awareness on nabh standard for hospital
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Awareness on NABH standard for hospitals
Associated Management Consultants Bokaro Steel City
YouIn Awareness Programon
welcomeNABH Standards 2011 [email protected] on NABH standard for hospitals
Associated Management Consultants
Bachelor in Chemical Engineering. PG Diploma in Management 35 years experience in SAIL/BSL 12 years experience in management system development and guidance Lead assessor for: ISO 9001:QMS ISO 140001: EMS OHSAS : 180012Our Team:-Mr. Vidya Pati Singh [email protected] on NABH standard for hospitals
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Our team contd.. Certified trainer on: Management development Hazard identification & risk analysis 5s house keeping system Quality Circle Unit Training Performance Improvement Work shopExpertise in : NABH - documentation & Implementation NABH - documentation & implementation NABET documentation and guidance System Development and Safety Audit [email protected] on NABH standard for hospitalsAssociated Management Consultants
Post Graduate in Medicine Physician & Consultant - Diabetologist Certified Interventional Ultrasonologist Certified in Diagnostic GI Endoscopy PG Diploma in Hospital Management Certified NABH Counselor Clinical experience of more than 10 years Experience on Hospital Management of 8 yearsConsultancy experience in NABH accreditation of 3 years.
Our Team:-Dr. Sudhir kumarExecutive [email protected] on NABH standard for hospitalsAssociated Management Consultants
Our services We provide consultancy services in the following areas:-
ISO 9001:2008 Quality Management System. ISO 140001: Environment Management System. OHSAS 18001: Occupational Health & Safety Management system. ISO 22000: Food Safety Management System. NABH Accreditation for Hospital and Nursing Homes.
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Services contd.. NABL accreditation for medical laboratories. 5 s Housekeeping System Hazard identification, Risk analysis System improvement and safety audits. Management development & Human Resource Development [email protected] on NABH standard for hospitalsAssociated Management Consultants
Health care scenario in IndiaIndia has achieved a Significant Progress in the Provision of health care since independence.Health care is one of Indians largest sectors, in terms of revenue and employment and the sector is expanding rapidly.During the 1990s Indian health care grew at a compounded rate of 16%. Today the total value of the sector is more than $ 36.0 billion. This translates to $ 29 per capita or roughly 6% of [email protected] on NABH standard for hospitalsAssociated Management Consultants
Health care scenario in India contd..The private sector accounts for more than 80% of total health care spending in India.70% of Indians health care infrastructure is concentrated in 20 big cities.Recent reforms and innovation under the National Rural Health Mission (NRHM) have resulted significant improvement in key health care indicators in many [email protected] on NABH standard for hospitalsAssociated Management Consultants
Health care scenario in India contd..These include:Institutional deliveriesOut-patient health careComplete immunizationAvailability of diagnostic and family welfare facilitiesDisease control program
South Korea-2.4Brazil-2.3China-2.0
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Health care scenario in India contd..Approximately 13000 hospitals and 42000 nursing homes are operating in India having bed strength of 1.05 million.Bed availability in India is 1.3 bed per 1000 population where WHO suggested norms is 3.5 bed per 1000 population.Bed availability in advance countries is far more than [email protected] on NABH standard for hospitalsAssociated Management Consultants
Health care scenario (Projection)Projected bed strength by 2017-1.7 millionBeds to be added by 2017-0.65 millionPopulation by 2017-1.33 billionIncrease in availability of bed from 1.3 to 1.7 per 1000 populationRequirements of beds to achieve this goal -2.25 millionsAdditional beds required -0.55 millions
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Health care scenario (Challenges)Mushroom growth substandard services.Poor or inconsistent quality of health care services.Regulatory mechanism either from the government or within medical profession is not effective.Inadequate availability of number of doctors per thousand population 0.65 doctors as against WHO norms of 2.5 doctors.Fast spread of non-communicable diseases and inadequate availability of diagnostic and treatment [email protected] on NABH standard for hospitalsAssociated Management Consultants
Health care scenario (Challenges) contd..Cardiac disease:5 million patients every year only 1050 cardiac centers adequate to perform 2 million angioplasty.Cancer:1.2 million patients diagnosed every yearAvailable facilities:Diagnostic PET and CT scanner 90 MRI- 1300 CT Scanner (above 6 slice)- [email protected] on NABH standard for hospitalsAssociated Management Consultants
