Journey towards healthcare excellance Tips to overcome ... · PDF file1 National Accreditation Board for Hospitals & Healthcare Providers Tips to overcome most common obstacles in

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National Accreditation Board for Hospitals & Healthcare Providers

Tips to overcome most common obstacles in Preparing for NABH

accreditation

Dr S Murali MD DMConsultant Neurologist

Manipal Hospital

Bangalore

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Journey towards healthcare excellance

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Achieve Service & Clinical Excellence

Healthcare Accreditation

Establish quality systems


Perceived Obstacles• Understanding by the TOP management

• Who will drive it

• Documentation

• Legal

• Infrastructure

• Manpower

• Clinician involvement

• Others including certain grey areas – viz End of

life care3


Regulatory Compliance

Total Quality Management in a Hospital

Regulations, Laws, Ethics


Documentation



Efficiency

Process Management



Excellence in patient care

Documentation



Complaint, Waste, and Defect

Reductions, Elimination of Rework

Efficiency

Process Management


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Recog-

nition of

Quality

Excellence in patient care

Documentation



Patient Satisfaction

Employees' Satisfaction

Management Satisfaction

Complaint, Waste, and Defect

Reductions, Elimination of Rework

Efficiency

Process Management

Regulations / Laws


TOP Management

• Should believe that having standard

quality through accreditation will add value

• Aim at improving quality and accreditation

is a by product

• Unconditional support to the quality team

• Should understand its own role – esp in

context to mission, vision, operation and

strategic plan

• Track of all legal requirements8


Who will drive it

• Team and not dependent on a single

individual

• Accreditation co ordinater

• Form subgroups involving relevant stake

holders.

• Educate the team - POI

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Documentation Pyramid

• 1 – Quality Manual (Apex Manual)

• 2 – Documented Policies & Procedures, Patient Flow Diagrams, Organograms

• 3 - Work Instructions, SOPs where required

• 4 - Records, Formats, Registers, Forms

• 5 - External Documents, Statutory &

Regulatory requirements

Ensure that the end user is involved in documentation.


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NABH ACCREDITATIONSample headings for Policies

• Scope / Aim / Objective

• Definition• Indications• Responsibilities• Contents / explanations / detailing or various processes • Pre procedure / procedure / post procedures

• Resources• Training requirements• Monitoring and analysis• Corrective and preventive action• References


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NABH ACCREDITATIONCommittees – Salient features• Composition

• tenure

• roles and responsibilities

• objectives

• functioning

• quoram

• Meetings / agenda

• minutes

• monitoring

• reporting pattern

• reports

• action taken

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Legal• Identify all legal requirements

• Maintain a compliance registrar with the

following

– Name

– Number

– Status

– One time or renewable( if renewable the next date)

– Responsibility for renewals and updating the

amendments

– Conditions if any13


Infrastructure

• Identify all the infrastructure requirements

• Segregate them into – essential and

desirable

• Prioritise as per the essentiality and the

availability of resources.

• Consult experts in the field if required and

start work early

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Manpower

• Identify requirement and have an effective

manpower planning

• Grey areas

• Compliance

• Reference

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Clinician Involvement

• Educate on the benefits of accreditation to

the clinician

• Educate on improvements in patient safety

that accreditation can provide

• Educate on what is the minimum

involvement of the clinician to ensure the

above

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Other perceived Pain areas

• PAIN

• ADVERSE DRUG EVENTS

• END OF LIFE CARE

• AIR CONDITIONING

• MEDICAL AUDITS

• INDICATORS

• TRAINING

• PREVILEGING AND CREDENTIALING17


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NABH ACCREDITATION

• Identify teams

• Identify and form / merge relevant committees

• Workshop

• Next deadline – Identify gaps and prepare draft

document - date

• Next meeting / frequency

• Training of various groups

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NABH ACCREDITATION

• Sensitisation of various professional

• Form Sub groups and delegate

• Have the mandatory committees formed

• Identify and implement training requirements

• Identify and address all infracture,statuary and legal

compliance

• Target dates for completing documentation and implementation

• Periodic review


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NABH ACCREDITATIONSteps

• Multidisciplinary team

• Steering committee for NABH

• Understand the standards - workshops

• Form subgroups and Identify gaps from the existing practices and from other quality management systems in relation to the NABH standards

• Interact / educate the end users regarding the same

• Help the relevant stake holders in preparation of the policies and procedures that complies with the NABH standard – approved by the core committee /director medical / admin services/legal team and implement


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NABH ACCREDITATIONSteps

• Ensure NABH standards are implemented and integrated in the hospital functioning

• Do an internal audit

• Call for pre-assessment

• Corrective actions

• Assessment

• ACCREDITATION

• Maintain quality improvement programme


Carry Home message• Prioritise

• Give importance to processes

• At every point ensure that the standard is

addressed

• Make the process simple – Have processes

that can be followed rather than what is ideal.

• Identify and address crucial infrastructure and

draw a plan for the rest

• Train your group - POI22


Carry Home message

• Manpower (IPHS) and bed occupancy

• Focus on training

• Statutory obligations has to be met

• Identify and implement completely all the

easily implementable processes

• Difficult one go on a step by step manner.

• Take 3 standards per week

• Accreditation levels23


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NABH ACCREDITATION

Follow each objective element meticulously and accreditation will follow

Thank You