accreditation: a magic wand isqua webinar july 10, 2014 b.k. rana joint director, nabh vice-...
TRANSCRIPT
Accreditation: A Magic Wand
ISQua WebinarJuly 10, 2014
B.K. RanaJoint Director, NABHVice- Chairman, Accreditation Council of ISQua
National Accreditation Board for Hospitals & Health Care Providers
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Topics to be covered
▫What is accreditation?▫Benefits of accreditation▫Various accreditation bodies – case study
of NABH▫Linkage with licensing/regulation▫Voluntary vs Mandatory▫Accreditation and Patient Safety▫Global Scenario & Role of ISQua▫Magic of Accreditation
National Accreditation Board for Hospitals & Health Care Providers
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What is accreditation?
•Procedure by which an authoritative body gives formal recognition that an organization is competent to carry out specific tasks.(ISO 15189:2012- Medical Laboratories: Requirements for Quality and Competence)
National Accreditation Board for Hospitals & Health Care Providers
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What is accreditation(AB Accreditation)?•A public recognition of the achievement of
the standards by a healthcare organisation, demonstrated through an independent external peer assessment (by AB) of that body’s organisational performance in relation to the standards.
National Accreditation Board for Hospitals & Health Care Providers
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What is accreditation (ISQua Accreditation)?
•A public recognition of the achievement of the standards by a healthcare external evaluation body, demonstrated through an independent external peer assessment (by ISQua) of that body’s organisational performance in relation to the standards.
(ISQua 2013)
National Accreditation Board for Hospitals & Health Care Providers
What is Accreditation?
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•Strategic change and risk management tool
•Proactive and continuous•Transparent and rigorous analysis
of service provision•Addresses current and future
patient needs facilitated by: ▫Independent third party▫Quality Improvement focus▫Objectivity
(slide from Phil Hassen’s webinar)
National Accreditation Board for Hospitals & Health Care Providers
AccreditationIs a
processNot an event
National Accreditation Board for Hospitals & Health Care Providers
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Benefits of accreditation
Benefits for Patients
Patients are the biggest beneficiary among all the stakeholders. Accreditation results in high quality of care and patient safety. The patients are serviced by medical staff with established credentials. Rights of patients are respected and protected. Patients satisfaction is regularly evaluated.
National Accreditation Board for Hospitals & Health Care Providers
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Benefits of accreditation
Benefits for Hospitals Accreditation to a hospital stimulates
continuous improvement. It enables hospital in demonstrating commitment to quality care. It raises community confidence in the services provided by the hospital. It also provides opportunity to healthcare unit to benchmark with the best.
National Accreditation Board for Hospitals & Health Care Providers
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Benefits of accreditation
Benefits for Hospital Staff The staff in an accredited hospital is more
satisfied as it provides for continuous learning, good working environment, leadership and above all ownership of clinical processes. It improves overall professional development of Clinicians, Nurses and Para Medical Staff and provides leadership for quality improvement.
National Accreditation Board for Hospitals & Health Care Providers
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Benefits of accreditation
Benefits to paying and regulatory bodies
Finally, accreditation provides an objective
system of empanelment by insurance and other third parties. Accreditation provides access to reliable and certified information on facilities, infrastructure and level of care.
