natonal accreditation for hospital & health care providers (nabh)
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NATONAL ACCREDITATIONFOR HOSPITAL & HEALTH CARE
PROVIDERS(NABH)
SHISHIR JAIN
NARAYANA HRUDALAYA
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WHAT IS QUALITY ?WHAT IS QUALITY ?
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AppropriateAppropriate applicationapplication ofof medicalmedical
knowledgeknowledge withwith duedue regardregard toto thethe
balancebalance betweenbetween thethe hazardhazard inherentinherent
inin everyevery medicalmedical interventionintervention andand thethe
benefitsbenefits expectedexpected fromfrom itit
ItIt is,is, howeverhowever moremore complexcomplex thanthan
thisthis..
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QUALITY FROMWHOSEQUALITY FROMWHOSEPOINT OF VIEW ?POINT OF VIEW ?
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Provider of Health care ServicesProvider of Health care Services
Recipient of the Health careRecipient of the Health care
servicesservices
Organizer of the Health careOrganizer of the Health care
servicesservices
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PROVIDERS CONCERNSPROVIDERS CONCERNS
ToTo provideprovide carecare asas perper establishedestablished
normsnorms
AdequateAdequate resourcesresources SelfSelf satisfactionsatisfaction withwith thethe finalfinal
outcomeoutcome
ShouldShould contributecontribute toto enhancementenhancement ofof
skills,skills, competencecompetence andand addadd toto
experienceexperience
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RECIPIENTS CONCERNSRECIPIENTS CONCERNS
Accessibility
Affordability
Prompt attention
Less waiting time
Early diagnosis and cure
Return to Productivity as early as possible
Humane Treatment ie to be treated with
empathy , respect and concern
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ORGANISERS CONCERNSORGANISERS CONCERNS
ResponsibleResponsible toto thethe SocietySociety forfor thethe fundsfunds
spentspent onon healthhealth carecare
ToTo ensureensure safetysafety ofof publicpublic andand preventprevent
inappropriateinappropriate oror suboptimalsuboptimal carecare
ToTo meetmeet thethe requirementsrequirements ofof thethe recipientrecipientandand providerprovider ofof thethe healthhealth carecare servicesservices atat
AcceptableAcceptable costscosts
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WHAT IS ACCREDITATION
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Accreditation is an external review ofAccreditation is an external review of
quality with four principal components:quality with four principal components:
ItIt isis basedbased onon writtenwritten andand publishedpublished
standardsstandards
ReviewsReviews areare conductedconducted byby professionalprofessionalpeerspeers
TheThe accreditationaccreditation processprocess isis
administeredadministered byby anan independentindependent bodybody
TheThe aimaim ofof accreditationaccreditation isis toto encourageencourage
organizationalorganizational developmentdevelopment..
