This document discusses understanding quality control and accreditation processes for Medishine Hospital in 2015. It covers the 10 chapters and 100 standards of the NABH accreditation process. The standards focus on both the provider and recipient perspectives to ensure quality and accessible healthcare. It outlines various patient-centered and organization-centered standards that the hospital must meet regarding areas like access, assessment, patient rights, infection control, and management. Gaining NABH accreditation provides benefits like improved health outcomes, client satisfaction, and a good reputation for both patients and healthcare providers.

1. Understanding
Quality Control
and
Accreditation Process
Medishine Hospital-2015

4. NABH Standards
• 10 chapters
• 100 standards
• 514 objective elements
• Each accreditation standard is a statement of an
expectation or requirement which makes it possible
to deliver quality care
• Objective element are sub components of standards

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

6. PATIENT CENTERED STANDARDS:
• Access, Assessment and Continuity of Care (AAC)
• Care of Patients (COP)
• Management of Medication (MOM)
• Patient Rights and Education (PRE)
• Hospital Infection Control (HIC)

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

8. ORGANIZATION CENTERED STANDARDS:
• Continuous Quality Improvement (CQI)
• Responsibilities of Management (ROM)
• Facility Management and Safety (FMS)
• Human Resource Management (HRM)
• Information Management System (IMS)

9. ORGANISERS CONCERNS
• Responsible to the
management for the funds
spent on health care
• To ensure safety of public &
prevent inappropriate or
suboptimal care
• To meet the requirements of
the recipient and provider of
the health care services at
Acceptable costs

10. HOSPITAL MANUAL
• The Hospital manual is a
mandatory documents for NABH
accreditation certification
• It maintains quality system in
hospital and medical lab and
research center.
• This manual documents describes
scope of services, hospital policy
and mission, applicable law and
regulation, quality policy and
organization structure.
ये क्या
है…?

12. HOSPITAL MANUAL
Access, Assessment
and
Continuity of Care
(AAC)

13. HOSPITAL MANUAL
Access - Scope of services
• Registration Policy for Admission
• Filling the admission form
• Procedure during non availability of beds
• Laboratory safe practices
• Radiology services
• Admission of patient in ICU
• …….etc

14. Assessment Policy – Scope of Services
• Discharge Procedure Care of Patients (COP)
• Uniform care of patient
• Administration of Anesthesia
• Admission Criteria for ICU
• Ambulance services
• Bed Management in ICU
• Care of patient under Surgical Procedure
• Care of Vulnerable Patient
• Criteria for Discharge of Patient
• Emergency care
• Handling of Medical Legal Cases

15. • End of Life Care
• Nutritional Assessment of Patient
• Pain Management
• Prevention on Adverse Event in Surgical Patient

16. • Pharmacy Services
• Acquisition of medicines
• Storage of medication
• Prescription of medicines
• Verbal order of medication
• List of high risk medication
• Dispensing of medication
• Medication administration

17. List of condition required informed consent
• Patient Charter
• Display Copy
• Hospital Infection Control (HIC)
• Infection control manual
• Personal Hygiene
• Personal Attire
• Hand Washing
• Receipt of used material for Processing
• Proper Method of cleaning

18. Benefits of
NABH
Accreditation

19. BENEFITS TO THE CLIENTS
• Good health outcomes.
• Client satisfaction.
• Value for money
• Less frustration

20. BENEFITS TO HEALTH PROVIDERS
• Health staff become more satisfied with their
work.
• Health workers understand patients better.
• Information flow among staff is improved.
• Health staff who perform well are rewarded.

21. BENEFITS TO THE HEALTH INSTITUTIONS
• Patients become more satisfied with the
services.
• More patients may use our services.
• The environment will become clean and
beautiful.
• The facility will have a good reputation

22. PREMANSHU DEY
Lead Trainer – IIC India