The presentation is solely meant for Academic purpose

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Regulation is mandatory

Accreditation is voluntary

Accreditation is promoted by way of

incentives and market forces

In order to achieve best of both worlds,

regulation in time to come can simply

rely on accreditation

Regulation Vs. Accreditation

Auditing

Quality System

Standards

Patient Safety

Physician

Surgeon

Nursing / Technician

Paramedical

Logistics

Management

Accreditation

Stimulates continuous improvement

Enables the HCO in demonstrating commitment to quality of care.

Raises community confidence in the services provided.

Provides opportunity to benchmark.

International recognition of services.

Better efficiency and Increase in revenue

Transparency in the overall operations

Provides the framework for an integrated and focused

management structure. Recognition by payers, government and vendors

Benefits to HCO

PATIENTS / ASSOCIATES PATIENT

REGISTRATIO

N

DAY TO DAY

MONITORING

OPD

ADMISSION

OPD

CONSULTATION

DISCHARGE

CERTIFICATE

FEE

COLLECTION

FRONT LINE STAFF

REGISTRATION ,PARAMEDICAL, NURSES, REDSIDENT

CONSULTANT / DOCTORS

CEO/HODs EMPOWERMENT

PATIENT

REGISTRATION

DAY TO DAY

MONITORING

OPD

ADMISSION

OPD

CONSULTATION

DISCHARGE

CERTIFICATE

FEE

COLLECTION

FRONT LINE STAFF

REGISTRATION ,PARAMEDICAL, NURSES, REDSIDENT

CONSULTANT / DOCTORS

CEO/HODs

Accredited hospital provides for effective

governance including structured support

services needed by Clinicians.

It provides for continuous learning

through monitoring of clinical indicators

including opportunity to benchmark.

Improves overall professional

development and provides opportunity

for leadership role in quality

improvement.

Benefits to Clinicians

Percentage of medication errors

Percentage of transfusion reactions

Urinary tract infection rate

Respiratory infection rate

Intra-vascular device infection rate

Surgical site infection rate

Incidence of falls

Incidence of bed sores after admission

Bed occupancy rate and average length of stay

Incidence of needle stick injuries

Systems are checked

Actual practice is not

Safety is given top priority

Measure what you do

Temp PACU arrival

Temp PACU exit

All 34.5 (32.8 – 36.8)

35.7 (34 – 37.2)

Patients with bear hugger

34.8 (34 -36.8)

36 (35- 37.2)

Without bear hugger

34.4 (32.8 – 36.4)

35.7(34 – 36.8)

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Cover preoperative patients

Minimize heat loss before surgery

Monitor temperature/s

Warmer / warm fluids/ early closure/ cover plastic sheet

Cover during transfer

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One of the top priority areas

HAIs

Hand hygiene compliance

Antibiotic use

Antibiogram

Abuse

Prophylactic antibiotic

Resistance pattern

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2005 2010

1 Anesthesia Spinal/epidural

Nerve blocks

2 High risk pts No Yes

3 Mobilization 24- 48 hrs 2-4 hrs

4 Pain relief OK excellent

5 Post op pts Slightly drowsy

Alert, no vomiting

5 Discharge 7 to 10 days 5 days

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2000 2010

1 Ventilator 24 hrs 2 to 3 hrs

2 ICU stay 2- 3 days 18 hours

3 Pain relief (0 to 10) 2 to 4 0 to 2

4 Postop status Slightly drowsy Alert awake

5 Mobilization 3 days Day 0

6 Climbing steps 4 to 5 days 2 to 3 days

7 Blood transfusion 4 to 5 units 0 to 1 unit

8 Infection <5 % <1%

9 Discharge from hospital 12 to 15 days 5 to 6 days

10 Return to work 2 months 2 to 4 weeks

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