NATONAL ACCREDITATION FOR HOSPITAL & HEALTH CARE PROVIDERS (NABH)

SHISHIR JAIN NARAYANA HRUDALAYA

WHAT IS QUALITY ?

Appropriate application of medical knowledge with due regard to the balance between the hazard inherent in every medical intervention and the benefits expected from it

It is, however more complex than this. this.

QUALITY FROM WHOSE POINT OF VIEW ?

 Provider

of Health care Services of the Health care

 Recipient

services
 Organizer

of the Health care

services

PROVIDERS CONCERNS


To provide care as per established norms Adequate resources Self satisfaction with the final outcome

 

Should contribute to enhancement of skills, competence and add to experience

RECIPIENTS 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

ORGANISERS CONCERNS


Responsible to the Society for the funds spent on health care

To ensure safety of public and prevent inappropriate or suboptimal care

To meet the requirements of the recipient and provider of the health care services at Acceptable costs

WHAT IS ACCREDITATION

Accreditation is an external review of quality with four principal components:

 It

is based on written and published standards are conducted by professional is

 Reviews

peers
 The  The

accreditation process administered by an independent body

aim of accreditation is to encourage organizational development. development.

Focus of standards
   

Patient Safety Staff and employee safety Environment and community safety Information Education and Communication

NABH STANDARDS

NABH Standards

  

10 Chapters 100 Standards 503 Objective Elements

Section I: PatientPatient-Centered Standards

STD  Access, Assessment and Continuity of Care (AAC) 15
   

OE 78 29 105 61 44 317

Patients Rights and Education (PRE) Care of Patients (COP) Management of Medications (MOM) Hospital Infection Control (HIC)

05 18 13 09 60

Section II: Health Care Organization Management Standards

STD
    

OE 37 20 41 47 41 186

Continuous Quality Improvement (CQI) Responsibilities of Management (ROM) Facility Management & Safety (FMS) Human Resource Management (HRM) Information Management Systems (IMS)

6 5 9 13 7 40

Accreditation Process

 Applications  Screening

of the Applications  Pre-assessment survey Pre Assessment Survey  Review of the recommendations of the assessing body by the Accreditation Committee  Recommendations to the board  Accreditation decision

WHO CAN APPLY

 

Any Health Care Organisation Requirements

 Currently

in operation as a HCO registered or licensed

 Preferably  Willing

to assume responsibility for improving quality of care

 Should

be able to meet the prescribed standards of the accrediting organisation

HOW CAN ONE APPLY



Basic Ingredients
 Organisations

apply on prescribed format of a self assessment form

giving details as required

 Submission

indicating the outcomes of its QMS and Internal Audits

 Extent

of adherence

to

the

laid down

standards

SCREENING OF APPLICATIONS
  

Completeness Accuracy Clarifications sought if required

PREASSESSMENT SURVEY
To ascertain the readiness of the organisation for Accreditation  Overview of the organizational preparedness and commitment to quality goals and consonance to laid down standards  Deficiencies noticed informed to the organisation  Advice rendered on the methodology to be followed during the Accreditation Survey  Time frame worked out for the survey in mutual consultation


ACCREDITATION SURVEY


Carried out by a team of Assessors depending upon the size, complexity and facilities provided by the organisation Scope will include all standards related functions and all patient care settings Onsite survey will consider specific cultural and legal factors which may influence or shape decisions regarding the provision of care and /or policies and procedures

METHODOLOGY OF SURVEY
     

Initial presentation by the hospital Document Review Adherence to statutory obligations Visits to various areas Facility surveys and tours Random structured interviews

INITIAL PRESENTATION BY THE HOSPITAL

Organogram  Quality management Team  Methodology followed for Quality Improvement  Facilities provided  Inputs on resources provided for Quality Improvement  Identified high Risk Areas for patient care and safety  Sentinel Events being monitored


INITIAL PRESENTATION BY THE HOSPITAL



Key Monitoring Indicators

 Resource  Volume  Utilization  Performance

 

Control charts Problems faced and remedial measures undertaken/ being undertaken

DOCUMENT REVIEW
Quality Manual Various Policies and Procedures Minutes of Meetings of various committees Medical Records Medical / Nursing Audit Adverse Events HAI Action Taken Reports Personal Records of Staff

OBSERVATIONS
Facility Safety Level of compliance with laid down policies and procedures BMW Management Standard Precautions Patient care Fire Safety Equipment Management

INTERVIEW
Staff Interview To determine their level of awareness and compliance with organisation policies and procedures To assess their awareness levels of their rights, privileges and patient rights To determine their satisfaction levels Patient and family Interview To assess their level of awareness of the care process and their rights To determine their satisfaction levels

SCORING PATTERN


NABH has laid down the following pattern  Non-compliance Non0  Partial compliance 5  Full compliance 10

No standard can have more than one zero  The average for a standard must exceed 5  The overall average score must exceed 7  No zeros in legal requirements


Process of Accreditation
       

Initial Application including Self Assessment as per the laid down standards Screening of the Application Pre assessment survey Assessment survey Accreditation committee Recommendations If required Verification Visit Approval of Accreditation by the NABH ReAssessment Surveys

OUTCOMES OF ACCREDITATION SURVEYS



Accredited  HCO shows acceptable compliance with laid down standards in all areas  Includes the scope of services for which accredited  Any increase in scope the survey has to be done for the increased scope Accreditation denied  HCO is consistently non compliant with standards Accreditation withdrawn  HCO withdraws voluntarily  Due to consistent non compliance or non adherence to safe and ethical practices

DURATION OF ACCREDITATION AWARDS



Generally three years with one Reassessment survey to ensure continued compliance and to assess the CQI programme If during accreditation The Accreditation

organisation receives inputs that the organisation is substantially out of compliance with the current standards then Resurvey or withdrawal of accredited decision may be resorted to

How to Go About
Create willingness  Initial impetus from Top management  Requires involvement of all staff  This requires repeated training and briefing  Once consensus is there identify core coordinating or Quality management Team


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

How to Go About
Focus on uniform training of all employees in key areas  Encourage by financial and / or nonfinancial 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


PROBLEMS AND CHALLENGES

    

HCOs are very enthusiastic Ill prepared Initial preparation is shoddy Resources required initially Benefits have a longer gestation period

PROBLEMS AND CHALLENGES

Quality Consciousness at all levels will take time  Sustenance and consistency of efforts will be required  Commitment on a consistent basis  High rates of attrition will require repeated and continual training  Public Sector will take a longer time to get into the process  Quality and consistency of assessors and assessments


These May Look Difficult Initially, But the First steps are Never easy.

Also Nothing Is Impossible For,

Impossible Means I M Possible

Quality Norms and Accreditation??

Response of Medical Fraternity

Expected Response

THE CURRENT STATUS OF ACCREDITATION IN INDIA

  

Initializing phase is over. over. Phase of consolidation. consolidation. The initial steps have been difficult but the journey has begun. begun.

 

The journey has to continue

Especially since ---------------------------

ACCREDITATION IS A JOURNEY AND NOT A DESTINATION.

BON VOYAGE !!!!!