Health care scenario (Challenges) contd..Comprehensive cancer centers 325About 70% of patients diagnosed with cancer die within the fist few years.45% of population travel more than 100 KM to access higher level care.Tariff levied on care is not uniform across the country and care provision is also not uniform.Patient safety is inadequately addressed causing death or [email protected] on NABH standard for hospitalsAssociated Management Consultants
Health care scenario (opportunities)6.5 lakh beds are projected to be added by 2017 in the present bed strength of 10.5 lakh beds at a total investment of INR 162500 crores(Private INR 130000 crore, Government INR 32500 crore).Under the National Rural Health Mission, over 2000 rural hospitals, at the level of primary community health centers are being upgraded to a uniform set of [email protected] on NABH standard for hospitalsAssociated Management Consultants
Health care scenario (opportunities) contd..MoR and MoHFW have jointly decided to set up thousands of diagnostic centers at each junction and small hospitals in each district on railway land.Renowned private player like Narayana, Appolo, Fortis, Max, Vastsalya, Vikram Birla etc are rapidly expanding their network of health care service on huge investment.HCL, a renowned IT Company has recently decided to establish a health care network by 2015 on an initial investment of INR 1000 [email protected] on NABH standard for hospitalsAssociated Management Consultants
Health care scenario (opportunities) contd..Dr. Lall Pathology, Raligare, Thyrocare etc are also expanding their diagnostic and medical laboratory network on huge investment.India enjoys a competitive advantage at the international level by venture of its vast scientific manpower.Steps are being taken to promote India as a preferred health care destination to attract people from different parts of [email protected] on NABH standard for hospitalsAssociated Management Consultants
Health care scenario (opportunities) contd..Cost of key health care procedures is cheap in India compared to advanced countries and competence of health professionals far exceeds the others.Cost of key Health Care Procedures:
(Source: India Brand Foundation Report, IBEF Research)Currency USDUSThailandIndiaIndia HC cost% of USCardiac surgery50,00014,2504,00012.5Bone marrow transplant62,50062,50030,00013.33Lever transplant5,00,00075,00045,00011.11Orthopedic surgery16,0006,9004,[email protected] on NABH standard for hospitalsAssociated Management Consultants
Health care scenario (opportunities) contd..High competence profile of Indian health professionals and cheaper cost of procedures have accelerated the inflow of foreign patients to get better health care.India is now becoming a preferred destination for health tourism across the globe.As per latest estimates the Health Tourism industry is of INR 7500 crore and expected to touch a level of INR 1200 crore by [email protected] on NABH standard for hospitalsAssociated Management Consultants
Health care scenario (Accreditation System)Quality Council of India established National Accreditation Board for hospitals and small health care organizations in 2005 to meet the need for Scientific and Systematic methodology of assessment as required by Insurance, TPAs, regulatory bodies and other stake holders.NABH accreditation of hospitals and SHCO was started in 2009 and the process is continuing at faster [email protected] on NABH standard for hospitalsAssociated Management Consultants
Health care scenario (Accreditation System) contd..
Status of accredited Hospitals & SHCOs(Till January 2014)
Note: Applicant hospitals and SHCOs are in different stages of accreditationAccreditedApplicantsHospitals201398SHCOs29123assmancon@gmail.com2122Awareness on NABH standard for hospitalsAssociated Management Consultants
Why NABH Accreditation? NABH Accreditation standards for hospitals and small health care organizations have been developed by Technical committee of NABH and reviewed every four yearsThe standards provide framework for quality assurance and quality improvement for hospitals and small healthcare organizationsNeed for a scientific systemic standardization methodology as required by Insurance Companies, TPAs, PSUs, CGHS and other empanelling paying and regulatory bodies.Competitive environment demands better healthcare services.NABH accreditation assures Quality, and trust of health care customer. [email protected] on NABH standard for hospitalsAssociated Management Consultants
Definition of accreditation
Accreditation is a process in which an entity, Separate and distinct from the health care organization, assesses the health care organization to determine if it meets a set of requirements designed to improve the quality of care
Accreditation is usually voluntary and provides a visible commitment by an organization to improve the quality of patient care, ensure a safe environment, and continually work to reduce risks to patients and staff.
