Presentation on theme: "Accreditation: A Magic Wand ISQua Webinar July 10, 2014"— Presentation transcript:
1 Accreditation: A Magic Wand ISQua Webinar July 10, 2014 B.K. RanaJoint Director, NABHVice- Chairman, Accreditation Council of ISQua
2 Topics to be covered What is accreditation? Benefits of accreditation Various accreditation bodies – case study of NABHLinkage with licensing/regulationVoluntary vs MandatoryAccreditation and Patient SafetyGlobal Scenario & Role of ISQuaMagic of Accreditation
3 What is accreditation?Procedure by which an authoritative body gives formal recognition that an organization is competent to carry out specific tasks.(ISO 15189:2012- Medical Laboratories: Requirements for Quality and Competence)
4 What is accreditation(AB Accreditation)? A public recognition of the achievement of the standards by a healthcare organisation, demonstrated through an independent external peer assessment (by AB) of that body’s organisational performance in relation to the standards.
5 What is accreditation (ISQua Accreditation)? A public recognition of the achievement of the standards by a healthcare external evaluation body, demonstrated through an independent external peer assessment (by ISQua) of that body’s organisational performance in relation to the standards.(ISQua 2013)
6 What is Accreditation? Strategic change and risk management tool 6What is Accreditation?Strategic change and risk management toolProactive and continuousTransparent and rigorous analysis of service provisionAddresses current and future patient needs facilitated by:Independent third partyQuality Improvement focusObjectivity(slide from Phil Hassen’s webinar)
8 Benefits of accreditation Benefits for PatientsPatients are the biggest beneficiary among all the stakeholders. Accreditation results in high quality of care and patient safety. The patients are serviced by medical staff with established credentials. Rights of patients are respected and protected. Patients satisfaction is regularly evaluated.
9 Benefits of accreditation Benefits for HospitalsAccreditation to a hospital stimulates continuous improvement. It enables hospital in demonstrating commitment to quality care. It raises community confidence in the services provided by the hospital. It also provides opportunity to healthcare unit to benchmark with the best.
10 Benefits of accreditation Benefits for Hospital StaffThe staff in an accredited hospital is more satisfied as it provides for continuous learning, good working environment, leadership and above all ownership of clinical processes. It improves overall professional development of Clinicians, Nurses and Para Medical Staff and provides leadership for quality improvement.
11 Benefits of accreditation Benefits to paying and regulatory bodiesFinally, accreditation provides an objective system of empanelment by insurance and other third parties. Accreditation provides access to reliable and certified information on facilities, infrastructure and level of care.
13 Various accreditation bodies Across the globe, in healthcare domain, several Accreditation Bodies (AB) are functional. There is no classification, however on the basis of length of their operation and credibility of their programs, I have classified them into:Developed ABDeveloping ABStruggling AB
14 Various accreditation bodies Developed AB (Long length of operations and ISQua accredited organisation, standards and surveyor training )Developing AB (Couple of years of operations and ISQua accredited organisation/standards/ surveyor training )Struggling AB (No ISQua accreditation*)* Exceptions may be there e.g. The Joint Commission, USA; China
15 Various accreditation bodies Developed AB:Accreditation CanadaACHS, AustraliaHAS, FranceJoint Commission International, USACOHSASA, South AfricaTJCHA, TaiwanMSQH, MalaysiaCHKS, UKNIAZ, The NetherlandsAABB, USAIKAS, Denmark
16 Various accreditation bodies Developing AB:NABH, IndiaHCAC, JordanDAP BC, CanadaHealthcare Accreditation Institute, ThailandAustralian General Practice Accreditation LtdAustralian Aged Care Quality AgencyDNV, NorwayHDAA, AustraliaHDANZ, New ZealandJapan Council for Quality Health Care
17 Various accreditation bodies Quality Improvement CouncilDAA Group Limited, New ZealandHealth Accreditation Service (ICONTEC), ColumbiaCanadian Accreditation Council of Human ServicesGlobal Mark, AustraliaQHA Trent, UKCQA Canada; RACGP Australia; KOIHA Korea; HKAG Hong Kong; CBAHI Saudi Arabia; MOH Kazakhstan; CPQ UAE; ONA Brazil; ALIAD Spain; MOH Turkey; CPSA Canada
18 Various accreditation bodies Struggling AB:Rest of the accreditation organizations not listed in A & B (with exceptions*)PCAHO, PhilippinesPakistan is trying to develop oneSri Lanka
19 Case study of National Accreditation Board for Hospitals and Healthcare Providers (NABH) Indian ABEstablished in 2006, under Quality Council of India, a not-for-profit Society.Independent Board comprising members from various stakeholders
20 VisionTo be apex national healthcare accreditation and quality improvement body, functioning at par with global benchmarks.MissionTo operate accreditation and allied programs in collaboration with stakeholders focusing on patient safety and quality of healthcare based upon national/international standards, through process of self and external evaluation.
