Hospital accreditation

P R E S E N T E D B Y : S A N A S A I Y E D
Seminar on Accreditation

Hospital accreditation
 Hospital accreditation has been defined as “A self-assessment and
external peer assessment process used by health care organizations to
accurately assess their level of performance in relation to established
standards and to implement ways to continuously improve”

Driving factors for accreditation
 Consumer protection Act
 Clinical Establishment Act
 Insurance companies regulation
 Empanelment by CGHS, ECHS, Corporate etc.
 Community Awareness & Response

Why accreditation???
 Ensure a quality index for health consumer. A growing number of
hospital in india are turning to accreditation agencies worldwide to both
standardize their protocol and project their international quality of health
care delivery.
 Attract foreign patients.
 Quality Assurance helps improve effectiveness, efficiency and in cost
containment, and accountability and the need to reduce error and
increase safety in the system.

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 The process of accreditation is envisaged to result in a process of
fundamental change in technical procedures of service delivery, in the
appropriate use of available technologies, in the integration of relevant
knowledge, in the recourses are used and in the efforts to ensure social
participation.

Benefits of accreditation
 Improve public trust that the organization is concerned for patient safety
and quality of care.
 Provide a safe and efficient work environment that contributes to worker
satisfaction.
 Listen to patient and their families, respect their rights, and involving
them in the care process as partners.
 Create a culture that is open to learning from the timely reporting of
adverse events and safety concerned.
 Established collaborative leadership that sets priorities for and continues
leadership for quality and patient safety levels.

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 Identify systemic break-down and close gaps or loopholes
 Provide ways to detect and correct error and problems
 Ensure conformance to and effectiveness of documented processes
 Focus on patient and provider needs and expectation
 Streamline work flow and maximize resource utilization
 Maximize customer satisfaction

Accreditation authority in India
 NABH (national accreditation board for hospitals & healthcare provider)
 QCI (quality council of india)

NABH(National Accreditation Board for Hospitals &
Healthcare Providers )
 NABH is a constituent board of Quality Council of India, set up to
establish and operate accreditation programmed for healthcare
organizations.
 The board is structured to cater to much desired needs of the
consumers and to set benchmarks for progress of health industry.
 NABH is an institutional member of the International Society for Quality
in Health Care (ISQUA).
 ISQUA is an international body which grants approval to Accreditation
Bodies in the area of healthcare as mark of equivalence of accreditation
program of member countries.

NABH Standards
 10chapters
 100 standards
 514 objective elements
 Each accreditation standards is a statement of an expectation or
requirement which makes it possible to deliver quality care.
 Objective element are sub components of slandered.

Standard (patient centered )
1.Access, assessment and continuity of care (AAC)
Standards for ‘Registration’, ‘Admission’, ‘Discharge 'Transfer’ &
‘Referral’ processes are covered in this group and are properly taken
care of using the Patient Administration System [PAS] module of an
HMIS
2.Patient Rights and Education (PRE)
Standards related to ‘Consent Recording/Archiving’ are an important
constituent of this group the Application too, making them available
across time and space.

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3.Care of Patients (COP)
By using specialty specific ‘Clinical Form sets’, ICT ensures
standardized delivery of clinical care across all locations & departments
of a Hospital. Ex. workflow template
4. Management of Medication (MOM)
Health care professionals need assistance while choosing a medication
from a large list of medications available with respect to Drug
Interaction and ‘Individual Sensitivity’. Develop electronic medication
administration reconciliation module.
5. Hospital Infection control (HIC)

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8. Facilities Management and Safety (FMS)
A ‘Materials Management System’, which includes Stores Management,
takes care of all the processes related to Equipments and Devices life
cycle.
9. Human Resource Management (HRM)
A standard functionality mapping to a HRM module in a HMIS is
necessary to meet these standards
10. Information Management System (IMS)
A modern HMIS takes care of the information needs of the care
providers, management of the organization as well as other agencies
that require data and information from the organization.

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Two important HMIS modules which cover the standards covered in this
section are ‘Central Sterilization & Store Department’ [CSSD] module
and ‘Bio Medical Waste management’ Module.
6.Continuous Quality Improvement (CQI)
An intelligent HMIS, which is capable of reporting ‘Key Performance
Indicators’ assists in achieving the standards mentioned in this section.
7.Responsibilities of Management (ROM)
A modern HMIS is capable of creating a hierarchy of ‘Roles’ with robust
‘Role Based Security Rules’ thereby ensuring proper accountable
Hospital Management.

Benefits of NABH Accreditation
• Benefits to the Clients:
• Good health outcomes
• Clint satisfaction
• Value for money
• Less frustration

Benefits to health care provider
 Health staff become more satisfied with their work.
 Health workers understand patients better.
 Information flow among staff is improved.
 Health staff who perform well are reworded.

Benefits to health institution
 Patient become more satisfied with the services.
 More patients may use a good services.
 The environment will become clean and beautiful.
 The facility will have a good reputation.

NABH Accreditation hospitals
 B.M. Birla Heart Research Center, Kolkata
 Moolchand hospital, New Delhi
 Fortis hospital, Noida
 Dr. L.H. Hiranandani hospital, Mumbai
 Columbia Asia medical center, bangalore

QCI (quality council of india)
 Quality Council of India (QCI) was set up in 1997 by Government of
India jointly with Indian Industry
 Establish and operate the National Accreditation Structure for conformity
assessment bodies; providing accreditation in the field of education,
health and quality promotion.
 It also promotes the adoption of quality standards relating to Quality
Management Systems (ISO 14001 Series)
 To realize the objective of improving quality competitiveness of Indian
products and services, QCI provides strategic direction to the quality
movement in the country by establishing conformity assessment system
which is recognized at the international level

Evidence based management
1. Health sector accreditation research: a systematic
review
Author : DAVID GREENFIELD
Purpose: The purpose of this study was to identify and
analyze research into accreditation and
accreditation processes.
Method : Systematic review
Result :
1. In two categories consistent findings were recorded: promote change
and professional development.

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2.Inconsistent findings were identified in five categories: professions’
attitudes to accreditation, organizational impact, financial impact, quality
measures and program assessment.
3.The remaining three categories—consumer views or patient
satisfaction, public disclosure and surveyor issues—did not have
sufficient studies to draw any conclusion.
 Conclusion. The health care accreditation industry appears to be
purposefully moving towards constructing the evidence to ground our
understanding of accreditation.

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2. The standard of healthcare accreditation standards: a review of
empirical research underpinning their development and impact
 Objective: Healthcare accreditation standards are advocated as an
important means of improving clinical practice and organizational
performance
 Method : Empirical research
 Result :
1.Three interventional studies were identified, with the remaining 10
studies having research designs to investigate clinical or organizational
impacts.

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2.Only one study noted implementation issues, identifying several enablers
and barriers. Standards were reported to improve organizational
efficiency and staff circumstances. However, the impact on clinical
quality was mixed, with both improvements and a lack of measurable
effects recorded.
 Conclusion: Standards are ubiquitous within healthcare and are
generally considered to be an important means by which to improve
clinical practice and organizational performance.
 Keywords: Healthcare, Accreditation, Standards

Hospital accreditation

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Hospital accreditation