Natonal Accreditation for Hospital & Health Care Providers (Nabh)

8/3/2019 Natonal Accreditation for Hospital & Health Care Providers (Nabh)

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NATONAL ACCREDITATIONFOR HOSPITAL & HEALTH CARE

PROVIDERS(NABH)

SHISHIR JAIN

NARAYANA HRUDALAYA


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WHAT IS QUALITY ?WHAT IS QUALITY ?


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AppropriateAppropriate applicationapplication ofof medicalmedical

knowledgeknowledge withwith duedue regardregard toto thethe

balancebalance betweenbetween thethe hazardhazard inherentinherent

inin everyevery medicalmedical interventionintervention andand thethe

benefitsbenefits expectedexpected fromfrom itit

ItIt is,is, howeverhowever moremore complexcomplex thanthan

thisthis..


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QUALITY FROMWHOSEQUALITY FROMWHOSEPOINT OF VIEW ?POINT OF VIEW ?


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Provider of Health care ServicesProvider of Health care Services

Recipient of the Health careRecipient of the Health care

servicesservices

Organizer of the Health careOrganizer of the Health care

servicesservices


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PROVIDERS CONCERNSPROVIDERS CONCERNS

ToTo provideprovide carecare asas perper establishedestablished

normsnorms

AdequateAdequate resourcesresources SelfSelf satisfactionsatisfaction withwith thethe finalfinal

outcomeoutcome

ShouldShould contributecontribute toto enhancementenhancement ofof

skills,skills, competencecompetence andand addadd toto

experienceexperience


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RECIPIENTS CONCERNSRECIPIENTS CONCERNS

Accessibility

Affordability

Prompt attention

Less waiting time

Early diagnosis and cure

Return to Productivity as early as possible

Humane Treatment ie to be treated with

empathy , respect and concern


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ORGANISERS CONCERNSORGANISERS CONCERNS

ResponsibleResponsible toto thethe SocietySociety forfor thethe fundsfunds

spentspent onon healthhealth carecare

ToTo ensureensure safetysafety ofof publicpublic andand preventprevent

inappropriateinappropriate oror suboptimalsuboptimal carecare

ToTo meetmeet thethe requirementsrequirements ofof thethe recipientrecipientandand providerprovider ofof thethe healthhealth carecare servicesservices atat

AcceptableAcceptable costscosts


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WHAT IS ACCREDITATION


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Accreditation is an external review ofAccreditation is an external review of

quality with four principal components:quality with four principal components:

ItIt isis basedbased onon writtenwritten andand publishedpublished

standardsstandards

ReviewsReviews areare conductedconducted byby professionalprofessionalpeerspeers

TheThe accreditationaccreditation processprocess isis

administeredadministered byby anan independentindependent bodybody

TheThe aimaim ofof accreditationaccreditation isis toto encourageencourage

organizationalorganizational developmentdevelopment..


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Focus of standardsFocus of standards

PatientPatient SafetySafety

StaffStaff andand employeeemployee safetysafety

EnvironmentEnvironment andand communitycommunity safetysafety

InformationInformation EducationEducation andand CommunicationCommunication


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NABH STANDARDS


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Section I:Section I:PatientPatient--Centered StandardsCentered Standards

STDSTD OEOE

Access, Assessment and Continuity of CareAccess, Assessment and Continuity of Care (AAC)(AAC) 1515 7878

Patients Rights and EducationPatients Rights and Education (PRE)(PRE) 0505 2929

Care ofPatientsCare ofPatients (COP)(COP) 18 10518 105

Management ofMedicationsManagement ofMedications (MOM)(MOM) 1313 6161

Hospital Infection ControlHospital Infection Control (HIC)(HIC) 0099 4444

6060 317317


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Section II:Health Care Organization