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Focus of standardsFocus of standards
PatientPatient SafetySafety
StaffStaff andand employeeemployee safetysafety
EnvironmentEnvironment andand communitycommunity safetysafety
InformationInformation EducationEducation andand CommunicationCommunication
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NABH STANDARDS
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Section I:Section I:PatientPatient--Centered StandardsCentered Standards
STDSTD OEOE
Access, Assessment and Continuity of CareAccess, Assessment and Continuity of Care (AAC)(AAC) 1515 7878
Patients Rights and EducationPatients Rights and Education (PRE)(PRE) 0505 2929
Care ofPatientsCare ofPatients (COP)(COP) 18 10518 105
Management ofMedicationsManagement ofMedications (MOM)(MOM) 1313 6161
Hospital Infection ControlHospital Infection Control (HIC)(HIC) 0099 4444
6060 317317
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Section II:Health Care Organization
Management StandardsSTDSTD OEOE
Continuous Quality ImprovementContinuous Quality Improvement (CQI)(CQI) 66 3737
Responsibilities ofManagementResponsibilities ofManagement (ROM)(ROM) 55 2020
Facility Management & SafetyFacility Management & Safety (FMS)(FMS) 99 4141
Human Resource ManagementHuman Resource Management (HRM)(HRM) 1313 4747
Information Management SystemsInformation Management Systems (IMS)(IMS) 77 4141
4040 186186
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Accreditation ProcessAccreditation Process
ApplicationsApplications
ScreeningScreening ofof thethe ApplicationsApplicationsPrePre--assessmentassessment surveysurvey
AssessmentAssessment SurveySurvey
ReviewReview ofof thethe recommendationsrecommendations ofof thetheassessingassessing bodybody byby thethe AccreditationAccreditationCommitteeCommittee
RecommendationsRecommendations toto thethe boardboard
AccreditationAccreditation decisiondecision
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WHO CAN APPLYWHO CAN APPLY
AnyAny HealthHealth CareCare OrganisationOrganisation
RequirementsRequirements
CurrentlyCurrently inin operationoperation asas aa HCOHCO
PreferablyPreferably registeredregistered oror licensedlicensed
WillingWilling toto assumeassume responsibilityresponsibility forfor improvingimproving
qualityquality ofof carecare
ShouldShould bebe ableable toto meetmeet thethe prescribedprescribed
standardsstandards ofof thethe accreditingaccrediting organisationorganisation
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HOW CAN ONE APPLYHOW CAN ONE APPLY
BasicBasic IngredientsIngredients
OrganisationsOrganisations applyapply onon prescribedprescribed formatformat
givinggiving detailsdetails asas requiredrequired
SubmissionSubmission ofof aa self self assessmentassessment formform
indicatingindicating thethe outcomesoutcomes ofof itsits QMSQMS andand
InternalInternalA
uditsA
udits ExtentExtent ofof adherenceadherence toto thethe laidlaid downdown
standardsstandards
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SCREENING OF APPLICATIONSSCREENING OF APPLICATIONS
CompletenessCompleteness
AccuracyAccuracy
ClarificationssoughtifrequiredClarificationssoughtifrequired
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PREASSESSMENT SURVEYPREASSESSMENT SURVEY
ToTo ascertainascertain thethe readinessreadiness ofof thetheorganisationorganisation forfor AccreditationAccreditation
OverviewOverview of of thethe organizationalorganizationalpreparednesspreparedness andand commitmentcommitment toto qualityqualitygoalsgoals andand consonanceconsonance toto laidlaid downdownstandardsstandards
DeficienciesDeficiencies noticednoticed informedinformed toto thethe
organisationorganisation AdviceAdvice renderedrendered onon thethe methodologymethodology toto bebe
followedfollowed duringduring thethe AccreditationAccreditation SurveySurvey
TimeTime frameframe workedworked outout forfor thethe surveysurvey ininmutualmutual consultationconsultation
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ACCREDITATION SURVEY ACCREDITATION SURVEY
CarriedCarried outout byby aa teamteam ofof AssessorsAssessorsdependingdepending uponupon thethe size,size, complexitycomplexity andand
facilitiesfacilities providedprovided byby thethe organisationorganisation
ScopeScope willwill includeinclude allall standardsstandards relatedrelated
functionsfunctions andand allall patientpatient carecare settingssettings
