparency in healthcare
helpful in medico legal perspectives

5. QA assurance in Ed
New concept in India
NABH announced exclusive ER
accreditation 2016
256 standards , 8 chapters
Comprehensive ,
Scope for upgradation or modification

8. EM accredited
Aster DM
healthcare
institutions

9. Road map to NABH
ER accreditation
Joint work with ED team and QA
department team
Consider Quality is the property of
concerned department
QA team may facilitate in the travel path
Motivation and passion is the
cornerstone in the success

10. Road map to NABH
ER accreditation
Download brochure
Download document
Apply for Accreditation
Remit fee as advised by NABH

12. Road map to NABH
ER accreditation
Start working up in reverse ladder
Find a tentative date for inspection
Fix various steps in the ladder
Form a task force

15. Road map to NABH
ER accreditation
Arrange awareness programs
Arrange motivation programs
Implement standards one by one
Do mock audits

16. Mock audits
Intra departmental -
Team comprises members
from department
Institutional Quality
Team
Team from out side
institution

17. Department audit
team
Emergency consultant
Head nurse / supervisor
Clinical pharmacist
Medical records in charge
Assigned staff from department

18. Institutional Audit
team
Quality Manager
Senior Doctor/ Nurse in charge of
quality affairs
Clinical pharmacist
MRD representative

19. External audit
team
An NABH auditor from other
institute
Quality Nurse
Clinical pharmacist

20. Mock audit
Prepare audit report after each audit
Identify and Document deficits
Discuss it in department core
committee
Correct each deficits in a specified
time frame and document it

23. Core areas
Medical records
Quality parameters
Pre- hospital care
Triage
Code blue

24. Core areas
Medico legal cases
Drug storage , dispensing ,
High risk medicine
Death and end of life care
Mortality and Morbidity audit
Communication, staff
empowerment

25. Core areas
Privileges and HR documentation
Trainings
Cost , Care of Unknowns
Transport to other centres , Hand
over
Multi disciplinary committee
meetings
Displays in the departments

26. Awareness
From Ambulance driver to
Security staff to Nursing
assistant to house keeping
staff, receptionist, Nurses ,
Residents ,doctors ,
consultant to HOD ,
director , Head of
institution

28. Final Audit
Team from NABH
Principal assessor
Supportive Assessor
Number of Assessors are depending
on the best strength

29. Facilitate final
Audit
Arrange a separate team comprises
quality staff, assigned staff from
department
Get ready and kept organised all
essential documents to support the
audit

30. Facilitate final
Audit
Opening meeting
Board room with internet , computer , printer
Method of audit based on prescribed audit
form
Team will physically verify the standard
Team will do essential interviews with staff
members

31. Facilitate final
Audit
Closing meeting
Feedbacks
Compliance
Non Compliance
Observations
Score

32. Facilitate final
Audit
Report in NABH
Corrections
Clarifications
Certification
Accreditation

34. Summary

38. “Quality is never an accident.It is
always the results of intelligent
effort ”
John Ruksin
drvengopalpp@gmail.com