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Accreditation: A Magic Wand ISQua Webinar July 10, 2014 B.K. Rana Joint Director, NABH Vice- Chairman, Accreditation Council of ISQua.

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Presentation on theme: "Accreditation: A Magic Wand ISQua Webinar July 10, 2014 B.K. Rana Joint Director, NABH Vice- Chairman, Accreditation Council of ISQua."— 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 National Accreditation Board for Hospitals & Health Care Providers 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 National Accreditation Board for Hospitals & Health Care Providers 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 National Accreditation Board for Hospitals & Health Care Providers 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 National Accreditation Board for Hospitals & Health Care Providers 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 National Accreditation Board for Hospitals & Health Care Providers What is Accreditation? 6 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 National Accreditation Board for Hospitals & Health Care Providers Accreditation Is a process Not an event

8 National Accreditation Board for Hospitals & Health Care Providers 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 National Accreditation Board for Hospitals & Health Care Providers 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 National Accreditation Board for Hospitals & Health Care Providers 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 National Accreditation Board for Hospitals & Health Care Providers 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 National Accreditation Board for Hospitals & Health Care Providers 12 Various Accreditation Bodies

13 National Accreditation Board for Hospitals & Health Care Providers 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 National Accreditation Board for Hospitals & Health Care Providers 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 National Accreditation Board for Hospitals & Health Care Providers 15 Various accreditation bodies A.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 National Accreditation Board for Hospitals & Health Care Providers 16 Various accreditation bodies B.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 National Accreditation Board for Hospitals & Health Care Providers 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 National Accreditation Board for Hospitals & Health Care Providers 18 Various accreditation bodies C.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 National Accreditation Board for Hospitals & Health Care Providers 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 National Accreditation Board for Hospitals & Health Care Providers 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. 20

21 National Accreditation Board for Hospitals & Health Care Providers NABH Accreditation Programs Accreditation of Hospitals Accreditation of SHCO/ Nursing Homes Accreditation of Dental Centers Accreditation of Blood Banks Accreditation of Wellness Centers Accreditation of PHC/CHCs Accreditation of OST Centers Accreditation of AYUSH hospitals Accreditation of Medical Imaging Services Allopathic Clinics

22 National Accreditation Board for Hospitals & Health Care Providers NABH Certification Programs Safe-I Nursing Excellence Medical Laboratory Quality Improvement Initiatives

23 National Accreditation Board for Hospitals & Health Care Providers Quality Improvement Initiatives Pre-Accreditation Entry Level Award Pre-Accreditation Progressive Level Award 23

24 National Accreditation Board for Hospitals & Health Care Providers Objective of these awards Provide a framework for quality improvement Focus on patient safety Set basic standards that all Organizations must achieve 24

25 National Accreditation Board for Hospitals & Health Care Providers NABH is an institutional member of the International Society for Quality in Health Care (ISQua) since

26 National Accreditation Board for Hospitals & Health Care Providers ISQua Accreditation of NABH Standards for Hospitals 2 nd ed., 2007 (April 2008 – March 2012) ISQua Accreditation of NABH Standards for Hospitals (April 2008 – March 2012)- 2 nd Edition (April 2012 – March 2016)- 3 rd Edition 26

27 National Accreditation Board for Hospitals & Health Care Providers ISQua Accreditation of NABH Standards for Hospitals 2 nd ed., 2007 (April 2008 – March 2012) ISQua Accreditation of NABH (as an Organisation) (September 2012 – August 2016)

28 National Accreditation Board for Hospitals & Health Care Providers 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 National Accreditation Board for Hospitals & Health Care Providers NABH International Formed in July 2010 Four facilities accredited in Philippines One application from Qatar

30 National Accreditation Board for Hospitals & Health Care Providers 30 Accreditation Standards for Hospitals 1)Chapters: 10 2)Standards: 102 3)Objective elements: 636

31 National Accreditation Board for Hospitals & Health Care Providers 31 Accreditation Standards for Hospitals 1)Access, Assessment and Continuity of Care (AAC) 2)Care of Patients (COP). 3)Management of Medication (MOM). 4)Patient Rights and Education (PRE). 5)Hospital Infection Control (HIC). 6)Continuous Quality Improvement (CQI). 7)Responsibility of Management (ROM). 8)Facility Management and Safety (FMS). 9)Human Resource Management (HRM) 10)Information Management System (IMS).

