1) Mahboob Ali Khan proposes establishing a quality management system and pursuing accreditation for a client hospital from JCI, NABH, and CBAHI. 2) The scope of consultancy services includes gap assessments, developing documentation, training programs, and providing support through the accreditation process over 12 months. 3) The client hospital is expected to commit resources including a dedicated quality team and provide access to records to support the accreditation work.

1. Proposal
For
Establishing Quality Management System
Leading to JCI, NABH, CBAHI
Accreditation
CLIENT -
PREPARED BY
MAHBOOB ALI KHAN MHA,CPHQ Healthcare Consultant

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Title
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Profile: Mahboob ali khan
Competitive advantage
Accreditation & Healthcare Quality
Scope of consultancy services in quality
and
Accreditation
Support required from the Hospital
Consultancy charges
Time lines for the project
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4. Profile:
MAHBOOB ALI KHAN
Bsc,MHA,CPHQ (Masters in Hospital Administration)
I guide and facilitate healthcare organizations (hospitals, clinics, polyclinics or health care professionals)to
define, document, implement and continually improve their working systems based on Quality principles and
International standards like JCIA,NABH,CBAHI.i am Masters in healthcare management and CPHQ USA and has
10 years of experience in CBAHI,NABH, JCIA accreditation in operations management.
1) Initial Review
2) Training Programs for staff
3) Complete documentation as per standards with forms and formats
4) Implementation Support
5) Readiness Audit & support till hospital is NABH,CBAHI or JCIA accredited
In order to strengthen the competitiveness of hospitals, clinics & Healthcare Industries ,i am presently in india
my mobile number 918790309122.my email is mahboob804@yahoo.co.in.
Over 9 Years experience in Healthcare
Expertise in implementing Accreditation standards, Training and
continuous professional Development Continuous quality
improvement and patient safety
Mr.Mahboob ali khan has worked in the field of Healthcare Consultancy
since, 2004 after obtaining his Masters in Hospital Administration,
Osmania University, Hyderabad. Currently Mr.Mahboob ali khan is
working in the one of the leading Healthcare Consultancy firm in India,
Astron Healthcare Consultants Private Limited as Manager South
consulting JCI accreditation and NABH accreditation program in various
hospitals. Mr.Mahboob ali khan is also associated with Federation of
Indian Chambers of commerce and Industry as a Jury member for the
annual evaluation on “Excellence in healthcare award for quality
improvement and patient safety” for the Hospitals and laboratories in
India.

5. Experience as a Healthcare Quality and accreditation consultant-
Planning and executing accreditation activities for client
hospitals with project management, vetting documentation,
organizational capacity building, and trend analysis.
Successfully conducted gap assessments and implemented for
JCI,NABH ,CBAHI accreditation program in various hospitals in
India and abroad such as CARE Hospital, Hyderabad (Year-2008)
,AR rawdha general hospital (JCIA)Dammam Kingdom of saudi
Arabia,Al sadiq Hospital Saudi arabia (CBAHI) Durdans Hospital
Colombo (year-2014), Ministry of Health Hospital PSBJH (CBAHI)
KSA.
Currently consulting various Hospitals for JCI
,CBAHI,NABH,accreditation under Astron Health Care Consultancy
Development of a “Hospital management Information software”
compatible to JCI standards as a domain expert
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6. Core Competencies-
 Advocate, develop and implement quality management systems
for continual quality improvement and accreditation (both
International accreditation-JCI and National accreditation -
NABH)
 Comprehensive understanding of medical and services processes,
workflows, best practices and standards to advocate, co-ordinate
and ensure standardised and consistency of practices.
 Competence to develop the monitoring and analysis system
for quality improvement activities in the hospital
 Hospital planning, Budgetting, setup, infrastructure,
administration set up, operational setup and management.
1.Manage and handle overall hospital administration and
operations
2.Maintain optimum stock levels of consumables at various
departments.
3.Identify and execute regular maintenance works with regard to
building and infrastructure, equipment, vehicles and service
connections.
4.Maintain the cost centre of various departments to take an
estimation of the revenue earned, profits generated and expenses
incurred.
5.Taking care of day to day admin and operational activities,
trouble shooting and business performances to achieve customer
satisfaction and financial targets.6.Generate required reports and

