Accreditation is a formal process where a recognized body assesses if a healthcare organization meets predetermined standards. The key purposes of accreditation are to improve healthcare quality and establish optimal standards. Health care accreditation bodies use various evaluation methods during on-site surveys, such as interviews, observations, and document reviews, to determine if organizations meet standards. Some of the main benefits of accreditation include stimulating quality improvement, enhancing healthcare organization image, and strengthening public confidence. In India, important accrediting bodies include the Quality Council of India, National Accreditation Board for Testing and Calibration Laboratories, and National Accreditation Board for Hospitals and Healthcare Providers.
Total Quality Management in HealthcareGunjan Patel
Now days, Healthcare systems are of fundamental interests to all level of Hospitals in our societies. Eventually, increasing importance and reliance are placed on total quality management in healthcare systems. Due to this rising importance that is also reflected in the increasing percentage of national and international resources for both private and public sector to allocated in hospital management systems. Hospitals and other healthcare organization across the globe have been progressively implementing TQM to reduce costs, improve efficiency and provide high quality patient care.
Total Quality Management in HealthcareGunjan Patel
Now days, Healthcare systems are of fundamental interests to all level of Hospitals in our societies. Eventually, increasing importance and reliance are placed on total quality management in healthcare systems. Due to this rising importance that is also reflected in the increasing percentage of national and international resources for both private and public sector to allocated in hospital management systems. Hospitals and other healthcare organization across the globe have been progressively implementing TQM to reduce costs, improve efficiency and provide high quality patient care.
Read and discuss the following three articles 1. ACAs Perform.pdfSALES97
Read and discuss the following three articles:
1. ACAs Performance Based Healthcare
Standards ACAsPerformanceBasedHealthCareStandards.pdf
2. Road to Accreditation RoadToAccreditation.pdf
3. JCAHO Accreditation and Quality of Care for Acute Myocardial Infarction JCAHO
accreditation and quality of care for acute myocardial infarction.pdf
Have an open discussion about these articles. Share your thoughts
For example, here are some questions to answer and discuss:
Does accreditation impact quality? Are there less errors in hospitals that are accredited? What is
the value of accreditation? Do quality concerns initiate changes in staff behavior? Should
accreditation be based on results?
Read and discuss the following three articles:
1. ACAs Performance Based Healthcare
Standards ACAsPerformanceBasedHealthCareStandards.pdf
2. Road to Accreditation RoadToAccreditation.pdf
3. JCAHO Accreditation and Quality of Care for Acute Myocardial Infarction JCAHO
accreditation and quality of care for acute myocardial infarction.pdf
Have an open discussion about these articles. Share your thoughts
For example, here are some questions to answer and discuss:
Does accreditation impact quality? Are there less errors in hospitals that are accredited? What is
the value of accreditation? Do quality concerns initiate changes in staff behavior? Should
accreditation be based on results?
Solution
ACAs Performance Based Healthcare Standards-
This booklet is intended to assist anyone dealing with or affected by Health and Employment
issues. It is one of a series of booklets and handbooks designed to give impartial advice on
employment matters to employers, employees and their representatives. Legal information is
provided for guidance only and should not be regarded as an authoritative statement of the law,
which can only be made by reference to the particular circumstances which apply. It may,
therefore, be wise to seek legal advice.
Acas is committed to building better relationships in the workplace and offers training to suit
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relations.
road to accrediation -
Accreditation is usually a voluntary program, sponsored by a non-governmental organization
(NGO), in which trained external peer reviewers evaluate a healthcare organization\'s
compliance and compare it with pre-established performance standard
Accreditation is a quality assurance process designed to ensure an educational program meets a
national standard. It serves to support and encourage program responsiveness to the ra pidly
changing environmental .
Health Education on prevention of hypertensionRadhika kulvi
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ICH Guidelines for Pharmacovigilance.pdfNEHA GUPTA
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R3 Stem Cells and Kidney Repair: A New Horizon in Nephrology" explores groundbreaking advancements in the use of R3 stem cells for kidney disease treatment. This insightful piece delves into the potential of these cells to regenerate damaged kidney tissue, offering new hope for patients and reshaping the future of nephrology.
Defecation
Normal defecation begins with movement in the left colon, moving stool toward the anus. When stool reaches the rectum, the distention causes relaxation of the internal sphincter and an awareness of the need to defecate. At the time of defecation, the external sphincter relaxes, and abdominal muscles contract, increasing intrarectal pressure and forcing the stool out
The Valsalva maneuver exerts pressure to expel faeces through a voluntary contraction of the abdominal muscles while maintaining forced expiration against a closed airway. Patients with cardiovascular disease, glaucoma, increased intracranial pressure, or a new surgical wound are at greater risk for cardiac dysrhythmias and elevated blood pressure with the Valsalva maneuver and need to avoid straining to pass the stool.
