The document discusses quality and accreditation in healthcare. It defines quality as the degree of excellence that satisfies user needs and expectations. Accreditation involves an external review based on published standards to encourage organizational development. The National Accreditation Board for Hospitals & Healthcare Providers (NABH) oversees accreditation in India based on 10 chapters and 100 standards covering areas like patient care, management, and quality improvement. The process involves application, assessment, scoring, and reassessment to obtain accredited status for 3 years. Benefits include improved patient and employee satisfaction. Challenges include initial preparation and longer time for benefits to accrue.

1. Quality and Accreditation

2. ? ………. ?……….?…… Degree of excellence possessed by a Product, Process or Person ‘The totality of features of a Product or Service that affects its ability to satisfy stated or implied needs and expectations of users . WHAT IS QUALITY ?

3. QUALITY FROM WHOSE POINT OF VIEW ? Provider of Health care Services Recipient of the Health care services Organizer of the Health care services

4. PROVIDERS CONCERNS To provide care as per established norms Adequate resources Self satisfaction with the final outcome Should contribute to enhancement of skills, competence and add to experience

5. RECIPIENTS CONCERNS Accessibility Affordability Prompt attention Less waiting time Early diagnosis and cure Return to Productivity as early as possible Humane Treatment ie to be treated with empathy , respect and concern

6. ORGANISER’S CONCERNS Responsible to the Society for the funds spent on health care To ensure safety of public and prevent inappropriate or suboptimal care To meet the requirements of the recipient and provider of the health care services at Acceptable costs

7. WHAT IS ACCREDITATION Accreditation is an external review of quality with four principal components: It is based on written and published standards globally / nationally accepted Reviews are conducted by professional peers The accreditation process is evaluated by an independent body The aim of accreditation is to encourage organizational development and enhancement

8. Focus of standards Patient Safety Staff and employee safety Environment and community safety Information Education and Communication

9. Hospital Accreditation in India Started in India in the year 2005 by National Accreditation Board for Hospitals & Healthcare Providers (NABH) NABH is a constituent board of Quality Council of India (QCI) set up to establish and operate accreditation programme for healthcare organizations. QCI is an Autonomous body jointly set up by the Government of India and Indian industries to establish and operate National Accreditation Structure. The board while being supported by all stakeholders including industry, consumers, government, has full functional autonomy in its operations.

10. A constituent board of Quality Council of India (QCI) To provide accreditation services to hospitals and healthcare providers

11. Structure of QCI Quality Council of India National Accreditation Board for Certification Bodies (NABCB ) National Board for Quality Promotion (NBQP) National Accreditation Board for Testing and Calibration Laboratories (NABL) National Accreditation Board for Education and Training (NABET) National Accreditation Board for Hospitals & Healthcare Providers (NABH) Quality Information and Enquiry Service (QIES )

12. Structure of NABH National Accreditation Board for Hospitals & Healthcare Providers Technical Committee Panel of Assessor/Expert Accreditation Committee Appeals Committee Quality Council of India Secretariat

13. International Recognition NABH is an institutional member of the International Society for Quality in Health Care (ISQua) since 2006.

14. International Recognition ISQua Accreditation of NABH Standards for Hospitals (April 2008 – March 2012)

15. Other International Standards Trent accreditation scheme based in UK- Europe QHA Trent Accreditation for UK JCI based in USA ACHSI based in Australia CCHSA based in Canada Accréditation of France ( La Haute Autorité de Santé ) based in Paris, France ISQua and UKAF are the umbrella organisations for those providing International Healthcare accréditation

16. DRIVING FACTORS FOR ACCREDITATION Globalization Economic liberalization Privatization of healthcare services Consumer Protection Act Clinical Establishment Act Insurance Companies Regulation Empanelment by CGHS, ECHS, Corporate companies etc. Community and Patient awareness & response Patient's expectations from healthcare providers Health Tourism

17. Benefits of NABH Accreditation Patient satisfaction Continuous quality improvement Employee’s satisfaction Empanelment with all Insurance Companies

18. Is it mandatory? Paper clippings, news articles – Insurance Coverage

19. NABH Standards 10 Chapters 100 Standards 515 Objective Elements

20. Section I :Patent-Centered Standards STD OE Access, Assessment and Continuity of Care (AAC) 15 78 Patients Rights and Education (PRE) 05 29 Care of Patients (COP) 18 105 Management of Medications (MOM) 13 61 Hospital Infection Control (HIC) 0 9 44 60 317

21. Section II: Health Care Organization Management Standards STD OE Continuous Quality Improvement (CQI) 6 37 Responsibilities of Management (ROM) 5 20 Facility Management & Safety (FMS) 9 41 Human Resource Management (HRM) 13 47 Information Management Systems (IMS) 7 41 40 186

22. Accreditation Process Applications Screening of the Applications Pre-assessment survey Assessment Survey Review of the recommendations of the assessing body by the Accreditation Committee Recommendations to the board Accreditation decision

23. WHO CAN APPLY Any Health Care Organization Requirements Currently in operation as a HCO Preferably registered or licensed Willing to assume responsibility for improving quality of care Should be able to meet the prescribed standards of the accrediting organization