National Accreditation Board for Hospitals & Health Care Providers
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Various Accreditation Bodies
National Accreditation Board for Hospitals & Health Care Providers
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Various accreditation bodies
Across the globe, in healthcare domain, several Accreditation Bodies (AB) are functional. There is no classification, however on the basis of length of their operation and credibility of their programs, I have classified them into:
•Developed AB •Developing AB•Struggling AB
National Accreditation Board for Hospitals & Health Care Providers
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Various accreditation bodies
•Developed AB (Long length of operations and ISQua accredited organisation, standards and surveyor training )
•Developing AB (Couple of years of operations and ISQua accredited organisation/standards/ surveyor training )
•Struggling AB (No ISQua accreditation*)* Exceptions may be there e.g. The Joint Commission, USA; China
National Accreditation Board for Hospitals & Health Care Providers
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Various accreditation bodiesA. Developed AB:
Accreditation Canada ACHS, Australia HAS, France Joint Commission International, USA COHSASA, South Africa TJCHA, Taiwan MSQH, Malaysia CHKS, UK NIAZ, The Netherlands AABB, USA IKAS, Denmark
National Accreditation Board for Hospitals & Health Care Providers
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Various accreditation bodiesB. Developing AB:
NABH, India HCAC, Jordan DAP BC, Canada Healthcare Accreditation Institute, Thailand Australian General Practice Accreditation Ltd Australian Aged Care Quality Agency DNV, Norway HDAA, Australia HDANZ, New Zealand Japan Council for Quality Health Care
National Accreditation Board for Hospitals & Health Care Providers
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Various accreditation bodies
Quality Improvement Council DAA Group Limited, New Zealand Health Accreditation Service (ICONTEC),
Columbia Canadian Accreditation Council of Human
Services Global Mark, Australia QHA Trent, UK
CQA Canada; RACGP Australia; KOIHA Korea; HKAG Hong Kong; CBAHI Saudi Arabia; MOH Kazakhstan; CPQ UAE; ONA Brazil; ALIAD Spain; MOH Turkey; CPSA Canada
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Various accreditation bodies
C. Struggling AB: Rest of the accreditation organizations not listed in A & B (with exceptions*) PCAHO, Philippines Pakistan is trying to develop one Sri Lanka
National Accreditation Board for Hospitals & Health Care Providers
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Case study of National Accreditation Board for Hospitals and Healthcare
Providers (NABH)
Indian ABEstablished in 2006, under Quality Council
of India, a not-for-profit Society.Independent Board comprising members
from various stakeholders
National Accreditation Board for Hospitals & Health Care Providers
Vision• To be apex national healthcare
accreditation and quality improvement body, functioning at par with global benchmarks.
Mission• To operate accreditation and allied
programs in collaboration with stakeholders focusing on patient safety and quality of healthcare based upon national/international standards, through process of self and external evaluation.
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National Accreditation Board for Hospitals & Health Care Providers
NABH Accreditation ProgramsAccreditation of Hospitals
Accreditation of SHCO/ Nursing Homes
Accreditation of Dental Centers
Accreditation of Blood Banks
Accreditation of Wellness Centers
Accreditation of PHC/CHCs
Accreditation of OST Centers
Accreditation of AYUSH hospitals
Accreditation of Medical Imaging Services
Allopathic Clinics
National Accreditation Board for Hospitals & Health Care Providers
NABH Certification ProgramsSafe-I
Nursing Excellence
Medical Laboratory
Quality Improvement Initiatives
National Accreditation Board for Hospitals & Health Care Providers
Quality Improvement Initiatives
Pre-Accreditation Entry Level Award
Pre-Accreditation Progressive Level Award
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National Accreditation Board for Hospitals & Health Care Providers
Objective of these awards
Provide a framework for quality improvement
Focus on patient safety
Set basic standards that all Organizations must
achieve
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National Accreditation Board for Hospitals & Health Care Providers
NABH is an institutional member of the International Society for Quality in Health Care (ISQua) since 2006
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National Accreditation Board for Hospitals & Health Care Providers
ISQua Accreditation of NABH Standards for Hospitals 2nd ed., 2007(April 2008 – March 2012)
ISQua Accreditation of NABH Standards for Hospitals (April 2008 – March 2012)- 2nd Edition
(April 2012 – March 2016)- 3rd Edition
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National Accreditation Board for Hospitals & Health Care Providers
ISQua Accreditation of NABH Standards for Hospitals 2nd ed., 2007(April 2008 – March 2012)
ISQua Accreditation of NABH (as an Organisation)
(September 2012 – August 2016)
National Accreditation Board for Hospitals & Health Care Providers
Elected Member of ISQua Board (2009-2011, 2011-2013)
Elected Member of ISQua Accreditation Council (2007, 2008-2012, 2013-)
NABH is founder member of Asian Society for Quality in Healthcare (ASQua)
National Accreditation Board for Hospitals & Health Care Providers
NABH International
Formed in July 2010
Four facilities accredited in Philippines
One application from Qatar
National Accreditation Board for Hospitals & Health Care Providers
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Accreditation Standards for Hospitals
1) Chapters: 10
2) Standards: 102
3) Objective elements: 636
National Accreditation Board for Hospitals & Health Care Providers
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Accreditation Standards for Hospitals1) Access, Assessment and Continuity of Care (AAC)2) Care of Patients (COP). 3) Management of Medication (MOM).4) Patient Rights and Education (PRE).5) Hospital Infection Control (HIC).6) Continuous Quality Improvement (CQI).7) Responsibility of Management (ROM).8) Facility Management and Safety (FMS).9) Human Resource Management (HRM)10) Information Management System (IMS).
