accriditation of healthcare facilities - dr j l meena

3rd International Public Health Management Development Program20-25 March, 2017

School of Public HealthPGIMER, Chandigarh, India

ACCREDITATION OF HEALTH CARE FACILITIES.



Dr J L MeenaState Quality Assurance Medical Officer

Department of Health & Family Welfare

Government of Gujarat - IndiaMember of NABH Accreditation Committee, QCIMember of Quality Expert Group, Govt of India.

Email:- [email protected]

mailto:[email protected]



"A self-assessment and external peer assessment process used by health care organizations to accurately assess their level of performance in relation to established standards and to implement ways to continuously improve"

What is Accreditation:-



Regulation Accreditation

An instrument mandated by theGovernment to impose set ofconditions, which a healthcareorganization must comply with,before and after it is permitted tooperate in the country.

A voluntary process by which an authorizedagency or organization evaluates andrecognizes health services according to aset of standards describing the structureand processes that contributes to desirablepatient outcomes.

It is based on minimum standards,inspection, enforcement andpublic accountability.

Compliance to documented Policies andguidelines. Review by an authorizedexternal agency.

Regulation is mandatory Accreditation is voluntary. Accreditation ispromoted by way ofincentives and market forces



• Joint Commission International - JCI

• Joint Commission of Taiwan – JCT

• Council for Health Service Accreditation of Southern Africa -COHSASA

• Danish Institute for Quality and Accreditation in Health Care -IKAS

• Diagnostic Accreditation Programme, British Columbia

• Health and Disability Auditing Australia Pty Ltd - HDAA

• Malaysian Society for Quality in Health - MSQH

• Quality Improvement Council, Australia - QIC

• National Accreditation Board for Hospitals & Health Care Providers, India - NABH

• Designated Auditing Agencies (DAA) Group Limited, New Zealand

• American Association of Blood Banks (AABB), USA

• Netherlands Institute for Accreditation in Healthcare - NIAZ

• Instituto Colombiano De Normas Tecnicas Y Certification(ICONTEC) Health Accreditation Service, Columbia

California Health Kids Survey - CHKS Accreditation Unit, UK

Canadian Accreditation Council of Human Services -CAC

Global-Mark Pty Ltd, Australia

Health and Disability Auditing New Zealand - HDANZ

Australian Aged Care Quality Agency - AACQA

The Healthcare Accreditation Institute (Public Organization), Thailand - HAI

Australian General Practice Accreditation Ltd / Quality in Practice Pty Ltd – AGPAL/QIP

Japan Council for Quality Health Care - JCQHC

The Australian Council on Health Care Standards - ACHS

Health Care Accreditation Council, Jordan - HCAC

DNV GL Business Assurance, Norway

Associacao Brasileira de Acreditacao De Sistemas e Servicos de Saude, Brazil – CBA

Haute Autorité de Santé – DAQSS, France

Accreditation Canada International (ACI) Canada

Accredited Organisations



What is common?



•Patient safety and•quality of care ………..



International Society for Quality in Health Care (ISQua )is an international body which grants approval toAccreditation Bodies in the area of healthcare as mark ofequivalence of accreditation program of membercountries.

So far hospital standards of only 12 countries viz.Australia , Canada , Egypt , Hong Kong , Ireland , Japan ,Jordan , Kyrgyz Republic , South Africa , Taiwan , UnitedKingdom & India were accredited by ISQua.



• Critical path issued

• Technical review

• Final Submission of Self Assessment

• Surveyor Assessment (survey)

• Factual Review

• Report Validated by Panel

• Accreditation Decision

• Award Pack to Organisation

• Continuous Assessment – 12 and 30 months post survey

International Accreditation Programme by ISQua - 4 year cycle



The Joint Commission (TJC) : Body foraccreditation of HCOs across USA which forms thebasis for licensure and Medicaid reimbursement

Joint commission International: For InternationalAccreditation, publication and education

International Scenario on Accreditation in Healthcare services - USA



JCI is the recognized leader in international health care accreditation.JCI maintain ISQua membership in the following categories:- Accreditation survey Surveyor education program Ambulatory Care Standards Clinical Laboratory Standards Care Continuum Standards Hospital Standards Primary Care Standards Clinical Care Program Certification Standards Home Care Standards Long Term Care Standards



800+ Accredited Organizations. 100+ Countries Served by JCI.