7. provide them to the required department.7.Ensure Customer
Satisfaction of the highest level
8.Lead general administrative matters for the division while
liaising with HR, accounting, legal, insurance etc.
Professional affiliations-
Indian Healthcare Quality Forum, Technical Committee Member
Indian Journal of healthcare quality and
Management, Domain expert Academy of
Hospital Administrators, Member
JCI Standards and Consulting Methodology,
Certificate of Completion Medical Audit & ICD
organized by ASCI, Certificate of Participation
Revenue Cycle Management,
Certificate of Participation
Epidemiology & Study Design,
Certificate of Completion

8. Competitive Advantage:
Accreditation from the Joint Commission International is regarded as the
Highest Achievement in Healthcare Standards around the Globe. It is the
most sought after and the most rigorous accreditation process which
encompasses each and every hospital processes and is restricted not only to
clinical but also the non clinical and support services.
Over the years, I have understood and interpreted the intent of the
standards, I tailor-made its implementation, not only to suit Indian
Hospitals but also in this part of the world and making sure that I comply
with the standards at the same time. I have improvised, failed, learned and
improvised further to achieve success and I assisted the first hospital in
south asia to face the JCI,NABH,CBAHI survey (first time conducted in this
country) which came out with an excellent result of 96% compliance of the
measurable elements.
My biggest advantage as resident consultants or advisors is that I can not only
see the latent hurdles but can provide an apt solution beforehand. During the
course of 2 years, consulting one of the major hospital in south east Asia, I have
gained an in-depth knowledge regarding the systemic problems and thereafter
tailoring solutions for some of the key issues in the private healthcare industry
of the country such as Credentialing & Privileging of the Visiting consultants,
implementation of JCI standards in the channeling chambers, complete BHT
documentation
.etc. As this is going to be the first venture where I will be responsible I

9. intend to leave absolutely no stone unturned.

10. Mahboob ali khan
Accreditation & Healthcare Quality:
Accreditation as a means for implementing Quality consciousness in health
care is fast gaining acclaim as a critical input. The improved efficiency and
efficacy of health care delivery as a result of improved quality has a direct
positive impact on health outcomes with derived consequences of greater
patient satisfaction. The basic premise for implementing standards as per
Accreditation norms in health care management is to provide a framework
for implementing quality initiatives with the tenet of improving resource
utilization and gaining improved health outcomes.
Accreditation establishes Quality Management System in health care
through a set of policies, processes and procedures in compatible physical
structure for planning and executing patient care services. It integrates
various internal processes within the organization. Thus Accreditation
focuses on process approach for improved service delivery. It enables the
organization to identify, measure, and improve the various processes and
instituting control mechanisms for improved performance.
Accreditation benefits all stake holders. Patients are undoubtedly the
biggest beneficiaries as it results in high quality of care and patient safety.
The staff in an accredited hospital is also more satisfied professionally, as
accreditation provides for continuous learning, good working environment,
leadership and above all ownership of clinical processes.
An important role for any health care system is to ensure the quality of its
services and to improve the efficiency and effectiveness of the service delivery
at all level. The Benefits of implementing Accreditation standards in
healthcare may be summarized as below:
Today’s hospitals and health care organizations are facing the rising
expectations of people for better healthcare and to meet the needs for
patient and community satisfaction. A well structured Quality

11. Management System, based on Accreditation Standards, helps the
health care organizations in not only meeting patient’s expectations
but also modulating these expectations.
It brings about uniformity in processes of health care delivery
through establishment of standards and practice guidelines,
ensuring patient and staff safety while minimizing risk and
adverse outcomes.
Reduce waste due to repetition or reworking as a result of wrong or
inappropriate process or techniques Safeguarding the organization
against litigation.
Enables hospital to demonstrate its commitment to quality care.
Accreditation is increasingly being used as a stimulus
for continuous improvement It also provides
opportunity to healthcare unit to benchmark with the
best.
It raises community confidence in the services provided by the hospital.
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Mahboob ali khan