21 NABH Accreditation Programs Accreditation of HospitalsAccreditation of SHCO/ Nursing HomesAccreditation of Dental CentersAccreditation of Blood BanksAccreditation of OST CentersAccreditation of PHC/CHCsAccreditation of AYUSH hospitalsAccreditation of Wellness CentersAccreditation of Medical Imaging ServicesAllopathic Clinics
23 Quality Improvement Initiatives Pre-Accreditation Entry Level Award Pre-Accreditation Progressive Level Award
24 Objective of these awards Provide a framework for quality improvement Focus on patient safety Set basic standards that all Organizations must achieve
25 NABH is an institutional member of the International Society for Quality in Health Care (ISQua) since 2006
26 (April 2012 – March 2016)- 3rd Edition ISQua Accreditation of NABH Standards for Hospitals (April 2008 – March 2012)- 2nd Edition(April 2012 – March 2016)- 3rd EditionISQua Accreditation of NABH Standards for Hospitals 2nd ed., 2007 (April 2008 – March 2012)
27 ISQua Accreditation of NABH (as an Organisation) (September 2012 – August 2016)ISQua Accreditation of NABH Standards for Hospitals 2nd ed., 2007 (April 2008 – March 2012)
28 Elected Member of ISQua Board ( , ) Elected Member of ISQua Accreditation Council (2007, , 2013-) NABH is founder member of Asian Society for Quality in Healthcare (ASQua)
29 NABH International Formed in July 2010 Four facilities accredited in PhilippinesOne application from Qatar
30 Accreditation Standards for Hospitals Chapters: 10Standards: 102Objective elements: 636
31 Accreditation Standards for Hospitals Access, Assessment and Continuity of Care (AAC)Care of Patients (COP).Management of Medication (MOM).Patient Rights and Education (PRE).Hospital Infection Control (HIC).Continuous Quality Improvement (CQI).Responsibility of Management (ROM).Facility Management and Safety (FMS).Human Resource Management (HRM)Information Management System (IMS).
32 Accreditation Standards for Hospitals ChaptersStandardsObjective ElementsAAC1486COP20136MOM1373PRE746HIC951CQI857ROM638FMS54HRM1052IMS43Total102636
33 Accreditation Process Application + Self-assessment + DocumentsAcknowledgment and Scrutiny of application(By NABH Secretariat)Pre - Assessment visit(By Assessment team)Final Assessment(By Assessment team)Review of Assessment Report(By NABH Secretariat)Recommendation for Accreditation(By Accreditation Committee)Approval for Accreditation(By Chairman, NABH)Issue of Accreditation certificate(By NABH Secretariat)
34 What after Accreditation? Accreditation Cycle: 3 yearsSurveillance Assessment: at 18 monthsRenewal Assessment: within 6 months before expiry of current accreditationSurprise checks: one hospital/ monthPerformance Indicators: Data submission every quarter for indicators
40 Licensing / Registration/ Regulation A mandatory processOperated by the GovernmentPrescribe certain basic requirements- mostly structural and may include some processesHealthcare facility to be licensed/ registered: not uniform in India, States have their own Acts, if any, central Act yet to be in placeHealthcare facility to obtain necessary licenses for different activities e.g. to procure and store alcohol, narcotics etc..