Normal defecation is painless, resulting in passage of soft, formed stool
CONSTIPATION
Constipation is a symptom, not a disease. Improper diet, reduced fluid intake, lack of exercise, and certain medications can cause constipation. For example, patients receiving opiates for pain after surgery often require a stool softener or laxative to prevent constipation. The signs of constipation include infrequent bowel movements (less than every 3 days), difficulty passing stools, excessive straining, inability to defecate at will, and hard feaces
IMPACTION
Fecal impaction results from unrelieved constipation. It is a collection of hardened feces wedged in the rectum that a person cannot expel. In cases of severe impaction the mass extends up into the sigmoid colon.
DIARRHEA
Diarrhea is an increase in the number of stools and the passage of liquid, unformed feces. It is associated with disorders affecting digestion, absorption, and secretion in the GI tract. Intestinal contents pass through the small and large intestine too quickly to allow for the usual absorption of fluid and nutrients. Irritation within the colon results in increased mucus secretion. As a result, feces become watery, and the patient is unable to control the urge to defecate. Normally an anal bag is safe and effective in long-term treatment of patients with fecal incontinence at home, in hospice, or in the hospital. Fecal incontinence is expensive and a potentially dangerous condition in terms of contamination and risk of skin ulceration
HEMORRHOIDS
Hemorrhoids are dilated, engorged veins in the lining of the rectum. They are either external or internal.
FLATULENCE
As gas accumulates in the lumen of the intestines, the bowel wall stretches and distends (flatulence). It is a common cause of abdominal fullness, pain, and cramping. Normally intestinal gas escapes through the mouth (belching) or the anus (passing of flatus)
FECAL INCONTINENCE
Fecal incontinence is the inability to control passage of feces and gas from the anus. Incontinence harms a patient’s body image
PREPARATION AND GIVING OF LAXATIVESACCORDING TO POTTER AND PERRY,
An enema is the instillation of a solution into the rectum and sig
Global launch of the Healthy Ageing and Prevention Index 2nd wave – alongside...ILC- UK
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Alongside the 77th World Health Assembly in Geneva on 28 May 2024, we launched the second version of our Index, allowing us to track progress and give new insights into what needs to be done to keep populations healthier for longer.
The speakers included:
Professor Orazio Schillaci, Minister of Health, Italy
Dr Hans Groth, Chairman of the Board, World Demographic & Ageing Forum
Professor Ilona Kickbusch, Founder and Chair, Global Health Centre, Geneva Graduate Institute and co-chair, World Health Summit Council
Dr Natasha Azzopardi Muscat, Director, Country Health Policies and Systems Division, World Health Organisation EURO
Dr Marta Lomazzi, Executive Manager, World Federation of Public Health Associations
Dr Shyam Bishen, Head, Centre for Health and Healthcare and Member of the Executive Committee, World Economic Forum
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CRISPR-Cas9, a revolutionary gene-editing tool, holds immense potential to reshape medicine, agriculture, and our understanding of life. But like any powerful tool, it comes with ethical considerations.
Unveiling CRISPR: This naturally occurring bacterial defense system (crRNA & Cas9 protein) fights viruses. Scientists repurposed it for precise gene editing (correction, deletion, insertion) by targeting specific DNA sequences.
The Promise: CRISPR offers exciting possibilities:
Gene Therapy: Correcting genetic diseases like cystic fibrosis.
Agriculture: Engineering crops resistant to pests and harsh environments.
Research: Studying gene function to unlock new knowledge.
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Off-target Effects: Unintended DNA edits can have unforeseen consequences.
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Equity: High costs could limit access to this potentially life-saving technology.
The Path Forward: Responsible development is crucial:
International Collaboration: Clear guidelines are needed for research and human trials.
Public Education: Open discussions ensure informed decisions about CRISPR.
Prioritize Safety and Ethics: Safety and ethical principles must be paramount.
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The Importance of Community Nursing Care.pdfAD Healthcare
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One of the most developed cities of India, the city of Chennai is the capital of Tamilnadu and many people from different parts of India come here to earn their bread and butter. Being a metropolitan, the city is filled with towering building and beaches but the sad part as with almost every Indian city
1. Accreditation of Health care
organization
Dr. Harpreet Kaur
PG student
Community Medicine
Guru Gobind Singh Medical College, Faridkot
2. Learning Objective
• To know the basic structure of accreditation of health care
organization
3. Lesson Plan
• Definition of accreditation
• Components of accreditation
• Purpose of accreditation
• Accreditation procedure
• Advantages of accreditation
• Different types of accreditation
4. Definition
• Accreditation may be defined as a formal process by which a
recognized body, usually a non-governmental organization (NGO),
assesses and recognizes that a healthcare organization meets pre-
determined standards.
