Accriditation of Healthcare Facilities - Dr J L Meena

3rd International Public Health Management Development Program
20-25 March, 2017
School of Public Health
PGIMER, Chandigarh, India
ACCREDITATION OF
HEALTH CARE FACILITIES.
20-25 March, 2017
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

20-25 March, 2017
"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:-

20-25 March, 2017
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

20-25 March, 2017
• Joint Commission International - JCI
• Joint Commission of Taiwan – 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
 California Health Kids Survey - CHKS Accreditation Unit,
UK
 Canadian Accreditation Council of Human Services -
CAC
 Global-Mark Pty Ltd, Australia
 Health and Disability Auditing New Zealand - HDANZ
 Australian Aged Care Quality Agency - AACQA
 The Healthcare Accreditation Institute (Public
Organization), Thailand - HAI
 Australian General Practice Accreditation Ltd / Quality
in Practice Pty Ltd – AGPAL/QIP
 Japan Council for Quality Health Care - JCQHC
 The Australian Council on Health Care Standards - ACHS
 Health Care Accreditation Council, Jordan - HCAC
 DNV GL Business Assurance, Norway
 Associacao Brasileira de Acreditacao De Sistemas e
Servicos de Saude, Brazil – CBA
 Haute Autorité de Santé – DAQSS, France
 Accreditation Canada International (ACI) Canada
Accredited Organisations

20-25 March, 2017
What is common?

20-25 March, 2017
•Patient safety and
•quality of care ………..

20-25 March, 2017
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.

20-25 March, 2017
• 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 – 12 and 30 months post survey
International Accreditation Programme by ISQua - 4 year cycle

20-25 March, 2017
 The Joint Commission (TJC) : Body for
accreditation of HCOs across USA which forms the
basis for licensure and Medicaid reimbursement
 Joint commission International: For International
Accreditation, publication and education
International Scenario on Accreditation
in Healthcare services - USA

20-25 March, 2017
JCI is the recognized leader in international health care accreditation.
JCI maintain ISQua membership in the following categories:-
 Accreditation survey
 Surveyor education program
 Ambulatory Care Standards
 Clinical Laboratory Standards
 Care Continuum Standards
 Hospital Standards
 Primary Care Standards
 Clinical Care Program Certification Standards
 Home Care Standards
 Long Term Care Standards

20-25 March, 2017
800+ Accredited
Organizations.
100+ Countries
Served by JCI.

20-25 March, 2017
• 360 Standards
• 1240 Measurable Elements
Section I : Patient Centered Standards
Section II : Health Care Organization
Management Standards
Joint Commission International Accreditation
Standards for Hospitals

20-25 March, 2017
Each applicable measurable elements is scored
Met (10)
Partially Met (5)
Not Met (0)

20-25 March, 2017
International Scenario on Accreditation
in Healthcare services - AUSTRALIA
The Australian Council of Healthcare
Standards
 (ACHS): Pioneer in accreditation of HCOs
in Australia
 ACHSI : for overseas accreditation

20-25 March, 2017
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.

20-25 March, 2017
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)

20-25 March, 2017
Accreditation Agencies in India:-
Quality Council of India (QCI):-
 National Accreditation Board for Hospital
and Health care Providers (NABH)
 National Accreditation Board for Testing
and Calibration of Laboratories (NABL)

20-25 March, 2017
Certification and Grading Agencies in
India:-
ISO 9001 – 2008 as amended by recently
issued ISO 9001 – 2015 standards
National Quality Assurance Certification
Indian Public Health Standards 2012

20-25 March, 2017
Quality Council of India:-
QCI is an autonomous body set up
by Govt. of India to establish and
operate accreditation structure in
the country.