41 Licensing / Registration/Regulation Healthcare facility to follow necessary Regulatory requirements e.g. Radiation Safety (AERB in India); Bio- Medical Waste Handling (BMW Act in India); Narcotic Drugs (NDPS Act in India) etc…….In India, Hospitals require to obtain and comply with all applicable licenses and regulations as a requirement to sign up for NABH Accreditation as these have been appropriately prescribed in Accreditation Standards.
43 By virtue of its definition, Accreditation is a voluntary process Government may prescribe it as a mandatory condition for hospitals to function e.g. HAS, France accreditation is mandatory for a hospitalGovernment / Paying organisation like insurance can prescribe it as a condition for empanelmentIn India, Central Government Health Scheme and Ex- Servicemen Contributory Health Scheme prescribed as one of the conditions for private hospitals to be empanelled with them.Some other examples: in USA, Australia, Taiwan insurance providers require accreditation for empanelment
45 (can not be achieved without patient safety & quality) Accreditation?(can not be achieved without patient safety & quality)
46 Accreditation standards include various aspects of quality and patient safety.
47 Patient Safety Encounters Patient safety informationInformed consent for proceduresPatient and family educationClinical safetyCPR, Code blueprevention against wrong side, wrong patient and wrong procedureMedication managementLabeling of drugsLabeling of prepared drugsHigh risk medication awareness
48 Patient Safety Encounters Environment of careStraps of trolleys, ill maintained wheel chairs, bed rails, disability friendly toiletsSurveillance of environmentCalibration of equipmentNeonatal abduction preventionInfection controlManual, policies, proceduresCompliance of hand washing
53 Why ISQua Accreditation? International Accreditation Programmes (IAP)ISQua accreditation helps to standardise by providingcurrent evidence based standards, self- assessment, peer review and consistent applicationall organisations despite maturity level assessed against the same standardsHCAC (Jordan) have been assessed and accredited against the same standards as JCI, Accreditation Canada etc
54 Accrediting the Accreditors International Accreditation Programmes (IAP)Accreditation of health carestandardsAccreditation of externalevaluation organisations Accreditation of surveyor trainingprogrammes
55 Setting exemplary standards IAP Awards to Date26 accredited organizations55 sets of standards15 surveyor training programmesSetting exemplary standards
57 Why I call it a magic wand? It is perceived to be doing everything.For Hospital:Good reputationBetter incomeDoing everything RightThe BestFor Patients:Less expenditureBest careEverything MUST be in placeAny shortcoming/error not acceptableHCAC (Jordan) have been assessed and accredited against the same standards as JCI, Accreditation Canada etc
58 Why I call it a magic wand? For Staff:Good reputationBetter incomeRight to get what they want (best in the market/ govt.)For Paying Agencies:Best careLess expenditureTransparency in billing/ claimsHCAC (Jordan) have been assessed and accredited against the same standards as JCI, Accreditation Canada etc
59 If anything missing? Accreditation/ Accreditation Body is responsible If a hospital is not accredited: People are happy even basic services are not available but it changes once it is accreditedHCAC (Jordan) have been assessed and accredited against the same standards as JCI, Accreditation Canada etc
60 It is considered to fix anything & everything in a hospital All structuresAll legal requirementsAll processAll outcomesZERO complaintsHCAC (Jordan) have been assessed and accredited against the same standards as JCI, Accreditation Canada etc
61 Patients/ Public consider Accreditation a Super Regulation (AB as Super Regulator) than a Tool for Improvement.HCAC (Jordan) have been assessed and accredited against the same standards as JCI, Accreditation Canada etc
62 Can we live up to such expectations? HCAC (Jordan) have been assessed and accredited against the same standards as JCI, Accreditation Canada etc