• It can also be defined as a system of external peer review of an
organization for determining compliance against predetermined
standards.
5. • Accreditation standards are usually regarded as optimal and
achievable and are designed to encourage continuous improvement
in delivery of healthcare within accredited organizations.
• An accreditation decision about a specific healthcare organization is
made following a periodic on-site evaluation by a team of peer
reviewers, typically conducted every two to three years.
• It is usually a voluntary process in which organizations choose to
participate, rather than one required by law and regulation.
6. Components of accreditation
a) It is based on written and published standards.
b) Reviews are conducted by professional peers.
c) The accreditation process is administered by an independent body.
d) The aim of accreditation is to encourage organizational
development.
7. Purpose of Accreditation
a) Improve the quality of healthcare by establishing optimal
achievement goals in meeting standards for healthcare
organizations.
b) Stimulate and improve the integration and management of health
services.
c) Establish a comparative database of healthcare organizations able
to meet selected structure, process and outcome standards or
criteria.
d) Reduce healthcare costs by focusing on increased efficiency and
effectiveness of services.
8. e) Provide education and consultation to healthcare organizations,
managers and health professionals on quality improvement
strategies and “best practices” in healthcare.
f) Strengthen the public’s confidence in the quality of healthcare and
reduce risks associated with injury and infections for patients and
staff.
g) Accountability to professional bodies.
9. Accreditation Procedure
• There are many recognized bodies providing Accreditation to
Healthcare Institutions.
• These have diverse policies and procedures.
• However, the common elements in a typical Accreditation procedure
are:
10. Resurvey after a fixed period
Accreditation report and award of Accreditation
Resurvey, if the Institution is found deficient in certain areas of delivery of care
Survey by the multidisciplinary team of Accreditation Body
Pre-survey activities
Payment of fees
a)Application for registration by the healthcare institution
a)Setting and publication of standards and elements of performance by a recognized body
11. Health care accrediting bodies use a variety of evaluation approaches
during the on-site survey in order to determine the healthcare
organization’s performance with predetermined standards.
12. These methods include any combination of the following:
a) Interviews of the top level Administrators or the Managers of the
organization
b) Clinical and support staff interviews.
c) Patient and family interviews.
d) Observation of patient care and services provided.
e) Tour of the building facilities, observation of patient care areas,
equipment management and diagnostic testing services.
f) Review of written documents such as policies and procedures, training
documents, financial documents and quality assurance plans.
g) Evaluation of the organization’s achievement of specific outcome
measures (e.g. Immunization rates, hospital acquired infection rates,
patient satisfaction).
h) Evaluation of patients’ medical records.
13. Advantages of Accreditation
Benefits to the Hospital
a) It Improves delivery of medical care and enhances the image of the
hospital. Thus, for private healthcare organizations it also results in
more business.
b) It stimulates a process of continuous improvement in delivery of
medical care.
c) Demonstrates commitment to quality care.
d) Raises community confidence.
e) Opportunity to benchmark with the best.
14. Advantages of Accreditation
Benefits for the employees
a) It helps in education, training and development of professional
staff.
b) Provides leadership for quality improvement within medical
profession and nursing.
c) Increases satisfaction of employees with working conditions and
leadership.
d) It aims for improved employee safety and security.
e) It promotes team work.
15. Advantages of Accreditation
Benefits for Patients
a) Provides access to organizations providing quality medical care.
b) Patient’s rights are respected and protected.
c) It increases patient’s Involvement in medical care decisions.
d) Focuses on patient safety.
16. Accreditation System in USA
There are a number of organizations in US performing the function of
accreditation of healthcare institutions:
1. The Joint Commission on Accreditation of Healthcare Organizations
(JCAHO).
2. The National Committee for Quality Assurance (NCQA).
3. The American Medical Accreditation Program (AMAP).
4. The American Accreditation Health Care Commission / Utilization
Review Accreditation Commission (AAHC/ URAC).
5. Accreditation Association for Ambulatory Health Care (AAAHC).
17. JCAHO/JCI
• JCAHO is the largest and oldest accrediting body of USA.
• It is now more usually known as The Joint Commission.
• It is an independent, non government and not-for-profit organization.
• It has provided accreditation to more than 20,000 healthcare
organizations both in US and outside.
18. The constitution of the JCI board includes :
(a) Administrators, Physicians, Medical directors and Nurses
(b) Consumers
(c) Providers of care
(d) Employers, Human Resource and quality expert
(e) Health Insurance expert and expert in Ethics
(f) Corporate and Public Members.
19. • In 1997, Joint Commission initiated first step in establishing a link
between accreditation and the outcomes of patient care, treatment
and service issues.
• During on site survey, the Joint Commission team assesses
performance improvement in conditions related to selected core
measures with the help of data from the hospital.
