1. HOSPITAL ACCREDITATION & RETAINING QUALITY
Dr. Bidhan Das

2. 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”

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

4. 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.

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

6. 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

7. 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)

8. 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

9. Methodology Re energizing the system Structure Outcomes Process
External Environment

10. 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.

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

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

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

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

16. 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.

17. 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.

18. 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

19. 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

20. 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

21. 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

22. 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

23. 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

24. 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.

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

26. INDICATOR
Clinical Indicator
Managerial Indicator

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

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

29. Ishikawa Diagram

30. 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

31. 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.

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

33. THANK YOU