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Accreditation: A Magic Wand ISQua Webinar July 10, 2014

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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. Rana Joint Director, NABH Vice- Chairman, Accreditation Council of ISQua

2 Topics to be covered What is accreditation? Benefits of accreditation
Various accreditation bodies – case study of NABH Linkage with licensing/regulation Voluntary vs Mandatory Accreditation and Patient Safety Global Scenario & Role of ISQua Magic 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
6 What is Accreditation? Strategic change and risk management tool Proactive and continuous Transparent and rigorous analysis of service provision Addresses current and future patient needs facilitated by: Independent third party Quality Improvement focus Objectivity (slide from Phil Hassen’s webinar)

7 Accreditation Is a process Not an event

8 Benefits of accreditation
Benefits for Patients Patients 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 Hospitals Accreditation 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 Staff The 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 bodies Finally, 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.

12 Various Accreditation Bodies

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 AB Developing AB Struggling 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 Canada ACHS, Australia HAS, France Joint Commission International, USA COHSASA, South Africa TJCHA, Taiwan MSQH, Malaysia CHKS, UK NIAZ, The Netherlands AABB, USA IKAS, Denmark

16 Various accreditation bodies
Developing AB: NABH, India HCAC, Jordan DAP BC, Canada Healthcare Accreditation Institute, Thailand Australian General Practice Accreditation Ltd Australian Aged Care Quality Agency DNV, Norway HDAA, Australia HDANZ, New Zealand Japan Council for Quality Health Care

17 Various accreditation bodies
Quality Improvement Council DAA Group Limited, New Zealand Health Accreditation Service (ICONTEC), Columbia Canadian Accreditation Council of Human Services Global Mark, Australia QHA Trent, UK CQA 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, Philippines Pakistan is trying to develop one Sri Lanka

19 Case study of National Accreditation Board for Hospitals and Healthcare Providers (NABH)
Indian AB Established in 2006, under Quality Council of India, a not-for-profit Society. Independent Board comprising members from various stakeholders

20 Vision To be apex national healthcare accreditation and quality improvement body, functioning at par with global benchmarks. Mission To 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 Hospitals Accreditation of SHCO/ Nursing Homes Accreditation of Dental Centers Accreditation of Blood Banks Accreditation of OST Centers Accreditation of PHC/CHCs Accreditation of AYUSH hospitals Accreditation of Wellness Centers Accreditation of Medical Imaging Services Allopathic Clinics

22 NABH Certification Programs
Quality Improvement Initiatives NABH Certification Programs Safe-I Nursing Excellence Medical Laboratory

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 Edition ISQua 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 Philippines One application from Qatar

30 Accreditation Standards for Hospitals
Chapters: 10 Standards: 102 Objective 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
Chapters Standards Objective Elements AAC 14 86 COP 20 136 MOM 13 73 PRE 7 46 HIC 9 51 CQI 8 57 ROM 6 38 FMS 54 HRM 10 52 IMS 43 Total 102 636

33 Accreditation Process
Application + Self-assessment + Documents Acknowledgment 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 years Surveillance Assessment: at 18 months Renewal Assessment: within 6 months before expiry of current accreditation Surprise checks: one hospital/ month Performance Indicators: Data submission every quarter for indicators

35 Update

36 Update on Activities

37 Geographical Distribution of Hospitals --Applicants

38 Accredited Hospitals

39 Linkage with Licensing/ Regulation

40 Licensing / Registration/ Regulation
A mandatory process Operated by the Government Prescribe certain basic requirements- mostly structural and may include some processes Healthcare facility to be licensed/ registered: not uniform in India, States have their own Acts, if any, central Act yet to be in place Healthcare 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.

42 Voluntary vs Mandatory

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 hospital Government / Paying organisation like insurance can prescribe it as a condition for empanelment In 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

44 Accreditation and Patient Safety

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 information Informed consent for procedures Patient and family education Clinical safety CPR, Code blue prevention against wrong side, wrong patient and wrong procedure Medication management Labeling of drugs Labeling of prepared drugs High risk medication awareness

48 Patient Safety Encounters
Environment of care Straps of trolleys, ill maintained wheel chairs, bed rails, disability friendly toilets Surveillance of environment Calibration of equipment Neonatal abduction prevention Infection control Manual, policies, procedures Compliance of hand washing

49 Accreditation supports...
Quality improvement Patient safety Risk management Change management

50 Does accreditation make a difference?
Better communication and collaboration Stronger teams Increased credibility and accountability

51 Global Scenario and Role of ISQua

52

53 Why ISQua Accreditation?
International Accreditation Programmes (IAP) ISQua accreditation helps to standardise by providing current evidence based standards, self- assessment, peer review and consistent application all organisations despite maturity level assessed against the same standards HCAC (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 care standards Accreditation of external evaluation organisations   Accreditation of surveyor training programmes

55 Setting exemplary standards
IAP Awards to Date 26 accredited organizations 55 sets of standards 15 surveyor training programmes Setting exemplary standards

56 Magic of Accreditation

57 Why I call it a magic wand?
It is perceived to be doing everything. For Hospital: Good reputation Better income Doing everything Right The Best For Patients: Less expenditure Best care Everything MUST be in place Any shortcoming/error not acceptable HCAC (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 reputation Better income Right to get what they want (best in the market/ govt.) For Paying Agencies: Best care Less expenditure Transparency in billing/ claims HCAC (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 accredited HCAC (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 structures All legal requirements All process All outcomes ZERO complaints HCAC (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

63 Presentation title Thank You


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