32 National Accreditation Board for Hospitals & Health Care Providers 32 Accreditation Standards for Hospitals ChaptersStandards Objective Elements AAC1486 COP20136 MOM1373 PRE746 HIC951 CQI857 ROM638 FMS854 HRM1052 IMS743 Total102636

33 National Accreditation Board for Hospitals & Health Care Providers 33 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) Application + Self-assessment + Documents Accreditation Process

34 National Accreditation Board for Hospitals & Health Care Providers 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 11 indicators

35 National Accreditation Board for Hospitals & Health Care Providers 35 Update

36 National Accreditation Board for Hospitals & Health Care Providers 36 Update on Activities

37 National Accreditation Board for Hospitals & Health Care Providers 37 Geographical Distribution of Hospitals --Applicants

38 National Accreditation Board for Hospitals & Health Care Providers 38 Accredited Hospitals

39 National Accreditation Board for Hospitals & Health Care Providers Linkage with Licensing/ Regulation

40 National Accreditation Board for Hospitals & Health Care Providers 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 National Accreditation Board for Hospitals & Health Care Providers 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 National Accreditation Board for Hospitals & Health Care Providers Voluntary vs Mandatory

43 National Accreditation Board for Hospitals & Health Care Providers 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 National Accreditation Board for Hospitals & Health Care Providers Accreditation and Patient Safety

45 National Accreditation Board for Hospitals & Health Care Providers Patient Safety? Quality? Accreditation? (can not be achieved without patient safety & quality)

46 National Accreditation Board for Hospitals & Health Care Providers Accreditation standards include various aspects of quality and patient safety.

47 National Accreditation Board for Hospitals & Health Care Providers 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 National Accreditation Board for Hospitals & Health Care Providers 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 National Accreditation Board for Hospitals & Health Care Providers Accreditation supports... Quality improvement Patient safety Risk management Change management 49

50 National Accreditation Board for Hospitals & Health Care Providers Does accreditation make a difference? Better communication and collaboration Stronger teams Increased credibility and accountability 50

51 National Accreditation Board for Hospitals & Health Care Providers Global Scenario and Role of ISQua

52 National Accreditation Board for Hospitals & Health Care Providers

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

54 National Accreditation Board for Hospitals & Health Care Providers Accrediting the Accreditors International Accreditation Programmes (IAP) Accreditation of health care standards Accreditation of external evaluation organisations Accreditation of surveyor training programmes

55 National Accreditation Board for Hospitals & Health Care Providers IAP Awards to Date 26 accredited organizations 55 sets of standards 15 surveyor training programmes Setting exemplary standards

56 National Accreditation Board for Hospitals & Health Care Providers Magic of Accreditation

57 National Accreditation Board for Hospitals & Health Care Providers 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

58 National Accreditation Board for Hospitals & Health Care Providers 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

59 National Accreditation Board for Hospitals & Health Care Providers 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

60 National Accreditation Board for Hospitals & Health Care Providers It is considered to fix anything & everything in a hospital ▫All structures ▫All legal requirements ▫All process ▫All outcomes ▫ZERO complaints

61 National Accreditation Board for Hospitals & Health Care Providers Patients/ Public consider Accreditation a Super Regulation (AB as Super Regulator) than a Tool for Improvement.

62 National Accreditation Board for Hospitals & Health Care Providers Can we live up to such expectations?

63 National Accreditation Board for Hospitals & Health Care Providers Thank You


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