Case study of an Accredited Hospital- our experience

NSD RajuRanjini Eye Hospital (India’s first NABH

Accredited SHCO )

• I have no financial interest or relationships to disclose

Day care Ophthalmic surgical Center

Small Health Care Organization ( SHCO)

Ambulatory Ophthalmic Surgical Centre

Our Ophthalmic Out patient surgical Centre

• Located in an open space• Accessibility• Parking facility• Built in area

5000 sq.ft

Journey towards Accreditation

• NABH came into being in 2006• Applied for NABH in 2007• Pre assessment and final auditing done • Did not fully conform to the rigid standards

laid down for bigger institutions• Assessors impressed by the standard of

Patient care and other supportive and utility services

Journey Continues

• NABH Set Standards• for Small Heath Care Org• Bed Strength up to 50• Appropriate supportive and utility services• Polyclinics and diagnostic centers not included• Specialty Day care centers included • Bed strength not mandatory

The Final Accreditation

• Our center then came under the category of SHCO

• Centre Eligible for NABH accreditation

• Reapplied for NABH accerditation after a self assessment auditing

• Final auditing in 2009 –cleared for NABH accrditation

Why NABH for Small Ophthalmology Hospitals

• Commitment to quality health care• Benchmark with international quality• Continuous improvement• Community confidence• Empanelment in government and insurance

schemes , medical tourism patronage

Accreditation Standards- Patient Care Oriented

• 1.Access, Assessment and continuity of Care (AAC)

• In the care of patients rehabilitation excluded

• Management of Medications narcotics delete• Patients Rights and education• Hospital Infection Control

Accreditation Standards- Organization Oriented

• Continuous Quality Improvement (CQI)

• Responsibilities of Management (ROM)

• Facility Management and Safety (FMS)

• Human Resource Management (HRM)

• Information Management System (IMS)

Continuous Quality Continuous Quality Improvement Improvement

Structured quality improvement Monitor tools for continual improvement of

structures processes and outcomes Established system for clinical audit Analyze sentinel events

Hospital Infection Control

• Well defined coordinated comprehensive HIC• Infection control manual• Measures to reduce hospital associated

infections – designing surgical suite• Documented Sterilization Procedures

Information Management System

• Effective management of data

• Converted to complete and accurate EMR

• Paperless Office ensure continuity of service

• Documented procedure for safety and security

Patient Rights and Education

• Protection of patient and family

• Documented policy for consent

• Right to information about their health care needs and cost of treatment

Responsibilities of Management

Responsibilities of management well defined

Patient safety aspects and risk management issues forms an integral part of hospital management

Other Measures

• MOU with Hospital for Patients needing admission/emergency

• Arrangement for ambulance Facility

Conclusion

• NABH Benefits• Ongoing continuing process of

improvement

• Ensures best possible team work in a Health Care Organization

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Thank You