Management StandardsSTDSTD OEOE

Continuous Quality ImprovementContinuous Quality Improvement (CQI)(CQI) 66 3737

Responsibilities ofManagementResponsibilities ofManagement (ROM)(ROM) 55 2020

Facility Management & SafetyFacility Management & Safety (FMS)(FMS) 99 4141

Human Resource ManagementHuman Resource Management (HRM)(HRM) 1313 4747

Information Management SystemsInformation Management Systems (IMS)(IMS) 77 4141

4040 186186


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Accreditation ProcessAccreditation Process

ApplicationsApplications

ScreeningScreening ofof thethe ApplicationsApplicationsPrePre--assessmentassessment surveysurvey

AssessmentAssessment SurveySurvey

ReviewReview ofof thethe recommendationsrecommendations ofof thetheassessingassessing bodybody byby thethe AccreditationAccreditationCommitteeCommittee

RecommendationsRecommendations toto thethe boardboard

AccreditationAccreditation decisiondecision


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WHO CAN APPLYWHO CAN APPLY

AnyAny HealthHealth CareCare OrganisationOrganisation

RequirementsRequirements

CurrentlyCurrently inin operationoperation asas aa HCOHCO

PreferablyPreferably registeredregistered oror licensedlicensed

WillingWilling toto assumeassume responsibilityresponsibility forfor improvingimproving

qualityquality ofof carecare

ShouldShould bebe ableable toto meetmeet thethe prescribedprescribed

standardsstandards ofof thethe accreditingaccrediting organisationorganisation


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HOW CAN ONE APPLYHOW CAN ONE APPLY

BasicBasic IngredientsIngredients

OrganisationsOrganisations applyapply onon prescribedprescribed formatformat

givinggiving detailsdetails asas requiredrequired

SubmissionSubmission ofof aa self self assessmentassessment formform

indicatingindicating thethe outcomesoutcomes ofof itsits QMSQMS andand

InternalInternalA

uditsA

udits ExtentExtent ofof adherenceadherence toto thethe laidlaid downdown

standardsstandards


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SCREENING OF APPLICATIONSSCREENING OF APPLICATIONS

CompletenessCompleteness

AccuracyAccuracy

ClarificationssoughtifrequiredClarificationssoughtifrequired


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PREASSESSMENT SURVEYPREASSESSMENT SURVEY

ToTo ascertainascertain thethe readinessreadiness ofof thetheorganisationorganisation forfor AccreditationAccreditation

OverviewOverview of of thethe organizationalorganizationalpreparednesspreparedness andand commitmentcommitment toto qualityqualitygoalsgoals andand consonanceconsonance toto laidlaid downdownstandardsstandards

DeficienciesDeficiencies noticednoticed informedinformed toto thethe

organisationorganisation AdviceAdvice renderedrendered onon thethe methodologymethodology toto bebe

followedfollowed duringduring thethe AccreditationAccreditation SurveySurvey

TimeTime frameframe workedworked outout forfor thethe surveysurvey ininmutualmutual consultationconsultation


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ACCREDITATION SURVEY ACCREDITATION SURVEY

CarriedCarried outout byby aa teamteam ofof AssessorsAssessorsdependingdepending uponupon thethe size,size, complexitycomplexity andand

facilitiesfacilities providedprovided byby thethe organisationorganisation

ScopeScope willwill includeinclude allall standardsstandards relatedrelated

functionsfunctions andand allall patientpatient carecare settingssettings

OnsiteOnsite surveysurvey willwill considerconsider specificspecific culturalculturalandand legallegal factorsfactors whichwhich maymay influenceinfluence oror

shapeshape decisionsdecisions regardingregarding thethe provisionprovision ofof

carecare andand /or/or policiespolicies andand proceduresprocedures


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METHODOLOGY OF SURVEYMETHODOLOGY OF SURVEY

InitialInitial presentationpresentation byby thethe hospitalhospital

DocumentDocument ReviewReview

AdherenceAdherence toto statutorystatutory obligationsobligations

VisitsVisits toto variousvarious areasareas

FacilityFacility surveyssurveys andand tourstours

RandomRandom structuredstructured interviewsinterviews


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INITIAL PRESENTATION BYINITIAL PRESENTATION BYTHE HOSPITALTHE HOSPITAL