OnsiteOnsite surveysurvey willwill considerconsider specificspecific culturalculturalandand legallegal factorsfactors whichwhich maymay influenceinfluence oror
shapeshape decisionsdecisions regardingregarding thethe provisionprovision ofof
carecare andand /or/or policiespolicies andand proceduresprocedures
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METHODOLOGY OF SURVEYMETHODOLOGY OF SURVEY
InitialInitial presentationpresentation byby thethe hospitalhospital
DocumentDocument ReviewReview
AdherenceAdherence toto statutorystatutory obligationsobligations
VisitsVisits toto variousvarious areasareas
FacilityFacility surveyssurveys andand tourstours
RandomRandom structuredstructured interviewsinterviews
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INITIAL PRESENTATION BYINITIAL PRESENTATION BYTHE HOSPITALTHE HOSPITAL
OrganogramOrganogram
QualityQuality managementmanagementTeamTeam
MethodologyMethodology followedfollowed forfor QualityQuality
ImprovementImprovement FacilitiesFacilities providedprovided
InputsInputs onon resourcesresources providedprovided forfor QualityQuality
ImprovementImprovement IdentifiedIdentified highhigh RiskRisk AreasAreas forfor patientpatient carecare
andand safetysafety
SentinelSentinel EventsEvents beingbeing monitoredmonitored
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INITIAL PRESENTATION BYINITIAL PRESENTATION BYTHE HOSPITALTHE HOSPITAL
KeyKey MonitoringMonitoring IndicatorsIndicators
ResourceResource
VolumeVolume UtilizationUtilization
PerformancePerformance
ControlControl chartscharts ProblemsProblems facedfaced andand remedialremedial measuresmeasures
undertaken/undertaken/ beingbeing undertakenundertaken
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DOCUMENT REVIEWDOCUMENT REVIEW
QualityQuality ManualManual
VariousVarious PoliciesPolicies andand ProceduresProcedures
MinutesMinutes ofof MeetingsMeetings ofof variousvarious committeescommittees
MedicalMedical RecordsRecords
MedicalMedical // NursingNursing AuditAudit
AdverseAdverse EventsEvents
HAIHAI
ActionAction TakenTaken ReportsReports
PersonalPersonal RecordsRecords ofof StaffStaff
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OBSERVATIONSOBSERVATIONS
FacilityFacility SafetySafety
LevelLevel ofof compliancecompliance withwith laidlaid downdown policiespolicies andand
proceduresprocedures
BMWBMW ManagementManagement
StandardStandard PrecautionsPrecautions
PatientPatient carecare
FireFire SafetySafety
EquipmentEquipment ManagementManagement
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INTERVIEWINTERVIEW
StaffStaff InterviewInterview ToTo determinedetermine theirtheir levellevel ofof awarenessawareness andand
compliancecompliance withwith organisationorganisation policiespolicies andand
proceduresprocedures
ToTo assessassess theirtheir awarenessawareness levelslevels ofof theirtheir
rights,rights, privilegesprivileges andand patientpatient rightsrights
ToTo determinedetermine theirtheir satisfactionsatisfaction levelslevels
PatientPatient andand familyfamily InterviewInterview
ToTo assessassess theirtheir levellevel ofof awarenessawareness ofof thethe
carecare processprocess andand theirtheir rightsrights
ToTo determinedetermine theirtheir satisfactionsatisfaction levelslevels
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SCORING PATTERNSCORING PATTERN
NABHhaslaiddownthefollowingpatternNABHhaslaiddownthefollowingpattern
NonNon--compliancecompliance 00
PartialcompliancePartialcompliance 55FullcomplianceFullcompliance 1010
NostandardcanhavemorethanonezeroNostandardcanhavemorethanonezero
Theaverageforastandardmustexceed5Theaverageforastandardmustexceed5
Theoverallaveragescoremustexceed 7Theoverallaveragescoremustexceed 7
NozerosinlegalrequirementsNozerosinlegalrequirements
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ProcessofAccreditation
Initial Application including Self Assessment asper the laid down standards
Screening of the Application
Pre assessment survey
Assessment survey
Accreditation committee Recommendations
If required Verification Visit Approval ofAccreditation by the NABH
ReAssessment Surveys
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OUTCOMES OF ACCREDITATIONOUTCOMES OF ACCREDITATIONSURVEYSSURVEYS
AccreditedAccredited HCOHCO showsshows acceptableacceptable compliancecompliance withwith laidlaid
downdown standardsstandards inin allall areasareas IncludesIncludes thethe scopescope ofof servicesservices forfor whichwhich
accreditedaccredited AnyAny increaseincrease inin scopescope thethe surveysurvey hashas toto bebe