24. HOW CAN ONE APPLY Basic Ingredients Organization apply on prescribed format giving details as required Submission of a self assessment form indicating the outcomes of its QMS and Internal Audits Extent of adherence to the laid down standards

25. SCREENING OF APPLICATIONS Completeness Accuracy Clarifications sought if required

26. PREASSESSMENT SURVEY To ascertain the readiness of the organization for Accreditation Overview of the organizational preparedness and commitment to quality goals and consonance to laid down standards Deficiencies noticed informed to the organization Advice rendered on the methodology to be followed during the Accreditation Survey Time frame worked out for the survey in mutual consultation

27. ACCREDITATION SURVEY Carried out by a team of Assessors depending upon the size, complexity and facilities provided by the organization Scope will include all standards related functions and all patient care settings Onsite survey will consider specific cultural and legal factors which may influence or shape decisions regarding the provision of care and /or policies and procedures

28. METHODOLOGY OF SURVEY Initial presentation by the hospital Document Review Adherence to statutory obligations Visits to various areas Facility surveys and tours Random structured interviews

29. INITIAL PRESENTATION BY THE HOSPITAL Organogram Quality management Team Methodology followed for Quality Improvement Facilities provided Inputs on resources provided for Quality Improvement Identified high Risk Areas for patient care and safety Sentinel Events being monitored

30. INITIAL PRESENTATION BY THE HOSPITAL Key Monitoring Indicators Resource Volume Utilization Performance Control charts Problems faced and remedial measures undertaken/ being undertaken

31. DOCUMENT REVIEW Quality Manual Various Policies and Procedures Minutes of Meetings of various committees Medical Records Medical / Nursing Audit Adverse Events HAI Action Taken Reports Personal Records of Staff

32. OBSERVATIONS Facility Safety Level of compliance with laid down policies and procedures BMW Management Standard Precautions Patient care Fire Safety Equipment Management

33. INTERVIEW Staff Interview To determine their level of awareness and compliance with organization policies and procedures To assess their awareness levels of their rights, privileges and patient rights To determine their satisfaction levels Patient and family Interview To assess their level of awareness of the care process and their rights To determine their satisfaction levels

34. SCORING PATTERN NABH has laid down the following pattern Non-compliance 0 Partial compliance 5 Full compliance 10 No standard can have more than one zero The average for a standard must exceed 5 The overall average score must exceed 7 No zeros in legal requirements

35. Process of Accreditation Initial Application including Self Assessment as per the laid down standards Screening of the Application Pre assessment survey Assessment survey Accreditation committee Recommendations If required Verification Visit Approval of Accreditation by the NABH Re-Assessment Surveys

36. OUTCOMES OF ACCREDITATION SURVEYS Accredited HCO shows acceptable compliance with laid down standards in all areas Includes the scope of services for which accredited Any increase in scope the survey has to be done for the increased scope Accreditation denied HCO is consistently non compliant with standards Accreditation withdrawn HCO withdraws voluntarily Due to consistent non compliance or non adherence to safe and ethical practices

37. DURATION OF ACCREDITATION AWARDS Generally three years with one Reassessment survey to ensure continued compliance and to assess the CQI programme If during accreditation The Accreditation organization receives inputs that the organization is substantially out of compliance with the current standards then Resurvey or withdrawal of accredited decision may be resorted to

38. How to Go About Create willingness Initial impetus from Top management Requires involvement of all staff This requires repeated training and briefing Once consensus is there identify core coordinating or Quality management Team

39. How to Go About Examine what are you doing Find what you should be doing Document the gaps Compare with the standards Complete gap analysis Identify areas for improvement

40. How to Go About Focus on uniform training of all employees in key areas Encourage by financial and / or non-financial incentives Initially prepare to provide extra resources Avoid disappointments if initial benefits do not accrue as expected Be prepared for a longer gestation period for benefits to accrue

41. PROBLEMS AND CHALLENGES HCOs are very enthusiastic Ill prepared Initial preparation is shoddy Resources required initially Benefits have a longer gestation period

42. PROBLEMS AND CHALLENGES Quality Consciousness at all levels will take time Sustenance and consistency of efforts will be required Commitment on a consistent basis High rates of attrition will require repeated and continual training Public Sector will take a longer time to get into the process Quality and consistency of assessors and assessments

43. THE CURRENT STATUS OF ACCREDITATION IN INDIA Initializing phase is over. Phase of consolidation. The initial steps have been difficult but the journey has begun. The journey has to continue………. Especially since ---------------------------

44. How will IASO help? To provide guidelines To submit the application form To submit the self assessment form To provide training To prepare SOPs and Manuals To conduct mock drills Internal auditing To prepare different forms as per the requirement of accreditation To provide guidelines for different activities related to accreditation.

45. Contd…. To prepare for pre assessment. To prepare for Final assessment. To review quality improvement time to time .

46. These May Look Difficult Initially, But the First steps are Never easy.

47. Also Nothing Is Impossible For,

48. Impossible Means I’ M Possible

49. ACCREDITATION IS A JOURNEY AND NOT A DESTINATION.

50. BON VOYAGE !!!!!

51. Looking forward to a long term association, Thank You! For more information, please contact [email_address] [email_address] bhaveen.sheth @iasosol.com