• 360 Standards

• 1240 Measurable Elements

Section I : Patient Centered Standards

Section II : Health Care OrganizationManagement Standards

Joint Commission International Accreditation Standards for Hospitals



Each applicable measurable elements is scoredMet (10)Partially Met (5)Not Met (0)



International Scenario on Accreditation

in Healthcare services - AUSTRALIA

The Australian Council of HealthcareStandards (ACHS): Pioneer in accreditation of HCOsin Australia ACHSI : for overseas accreditation



The Australian Council of HealthcareStandards (ACHS) International deliverseducation / consultancy services as well asquality improvement and accreditationprograms throughout New Zealand, HongKong, India, Saudi Arabia, Sri Lanka, Bahrain,the United Arab Emirates and Malaysia etc.



A proven pathway to accreditation

10 steps that hospitals and academic medical centers typically follow toward accreditation success. (Average duration 18-24 months).

1. Become familiar with Accreditation Standards and Survey Process (2-3 Months)2. Conduct Gap Analysis and Build Action Plan. (2-3 Months)3. Update Policies and Procedure. (2 Months)4. Target Improvement where Needed. (2-3 Months)5. Work with Staff to overcome obstacles. (2-3 Months)6. Assess your readiness at midpoint. (2-3 Months)7. Continues Training for Sustainable Change. (2-3 Months)8. Evaluate and Refine Process. (2-3 Months)9. Use a Mock Survey to assess your readiness. (2-3 Months)10. Make Final Modification (Process for 3rd Party Assessment by Accreditation organization

e.g.-JCI or NABH etc, Fulfill gaps, review in board and Accreditation). (6-7 Months)



Accreditation Agencies in India:-

Quality Council of India (QCI):-

National Accreditation Board for Hospital

and Health care Providers (NABH)

National Accreditation Board for Testingand Calibration of Laboratories (NABL)



Certification and Grading Agencies inIndia:-

ISO 9001 – 2008 as amended by recently issued ISO 9001 – 2015 standards

National Quality Assurance Certification Indian Public Health Standards 2012



Quality Council of India:-

QCI is an autonomous body set upby Govt. of India to establish andoperate accreditation structure inthe country.



• NABH is an institutional member of the International Society for Quality in Health Care (ISQua)• NABH is also a member of ISQua Accreditation Council• NABH is founder Member of Asian Society for Quality in Health care (ASQua)• NABH is also represented on WHO International Patient Safety Committee.

NABH Global Recognition



•Creation of NABHI was approved by Board in

July 2010

•Started work in Philippines

•Qatar

•Nepal•Bangladesh

NABH International



•Autonomous Body under the aegis of Dept of Scienceand Technology, GoI but now it’s under QCI•Sole Accreditation Body for Testing and Calibration Labs• Accessible to all Labs irrespective to their Status•Maintains International linkages• International Lab Accreditation Cooperation• Asia Pacific Lab Accreditation Cooperation

National Accreditation Board for Testing and calibration Laboratories



Chapters : 10Standards : 105 (102)Objective Elements : 683 (636)

NABH Standards for the Hospitals: 4th Edition



• Assessment is based on the scoring on a scale of 0, 5 and 10as per the following details:

– Compliance to the requirement:10

– Partial compliance to the requirement: 5 (if any of thesample is found to be non complying out of total samplesselected)

– Non-compliance to the requirement:0

• Not Applicable: NA

Scoring Pattern



Outcome

• Pre-accreditation entry level

• Pre-accreditation progressive level

• Accredited



Pre-accreditation entry level• Conditions for qualifying to this award are:

– All the regulatory legal requirements should be fully met.

– No individual standard should have more than two zeros.

– The average score for 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.

• The validity period for pre-accreditation entry level stage isfrom a minimum 6 months to a maximum of 18 months.