20-25 March, 2017

20-25 March, 2017
• 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

20-25 March, 2017
•Creation of NABHI was approved by Board in
July 2010
•Started work in Philippines
•Qatar
•Nepal
•Bangladesh
NABH International

20-25 March, 2017
•Autonomous Body under the aegis of Dept of Science
and Technology, GoI but now it’s under QCI
•Sole Accreditation Body for Testing and Calibration Labs
• Accessible to all Labs irrespective to their Status
•Maintains International linkages
• International Lab Accreditation Cooperation
• Asia Pacific Lab Accreditation Cooperation
National Accreditation Board for Testing and
calibration Laboratories

20-25 March, 2017
Chapters : 10
Standards : 105 (102)
Objective Elements : 683 (636)
NABH Standards for the Hospitals:
4th Edition

20-25 March, 2017
• Assessment is based on the scoring on a scale of 0, 5 and 10
as per the following details:
– Compliance to the requirement:10
– Partial compliance to the requirement: 5 (if any of the
sample is found to be non complying out of total samples
selected)
– Non-compliance to the requirement:0
• Not Applicable: NA
Scoring Pattern

20-25 March, 2017
Outcome
• Pre-accreditation entry level
• Pre-accreditation progressive level
• Accredited

20-25 March, 2017
Pre-accreditation entry level
• Conditions for qualifying to this award are:
– All the regulatory legal requirements should be fully met.
– No individual standard should have more than two zeros.
– The average score for individual standard must not be less than 5.
– The average score for individual chapter must be more than 5.
– 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.

20-25 March, 2017
Pre-accreditation progressive level
– No individual standard should have more than two zeros.
• The validity period for pre-accreditation entry level stage is from a
minimum 3 months to a maximum of 12 months.

20-25 March, 2017
Accredited
– No individual standard should have more than one zero to qualify.
• The validity period for accreditation is 3 years subject to terms
and conditions.

20-25 March, 2017
Feedback
To
Health care
Organization
And
Necessary
Corrective
Action
Taken
By
Health care
Organization

20-25 March, 2017
Feedback
To
Laboratory
And
Necessary
Corrective
Action
Taken
By
Laboratory

20-25 March, 2017
High quality of care
Dedicated and sincere medical staff
Access to a quality focused organization
Rights respected and protected
Patient Satisfaction evaluated
Involvement in care process
Patient safety
Pain management
Safe transport
Continuity of care
Benefits of Accreditation for Patient

20-25 March, 2017
Professional staff development
Provides education on laid down standards
Provides leadership for quality improvement
within medicine and nursing
Increases satisfaction with continuous learning,
good working environment, leadership and
ownership
Benefits of Accreditation to Staff

20-25 March, 2017
Improves care
Brings in Corporate Governance
Stimulates continuous improvement
Demonstrates commitment to quality care
Raises community confidence
Opportunity to benchmark with the best
Benefits of Accreditation to Hospital

20-25 March, 2017
Quality revolution
Disaster preparedness
- Epidemics
- Physical
Access to comparative database
Benefits of Accreditation for Community

20-25 March, 2017
 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.
 Given a sense of pride to the government for ensuring quality
services to the poorest of the poor.
 Confidence has been restored of the community in Govt
hospitals
Benefits of Accreditation to the
Government

20-25 March, 2017
•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.
•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 “Role of Quality in Globalization of Indian Healthcare”. Place: - Gurgaon, Haryana Date: 30thAugust 2010.
•FICCI Health care Excellence Award to Dist Hospital Gandhinagar & PHC Gadboriad, Govt of Gujarat in FICCI Heal 2010, New
Delhi Date: 6th Sept 2010
•FICCI Health care Excellence Award to Dist Hospital Gandhinagar, Govt of Gujarat in FICCI Heal 2011, New Delhi Date: 8th Sept
2011
•FICCI Health care Excellence Award to Community Health Centre Bardoli, Govt of Gujarat in FICCI Heal 2013, New Delhi Date:
2nd Sept 2013
•Operational excellence award in IndiZen 2014 to Govt. of Gujarat-department of health and family welfare was achieved.
•FICCI Health care Excellence Award to Community Health Centre Bardoli, Govt of Gujarat in FICCI Heal
2014, New Delhi
Date: 1st Sept 2014
•FICCI Health care Excellence Award to Paraplegia Hospital- Ahmedabad, Govt of Gujarat in FICCI Heal
2014 New Delhi
Date: 1st Sept 2014
•FICCI Healthcare Excellence Award to Laboratory Information System, B J Medical College – Ahmedabad,
Govt of
Gujarat in FICCI Heal 2016 New Delhi Date: 31st August 2016.

20-25 March, 2017
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

20-25 March, 2017
ThanksThanks
2nd International Public Health Management Development Program
20-25 March, 2017

Accriditation of Healthcare Facilities - Dr J L Meena

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