Slide 1: ACCREDITATION AS A TOOL FOR QUALITY IMPROVEMENT IN A HEALTCARE SETTING: INDIAN SCENARIO
Kuwait Quality Summit
May 25-26, 2010 B.K. Rana, Ph.D
National Accreditation Board for Hospitals & Healthcare Providers (NABH)
Institution of Engineers Building, 2nd Floor
Bahadur Shah Zafar Marg, New Delhi- 110002, India
Tel: 91-11- 23379321,23379260,23370567 Web: www.qcin.org
E-mail:email@example.com What is Accreditation? : What is Accreditation? Public recognition of the achievement of accreditation standards by a healthcare organization, demonstrated through an independent external assessment of that organization’s level of performance in relation to the standard.
(ISQua) Hospital Accreditation in India : 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. Slide 4: 4 A constituent board of Quality Council of India (QCI)
To provide accreditation services to hospitals and healthcare providers Structure of QCI : Structure of QCI 5 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) Structure of NABH : Structure of NABH 6 National Accreditation Board for Hospitals & Healthcare Providers Technical Committee Panel of Assessor/Expert Accreditation Committee Appeals Committee Quality Council of India Secretariat Slide 7: Accreditation of Wellness Centers Accreditation of PHC/CHCs Accreditation of OST Centers Accreditation of AYUSH hospitals Accreditation of Medical Imaging Services
(Ready for launch) International Recognition NABH is an institutional member of the International Society for Quality in Health Care (ISQua) since 2006. : International Recognition NABH is an institutional member of the International Society for Quality in Health Care (ISQua) since 2006. 8 International Recognition : 9 ISQua Board Member
Member of Accreditation Council
ASQua Board Member International Recognition International Recognition : 10 ISQua Accreditation of NABH Standards for Hospitals (April 2008 – March 2012) International Recognition Basic Principles of Accreditation : Basic Principles of Accreditation Statutory/ Regulatory/ Licensing – Compliance Must
It is based on structure, process and outcomes
Focused on Patient Care and Safety Slide 12: 12 Accreditation Standards Accreditation Standards for Hospitals : Accreditation Standards for Hospitals Access ,Assessment and Continuity of Care (AAC)
Care of Patients (COP).
Management of Medication (MOM).
Patient Right and Education (PRE).
Hospital Infection Control (HIC).
Continuous Quality Improvement (CQI).
Responsibility of Management (ROM).
Facility Management and Safety (FMS).
Human Resource Management (HRM)
Information Management System (IMS).
10 chapters,100 standards,514 objective elements. Objective of the study : Objective of the study To analyze the improvements in the quality of services rendered by different hospitals, accredited under the accreditation program of NABH, based on certain service and clinical standard indicators. Methodology : Methodology The hospitals were provided with questionnaire related to some service and clinical standards. They were requested to provide information on benefits of accreditation in terms of improvement in performance under different standards provided.
The standards selected are:
Service standards: a) Registration desk
c) IT and Billing
Clinical Standards: a) OPD standards
b) Diagnostic (Laboratory and Radiology)
c) OT and Nursing Slide 16: The data from hospitals accredited under NABH accreditation program was collected, analyzed and following observations were made RESULTS Slide 17: SERVICE STANDARDS
INDICATORS Slide 18: Scope of services well defined and understood by staff Job responsibilities of staff clearly defined Patients rights and responsibilities are identified and respected Admission process streamlined, admission counseling started Increased patient satisfaction and quality of care Increase in staff strength
in areas like enquiry, doctors
booking & console as per work load Staff review meetings for discussion complaints & suggestions REGISTRATION DESK Slide 19: Procurement, storage &
for medications well defined Special care taken in handling,
storing and dispensing sound
alike, look alike and high risk
medicines Improved inventory practices as a result of training of staff Regular medical audits Policies defined for handling of narcotic, radioactive& chemotherapeutic drugs. Adverse drug reactions & medication error tracking & review has been reinforced Lower incidents of medication related adverse events in care PHARMACY Slide 20: IT &
BILLING Auto stoppage of medication which have serious side effects unless reordered by the physician New out patient and in patient billing counters to meet up additional workload. Introduction of billing counseling Auto log& limitation on viewing privileges IT generated discharge summary Schedule of charges displayed through kiosk and handouts Safety of patient data & decrease in waiting time for billing Slide 21: CLINICAL STANDARDS
INDICATORS Slide 22: Corrective steps taken to reduce OPD consultation waiting time More emphasis on preventive care through patient education. Protocols for preventive health checks, cardiac evaluation, pre operative anesthesia, angiography have been reinforced Monthly review of statistics on mortality, code blue occurrence, capacity utilization, doctor’s performance etc. Increased patient satisfaction OPD Consultation Slide 23: Procedures and policies for pathology & radiology depts. implemented with standardized processes Wastages identified
and corrective actions
taken. Biomedical waste
practices improved Regular training of
radiation safety Continuous monitoring
of clinical tests
results Staff with requisite
employed Increased patient safety and enhanced quality of services provided DIAGNOSTICS Slide 24: Policy to prevent adverse
events like wrong site,
wrong patient &wrong
surgery is defined and
implemented Sterilization and disinfection practices are monitored and are in place Infection and environmental surveillance carried out regularly Rational use of blood and blood products in OT Proper documentation of OT notes and sign offs by treating surgeons are in place Improved practices in OT and reduced chances of error OT & Nursing Slide 25: Registration:
Staff awareness about various policies, procedures and services improved considerably.
Patient’s rights are now recognized and respected.
Turn around time reduced
Waiting time reduced
Ready stock of emergency drugs at all times
Improved inventory practices. CONCLUSION Slide 26: IT and Billing:
Security policy for the access of data and OPD records.
Restricted control and access to patient’s data.
Mandatory nutritional assessment .
Patient rights regarding privacy and confidentiality reinforced. Slide 27: Diagnostics:
Equipment calibration/preventive maintenance schedule monitored regularly.
Quality assurance programme implemented.
Corrective actions identified & implemented.
OT and Nursing:
Fumigation policy and hands washing is continuously monitored in OT.
Better Infection control
Continuous training, incidental teaching and supervision to ensure quality nursing service.
Motivation to nursing staff to be a partner in delivery of healthcare. Slide 29: THANK YOU