hospital nabh accrediation challenges

NABH Hospital accreditation challenges

Deepak.Venkatesh. Agarkhed

Name: Deepak.Venkatesh.Agarkhed

• Designation: GM-Facilities & Quality.

• Name of Institution: Sakra World Hospital.

• Any other position(s) held:TC Member-NABH

• No. of Publications: Several like NABH-Medical devices, AHPI-Patient safety & trade journals like Express Healthcare

• Special Awards and Recognition: Excellence Award in the Bio Medical Equipment / Facilities Improvement category an International Award, Hospital Management Asia (HMA) at Philippines

• Any other relevant information:

• Master Black belt in Six Sigma from ISI,New Delhi

• Part of Toyota Production System implementation

11/13/2016 deepakagarkhed@gmail.com 3

KALEIDOSCOPE 2016 ,13th Nov 2016,J.W.Marriott,Bengaluru

1.Need for TEAM approach towards continuous quality improvement ( CQI )• Quality improvement left only to quality team who has no bandwidth

to cover entire HCO.

• Non availability of core committee.

• Each functional department working in silo mode.

• Ineffective committee functioning.

• Inadequate support from Top management

deepakagarkhed@gmail.com 411/13/2016

2.NABH accreditation :Improper Project planning ( CQI )• Understanding it as time bound project approach

• Creating core team consisting of quality team,Clinicans,nursing,non clinical team members, medical admin & management.

• Doing proper gap analysis to know ground reality.

• Decentralizing tasks & approaching each milestone systematically.

deepakagarkhed@gmail.com 511/13/2016

3.Incorrect NABH standard Gap analysis on ground by core team ( CQI)

deepakagarkhed@gmail.com 6

Documentation

(Yes/ No)

Implementation

(Yes/ No)

Evidence (cross reference

to documents/

manuals etc.)

Scores

(0/ 5/ 10)

a

Yes Yes SOP PSM 13 5

b

Yes Yes SOP PSM 14 10

cYes Yes SOP NS 68 5

d

Yes Yes SOP NS 79 10

SELF ASSESSMENT TOOLKIT

Elements

MOM.12: Documented policies and procedures guide the use of

implantable prosthesis and medical devices.

Usage of implantable prosthesis and medical devices is guided by scientific

criteria for each individual item and national/international recognised guidelines/

approvals for such specific item(s).

Documented policies and procedures govern procurement, storage/stocking,

issuance and usage of implantable prosthesis and medical devices

incorporating manufacturer’s recommendation(s).*

Patient and his/her family are counselled for the usage of implantable

prosthesis and medical device including precautions, if any.

The batch and serial number of the implantable prosthesis and medical devices

are recorded in the patient’s medical record, the master logbook and the

discharge summary.

11/13/2016

11/13/2016 deepakagarkhed@gmail.com 7

4.Dealing with people with inertia

• Difficult to handle• Clinicians

• Functional Heads

• Supportive team • Nursing

• Outsourced staff

deepakagarkhed@gmail.com 811/13/2016

5.Inconsistent processes

• No written standard operating procedures ( SOP )

• Each employee /staff with varied process steps

• No training on SOP

• No adherence of SOP on ground

• No attempt to update SOP based on process improvement

deepakagarkhed@gmail.com 911/13/2016

6.Unsafe environment ( FMS)

• Adequate back of power & Medical Gas & provision of alternate source

• Fire exits blocked & non/partial functional fire fighting & sensing devices.

• Adequate fire protection in area like Kitchen, Deiseal storage yard.

• Electrical safety compromised like bypassing of fuse/RCCB,extension board used in wet points, on availability of safety mats.

• Facility with sharp turns, low heights, low light intensity.

• Radiation safety protection in designated radiation zones.

• Slipper rest rooms, beds without side rails etc.

• Non available/functional medical gas alarm units

deepakagarkhed@gmail.com 1011/13/2016

7.Improper documentation (COP & IMS)

• Non availability of forms or formats

• Medical records with inadequate documentation

• Checklists not duly signed

• Improper document control

deepakagarkhed@gmail.com 1111/13/2016

8.Lack of comprehensive training program (HRM)

•Training - Induction•Training-On Job

•Training-Refresher

•Ensuring staff availability

•Ensuring timely training

•Ensuring effectiveness

deepakagarkhed@gmail.com 1211/13/2016

9.Untrained staff for emergency preparedness ( FMS & COP)• No structured approach on timely execution of various drills like Fire,

community disaster.

• Understanding gaps & training staff on emergency preparedness.

deepakagarkhed@gmail.com 1311/13/2016

10.Inadequate inventory control measures (MOM) • Not following good practices of inventory managements

• Reorder level monitoring

• Expiry & near expiry drug monitoring

• Not following FIFO

deepakagarkhed@gmail.com 1411/13/2016

11.Lack of acceptance of data driven approach ( ROM)

• Moving from gut feeling to data driven approach

• Capturing quality measures to understand where we stand.

• Analyzing & acting towards improvement

deepakagarkhed@gmail.com 1511/13/2016

12.Involvement of Clinicians in quality improvement ( CQI )• Mostly clinicians & their team do not get involved in quality

improvement programs like accreditation process.

• They do object if someone audits them on the best practices like hand hygiene compliances.

deepakagarkhed@gmail.com 1611/13/2016

13.Partial implementation of laws & regulations ( ROM)• Non availability of tracking system for legal compliance.

• Making functional heads accountable for timely renewal.

• Unorganized central depository of legal compliance documents.

deepakagarkhed@gmail.com 1711/13/2016

14.Antibiotic policy adherence ( HIC)

• No takers of antibiotic policy .

• No initiation of corrective & preventive measures for deviation in adherence.

deepakagarkhed@gmail.com 1811/13/2016

79%

50%

81%85%

80%74%

59%

100%

74%

61%69%

58%

76%80%

58%

0%

20%

40%

60%

80%

100%

120%

Nurses Doctors Tech Physio HK/GDA

Compliance of Hand Hygiene by healthcare workers July Aug Sep

11/13/2016 deepakagarkhed@gmail.com 19

17.Absence of effective action based on Patient Feedback ( PRE)

deepakagarkhed@gmail.com 20

2.89

2.962.98

2.92

2.80

2.85

2.90

2.95

3.00

OVERALL IPD PSI FOR FOUR MONTHS Low scoring Services ( Maximum score 4 )

1. Food Tray Clearance2. Timely Meal service3. Delay in patient discharge4. Clinical nutrition assessment5. Efficiency of the bill settlement.

11/13/2016

18.Absence of validation of quality assurance of Clinically outsourced organization Lack of availability /renewal of MoU .

No evidence on methodology to select .

No review of performance service .

deepakagarkhed@gmail.com 2111/13/2016

19.Lack of implementation of effective CPR policies & procedures( COP )• Training to nurse in high risk area

• CRP mock Drills

• CPR event recording & CAPA based post event analysis

deepakagarkhed@gmail.com 2211/13/2016

20.Want of Sentinel event intensive analysis (CQI )

• Lack of mechanism to identify sentinel events

• Analysis of RCA for sentinel events

• CAPA on sentinel events

deepakagarkhed@gmail.com 2311/13/2016

Thank You

deepakagarkhed@gmail.com 2411/13/2016