Date post: | 12-Nov-2014 |
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Pillars of QualityAn overview of NABH
Dr. A. M. Joglekar
QualityQuality in Hospitals is all about meeting expectations of:
PatientsStatutory / Legal bodiesInternal CustomersOwners / TrustOthersThird parties (NABH)
NABH has simplified matters by laying down accreditation standards for Hospitals and Healthcare providers
3rd Edition (Nov. 2011)
Accreditation standards for Hospitals and healthcare providers
NABH
636 (514) Objective Elements102 (100) Standards10 Chapters
“Patient safety” and “Continuous Quality improvement” have been given emphasis
Standards are non-prescriptiveGuidance (remarks, interpretations) is integrated Shall/should vs. can/could Intent of each chapter explained
NABH – 3rd edition
NABH 3rd edition
Patient related
Employee related
Regulatory
related
Organization policies
related
NABH Standard related
Key issues addressed
NABH
Multi disciplinary approach at HosmacDoctorsMHAs (Administrators)Bio medical EngineersCivil EngineersArchitectsTechnical experts
References
MTP ActPNDT ActNACO policies on HIV/AIDSSOPs by NACOWHO GuidelinesCDC guidelinesControl of Hospital infection
guidelines (CDC)NABH guidelines for OTsNABL guidelinesAERB for Radiology
Critical Care guidelinesClinical Audit guidelinesICMR guidelines for research
and research relatedFDA ActNational list of essential
medicinesCode of Medical ethics by MCIOrgan Transplantation ActBIS StandardsClinical establishment Act
Patient centered StandardsAccess, Assessment and Continuity of Care (AAC)Care of patients (COP)Management of Medication (MOM)Patient’s rights and education (PRE)Hospital Infection Control (HIC)
NABH Standards - Recap
Organization centered StandardsContinuous Quality improvement (CQI)Responsibility of Management (ROM)Facility management and safety (FMS)Human Resource Management (HRM)Information management system (IMS)
NABH Standards - Recap
Impact of improvement Patient centered
AAC 15/14 ; 78/86UID, Std. reports, DAR, OPD follow up, etc.
COP 18/20 ; 105/136Nursing care std, Blood transfusion, Special groups, etc.
MOM 61/73Rational use of drugs, Audit of prescriptions, patient counseling on prosthesis/devices, etc.
PRE 5/7 ; 30/46Info to patients, consents, complaint redressal, etc.
HIC 46/51IC officer, Hand hygiene, safe inj and inf practices, reprocessing, etc.
CQI 6/8 ; 39/57Analyzing complains, feedback and incidences, regular audits, review of nursing care, patient safety program, etc.
ROM 5/6 ; 25/38Senior leaders and committee performance, service standards, outsourced services, etc.
FMS 9/8 ; 43/54Disaster management, Alt sources for gases, vacuum and comp. air, etc.
HRM 13/10 ; 47/52Recruitment procedure, manpower planning, etc.
IMS 41/4324 hr access to medical records, records to contain test results
Impact of improvement Organization centered
NABH Accreditation ProcessApplication for Accreditation (By Healthcare organizations)
Acknowledgement & Scrutiny of the Application (By NABH Secretariat)
Self assessments by Healthcare organizations (Toolkit provided by NABH)
Pre-Assessment visits (By Assessment Team)
Final Assessment of Hospital (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 Certificates (By NABH Secretariat)
Feedback to Healthcare
Organizations
And
Necessary Corrective
Actions Taken
By Healthcare Organizations
Surveillance and Re assessment
Accreditation to a hospital shall be valid for a period of three years.
NABH conducts one surveillance of the accredited hospitals in one
accreditation cycle of three years.
The surveillance visit will be planned during the 2nd year i.e. after 18 months
of accreditation.
The hospitals may apply for renewal of accreditation at least six months
before the expiry of validity of accreditation for which reassessment shall be
conducted.
NABH may call for un-announced visit, based on any concern or any serious
incident reported upon by an individual or organization or media.
