HOSPITAL ACCREDITATION & RETAINING QUALITY Dr. Bidhan Das

ACCREDITATION “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”

ACCREDITATION COUNCILS National Accreditation Board for Hospitals & Healthcare providers (NABH) Australian Council on Healthcare Standards (ACHS) Joint Commission International (JCI)

STANDARD A standard is a statement of expectation that defines the structures and processes that must be substantially in place in an organization to enhance the quality of care.

Standards Address a recognized need Evidence based (as far as practicable) Developed through a transparent and consultative process Outcome focused Achievable Measurable

Comparison ACCREDITATION LICENSURE Based on optimum standards, professional accountability and cooperative relationships and public accountability Based on minimum standards, investigation, enforcement Improved performance and reducing risk General review of internal systems In-depth probe of conditions and activities Focus on education, self-development Compliance checking as a direct response to complaints and adverse events

NABH Standards Access ,Assessment and continuity of care (AAC) Care of Patients (COP) Management of Medication (MOM) Patient Right 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)

ACHS Standards - EQuIP CLINICAL 2. SUPPORT 3. CORPORATE 1.1 Continuity of Care 1.2 Access 1.3 Appropriateness 1.4 Effectiveness 1.5 Safety 1.6 Consumer Participation and Acceptability 2.1 Risk Management and Quality Improvement 2.2 Human Resources Management 2.3 Information and Knowledge 2.4 Population Health 2.5 Research 3.1 Leadership and Management 3.2 Safe Practice and Environment

Methodology Re energizing the system Structure Outcomes Process External Environment

These are the performance components: Structure: Resources E.g. adequate staff, supplies, building, infrastructure. Process: Activities E.g. patient care , nursing assessment Outcomes: Results E.g. Decrease in infection rate, ALOS etc.

CORE ELEMENTS OF QUALITY ASSURANCE PROGRAM Defining Quality Quality Assurance Program Improving quality Measuring Quality

MEASURING QUALITY Quality Assessment Quality Monitoring External Evaluation of Quality Licensing Certification Accreditation

IMPROVING QUALITY Applying appropriate methods to close the gap between current and expected levels of quality as defined by standards.

Quality Assurance v/s Continuous Quality Improvement Prevention FOCUS Inspection Inspection People People Processes PROBLEMS Department Department RESPONSIBILITY Everyone

HOSPITALS & HEALTH SYSTEM REFORMS Hospitals dominate health systems. Hospitals account for 40%–70% of the national health budget. Efficiency in hospitals is demanded by all stakeholders. Hospitals are important symbols for the public. Hospitals are labour intensive. On average, hospitals employ half the physicians and two-thirds of the nurses in a country.

HOSPITAL ACCREDITATION – Why? Failure of hospitals to live up to expectations of people for quality care at optimal cost. Ignorance of the importance of quality management by hospitals’ staff. Mushrooming of health care establishments without any adequately prescribed norms in terms of structure and facilities Sporadic availability of medical care resources i.e. inequity in availability of resources. Training of staff in quality management once the standards for performance through accreditation in place.

Stimulate continuous improvement in patient care processes and outcomes Strengthen the public’s confidence Improve the management of health services Provide comparison with self, others, and best practices Development and upgradation of indicator measurement system for better monitoring and evaluation Dealing with the healthcare laws Enhancement of system to take on health care insurers Best care provided with maximum efficiency, effectiveness and at optimal cost

Strengths of Accreditation External, objective evaluation Uses consensus standards Involves the health care professions Proactive not reactive Organization wide Focus on systems not individuals Stimulates quality culture in the organization Periodic re-evaluation against standards

Benefits to the Hospital Improves care and enhances public confidence Stimulates continuous improvement Demonstrates commitment to quality care Raises community confidence Comparison with self and other similar organizations

Benefits to Medical & Nursing Staff Improves professional staff development Provides education on consensus standards Provides leadership for quality improvement within medicine and nursing Increases satisfaction with working conditions, leadership and accountability

Benefits to Hospital Employees Values employee opinions Measures employee satisfaction Involvement in quality activities Improved employee safety and security Clearer lines of authority and accountability Promotes teamwork

Benefits to Patients Access to a quality focused organization Rights are respected and protected Understandable education and communication Satisfaction is evaluated Involvement in care decisions and care process Focus on patient safety

Recommendations Constitution of accreditating agency involving the professionals from clinical and administrative side of hospital. Timely evaluation of the relevance of standards of health care quality by this organization. Accreditating body be autonomous but mandatory for all health care facilities by statute.

INDICATOR A statistical measure of the performance of functions, systems or processes over time.

INDICATOR Clinical Indicator Managerial Indicator

MONITORING OF INDICATORS Benchmark every indicator Apply statistical and managerial tools whenever required: RCA FMEA PERT CPM Take appropriate action

ROOT CAUSE ANALYSIS problems are best solved by attempting to correct or eliminate root causes Ishikawa diagram Pareto analysis

Ishikawa Diagram

FAILURE MODE & EFFECT ANALYSIS (FMEA) Is a procedure in operations management For analysis of potential failure modes within a system for classification by severity or determination of the effect of failures on the system

PROGRAMME EVALUATION & REVIEW TECHNIQUE (PERT) A method to analyze the involved tasks in completing a given project Especially the time needed to complete each task, and identifying the minimum time needed to complete the total project.

CRITICAL PATH METHOD (CPM) It is a mathematically based algorithm for scheduling a set of project activities. Important tool for effective project management.

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