The document discusses various challenges faced by hospitals in achieving NABH accreditation. Some of the key challenges mentioned are: lack of a team approach and proper project planning for accreditation; incorrect gap analysis of NABH standards; dealing with inertia from clinicians and staff; inconsistent processes due to lack of SOPs and training; and unsafe facility environment issues like blocked fire exits and improper electrical safety. The document provides suggestions on addressing these challenges through measures like decentralizing accreditation tasks, conducting proper gap analysis, developing SOPs and training programs, and ensuring staff involvement and buy-in for quality improvement.

1. NABH Hospital accreditation
challenges
Deepak.Venkatesh. Agarkhed

2. Name:
Deepak.Venkatesh.Agarkhed
• Designation: GM-Facilities & Quality.
• Name of Institution: Sakra World Hospital.
• Any other position(s) held:TC Member-NABH
• No. of Publications: Several like NABH-Medical devices,
AHPI-Patient safety & trade journals like Express Healthcare
• Special Awards and Recognition: Excellence Award in the Bio
Medical Equipment / Facilities Improvement category an
International Award, Hospital Management Asia (HMA) at
Philippines
• Any other relevant information:
• Master Black belt in Six Sigma from ISI,New Delhi
• Part of Toyota Production System implementation

3. 11/13/2016 deepakagarkhed@gmail.com 3
KALEIDOSCOPE 2016 ,13th Nov 2016,J.W.Marriott,Bengaluru

4. 1.Need for TEAM approach towards
continuous quality improvement ( CQI )
• Quality improvement left only to quality team who has no bandwidth
to cover entire HCO.
• Non availability of core committee.
• Each functional department working in silo mode.
• Ineffective committee functioning.
• Inadequate support from Top management
deepakagarkhed@gmail.com 411/13/2016

5. 2.NABH accreditation :Improper Project
planning ( CQI )
• Understanding it as time bound project approach
• Creating core team consisting of quality team,Clinicans,nursing,non
clinical team members, medical admin & management.
• Doing proper gap analysis to know ground reality.
• Decentralizing tasks & approaching each milestone systematically.
deepakagarkhed@gmail.com 511/13/2016

6. 3.Incorrect NABH standard Gap analysis on
ground by core team ( CQI)
deepakagarkhed@gmail.com 6
Documentation
(Yes/ No)
Implementation
(Yes/ No)
Evidence
(cross reference
to documents/
manuals etc.)
Scores
(0/ 5/ 10)
a
Yes Yes SOP PSM 13 5
b
Yes Yes SOP PSM 14 10
c
Yes Yes SOP NS 68 5
d
Yes Yes SOP NS 79 10
SELF ASSESSMENT TOOLKIT
Elements
MOM.12: Documented policies and procedures guide the use of
implantable prosthesis and medical devices.
Usage of implantable prosthesis and medical devices is guided by scientific
criteria for each individual item and national/international recognised guidelines/
approvals for such specific item(s).
Documented policies and procedures govern procurement, storage/stocking,
issuance and usage of implantable prosthesis and medical devices
incorporating manufacturer’s recommendation(s).*
Patient and his/her family are counselled for the usage of implantable
prosthesis and medical device including precautions, if any.
The batch and serial number of the implantable prosthesis and medical devices
are recorded in the patient’s medical record, the master logbook and the
discharge summary.
11/13/2016

7. 11/13/2016 deepakagarkhed@gmail.com 7

8. 4.Dealing with people with inertia
• Difficult to handle
• Clinicians
• Functional Heads
• Supportive team
• Nursing
• Outsourced staff
deepakagarkhed@gmail.com 811/13/2016

9. 5.Inconsistent processes
• No written standard operating procedures ( SOP )
• Each employee /staff with varied process steps
• No training on SOP
• No adherence of SOP on ground
• No attempt to update SOP based on process improvement
deepakagarkhed@gmail.com 911/13/2016