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Introduction of NABH NABH- National Accreditation Board for Hospitals and Healthcare providers was established in early 2005. It is the sole accreditation body In India It is autonomous and a constituent board of the Quality Council of India(QCI) It has been set up to establish and operate accreditation program for hospitals and other healthcare organizations.NABH has also published separate standard for Accreditation of Blood Banks and Imaging Services. Its main objective is to enhance health systems and promoting continuous quality improvement and patients [email protected] on NABH standard for hospitalsAssociated Management ConsultantsQuality Council of India NABHAppeals CommitteeSecretariatTechnical CommitteeAccreditation CommitteePanel of expertsStructure of [email protected] on NABH standard for hospitalAssociated Management Consultants
International Linkages: NABH is Institutional Member as well as a member of Accreditation Council of the International Society for Quality In Health Care (ISQua). ISQua has accredited Standards for hospitals by NABH. India became the 12th country in the world to be recognized by ISQua. Hospital accredited by NABH will have international [email protected] on NABH standard for hospitalsAssociated Management Consultants
Linkages contd..NABH is the founder member of proposed Asian Society for Quality in Health care for patient safety as a nominee of ISQua. NABH is member of International Steering Committee of WHO Collaborating Centre for Patient Safety as a nominee of ISQua.
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Outlines of NABH standard :2011 10 chapters 102 standards 636 objective elements
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Standards and Objective Elements A standard is a statement that defines the structures and processes that must be substantially in place in an organization to enhance the quality of care Objective Element is a measurable component of a standard. Acceptable compliance with objective element determines the overall compliance with a standard
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Patient centered standards:
ChapterTitleStandardsObjective elements1.Access, assessment & continuity of care 14862.Care of patient201363.Management of medication13734.Patient rights and education 07465.Hospital infection [email protected] on NABH standard for hospitalAssociated Management Consultants
Organization Centered Standards:
ChapterTitleStandardsObjective Elements6.Continuous Quality improvement08577.Responsibilities of management06388.Facility management and safety08549.Human resource management105210.Information Management System0743Total 39244Grand Total [email protected] on NABH standard for hospitalAssociated Management Consultants
Chapter.1. Access, Assessment and Continuity of Care (AAC) Standards 14, OEs- 86
Intent :- Patient are well informed of the servicesPatients matching with organization's resources will be admittedPatient not matching with organizations resources are referred to other suitable [email protected] on NABH standard for hospitalAssociated Management Consultants
Continued..
Admission based on defined process including patient and family education Systems of initial, periodic and regular assessment based on laboratory and imaging services result. Well defined transfer and discharge protocols.
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Chapter 2. Care of patients(COP)Standards- 20, Oes-136
Intent :- Standards aim patient safety as overall principle for providing care to patients. Uniform Care of Patient
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Contd.. Policy, procedure, applicable laws and regulations guide Cardio- Pulmonary Resuscitation, Use of blood products. Patient care in intensive care and high dependency care units, vulnerable patients, high risk obstetrical patients, pediatric patients, moderate sedation cases, administration of anesthesia, surgical procedures, research activities, end of life care, pain management, nutritional therapy and rehabilitative [email protected] on NABH standard for hospitalAssociated Management Consultants
Chapter 3. Management of Medication (MOM)Standards -13, OEs 73Intent :- Safe, organized medication policies and procedures for safe storage, prescription, dispensing and administration of medications. Availability of emergency medications ( crash carts).
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Contd.. Procedures for high risk medication like narcotics, chemotherapeutic agents, radioactive isotopes etc. Mechanism to ensure that required medications are always stocked within expiry dates.
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Chapter 4. Patient Rights and Education (PRE)Standards 07-Oes- 46Intent :- Organization defines patient and family rights and responsibilities. Staff is aware and trained. Patients are informed of their rights and responsibilities.
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Contd..
Documented process for consent exits. Patients and families have right to information about healthcare needs in a language and manner that is understood by them.
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Chapter 5. Hospital infection control (HIC)Standards 09, OEs 51
Intent :- Provision of Documented and effective infection control program. Aims at reducing / eliminating infection risks to patients, visitors and hospital employees. Provision of proper facility and adequate resources for infection control [email protected] on NABH standard for hospitalAssociated Management Consultants
Contd..
Action plan for outbreak of infections, procedures for sterilization activities. Compliance of statutory provisions of Bio-medical Waste treatment and disposal. Training of employees.
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Chapter 6. Continuous Quality Improvement (CQI)Standards 08, OEs 57
Intent :- Structured and documented Quality improvement program Continuous monitoring of identified key indicators. Established system for audit of patient care services. Sentinel events are intensively analyzed for prevention.
