Understanding Quality Control

and

Accreditation Process

Medishine Hospital-2015

NABH Standards

• 10 chapters

• 100 standards

• 514 objective elements

• Each accreditation standard is a statement of an

expectation or requirement which makes it possible

to deliver quality care

• Objective element are sub components of standards

QUALITY FROM WHOSE POINT OF VIEW ?

• Provider of Health

care Services

• Recipient of the

Health care services

PATIENT CENTERED STANDARDS:

• Access, Assessment and Continuity of Care (AAC)

• Care of Patients (COP)

• Management of Medication (MOM)

• Patient Rights and Education (PRE)

• Hospital Infection Control (HIC)

RECIPIENTS CONCERNS

• Accessibility

• Affordability

• Prompt attention

• Less waiting time

• Early diagnosis and cure

• Return to Productivity as early as possible

• Humane Treatment i.e. to be treated with empathy ,

respect and concern

ORGANIZATION CENTERED STANDARDS:

• Continuous Quality Improvement (CQI)

• Responsibilities of Management (ROM)

• Facility Management and Safety (FMS)

• Human Resource Management (HRM)

• Information Management System (IMS)

ORGANISERS CONCERNS

• Responsible to the

management for the funds

spent on health care

• To ensure safety of public &

prevent inappropriate or

suboptimal care

• To meet the requirements of

the recipient and provider of

the health care services at

Acceptable costs

HOSPITAL MANUAL

• The Hospital manual is a

mandatory documents for NABH

accreditation certification

• It maintains quality system in

hospital and medical lab and

research center.

• This manual documents describes

scope of services, hospital policy

and mission, applicable law and

regulation, quality policy and

organization structure.

ये क्या है…?

HOSPITAL MANUAL

Access, Assessment

and

Continuity of Care

(AAC)

HOSPITAL MANUAL

Access - Scope of services

• Registration Policy for Admission

• Filling the admission form

• Procedure during non availability of beds

• Laboratory safe practices

• Radiology services

• Admission of patient in ICU

• …….etc

Assessment Policy – Scope of Services

• Discharge Procedure Care of Patients (COP)

• Uniform care of patient

• Administration of Anesthesia

• Admission Criteria for ICU

• Ambulance services

• Bed Management in ICU

• Care of patient under Surgical Procedure

• Care of Vulnerable Patient

• Criteria for Discharge of Patient

• Emergency care

• Handling of Medical Legal Cases

• End of Life Care

• Nutritional Assessment of Patient

• Pain Management

• Prevention on Adverse Event in Surgical Patient

• Pharmacy Services

• Acquisition of medicines

• Storage of medication

• Prescription of medicines

• Verbal order of medication

• List of high risk medication

• Dispensing of medication

• Medication administration

List of condition required informed consent

• Patient Charter

• Display Copy

• Hospital Infection Control (HIC)

• Infection control manual

• Personal Hygiene

• Personal Attire

• Hand Washing

• Receipt of used material for Processing

• Proper Method of cleaning

Benefits of

NABH

Accreditation

BENEFITS TO THE CLIENTS

• Good health outcomes.

• Client satisfaction.

• Value for money

• Less frustration

BENEFITS TO HEALTH PROVIDERS

• Health staff become more satisfied with their

work.

• Health workers understand patients better.

• Information flow among staff is improved.

• Health staff who perform well are rewarded.

BENEFITS TO THE HEALTH INSTITUTIONS

• Patients become more satisfied with the

services.

• More patients may use our services.

• The environment will become clean and

beautiful.

• The facility will have a good reputation

PREMANSHU DEY Lead Trainer – IIC India