NABH Project Proposal - Blue Ocean Consultantsblueoceanconsultants.in/.../uploads/2014/07/NABH-Project-Proposal.… · NABH Project Proposal ... NABH consultants and quality coordinators

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NABH Project ProposalNABH Project Proposal

Blue Ocean Consultantswww.blueoceanconsultants.in

[email protected]: 09811114879

1. Feasibility Study1. Feasibility Study

• Onsite visit by BOC Team of consultants• Interaction• Feasibility round of the facility• Manpower availability with the hospital for

supporting quality programme• Estimates of on site & off site period of consultancy

and man days• Manpower required for consultancy• Discussions with the top management

[email protected] 09811114879www.blueoceanconsultants.in

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2. Signing of MOU2. Signing of MOU

• Discussions with top management & reachingan agreed plan and period

• Financials of consultancy• Roles of BOC & Client organization• Support during the project period• Communication channel


3. Rolling the Project3. Rolling the Project

• Detailed discussions with top management– Clarification of Consultant- Client relationship– Agreement on the time frame– Nomination of a Management Representative and

a Quality Coordinator– Allocation of Resources for hospital quality cell


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4. Sensitization Training4. Sensitization Training

• Sensitization of all the workers/ staff membersof the Hospital to NABH Standard andvolunteer enrollment


5. Conducting Gap Analysis5. Conducting Gap Analysis

• Preparation of detailed Gap Analysis report:Extensive activity spread over a period ofabout 20-30 days with both onsite (2X1 + 3X2Man days) and off site activities by team ofNABH consultants and quality coordinators

• Manpower, equipment, engineering, processgaps


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6. Process map6. Process map

• Preparation of process map of major activitiesto be undertaken for NABH as per the gaps

• This shall also form a part of the gap report


7. Gap Closure Strategy7. Gap Closure Strategy

• Recommendations and preparation of strategyto close the major gaps


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8. Gap Presentation8. Gap Presentation

• Submission & Discussions on details of GapAnalysis report (One hard copy & One PDFcopy)


9. Formation of Quality Committees9. Formation of Quality Committees

• Formation of Hospital Quality committees togo into detailed process charting and systemdevelopment and implementation

• One to one meetings with these committeesto evolve the system


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10. Training of Quality Committees10. Training of Quality Committees

• Conduct of quality committees• Area of work for each quality committee• Activation of committees• Committee meetings and records• Identification of in-house trainers

• Regular committee meetings and records


11. Training on complete NABH11. Training on complete NABHstandardsstandards

• Top management• Quality coordinator and managers• Administrators• All quality committees• HODs and active hospital staff• Nursing• Paramedics• Support staff


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12. System Development12. System Development

• Assist in system development- Policies,Procedures, SOPs, Work instructions, Clinicalguidelines, new forms (Clinical administrative)etc.

• Most time consuming & resource intensiveactivity


13. Quality Manuals13. Quality Manuals

• Guidance on the documents (Quality manuals)and review of all documents, forms, brochuresetc.

• Printing and distribution of quality manuals,SOPs, forms, files etc.

• Repeated reading and understanding by thestaff


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14. Indicator Programme14. Indicator Programme• Identification of indicators and preparation of a Dash Board

for monitoring the system.• 64 Mandatory indicators: expanded to about 90+ in number• Other indicators• Data collection• Data entry• Data compilation• Information generation• RCA• CAPA• Repeat monitoring• Records• Hospital shall conduct this activity under BOC Consultants

[email protected] 09811114879

www.blueoceanconsultants.in

15. Trainings15. Trainings

• Training & Orientation of in-house Qualityteams and other workers of the Hospital inboth clinical and administrative as required bythe applicable NABH Standards.


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• NABH Standards• Committee trainings• Medication safety• Training on making entries to the medical records• Infection control, surveillance and monitoring• Regulatory and legal requirements• Consent in medical practice• Indicator programme in hospital• Surgical safety• Patients and family rights and responsibilities• General conduct of medical and nursing staff• Disaster management and safety• Medical Audit training and work shop• Internal audit training


16. Implementation16. Implementation

• Implementation of system through theHospital appointed quality executive & staffmembers, by providing guidance & othersupport

• Parallel activity


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17. Internal Assessment17. Internal Assessment

• Internal Audit and generation of Gap toolkitReport on objective elements of qualitystandards applied.