12. All these have direct or indirect effects towards reducing the cost of
healthcare delivery, differentiation in the market and greater profitability.
Scope of consultancy services in quality and accreditation:
1. Gap assessment and analysis programme
Assessment of infrastructure, human resources, biomedical equipment
management programs, various clinical and non clinical processes,
documentation (Policies, procedures, Plans and Programs), orientation
of staff (both clinical and non clinical staff), Quality improvement
monitoring mechanism and other features with respect to the JCI
accreditation norms. Assisting on developing Action plans towards
fulfilment of the gaps in association with Managers and other leaders
of the Hospital
2. Assistance in developing and reviewing the hospital action plan
periodically for JCI Accreditation
3. Assistance in formulation and coordination of various committees
and teams(Hospital facility safety team, patient safety team,
infection control team, Quality champions team.etc)
4. Guidance on the Development of Quality Assurance Programme for
radiology, laboratory, critical care services and surgical services of
the Hospital
5. Assistance in the Development of Documents, (Policies, Plans,
Programs, Manuals and departmental SOPs.etc) modulating the existing
system and suggesting changes to support JCI accreditation norms.
Where required documents will be developed in collaboration with the
hospital staff. It will be our endeavour to guide the development of
documents in a manner such that the feeling of ownership of the
system facilitates compliance. Mr.Mahboob ali khan would not develop
the documents on behalf of the organisation as it would defeat the
purpose of sustainability and compliance.
6. Assistance the Quality Assurance department of the Hospital in

13. the formulation of process for data collection, aggregation and
analysis of various quality indicator(both clinical and
nonclinical)
7. Assistance in formulation of clinical pathways and clinical
protocols guidelines and monitoring of adherence of the same as
per JCI accreditation norms.
8. Assistance in development of process for data collection, aggregation
analysis of the International Library measures
9. Guide on the development of the Incident report mechanism to
identify near miss events, adverse events and sentinel events
,Medication error, Adverse reactions .etc
10. Assistance in conducting FMEA (Failure Mode Effect Analysis) on
the various process of the Hospital as per the JCI standard
requirement.
11. Guidance on the various auditing process to monitor the quality
improvement activities(IPSG Tracer
Audits, Fire safety Audits, Hand hygiene audits, Prescription audits,
Open BHT audits, Closed BHT audits, Department quality assurance
audits.etc)
12. Assistance in the Development of Record Keeping
Programme of the healthcare facility through guidance on the
a. Organising of records(BHts and Others) as per JCI standards
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Mahboob ali khan

14. b. Development of formats(clinical and non clinical) wherever
required
c. Operationalising of Monitoring system
13. Assisting in Training programs throughout the JCI accreditation
preparation process. Guidance on the formulation of training need
analysis across the organisation (yearly and monthly), training
calendars, Training evaluation process and refresher Training courses
.etc. These training programmes would be consisted of various training
modules such as:
a. JCI sensitization Module for Leaders
b. JCI Sensitization Module for Doctors
c. JCI Sensitization Module for Nurses
d. JCI Sensitization Module for Other staff
e. JCI policy Training for Doctors
f. JCI policy Training for Nurses
g. JCI policy Training for Other staff
h. Other Training programs as per the specific requirement to meet
the JCI standard.
14. Facilitation on the development of an facility assessment programme
through
a. Assistance in the conducting various mock drills to address the
emergencies(internal& external)
b. Training of facility staff (Engineering depart. staff) to conduct
assessments
c. Assistance in organising for internal assessments
d. Facilitation in the Conduction of internal assessments
e. Assistance in evaluating the results of internal assessment
15. Monitoring of accreditation compliances
a. Internal Mock Survey
b. Monitoring of effectiveness of training programmes