OrganogramOrganogram

QualityQuality managementmanagementTeamTeam

MethodologyMethodology followedfollowed forfor QualityQuality

ImprovementImprovement FacilitiesFacilities providedprovided

InputsInputs onon resourcesresources providedprovided forfor QualityQuality

ImprovementImprovement IdentifiedIdentified highhigh RiskRisk AreasAreas forfor patientpatient carecare

andand safetysafety

SentinelSentinel EventsEvents beingbeing monitoredmonitored


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INITIAL PRESENTATION BYINITIAL PRESENTATION BYTHE HOSPITALTHE HOSPITAL

KeyKey MonitoringMonitoring IndicatorsIndicators

ResourceResource

VolumeVolume UtilizationUtilization

PerformancePerformance

ControlControl chartscharts ProblemsProblems facedfaced andand remedialremedial measuresmeasures

undertaken/undertaken/ beingbeing undertakenundertaken


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DOCUMENT REVIEWDOCUMENT REVIEW

QualityQuality ManualManual

VariousVarious PoliciesPolicies andand ProceduresProcedures

MinutesMinutes ofof MeetingsMeetings ofof variousvarious committeescommittees

MedicalMedical RecordsRecords

MedicalMedical // NursingNursing AuditAudit

AdverseAdverse EventsEvents

HAIHAI

ActionAction TakenTaken ReportsReports

PersonalPersonal RecordsRecords ofof StaffStaff


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OBSERVATIONSOBSERVATIONS

FacilityFacility SafetySafety

LevelLevel ofof compliancecompliance withwith laidlaid downdown policiespolicies andand

proceduresprocedures

BMWBMW ManagementManagement

StandardStandard PrecautionsPrecautions

PatientPatient carecare

FireFire SafetySafety

EquipmentEquipment ManagementManagement


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INTERVIEWINTERVIEW

StaffStaff InterviewInterview ToTo determinedetermine theirtheir levellevel ofof awarenessawareness andand

compliancecompliance withwith organisationorganisation policiespolicies andand

proceduresprocedures

ToTo assessassess theirtheir awarenessawareness levelslevels ofof theirtheir

rights,rights, privilegesprivileges andand patientpatient rightsrights

ToTo determinedetermine theirtheir satisfactionsatisfaction levelslevels

PatientPatient andand familyfamily InterviewInterview

ToTo assessassess theirtheir levellevel ofof awarenessawareness ofof thethe

carecare processprocess andand theirtheir rightsrights

ToTo determinedetermine theirtheir satisfactionsatisfaction levelslevels


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SCORING PATTERNSCORING PATTERN

NABHhaslaiddownthefollowingpatternNABHhaslaiddownthefollowingpattern

NonNon--compliancecompliance 00

PartialcompliancePartialcompliance 55FullcomplianceFullcompliance 1010

NostandardcanhavemorethanonezeroNostandardcanhavemorethanonezero

Theaverageforastandardmustexceed5Theaverageforastandardmustexceed5

Theoverallaveragescoremustexceed 7Theoverallaveragescoremustexceed 7

NozerosinlegalrequirementsNozerosinlegalrequirements


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ProcessofAccreditation

Initial Application including Self Assessment asper the laid down standards

Screening of the Application

Pre assessment survey

Assessment survey

Accreditation committee Recommendations

If required Verification Visit Approval ofAccreditation by the NABH

ReAssessment Surveys


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OUTCOMES OF ACCREDITATIONOUTCOMES OF ACCREDITATIONSURVEYSSURVEYS

AccreditedAccredited HCOHCO showsshows acceptableacceptable compliancecompliance withwith laidlaid

downdown standardsstandards inin allall areasareas IncludesIncludes thethe scopescope ofof servicesservices forfor whichwhich

accreditedaccredited AnyAny increaseincrease inin scopescope thethe surveysurvey hashas toto bebe

donedone forfor thethe increasedincreased scopescope AccreditationAccreditation denieddenied