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Chapter 7. Responsibilities of Management (ROM)Standards 06, OEs 38
Intent :- Governance in professional & ethical manner. Services of each department documented. Qualified and experienced individual heads the department. Patient safety aspects and risk management issues are an integral part of patient care and hospital [email protected] on NABH standard for hospitalAssociated Management Consultants
Chapter 8. Facility Management and Safety (FMS)Standards 09, OEs 54Intent :- Compliance of relevant rules and regulations, laws and by-laws Environment and facilities to ensure safety of patients, their families, staff and visitors. Plans for fire and non-fire emergencies. Smoking limitation policy and management of hazardous [email protected] on NABH standard for hospitalAssociated Management Consultants
Chapter.9 , Human Resource Management (HRM)Standards 10, OEs 52Intent :- Human resources are an asset for efficient functioning of Hospitals. Goal of HRM is to acquire, provide, retain and maintain competent people. System of appraisal, disciplinary procedures, Grievance handling procedure. Addressing safety and health needs of employees. Process for collecting, verifying and evaluating the credentials of medical professionals and nursing [email protected] on NABH standard for hospitalAssociated Management Consultants
Chapter 10. information Management System (IMS)Standards 07, OEs 47
Intent: Procedure for information generation, storage and appropriate utilization. Process for effective management of data. Complete and confidentiality, integrity of information and retention time of records. Regular review of medical records
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Steps to NABH Accreditation
Preparing for Accreditation :-
Steps 1 Obtain a copy of NABH StandardSteps 2Carry out self assessment on the status of compliance with the NABH StandardsSteps 3Ensure that NABH Standards are implemented and integrated with the hospital [email protected] 4Obtain a copy of application form (from NABH office or website)Steps 5Fill & submit the application form in NABH office Steps 6Pay the accreditation feeAwareness on NABH standard for hospitalAssociated Management Consultants
Steps contd..
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Steps to NABH Accreditation
B. Accreditation process:-Steps 1. Application for accreditation (submitted by the Health Organization)Steps 2.Acknowledgement for accreditation ( by NABH secretariat) Steps 3.Pre assessment visit (by Assessor) Steps 4.Final assessment of hospital (by assessment team)[email protected] 5.Scrutiny of the assessment report (by NABH secretariat)Steps 6.Recommendation for accreditation ( by accreditation committee)Steps 7.Approval for accreditation (by chairman NABH) Steps 8.Issue of accreditation certificate (by NABH secretariat)Awareness on NABH standard for hospitalAssociated Management Consultants
Accreditation process contd..
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Pre-accreditation Entry Level
Establish the system, implement standards, maintain it at least for three months. Carry out self assessment using NABH self assessment toolkit in a stringent manner.
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Condition for Qualifying for the Award
All the regulatory and legal requirements should be fully met. No individual standard should have more than two zeros.The average score for the individual standard must not be less than 5. The average score for individual chapter must be more than 5. The overall average score for all standards must exceed 5.
Validity period Minimum 6 months to maximum 18 months. [email protected] on NABH standard for hospitalAssociated Management Consultants
Pre accreditation progressive Level All the regulatory and legal requirements must be fully met No individual standard should have more than two zeros. The average score for the individual standard must not be less than 5. The average score for individual chapter must be more than 6. The overall average score for all standards must exceed 6.
Validity period Minimum 3 months to maximum 6 months.
