+ All Categories
Home > Health & Medicine > Pillars of Quality : An Overview of NABH - Dr. A.M Joglekar at Knowledge Series Seminar-Pune

Pillars of Quality : An Overview of NABH - Dr. A.M Joglekar at Knowledge Series Seminar-Pune

Date post: 12-Nov-2014
Category:
Upload: hosmac-india-pvt-ltd
View: 8,664 times
Download: 8 times
Share this document with a friend
Description:
 
Popular Tags:
31
Pillars of Quality An overview of NABH Dr. A. M. Joglekar
Transcript
Page 1: Pillars of Quality : An Overview of NABH - Dr. A.M Joglekar at Knowledge Series Seminar-Pune

Pillars of QualityAn overview of NABH

Dr. A. M. Joglekar

Page 2: Pillars of Quality : An Overview of NABH - Dr. A.M Joglekar at Knowledge Series Seminar-Pune

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

Page 3: Pillars of Quality : An Overview of NABH - Dr. A.M Joglekar at Knowledge Series Seminar-Pune

3rd Edition (Nov. 2011)

Accreditation standards for Hospitals and healthcare providers

NABH

Page 4: Pillars of Quality : An Overview of NABH - Dr. A.M Joglekar at Knowledge Series Seminar-Pune

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

Page 5: Pillars of Quality : An Overview of NABH - Dr. A.M Joglekar at Knowledge Series Seminar-Pune

NABH 3rd edition

Patient related

Employee related

Regulatory

related

Organization policies

related

NABH Standard related

Key issues addressed

Page 6: Pillars of Quality : An Overview of NABH - Dr. A.M Joglekar at Knowledge Series Seminar-Pune

NABH

Multi disciplinary approach at HosmacDoctorsMHAs (Administrators)Bio medical EngineersCivil EngineersArchitectsTechnical experts

Page 7: Pillars of Quality : An Overview of NABH - Dr. A.M Joglekar at Knowledge Series Seminar-Pune

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

Page 8: Pillars of Quality : An Overview of NABH - Dr. A.M Joglekar at Knowledge Series Seminar-Pune

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

Page 9: Pillars of Quality : An Overview of NABH - Dr. A.M Joglekar at Knowledge Series Seminar-Pune

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

Page 10: Pillars of Quality : An Overview of NABH - Dr. A.M Joglekar at Knowledge Series Seminar-Pune

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.

Page 11: Pillars of Quality : An Overview of NABH - Dr. A.M Joglekar at Knowledge Series Seminar-Pune

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

Page 12: Pillars of Quality : An Overview of NABH - Dr. A.M Joglekar at Knowledge Series Seminar-Pune

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

Page 13: Pillars of Quality : An Overview of NABH - Dr. A.M Joglekar at Knowledge Series Seminar-Pune

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.

Page 14: Pillars of Quality : An Overview of NABH - Dr. A.M Joglekar at Knowledge Series Seminar-Pune

PrinciplesNABH system integrates the following for

managing quality at HCOs:

Hospital Quality

assurance programs

Quality assurance

applications

Quality assurance techniques

Programs assessment and trends

Page 15: Pillars of Quality : An Overview of NABH - Dr. A.M Joglekar at Knowledge Series Seminar-Pune

Transition

NABH

Process bashing in lieu of person bashing

Quality Improvement programs

Crisis Management (Traditional)

Page 16: Pillars of Quality : An Overview of NABH - Dr. A.M Joglekar at Knowledge Series Seminar-Pune

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…

Page 17: Pillars of Quality : An Overview of NABH - Dr. A.M Joglekar at Knowledge Series Seminar-Pune

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

Page 18: Pillars of Quality : An Overview of NABH - Dr. A.M Joglekar at Knowledge Series Seminar-Pune

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.

Page 19: Pillars of Quality : An Overview of NABH - Dr. A.M Joglekar at Knowledge Series Seminar-Pune

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

Page 20: Pillars of Quality : An Overview of NABH - Dr. A.M Joglekar at Knowledge Series Seminar-Pune

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 .

Page 21: Pillars of Quality : An Overview of NABH - Dr. A.M Joglekar at Knowledge Series Seminar-Pune

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.

Page 22: Pillars of Quality : An Overview of NABH - Dr. A.M Joglekar at Knowledge Series Seminar-Pune

Quality Concepts

Page 23: Pillars of Quality : An Overview of NABH - Dr. A.M Joglekar at Knowledge Series Seminar-Pune

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

Page 24: Pillars of Quality : An Overview of NABH - Dr. A.M Joglekar at Knowledge Series Seminar-Pune

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

Page 25: Pillars of Quality : An Overview of NABH - Dr. A.M Joglekar at Knowledge Series Seminar-Pune

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

Page 26: Pillars of Quality : An Overview of NABH - Dr. A.M Joglekar at Knowledge Series Seminar-Pune

Accredited Hospitals

Applicant Hospitals

138 471

Huge improvement opportunity for hospitals

Current scenario for NABH in India

Page 27: Pillars of Quality : An Overview of NABH - Dr. A.M Joglekar at Knowledge Series Seminar-Pune

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.

Page 28: Pillars of Quality : An Overview of NABH - Dr. A.M Joglekar at Knowledge Series Seminar-Pune

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

Page 29: Pillars of Quality : An Overview of NABH - Dr. A.M Joglekar at Knowledge Series Seminar-Pune

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

Page 30: Pillars of Quality : An Overview of NABH - Dr. A.M Joglekar at Knowledge Series Seminar-Pune

NABH – a journey of continuous quality improvement….

NABH

Accreditation

Surveillance

Pre assessme

nt

Final assessme

nt

Self assessme

nt

Re-accreditati

on

Page 31: Pillars of Quality : An Overview of NABH - Dr. A.M Joglekar at Knowledge Series Seminar-Pune

THANK YOU


Recommended