• The JCI expects home health agencies to establish their own
performance measures, which gives these organizations the freedom
to develop their own quality assurance programs and outcome
measures.
20. Accreditation system in INDIA
Quality Council of India (QCI)
• QCI is an autonomous body set up jointly by Government of India and
Industry to establish and operate accreditation structure in the
country.
• It offers services like certification, inspection, testing, calibration and
registration.
• Initially it started with product certification and inspection under ISO
9001 series.
21. • Objectives of QCI include:
• Establish & operate accreditation structure in the country.
• Provide right & unbiased information on quality & related standards.
• Spread quality movement in India.
• Represent India’s interest in international platform.
• Help establish brand equity of Indian products.
• QCI developed standards for accreditation of laboratories and the
Hospital as different boards-
• National Accreditation Board for Testing and Calibration Laboratories (NABL)
• National Accreditation Board for Hospitals and Healthcare providers (NABH)
22. National Accreditation Board for Testing
and Calibration Laboratories (NABL)
• NABL is an autonomous body under the aegis of Department of
Science & Technology, Government of India and is registered under
the Societies Act.
• Government of India has authorized NABL as the sole accreditation
body for Testing and Calibration laboratories.
23. • NABL provides laboratory accreditation services to laboratories that
are performing tests / calibrations.
• These services are offered in a non-discriminatory manner and are
accessible to all testing and calibration laboratories in India and
abroad, regardless of their ownership, legal status, size and degree of
independence.
• The accreditation granted to a laboratory is valid for a period of 3
years subject to satisfactory annual surveillance.
24. National Accreditation Board for Hospitals
and Healthcare providers (NABH)
• NABH is a constituent board of QCI set up with cooperation of the
Ministry of Health and Family Welfare, Government of India and the
health Industry.
• The board while being supported by all stakeholders including
industry, consumers, government, but board have full autonomy in its
operation.
• The Technical Committee of NABH had formulated first edition of
standards for hospitals in 2005 which have been revised and in
November 2007 second edition of standards have been published.
25. • Vision of NABH
To be the apex national healthcare accreditation and quality
improvement body, functioning at par with global benchmarks.
• Mission of NABH
To operate accreditation and allied programs in collaboration with
stakeholders focusing on patient safety and quality of healthcare
based upon national/international standards, through process of
self and external evaluation.
26. • Values of NABH
Credibility:
Provide credible and value addition services
Responsiveness:
Willingness to listen and continuously improving service
Transparency:
Openness in communication and freedom of information to its
stakeholders
Innovation:
Incorporating change, creativity, continuous learning and new
ideas to improve the services being provided
27. • NABH is a member of International Society for Quality in healthcare
(ISQua).
• ISQua is an international body which grants approval to Accreditation
bodies in the area of healthcare as mark of equivalence of
accreditation programme member countries.
• So far hospital standards of 11 countries viz. Australia, Canada, Egypt,
Hong Kong, Ireland, Japan, Jordan, Kyrgyz Republic, South Africa,
Taiwan, United Kingdom.
• India becomes the 12th country to join in this group.
• The hospitals accredited by NABH will have international recognition.
28. Standards of NABH
• There are 10 chapters in NABH document including 100 standards.
• The standards can be classified as :
(a) Patient Centered standards : These include :
(i) Access, Assessment and Continuity of Care (AAC)
(ii) Care of patients (COP)
(iii) Management of medication (MOM)
(iv) Patient Rights and Education (PRE)
(v) Hospital Infection Control (HIC)
29. (b) Organization Centered Standards : These include :
(i) Continuous Quality Improvement (CQI)
(ii) Responsibilities of Management (ROM)
(iii) Facility Management and Safety (FMS)
(iv) Human Resource Management (HRM)
(v) Information management System (IMS)
• Each standard is further divided into variable number of objective
elements.
• Objective elements frame the guidelines for achieving a particular
standard.
30. SUMMARY
Accreditation can be regarded as one of the most attractive form of
tool for External Quality Assessment of healthcare organizations. Joint
Commission Resources now provides consultation by Joint Commission
worldwide on healthcare issues and Joint Commission International is
the largest Accreditation body, concerned with global accreditation.
One of the chief purposes of Accreditation is to Improve the quality of
healthcare by establishing optimal achievement goals in meeting
standards for healthcare organizations. Health care accrediting bodies
use a variety of evaluation approaches during the on-site survey in
order to determine the healthcare organization’s performance with
predetermined standards.
31. References
• Bhalwar R, Health Policy & Health Care Systems, Textbook of Public
Health and Community Medicine, 1st ed. Department of community
medicine, AFMC, Pune in collaboration with WHO, India office, New
delhi; 2009. p.420-26.
• Kishore J, Health care delivery system in India, J. Kishore’s National
Health Programs of India, 12th ed. Century Publications; 2017.p.108-
09.