PrinciplesNABH system integrates the following for
managing quality at HCOs:
Hospital Quality
assurance programs
Quality assurance
applications
Quality assurance techniques
Programs assessment and trends
Transition
NABH
Process bashing in lieu of person bashing
Quality Improvement programs
Crisis Management (Traditional)
What NABH gives HCOs ??Patient focusedSupport from Top Management (by personal
examples)Quality is everyone’s businessProcess or system approachRationality and logic in
decision makingContinuous improvement
QUALITY
NABH – a journey…
New hospital v/s Old hospitalQuality “system” were focusedDefined vision – Quality, affordability, rationality,
ethics and focus on emergency careFraming policies in support of the visionProcess and procedures definedForms and formats designed and developed
in accordance to above
Approach at GMH
Approach at GMHHospital design validated
according to BIS standards.Operation theatre according to ASHRAE standards.Biomedical equipments from standard reputed
companies complying with quality standards.Support and auxiliary equipments also from firms
complying quality standards. All statutory/legal authorizations obtained and
complied with.All personnel deployed were appropriately
qualified and experienced.
Approach at GMHPrepared policy and process/other
manualsInstalled processes as per process manualsRegular training to orient personnel Formulated committees (Medical/non medical)Designated medical departmental coordinatorsInstituted patient feedback and analysis system
from Day 1 NABL accreditation for hospital lab obtained
prior to NABH
Approach at GMHSenior management attended
NABH Assessor's course and assessed other HCOs.
Conducted several self assessments.Middle management/Doctors/Staff attended
various NABH workshops and participated in NABH sponsored projects. (Six Sigma)
GMH was NABH accredited in June 2009, followed by a surveillance visit. Re-accreditation was accorded in June 2012 .
Quality ConceptsQuality was conceptualized, defined,
implemented, monitored, measured, reinforced and constantly improved.
Apex body (Think Tank) was for generating quality ideas, defining benchmarks and quality indicators.
Hospital committees and others advised and gave feedback to the Apex body.
Quality Concepts
Approach to AssessmentAt assessment, non compliances/partial
compliances were considered as opportunities to improve rather than a matter of dispute, maximizing benefits to the organization.
NABH system is a continuousquality improvement journey
NABH
Doctor interviewsMedical DocumentationPatient InterviewsHand Wash facilityRegistration of StaffCredentialing and privilegingBMW Storage (bins)Safety (Grab bars)Fatal case analysis Infection ControlPolice verificationQuestion of affordability ??Question on Ethicality
Assessment Experience
Fire Safety – Fire NOC, Fire alarms, expired extinguishers, Fire training and drills, Fire officer
Medical Documentation – Illegible, Date and time, Name, designation of doctors, completeness
Calibration of equipments – Balances, centrifuges and Bio Med equipments Testing – water, air, RO water Consents, time out and PA check Marking of Surgical sites Medical Audits Committee meeting and MOM MLC Reporting on discharge Discharge at request (DAR) Signage – Fire, emergency exits, scope of services, clinical protocols, etc. CPR Analysis Others
Col. S. K. M. Rao has conducted a detailed scientific study of the deficient areas in Hospitals
Assessment Experience
Accredited Hospitals
Applicant Hospitals
138 471
Huge improvement opportunity for hospitals
Current scenario for NABH in India
Benefits of Accreditation Patients : High quality of care & safety. Service by credentialed medical staff. Rights of patients are safeguarded. Patient satisfaction is the focused.
Hospitals : Systemized approach rather than personalized approach. Process driven rather than person driven. Stimulates constant improvement in the healthcare organization. Demonstrates commitment to quality care. Raises community confidence in the healthcare organization. Opportunity for the healthcare organization to benchmark itself against the
best.
Hospital Staff : Improves staff satisfaction due to continuous learning, good working
environment, leadership and ownership of clinical processes. Improves overall development of medical & paramedical staff.
Paying & regulatory bodies : Objective system of empanelment for insurance bodies and other third
parties. Access to reliable and certified information on facilities, infrastructure and
level of care.
Benefits of Accreditation
NABH encourages us to do, what we should be doing in the first place.
Quality is “made to happen” via sincere efforts of a HCO. NABH makes the task easier.
Being good is difficult enough, demonstrating goodness (by evidence) requires far more efforts.
NABH
NABH – a journey of continuous quality improvement….
NABH
Accreditation
Surveillance
Pre assessme
nt
Final assessme
nt
Self assessme
nt
Re-accreditati
on
THANK YOU