18. Gap Closure18. Gap Closure

• Guide the organization in closure of Gaps• Review & Advice


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19. Internal Assessment Toolkit19. Internal Assessment Toolkit

• Final Internal Assessment (Toolkit as per theapplied standards)


20. Application for Pre20. Application for Pre--AssessmentAssessment

• Giving advice on timing of application• Assisting in preparation of application for

NABH pre-assessment

• Time consuming activity


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STEPS TO ACCREDITATIONSTEPS TO ACCREDITATIONBOC

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PreparatoryPhase I

(6-8 Months))

TopManagementConsultation

BaselineAssessmentGap Analysis

Chapter-wiseOrientation,

Hospitalstationery and

committeeformation

Hospital-wideDocumentation

Hospital wideQuality

indicators

ImplementationPhase II

(4 Months)

Hospital-widetrainings & Mock

Drills

ComprehensiveNABH Training

Monitoring &Assessment Phase

III(3-4 Months)

NABH StandardsCompliance Audit -

Internalassessment I


Internal assessment - II


Internal assessment III


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NABH Accreditation Process

Self Assessment

Pre Assessment

FinalAssessment

Intense preparationof 8- 10 months

NABHCertification

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NABH ACCREDITATION PROCESSNABH ACCREDITATION PROCESS

Application for Accreditation by HCO

Acknowledgment & Scrutiny ofapplication by NABH Secretariat

Self Assessment submission by HCO(as per NABH Toolkit)

Pre-Assessment Visit (By NABHAssessment Team)

Final Assessment of Hospital (ByNABH Assessment Team

Review of Assessment Report (byNABH Secretariat)

Recommendation for Accreditation (ByAccreditation Committee)

Approval for Accreditation (ByChairman – NABH)

Issue of NABH Certificate

Feedback toHCO

And

NecessaryCorrection

Action takenby HCO

HCO

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HOW TO GO ABOUT?HOW TO GO ABOUT?BOC


• The project involves a lot of back office andoffsite activities that the BOC shall conductduring the project period


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Staff Allocation by BOC ConsultantsStaff Allocation by BOC Consultants

• One Senior BOC Quality Consultant for regularguidance. Onsite visits about 16-18 man days + Off siteinvolvement

• One onsite BOC quality coordinator for assisting in dayto day activities for the duration of project. Availablefor a maximum of 8-10 days a month onsite + Off siteactivities

• Additional Staff for gap report• Back office staff at BOC House for supporting the

project including research, documentation, reports,project management, communication etc.


• Team for Initial Gap analysis– NABH Senior consultant - 1– NABH Consultants- 2-3– Hospital Architect-1 (Not mandatory)– NABH Advisor Consultant(s)– Back office staff, Off-site for preparing reports and

providing all necessary material, documents,logistics

– Coordinator


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Duration of ProjectDuration of Project

• 10 months, including feasibility & gap analysis


Other requirements: Hospital needsOther requirements: Hospital needsto provide for:to provide for:

• Hospital Quality Executive/ Manager• Quality cell with dedicated hospital staff:

a) Hospital Quality Manager/ Executive/ Coordinatorb) DEO: Data entry, maintenance of quality documents/ records/

circulars• Internet and phone access• Computer, printer• Stationary• Meeting place with PPT project/ Audio system for large

audience for training• Meeting place like board room for small meetings/

trainings


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• ACLS/ BLS Trainings by recognized agencies/bodies/ individuals

• Disaster trainings and Mock drills with thehelp of local district/ civic agencies

• Clinical trainings, if required• Professional development


Regulatory Gap ClosureRegulatory Gap Closure

• Become a legally compliant organization• All major areas involved• Gap identification• Requires dedicated team for gap closure• Persistence• Monitoring on day to day basis with external

agencies•• Outcome: User SafetyOutcome: User Safety


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Building InfrastructureBuilding Infrastructure

• Modifications• New areas• New requirements• Signage• Safety

•• On time execution & qualityOn time execution & quality


Manpower gap closureManpower gap closure• Number: Need to close this gap at the earliest (Max in

3months) so that they are a part of quality trainingsprovided by BOC/ Hospital trainers

• Qualifications• Trainings• HR policies• HR issues• Staff Retention strategies

•• Outcome: Satisfied, trained and safe staffOutcome: Satisfied, trained and safe staff


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Equipment gap closureEquipment gap closure• Number• Procurement• Legal• AMC/CMC• Inventorying• Labelling• Calibration• Utilization• Maintenance• Staff Training• Safety• BME dept/ personnel


Process Gap ClosureProcess Gap Closure

• Supporting the changing processes,procedures and practices

• Ensuring proper staff attendance in alltrainings and mock drills

• Developing proper communication of thequality cell with the hospital staff

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Top ManagementTop Management

• Support• Commitment• Resource allocation• Monitoring• Guidance


Documents

NABH Project Proposal - Blue Ocean Consultantsblueoceanconsultants.in/.../uploads/2014/07/NABH-Project-Proposal.… · NABH Project Proposal ... NABH consultants and quality coordinators