1. P. K. Roy
Chairman,
Lions Seva Eye Hospital

2. Importance of Accreditation for
Lions Eye Hospitals
•
Lions Eye Hospitals mostly engaged in Free
cataract Surgery
• Economy of the hospitals dependent on Cataract
Surgery re-imbursement grant by LCIF or DBCS
• LCIF stopped financing against cataract surgery
and DBCS funding is uncertain
• Economy of the Lions Eye Hospitals are at stake.

3. Threats
 A good number of Private hospitals
have started operation recently posing
threats to Lions Eye Hospitals
 Technical Infrastructure of the Pvt.
Hospitals are better than Lions Eye
Hospitals.
 Pvt. Hospitals have provided better
service.

4. Threats
 Priority of these Pvt. hospitals are
patient satisfaction.
 Professional
approach
and
corporate style of functioning
develop patient confidence.
 But the cost of service of Pvt.
Hospitals are much higher than
Lions Eye Hospitals

5. Steps necessary for Lions Eye Hospitals
 Lions Eye Hospitals has to find out
avenues
to
overcome
these
imminent threats.
 Measures need to be taken:
i) Improve technical infrastructure for
attracting patients
ii) Improve quality of service to
develop confidence of the patient

6. Steps necessary for Lions Eye Hospitals
iii. Attract
patients(other than free)
who are agree to pay the cost of
service.
iv. Utilize the low overhead cost and
comparatively cheap price of service
in Lions Hospitals.
v. To compete with Pvt. Hospitals and
for sustainable growth Lions Eye
Hospitals has to go for Accreditation

7. What is Accreditation
Accreditation means Certification of competence in a
specified subject or areas of expertise by external
agencies.
Accreditation is an external review of quality .There are
four principal component
 It is based on written and published standards
 Reviews are conducted by professional peers
 The accreditation process is administered by an
independent body
 The aim of accreditation is to encourage
organizational development.

8. Focus of standards
 Patient Safety
 Staff and employee safety
 Environment and community safety
 Information Education and Communication

9. Patient Centered Standards
Section I
 Access, Assessment and Continuity of Care
 Patients Rights and Education
 Care of Patients
 Management of Medications
 Hospital Infection Control

10. Health Care Organization
Management Standard, Section - II
 Continuous Quality Improvement (CQI)
 Responsibilities of Management (ROM)
 Facility Management & Safety (FMS)
 Human Resource Management (HRM)
 Information Management Systems (IMS)

11. Accreditation - Procedure
 First step
: Self-evaluation by unit seeking
accreditation
 Second step : External evaluation / on-site
visit by independent experts
 Third step
: Decision, based on assessment
of predetermined quality
standards

12. WHO CAN APPLY
Any Health Care Organization
Requirements
 Currently in operation as a HCO
 Preferably registered or licensed
 Willing to assume responsibility for improving
quality of care
 Should be able to meet the prescribed standards
of the accrediting organization

13. HOW CAN ONE APPLY
Basic Ingredients
 Organizations apply on prescribed format giving
details as required
 Submission of a self assessment form indicating
the outcomes of its own survey and Internal
Audits
 Extent of adherence to the laid down standards

14. WHERE TO APPLY
Several quality accreditation agencies are available.
 These are :
i.
Joint Commission International (JCI) is an
International body working for maintaining standard
in the HCO),
ii. National Accreditation Board for Hospitals (NABH), a constituent board of Quality Council of India
iii. ISO 9001-2000- is an international quality
management system
iv. Malcolm Baldridge, - Baldrige Program is dedicated
to performance excellence.
The most common one being ISO and NABH.

15. DOCUMENT REVIEW
• Quality Manual
• Various Policies and Procedures
• Minutes of Meetings of various committees
• Medical Records
• Medical / Nursing Audit
• Adverse Events
• Action Taken Reports
• Personal Records of Staff

16. Accreditation Process
 Applications
 Screening of the Applications
 Pre-assessment survey
 Assessment Survey
 Review of the recommendations of the assessing
body by the Accreditation Committee
 Recommendations to the board
 Accreditation decision

17. ACCREDITATION
 These May Look Difficult ,
 But Nothing Is Impossible
 Impossible Means - I’ M Possible
ACCREDITATION IS A JOURNEY AND NOT A DESTINATION.

18. THANK YOU
For your
patience…