National Accreditation Board for Hospitals & Health Care Providers
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Accreditation Standards for Hospitals
Chapters Standards Objective Elements
AAC 14 86COP 20 136MOM 13 73PRE 7 46HIC 9 51CQI 8 57ROM 6 38FMS 8 54HRM 10 52IMS 7 43
Total 102 636
National Accreditation Board for Hospitals & Health Care Providers
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Acknowledgment and Scrutiny of application(By NABH Secretariat)
Pre - Assessment visit(By Assessment team)
Final Assessment(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 certificate(By NABH Secretariat)
Application + Self-assessment + Documents
Accreditation Process
National Accreditation Board for Hospitals & Health Care Providers
What after Accreditation?
Accreditation Cycle: 3 years
Surveillance Assessment: at 18 months
Renewal Assessment: within 6 months before expiry of current accreditation
Surprise checks: one hospital/ month
Performance Indicators: Data submission every quarter for 11 indicators
National Accreditation Board for Hospitals & Health Care Providers
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Update
Yr 2006 Yr 2007 Yr 2008 Yr 2009 Yr 2010 Yr 2011 Yr 2012 Yr 2013 Yr 20140
100
200
300
400
500
600
700
800
900
1000
Applicant Hospitals (863)
Applicant Hospital
National Accreditation Board for Hospitals & Health Care Providers
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Update on Activities
Yr 2006 Yr 2007 Yr 2008 Yr 2009 Yr 2010 Yr 2011 Yr 2012 Yr 2013 Yr 20140
50
100
150
200
250
Accredited Hospitals (230)
Accredited Hospital
National Accreditation Board for Hospitals & Health Care Providers
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Geographical Distribution of Hospitals --Applicants
National Accreditation Board for Hospitals & Health Care Providers
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Accredited Hospitals
National Accreditation Board for Hospitals & Health Care Providers
Linkage with Licensing/ Regulation
National Accreditation Board for Hospitals & Health Care Providers
Licensing / Registration/ Regulation
• A mandatory process• Operated by the Government• Prescribe certain basic requirements- mostly structural
and may include some processes• Healthcare facility to be licensed/ registered: not uniform
in India, States have their own Acts, if any, central Act yet to be in place
• Healthcare facility to obtain necessary licenses for different activities e.g. to procure and store alcohol, narcotics etc..
National Accreditation Board for Hospitals & Health Care Providers
Licensing / Registration/Regulation
• Healthcare facility to follow necessary Regulatory requirements e.g. Radiation Safety (AERB in India); Bio-Medical Waste Handling (BMW Act in India); Narcotic Drugs (NDPS Act in India) etc…….
In India, Hospitals require to obtain and comply with all applicable licenses and regulations as a requirement to sign up for NABH Accreditation as these have been appropriately prescribed in Accreditation Standards.