10. 6.Unsafe environment ( FMS)
• Adequate back of power & Medical Gas & provision of alternate source
• Fire exits blocked & non/partial functional fire fighting & sensing devices.
• Adequate fire protection in area like Kitchen, Deiseal storage yard.
• Electrical safety compromised like bypassing of fuse/RCCB,extension board
used in wet points, on availability of safety mats.
• Facility with sharp turns, low heights, low light intensity.
• Radiation safety protection in designated radiation zones.
• Slipper rest rooms, beds without side rails etc.
• Non available/functional medical gas alarm units
deepakagarkhed@gmail.com 1011/13/2016

11. 7.Improper documentation (COP & IMS)
• Non availability of forms or formats
• Medical records with inadequate documentation
• Checklists not duly signed
• Improper document control
deepakagarkhed@gmail.com 1111/13/2016

12. 8.Lack of comprehensive training program
(HRM)
•Training - Induction
•Training-On Job
•Training-Refresher
•Ensuring staff availability
•Ensuring timely training
•Ensuring effectiveness
deepakagarkhed@gmail.com 1211/13/2016

13. 9.Untrained staff for emergency preparedness
( FMS & COP)
• No structured approach on timely execution of various drills like Fire,
community disaster.
• Understanding gaps & training staff on emergency preparedness.
deepakagarkhed@gmail.com 1311/13/2016

14. 10.Inadequate inventory control measures
(MOM)
• Not following good practices of inventory managements
• Reorder level monitoring
• Expiry & near expiry drug monitoring
• Not following FIFO
deepakagarkhed@gmail.com 1411/13/2016

15. 11.Lack of acceptance of data driven approach
( ROM)
• Moving from gut feeling to data driven approach
• Capturing quality measures to understand where we stand.
• Analyzing & acting towards improvement
deepakagarkhed@gmail.com 1511/13/2016

16. 12.Involvement of Clinicians in quality
improvement ( CQI )
• Mostly clinicians & their team do not get involved in quality
improvement programs like accreditation process.
• They do object if someone audits them on the best practices like
hand hygiene compliances.
deepakagarkhed@gmail.com 1611/13/2016

17. 13.Partial implementation of laws &
regulations ( ROM)
• Non availability of tracking system for legal compliance.
• Making functional heads accountable for timely renewal.
• Unorganized central depository of legal compliance documents.
deepakagarkhed@gmail.com 1711/13/2016

18. 14.Antibiotic policy adherence ( HIC)
• No takers of antibiotic policy .
• No initiation of corrective & preventive measures for deviation in
adherence.
deepakagarkhed@gmail.com 1811/13/2016

19. 79%
50%
81%
85%
80%
74%
59%
100%
74%
61%
69%
58%
76%
80%
58%
0%
20%
40%
60%
80%
100%
120%
Nurses Doctors Tech Physio HK/GDA
Compliance of Hand Hygiene by healthcare workers July Aug Sep
11/13/2016 deepakagarkhed@gmail.com 19

20. 17.Absence of effective action based on
Patient Feedback ( PRE)
deepakagarkhed@gmail.com 20
2.89
2.96
2.98
2.92
2.80
2.85
2.90
2.95
3.00
OVERALL IPD PSI FOR FOUR
MONTHS Low scoring Services ( Maximum score 4 )
1. Food Tray Clearance
2. Timely Meal service
3. Delay in patient discharge
4. Clinical nutrition assessment
5. Efficiency of the bill settlement.
11/13/2016

21. 18.Absence of validation of quality assurance
of Clinically outsourced organization
 Lack of availability /renewal of MoU .
 No evidence on methodology to select .
 No review of performance service .
deepakagarkhed@gmail.com 2111/13/2016

22. 19.Lack of implementation of effective CPR
policies & procedures( COP )
• Training to nurse in high risk area
• CRP mock Drills
• CPR event recording & CAPA based post event analysis
deepakagarkhed@gmail.com 2211/13/2016

23. 20.Want of Sentinel event intensive analysis (CQI )
• Lack of mechanism to identify sentinel events
• Analysis of RCA for sentinel events
• CAPA on sentinel events
deepakagarkhed@gmail.com 2311/13/2016

24. Thank You
deepakagarkhed@gmail.com 2411/13/2016