donedone forfor thethe increasedincreased scopescope AccreditationAccreditation denieddenied
HCOHCO isis consistentlyconsistently nonnon compliantcompliant withwithstandardsstandards AccreditationAccreditation withdrawnwithdrawn
HCOHCO withdrawswithdraws voluntarilyvoluntarily DueDue toto consistentconsistent nonnon compliancecompliance oror nonnon
adherenceadherence toto safesafe andand ethicalethical practicespractices
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DURATION OF ACCREDITATIONDURATION OF ACCREDITATIONAWARDSAWARDS
GenerallyGenerally threethree yearsyears withwith oneone ReassessmentReassessment
surveysurvey toto ensureensure continuedcontinued compliancecompliance andand toto
assessassess thethe CQICQI programmeprogramme IfIf duringduring accreditationaccreditation TheThe AccreditationAccreditation
organisationorganisation receivesreceives inputsinputs thatthat thethe organisationorganisation
isis substantiallysubstantially outout ofof compliancecompliance withwith thethe currentcurrentstandardsstandards thenthen ResurveyResurvey oror withdrawalwithdrawal ofof
accreditedaccredited decisiondecision maymay bebe resortedresorted toto
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How to Go About
Create willingness
Initial impetus from Top management
Requires involvement of all staff This requires repeated training andbriefing
Once consensus is there identify corecoordinating or Quality managementTeam
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How to Go About
Examine what are you doing
Find what you should be doing
Document the gaps
Compare with the standards
Complete gap analysis
Identify areas for improvement
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How to Go About
Focus on uniform training of all employeesin key areas
Encourage by financial and / or non-
financial incentives
Initially prepare to provide extra resources
Avoid disappointments if initial benefits do
not accrue as expected Be prepared for a longer gestation period
for benefits to accrue
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PROBLEMS AND CHALLENGESPROBLEMS AND CHALLENGES
HCOsHCOs areare veryvery enthusiasticenthusiastic
IllIll preparedprepared
InitialInitial preparationpreparation isis shoddyshoddy
ResourcesResources requiredrequired initiallyinitially
BenefitsBenefits havehave aa longerlonger gestationgestation
periodperiod
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PROBLEMS AND CHALLENGESPROBLEMS AND CHALLENGES
QualityQuality ConsciousnessConsciousness atat allall levelslevelswillwill taketake timetime
SustenanceSustenance andand consistencyconsistency ofofeffortsefforts willwill bebe requiredrequired
CommitmentCommitment onon aa consistentconsistent basisbasis
HighHigh ratesrates ofof attritionattrition willwill requirerequirerepeatedrepeated andand continualcontinual trainingtraining
PublicPublic SectorSector willwill taketake aa longerlonger timetimetoto getget intointo thethe processprocess
QualityQuality andand consistencyconsistency ofof assessorsassessors
andand assessmentsassessments
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These May Look DifficultThese May Look Difficult
Initially, But the FirstInitially, But the First
steps are Never easy.steps are Never easy.
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Also Nothing IsAlso Nothing Is
ImpossibleImpossible
For,For,
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ImpossibleImpossible
MeansMeans
I M PossibleI M Possible
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Quality Norms and Accreditation??
Response of Medical Fraternity
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ExpectedResponseExpectedResponse
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THE CURRENT STATUS OFTHE CURRENT STATUS OFACCREDITATION IN INDIAACCREDITATION IN INDIA
InitializingInitializing phasephase isis overover..
PhasePhase ofof consolidationconsolidation..
TheThe initialinitial stepssteps havehave beenbeen difficultdifficult butbut
thethe journeyjourney hashas begunbegun..
TheThe journeyjourney hashas toto continuecontinue..
EspeciallyEspecially sincesince ------------------------------------------------------
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ACCREDITATION IS A JOURNEYACCREDITATION IS A JOURNEY
ANDAND
NOT A DESTINATION.NOT A DESTINATION.
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BON VOYAGE !!!!!BON VOYAGE !!!!!
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