Pre-accreditation progressive level

• Conditions for qualifying to this award are:

– All the regulatory legal requirements should be fully met.

– No individual standard should have more than two zeros.

– The average score for 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.

• The validity period for pre-accreditation entry level stage is from aminimum 3 months to a maximum of 12 months.



Accredited

• Conditions for qualifying to this award are:– All the regulatory legal requirements should be fully met.– No individual standard should have more than one zero to qualify.– The average score for individual standard must not be less than 5.– The average score for individual chapter must be more than 7.– The overall average score for all standards must exceed 7.

• The validity period for accreditation is 3 years subject to terms and conditions.



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High quality of care

Dedicated and sincere medical staff

Access to a quality focused organization

Rights respected and protected

Patient Satisfaction evaluated

Involvement in care process

Patient safety

Pain management

Safe transport

Continuity of care

Benefits of Accreditation for Patient



Professional staff developmentProvides education on laid down standardsProvides leadership for quality improvementwithin medicine and nursingIncreases satisfaction with continuous learning,good working environment, leadership andownership

Benefits of Accreditation to Staff



Improves careBrings in Corporate GovernanceStimulates continuous improvementDemonstrates commitment to quality careRaises community confidenceOpportunity to benchmark with the best

Benefits of Accreditation to Hospital



Quality revolutionDisaster preparedness- Epidemics- PhysicalAccess to comparative database

Benefits of Accreditation for Community



Efficiency of Government hospitals as key contributors for

building trust and confidence for the hospitals in the hearts of

the citizens of the State through actively pursuing quality

improvement programme in various facilities.

Given a sense of pride to the government for ensuring quality

services to the poorest of the poor.

Confidence has been restored of the community in Govthospitals

Benefits of Accreditation to the Government



•Appreciation awarded by QCI to Ministry of Health and Family Welfare Government of Gujarat for establishing QualityAssurance framework in providing quality healthcare to the people of Gujarat in 5th National Quality Conclave, New Delhi.•Appreciation awarded to Department of Health and Family Welfare Government of Gujarat for their pioneering effort tospearhead the Quality and Accreditation Programme in health care organization. In 3rd International Health Care QualityConclave on “Role of Quality in Globalization of Indian Healthcare”. Place: - Gurgaon, Haryana Date: 30thAugust 2010.•FICCI Health care Excellence Award to Dist Hospital Gandhinagar & PHC Gadboriad, Govt of Gujarat in FICCI Heal 2010, NewDelhi Date: 6th Sept 2010•FICCI Health care Excellence Award to Dist Hospital Gandhinagar, Govt of Gujarat in FICCI Heal 2011, New Delhi Date: 8th Sept2011•FICCI Health care Excellence Award to Community Health Centre Bardoli, Govt of Gujarat in FICCI Heal 2013, New Delhi Date:2nd Sept 2013•Operational excellence award in IndiZen 2014 to Govt. of Gujarat-department of health and family welfare was achieved.•FICCI Health care Excellence Award to Community Health Centre Bardoli, Govt of Gujarat in FICCI Heal

2014, New Delhi

Date: 1st Sept 2014•FICCI Health care Excellence Award to Paraplegia Hospital- Ahmedabad, Govt of Gujarat in FICCI Heal

2014 New Delhi

Date: 1st Sept 2014•FICCI Healthcare Excellence Award to Laboratory Information System, B J Medical College – Ahmedabad,

Govt ofGujarat in FICCI Heal 2016 New Delhi Date: 31st August 2016.



Web:-1. https://gujhealth.gujarat.gov.in/quality-assurance-program.htm2. http://www.facebook.com/drjitulal?ref=tn_tnmn3. https://www.youtube.com/user/drjlmeenaEmail:[email protected], [email protected] No:- 09099075162

https://gujhealth.gujarat.gov.in/quality-assurance-program.htm

http://www.facebook.com/drjitulal?ref=tn_tnmn

https://www.youtube.com/user/drjlmeena





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2nd International Public Health Management Development Program20-25 March, 2017