HCOHCO isis consistentlyconsistently nonnon compliantcompliant withwithstandardsstandards AccreditationAccreditation withdrawnwithdrawn

HCOHCO withdrawswithdraws voluntarilyvoluntarily DueDue toto consistentconsistent nonnon compliancecompliance oror nonnon

adherenceadherence toto safesafe andand ethicalethical practicespractices


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DURATION OF ACCREDITATIONDURATION OF ACCREDITATIONAWARDSAWARDS

GenerallyGenerally threethree yearsyears withwith oneone ReassessmentReassessment

surveysurvey toto ensureensure continuedcontinued compliancecompliance andand toto

assessassess thethe CQICQI programmeprogramme IfIf duringduring accreditationaccreditation TheThe AccreditationAccreditation

organisationorganisation receivesreceives inputsinputs thatthat thethe organisationorganisation

isis substantiallysubstantially outout ofof compliancecompliance withwith thethe currentcurrentstandardsstandards thenthen ResurveyResurvey oror withdrawalwithdrawal ofof

accreditedaccredited decisiondecision maymay bebe resortedresorted toto


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How to Go About

Create willingness

Initial impetus from Top management

Requires involvement of all staff This requires repeated training andbriefing

Once consensus is there identify corecoordinating or Quality managementTeam


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How to Go About

Examine what are you doing

Find what you should be doing

Document the gaps

Compare with the standards

Complete gap analysis

Identify areas for improvement


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How to Go About

Focus on uniform training of all employeesin key areas

Encourage by financial and / or non-

financial incentives

Initially prepare to provide extra resources

Avoid disappointments if initial benefits do

not accrue as expected Be prepared for a longer gestation period

for benefits to accrue


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PROBLEMS AND CHALLENGESPROBLEMS AND CHALLENGES

HCOsHCOs areare veryvery enthusiasticenthusiastic

IllIll preparedprepared

InitialInitial preparationpreparation isis shoddyshoddy

ResourcesResources requiredrequired initiallyinitially

BenefitsBenefits havehave aa longerlonger gestationgestation

periodperiod


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PROBLEMS AND CHALLENGESPROBLEMS AND CHALLENGES

QualityQuality ConsciousnessConsciousness atat allall levelslevelswillwill taketake timetime

SustenanceSustenance andand consistencyconsistency ofofeffortsefforts willwill bebe requiredrequired

CommitmentCommitment onon aa consistentconsistent basisbasis

HighHigh ratesrates ofof attritionattrition willwill requirerequirerepeatedrepeated andand continualcontinual trainingtraining

PublicPublic SectorSector willwill taketake aa longerlonger timetimetoto getget intointo thethe processprocess

QualityQuality andand consistencyconsistency ofof assessorsassessors

andand assessmentsassessments


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These May Look DifficultThese May Look Difficult

Initially, But the FirstInitially, But the First

steps are Never easy.steps are Never easy.


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Also Nothing IsAlso Nothing Is

ImpossibleImpossible

For,For,


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ImpossibleImpossible

MeansMeans

I M PossibleI M Possible


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Quality Norms and Accreditation??

Response of Medical Fraternity


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ExpectedResponseExpectedResponse


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THE CURRENT STATUS OFTHE CURRENT STATUS OFACCREDITATION IN INDIAACCREDITATION IN INDIA

InitializingInitializing phasephase isis overover..

PhasePhase ofof consolidationconsolidation..

TheThe initialinitial stepssteps havehave beenbeen difficultdifficult butbut

thethe journeyjourney hashas begunbegun..

TheThe journeyjourney hashas toto continuecontinue..

EspeciallyEspecially sincesince ------------------------------------------------------


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ACCREDITATION IS A JOURNEYACCREDITATION IS A JOURNEY

ANDAND

NOT A DESTINATION.NOT A DESTINATION.


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BON VOYAGE !!!!!BON VOYAGE !!!!!


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Documents

Natonal Accreditation for Hospital & Health Care Providers (Nabh)