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Accreditation Condition for Qualifying for accreditation All the regulatory legal requirements must be fully metNo individual standard should have more one zero. The average score for individual standard must be more than 5.The average score for individual chapter must be more than 7 The overall average score for all standards must exceed 7. Validity period 3 years. [email protected] on NABH standard for hospitalAssociated Management Consultants
Scoring criteriaCompliance to the requirement- 10Partial compliance to the requirement - 5Non- compliance to the requirement - 0Not applicable-NA
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State wise status of NABH accreditation of hospitals in developed states (Jan2014)S. No.StateNo. of accredited HospitalsApplicant HospitalsTill Dec'12Till Jan'14Total1Andhra Pradesh180523412Delhi380139393Gujarat150017274Karnatka170825285Kerala080210296Maharashtra150722287Tamil Nadu170118268Punjab & [email protected] on NABH standard for hospitalAssociated Management Consultants
State wise status of NABH accreditation of hospitals in Progressive states (Jan2014)S. No.StateNo. of accredited HospitalsApplicant HospitalsTill Dec'12Till Jan'14Total1CG & MP000303212Rajasthan050207143UP & UK050106744W. [email protected] on NABH standard for hospitalAssociated Management Consultants
State wise status of NABH accreditation of hospitals in developed states (Jan2014)S. No.StateNo. of accredited HospitalsApplicant HospitalsTill Dec'12Till Jan'14Total1Assam00101022Bihar000033Goa0010104Himachal Pradesh000015J & K000086Jharkhand000027Orissa01030404Total01050620Grand [email protected] on NABH standard for hospitalAssociated Management Consultants
State wise status of NABH accreditation of SHCOs in developed states (Jan2014)S. No.StateAccredited SHCOs (jan'14)Applicant SHCOs1Andhra Pradesh02082Delhi05203Gujarat04104Haryana & Punjab03155Karnataka02126Kerala04107Maharashtra05078Tamil [email protected] on NABH standard for hospitalAssociated Management Consultants
State wise status of NABH accreditation of SHCOs in Progressive states (Jan2014)S. No.StateAccredited SHCOs (jan'14)Applicant SHCOs1CG & MP0052Rajasthan0033UP & UK01204W. [email protected] on NABH standard for hospitalAssociated Management Consultants
State wise status of NABH accreditation of SHCOs in Other states (Jan2014)S. No.StateAccredited SHCOs (jan'14)Applicant SHCOs1Assam002Bihar003Himachal Pradesh014Jharkhand105Orissa016J&K01Total13Grand [email protected] on NABH standard for hospitalAssociated Management Consultants
Surveillance and Re-Assessment The accreditation is valid for 3 years. NABH conducts one surveillance in one accreditation cycle of 3 years. Surveillance is planned in 2nd year i.e. after 18 months of accreditation. Hospital should apply for renewal of accreditation at least 6 months before the expiry of validity. Re-assessment by NABH will be done thereafter. NABH may call for un-announced visit based on any serious incident reported upon by an individual, or organization or [email protected] on NABH standard for hospitalAssociated Management Consultants
Benefits of NABH Accreditation Strengthens community confidence in he quality and safety of care, treatment and services. Provides a competitive edge in the marketplace. improvers risk management and risk reduction. Helps organize and strengthen patient safety effort. provides education on good practices to improve business operations.
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Benefits contd..Provides professional advice and counsel there by to enhancing staff education. Attracts qualified personnel who prefer to serve in an accredited organization. Provides deeming authority for the other certifications. Recognized by insurers and other TPAs May reduce liability of insurance cost. Grants eligibility for empanelment with CGHS, ECHS, TPAs and PSUs. Provides opportunities to benchmark with the best.
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NABH is to your advantage It stratifies the legal, commercial and infrastructural processes of the hospital Hospitals can commit to provide safe and quality healthcare to patients. It streamlines the processes for the hospitals top management and key personnel Ease in decision making saves time and resources.
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NABH to contd.. It suggests the necessary changes in the hospital policies for standardization Increases confidence of the external bodies associated with the hospital. It recommends changes in the resources and infrastructure to manage the information flow more effectively and efficiently.Provides an all-inclusive approach right from the patient entry or access to the hospital to the discharge of patients. [email protected] on NABH standard for hospitalAssociated Management Consultants
NABH to contd.. It rationalizes the work procedures that exist in the day-to- day functioning of the hospital. Analysis of the strategies of the hospital to take necessary corrective measures. Supervising the system to overcome gaps in the workflow. [email protected] Awareness on NABH standard for hospitalAssociated Management ConsultantsNABH to contd.. Improvising co- ordination between departments causing efficient handling of task assigned. Inspection and surveillance of Processes and Structures Rectifying in processes like diagnosis, pathology and imaging services, operation theatres and ICU maintenance. Management of biological wastes to prevent [email protected] Awareness on NABH standard for hospitalAssociated Management ConsultantsWhat Associated Management Consultant offers? Study and assessment of current status through gap analysis Conducting awareness on NABH standards for hospitals Working hand in hand with hospitals in documentationSound rework on hospital policies, processes and procedures Guiding implementation of NABH standards
[email protected] Awareness on NABH standard for hospitalAssociated Management ConsultantsWhat AMC Offers.. Guiding design and development of required displayed, formats, pamphlets and various booklets. Assisting in designing and setting corporate goals. Assisting in setting quality objectives and improvement targets Conducting HIRA and Safety Audit (except fire safety)
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What AMC Offers.. Restructuring procedures for the core departments of the hospital and HRD. Developing feedback process for the patients as well as employees to understand their level of satisfaction. Developing effective complaint and grievance redress mechanism . Developing internal clinical auditors Assisting and guiding in third party clinical audits
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Thank youFor
Patience listening &Valuable queries!