15. c. Organising refresher training programmes as per need identified
16. Assistance during JCI Survey Period
a. Organising Mock Group sessions as per survey agenda of JCI.
b. Organising specific Mock group sessions for leaders/senior
managers regarding GLD Chapter (Governance and leadership)
c. Sensitization of the Quality assurance executives/survey
coordinator regarding the Survey Presentation/document
review session, Daily briefing sessions.etc
d. Guidance for smooth and effective conduct of all survey activities
during the survey period.
17. Development of niche hospital programmes. Certain activities of the
hospitals have multiple arenas of operations and representation. These
specific activities need to be addressed as programmes and which
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16. would require continuing and evolving support for maturing.
Both of us would provide guidance in organising and
implementation of these programmes depending upon the
maturation level of the organisation achieved during this
project.
Certain aspects form the soft part when implementing Quality Management
System and accreditation programme and would be beneficial for progress.
Towards this end we would assist in organising a change management
system with representation from expertise available in-house, discussions
and developing an action
plan so that the process of change is accomplished smoothly. This would
also help reduce the impact of accidental adversarial interactions
Support required from the Hospital:
We would be expecting the following support from the Client hospital for
implementing Quality Management System leading to JCI Accreditation.
1. Commitment of top management
2. Designation of a nodal person to interact with both of us.
3. A dedicated Quality Assurance Team consisting of at least
one Quality Assurance Manager suitably versed in ‘Quality
in Healthcare’ supported by three executives.
4. Providing proactive support in
i. Formulation of teams and committees,
ii.Conduct of meetings in a scheduled manner,
iii. Compilation of Documents with suitable secretarial
assistance,
iv. Organisation of trainings, audits, performance
measurements and assessments.
5. Timely fulfilment of gaps and accreditation compliances as

17. brought forth by both of us.
6. Arranging for delivery of lectures or other services from external
resources, where required, when undertaking activities related to
development of Niche hospital programmes, study on
optimisation of services, soft aspects for developing quality
management systems and any special audits if the management
desires.
7. Any other support that may be required in organisation and
implementation of Quality Management System including
contractual arrangements.
8. Access to records and documents for undertaking historical and
concurrent data analysis.
9. Arranging for interview with various staff members and
management personnel.
10. Deputing Executives and other staff to assist in
undertaking surveys and collecting data – primary and
secondary, based on templates developed by both of us.
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Mahboob Ali Khan

18. Consultancy charges:
Based on our understanding of the organisation the consultancy charges
for implementing Quality Management System leading to JCI Accreditation
is 40,000 USD- for the above scope of services rendered to the hospital.
This fee is exclusive of service tax or any other tax mandated by the
government and that the same would be paid by the Client hospital as per
existing levels and from time to time. The fee is also exclusive of charges to
be paid for specialised surveys for system optimisation or other programmes
that may be required to be conducted through external agencies as deemed
necessary in concurrence with the management apart from the above scope
of works. This fee is also exclusive of the residential visa charges as per
government and client Hospital shall provide individual accommodation
facility to Mr.Mahboob ali khan throughout the project period.
We propose below a fee payment structure which we would appreciate to
meet your concurrence.
1. On Initiation of job
25
%
2.
Completion of
Documentation
25
%
3.
On application of the
facility for JCI
15
%
4. On first Mock Survey
15
%
5. On second Mock Survey
10
%
6. On Accreditation
10
%

19. Total
100
%
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20. Time lines for the project:
We propose that the project be taken up on the defined time lines of 12
months. A concrete time line would be developed upon completion of gap
assessment/initial study, which would provide us greater information of the
work to be undertaken. We would appreciate the modulation and
finalisation of this in consultation with the management of the Client
hospital, keeping in view the deeper understanding of the organisational
capabilities by them. The time lines would also be open for review at
suitable intervals, to be decided mutually from time to time, depending
upon the prevailing or special circumstances.
THANK YOU
For any queries feel free to contact for healthcare consultancy
mahboob804@yahoo.co.in
00918790309122
00914064502081

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Mahboob ali khan