Case study of an accredited hospital final
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This document discusses the experience of Ranjini Eye Hospital in India in becoming the country's first small healthcare organization (SHCO) to achieve accreditation from the National Accreditation Board for Hospitals & Healthcare Providers (NABH). It applied for NABH accreditation in 2007 but did not fully meet the standards for larger institutions. However, assessors were impressed by the standard of patient care. NABH later established new standards for SHCOs with a bed strength up to 50 and including specialty day care centers. Ranjini Eye Hospital reapplied after a self-assessment and was granted NABH accreditation in 2009. The document outlines some of the key accreditation standards around
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Case study of an accredited hospital final
- 1. Case study of an Accredited Hospital- our experience NSD Raju Ranjini Eye Hospital (India’s first NABH Accredited SHCO )
- 2. • I have no financial interest or relationships to disclose
- 3. Day care Ophthalmic surgical Center Small Health Care Organization ( SHCO) Ambulatory Ophthalmic Surgical Centre
- 4. Our Ophthalmic Out patient surgical Centre • Located in an open space • Accessibility • Parking facility • Built in area 5000 sq.ft
- 5. Journey towards Accreditation • NABH came into being in 2006 • Applied for NABH in 2007 • Pre assessment and final auditing done • Did not fully conform to the rigid standards laid down for bigger institutions • Assessors impressed by the standard of Patient care and other supportive and utility services
- 6. Journey Continues • NABH Set Standards • for Small Heath Care Org • Bed Strength up to 50 • Appropriate supportive and utility services • Polyclinics and diagnostic centers not included • Specialty Day care centers included • Bed strength not mandatory
- 7. The Final Accreditation • Our center then came under the category of SHCO • Centre Eligible for NABH accreditation • Reapplied for NABH accerditation after a self assessment auditing • Final auditing in 2009 –cleared for NABH accrditation
- 8. Why NABH for Small Ophthalmology Hospitals • Commitment to quality health care • Benchmark with international quality • Continuous improvement • Community confidence • Empanelment in government and insurance schemes , medical tourism patronage
- 9. Accreditation Standards- Patient Care Oriented • 1.Access, Assessment and continuity of Care (AAC) • In the care of patients rehabilitation excluded • Management of Medications narcotics delete • Patients Rights and education • Hospital Infection Control
- 10. Accreditation Standards- Organization Oriented • Continuous Quality Improvement (CQI) • Responsibilities of Management (ROM) • Facility Management and Safety (FMS) • Human Resource Management (HRM) • Information Management System (IMS)
- 11. Continuous Quality Improvement Structured quality improvement Monitor tools for continual improvement of structures processes and outcomes Established system for clinical audit Analyze sentinel events
- 12. Hospital Infection Control • Well defined coordinated comprehensive HIC • Infection control manual • Measures to reduce hospital associated infections – designing surgical suite • Documented Sterilization Procedures
- 13. Information Management System • Effective management of data • Converted to complete and accurate EMR • Paperless Office ensure continuity of service • Documented procedure for safety and security
- 14. Patient Rights and Education • Protection of patient and family • Documented policy for consent • Right to information about their health care needs and cost of treatment
- 15. Responsibilities of Management Responsibilities of management well defined Patient safety aspects and risk management issues forms an integral part of hospital management
- 16. Other Measures • MOU with Hospital for Patients needing admission/emergency • Arrangement for ambulance Facility
- 17. Conclusion • NABH Benefits • Ongoing continuing process of improvement • Ensures best possible team work in a Health Care Organization •
- 18. Thank You
Editor's Notes
- As we have just heard the basic objective of NABH accreditation is to ensure provision of quality health care and guarantee patient safety. Ever since NABH was introduced in 2006 many health care institutions across the country have achieved accreditation and have become accomplished quality health care providers as envisaged in the NABH requirements. But the major share of the health care industry has not still come under the purview of NABH. Let us now look at the process of accreditation and performance of a small day care ophthalmic center surgical centre
- I have no financial interest or relationships to disclose
- As mentioned ours is an ambulatory Ophthalmic Center in the category of Small Health Care Organization which by the way make up 80% of health care institutions in the country
- Our ophthalmic Hospital is located in an open space with easy accessibility and enough parking facility. We have a built in area of 5000 sq. feet and we offer both anterior segment and posterior segment surgery
- We had applied for NABH as early as 2007 just one year past its introduction. But the guidelines at that time were intended only for big multispecialty institutions and therefore did not conform to those rigid standard
- NABH set standards for SHCO and issued fresh guidelines for them.These standards were applicable to small hospitals with bed strength below 100 and these includes specialty day care centres also and our institution came under this category, and in this category bed strenth is not mandatory
- We reapplied for NABH accreditation in 2009 and the final auditing and apprisal was done by the NABH assessors in 2009 itself and our institution was sccredited with NABH and became the first NABH accredited hospital in the country in the SHCO category
- Now what are the major benefits of accreditation ? In the first place it streamlines the institution as provider of quality health care bench marked with international standards. Moreover the accredited institution continues its efforts for further and further improvement in all aspects related to quality patient care and safety . The community confidence will certainly go up and it also opens up other avenues of enhanced patronage facilitated by empanelment and of course patronage from medical tourism as well
- These are the 5 important accreditation standards which are patient oriented and about this mention has already been made by eareler speakers . Some of the requirements for major institutions have been removed from SHCO. For example in the care of patients Rehabilitation measures have been removed . So also the narcotics section heleted from Mangement of medications . Patients rights and educationand Hosptal infection control are the same except that control of out break of infection does not apply to SHCO A module for all these requiremets were made and subsequently implemented
- These 5 modules are the acrreditations standards pertaining to the organisation . Sweparate module for each category was made and the required facilities provided as per the guidelines . Self pre assessment audits periodically gave us an indication of the achievement staus of accreditation standards
- For example , in the continuous quality improvement module we designed a structured quality improvement scheme to ensure its its implementation and continued functioning and these were monitored by periodic audting. This also included analysis of sentinel events if any
- Let take another example from patient centered guidline module namelt the the hospital infection control Infection A meticulous infection control manual was prepared and the infra structure of the surgical suite modified accordingly . We have a surgical suite exclusively in one floor and the operation theatre ha a laminar flow system with Hepa filter system All sterlization procedures are documented
- Data management is an important and essential requirement. An effective system for maitenance of data was established Although not mandatory requirement , converting to Electronic Medical Record makes it easier and enhances the efficeincy of data maintenance. Moreover the paperless office ensures continuity of service All patient data and procedures are documented electronically and and maintained in a safe and secure custody
- The Manual for PRE is an important modules and the patients rights and education information are displayed prominently in the front office and waiting area . So also a documented policy for recording informed consent is being practiced for all procedures
- Under the responsibilities of management all measures of patient saftey are implemented . These include fire fighting set up crisis, management and emergency evacuation procedures
- Availability of an ambulance for emergency cases is an important pre requisite . Ours being an out patient or ambulatory ophthalmic surgical center the ambulance provision and emergency admission system are arranged with a nearby by tertiary care hospital and we have made an MoU with the hospital for the same.
- In short NABH accreditation besides ensuring quality health care to the patients will also ensure aan ongoing process of continuing improvenent in all spheres of health care In that process it will also make sure that the best possible team work is established in the health Care organuisation