National Accreditation Board for Hospitals & Health Care Providers
Voluntary vs Mandatory
National Accreditation Board for Hospitals & Health Care Providers
• By virtue of its definition, Accreditation is a voluntary process
• Government may prescribe it as a mandatory condition for hospitals to function e.g. HAS, France accreditation is mandatory for a hospital
• Government / Paying organisation like insurance can prescribe it as a condition for empanelment
• In India, Central Government Health Scheme and Ex-Servicemen Contributory Health Scheme prescribed as one of the conditions for private hospitals to be empanelled with them. Some other examples: in USA, Australia, Taiwan insurance providers require accreditation for empanelment
National Accreditation Board for Hospitals & Health Care Providers
Accreditation and Patient Safety
National Accreditation Board for Hospitals & Health Care Providers
Patient Safety?
Quality?
Accreditation?(can not be achieved without patient safety & quality)
National Accreditation Board for Hospitals & Health Care Providers
Accreditation standards include various aspects of quality and patient safety.
National Accreditation Board for Hospitals & Health Care Providers
Patient Safety Encounters
• Patient safety information▫ Informed consent for procedures▫ Patient and family education
• Clinical safety▫ CPR, Code blue▫ prevention against wrong side,
wrong patient and wrong procedure
• Medication management▫ Labeling of drugs▫ Labeling of prepared drugs▫ High risk medication
awareness
National Accreditation Board for Hospitals & Health Care Providers
Patient Safety Encounters• Environment of care
▫ Straps of trolleys, ill maintained wheel chairs, bed rails, disability friendly toilets
▫ Surveillance of environment▫ Calibration of equipment▫ Neonatal abduction prevention
• Infection control▫ Manual, policies, procedures▫ Compliance of hand washing
National Accreditation Board for Hospitals & Health Care Providers
Accreditation supports...
•Quality improvement•Patient safety•Risk management•Change management
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National Accreditation Board for Hospitals & Health Care Providers
Does accreditation make a difference?
• Better communication and collaboration
• Stronger teams
• Increased credibility and accountability
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National Accreditation Board for Hospitals & Health Care Providers
Global Scenario and Role of ISQua
National Accreditation Board for Hospitals & Health Care Providers
National Accreditation Board for Hospitals & Health Care Providers
Why ISQua Accreditation?
•International Accreditation Programmes (IAP)
•ISQua accreditation helps to standardise by providing▫current evidence based standards, self-
assessment, peer review and consistent application
▫all organisations despite maturity level assessed against the same standards
National Accreditation Board for Hospitals & Health Care Providers
Accrediting the Accreditors
International Accreditation Programmes (IAP)
• Accreditation of health care standards• Accreditation of external evaluation organisations • Accreditation of surveyor
training programmes
National Accreditation Board for Hospitals & Health Care Providers
IAP Awards to Date
•26 accredited organizations•55 sets of standards•15 surveyor training programmes
Setting exemplary standards
National Accreditation Board for Hospitals & Health Care Providers
Magic of Accreditation
National Accreditation Board for Hospitals & Health Care Providers
Why I call it a magic wand?• It is perceived to be doing everything.
For Hospital:• Good reputation• Better income• Doing everything Right• The Best
For Patients:• Less expenditure• Best care• Everything MUST be in place• Any shortcoming/error not acceptable
National Accreditation Board for Hospitals & Health Care Providers
Why I call it a magic wand?
For Staff:•Good reputation•Better income•Right to get what they want (best in the
market/ govt.)
For Paying Agencies:•Best care•Less expenditure•Transparency in billing/ claims
National Accreditation Board for Hospitals & Health Care Providers
If anything missing?
•Accreditation/ Accreditation Body is responsible
•If a hospital is not accredited: People are happy even basic services are not available but it changes once it is accredited
National Accreditation Board for Hospitals & Health Care Providers
•It is considered to fix anything & everything in a hospital▫All structures▫All legal requirements▫All process ▫All outcomes▫ZERO complaints
National Accreditation Board for Hospitals & Health Care Providers
Patients/ Public consider Accreditation a Super Regulation (AB as Super Regulator) than a Tool for Improvement.
National Accreditation Board for Hospitals & Health Care Providers
Can we live up to such expectations?
National Accreditation Board for Hospitals & Health Care Providers
Thank You
[email protected] www.nabh.co