cluster based technical support for nabh pre accreditation...

Cluster Based Technical Support for NABH Pre Accreditation Entry Level Certification –Maharashtra

IMA HBI Hospital Accreditation Initiative

Information Brochure

IMA HBI Hospital Accreditation Initiative Information Brochure

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Achievements of Phase I

- Managed jointly by IMA HBI Maharashtra and IMA

HBI Headquarters

- Phase I with 720 + hospital enrollments was the

largest organized hospital accreditation support

initiative in the country

- As on date 104 + hospitals certified, 156

assessments done and 500 + hospitals applications

done.

- Covered all major cities and IMA branches in state of

Maharashtra

- Experienced and committed team of implementation

consultants covering whole of Maharashtra

- Trusted and fair program with the stamp of IMA-HBI

family

Innovations in Phase II

-Technology lead implementation with unique

accreditation & QI support cloud based application.

-Real time progress tracking of hospitals with

involvement of IMA-HBI leadership

-Hospitals may opt for intensive support mode in

consultation with HBI leaders

-Learning and improvements in implementation based

on learnings from over 700+ hospitals in Maharashtra

and 900 + overall in the country under IMA banner.

Program Overview


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Program Leadership

IMA National Leadership

Dr. Santhanu Sen

National President Dr. R.V.Asokan

Hony. Secretary

General

Dr. Ramesh Kumar

Dutta

Hony. Finance Secretary

IMA Maharashtra State Leadership

Dr. Hozie Kapadia

President IMA MS

Dr. Suhas Pingle

Secretary IMA MS

Dr. Dhiren Kalawadia

Treasurer IMA MS

IMA Hospital Board of India - Trusted Leadership With Proven Track Record

Dr.V.K.Monga

Chairman

HBI HQ

Dr. Jayesh Lele

Hon.Secretary

HBI HQ

Dr. Mangesh Pate

National Treasurer

HBI HQ / Chairman

IMA HBI Maharashtra

Dr. Saurabh Sanjanwala

Hon. Secretary

IMA HBI Maharashtra


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Overview of Technical Support

Centralized Monitoring & Guidance

Program Management Team

- IMA-HBI Team

- Team Leader – Technical Support

- Program Coordinator

Technical Team Back Office

- Technical Clarifications

- Portal Operations

- Progress Tracking and Monitoring

of hospitals

- Review Calls with hospitals

- Grievances and Complaints

handling

Technical Support Portal

- Progress Tracking using hospital

dash board

- Submission and Reviews of

documents / evidences

- Monthly submission and tracking

of CQI

Onsite Activities at Hospitals

Onsite Visits (Committed)

- Initial Assessment

- Training

- Documentation Guidance

- Implementation Guidance & Review

- Mock Assessment

- Post Assessment Support

Off Site Support

- Documentation Reviews

- Guidance and Clarifications

- NABH Desktop Review Process

- Corrective Action Evidence review and

Approval – Initial Assessments,

Implementation Review Gaps, Post

Assessment CAR evidences

- Portal Based progress tracking

Technology & Tools

NABH Support Software

- Complete digitalization of NABH

process and compliance data

- Implementable through android

devices

Optional Activities on Additional Payment

Additional Visits

- Slippage Corrections

- Handholding support


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Initial Assessment

Onsite Assessment By Technical Team

- Standards Compliance

- Statutory & Regulatory Compliance

- Infrastructure Assessment

- Current Process Gaps

- Level of Documentation

- Human Resources

Report Submission

- Report Submitted with in 10 Days

(PDF – E-mailed)

- Provides gaps and actions to be

taken

- Action Points Uploaded to Portal

- Telephonic clearance of doubts

Corrective Actions By Hospital

- Each action point will be given time frame for

completion (Max 60 Days)

- Corrective action evidence to be submitted online at

program portal

- Technical team will review and provide comments /

approval – portal and / or phone

- If deadlines are crossed reminders are sent. Non

response would lead to termination

- Within 30 – 45 Days of enrollment - Time slot will be intimated through phone and

email - Cancellations and postponement will be charged

for additional visits - IMA – HBI NABH Support Portal will be initiated

during visit

- All report clarifications on telephone / email only - Clarification visits / additional infrastructure visits

if asked would be charged as additional visit - Program Coordinator will intimate owners /

coordinators on report emailing and portal updating

- Program Coordinator will schedule follow up call for doubts clarification if any

- Consultant & Program Coordinator will track completion / closing of each gap

- Maximum time is 60 days (for infrastructural and statutory gaps)

- Extension of completion days only on approval of IMA – HBI (Maximum 30 more days only for infrastructure / statutory gaps)

- After time period lapse additional visit charges would be charged for time spent supporting hospital for gaps closing


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Training & Capacity Building

Onsite Training for Key Staff By Technical

Team

- NABH Standards Basics

- Portal Features Usage

- Documentation Development

- Use of Training Modules / Materials

- Quality Indicators Collection and Reporting

- Training Attendance Certificate To be Provided by Technical Team – Hospital Level

- Handouts would be provided - Testing would be done for participants - Training Venue and refreshments to be

arranged by hospital - Projection / Display would be arranged by

Technical Team

Additional Information & Clarifications

- Staff attendance to be ensured by hospital

- Full Day Training – 6 Hours. Participation Compulsory for all staff

- Trainings will be scheduled only on working weekdays – Cannot be scheduled on week ends or holidays

- Repeat sessions would be charged on additional visit basis

- BLS Training not provided – Either through IMA / IMA HBI programs or own trainings


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Documentation Review & Guidance

Provision of Model Documentations

- List of required manuals, SOPs, forms/ formats /

registers will provided as part of initial assessment

- All required documentation first drafts would be made

available from technical support portal

- Documents would be downloadable on 15 days after initial assessment report submission

- Hospital owner / coordinator would be intimated at time of activation

- In case of difficulties Project Coordinator will mail a zip file of required documentation to hospital email ID

- Hospital to provide logo and other details to prepare first draft

Completion & Finalization of Documentation

- 60 Days of time overall. Finalized versions to be

submitted in 45 days (15 Days for review)

- Revised / finalized documents to be submitted for

review through portal.

- Hospitals would receive review comments and

corrected documents through portal

- Document support visits for onsite clarifications and

support

- In case of non-compliance of deadline additional visits rates will be charged for extra time spent on reviewing documents by technical team

- Additional clarifications provided through mail / phone by Consultant / Project Coordinator

- Specific forms / formats may be provided through mail / phone by project coordinator on request


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Monitoring & Implementation Visits & Tracking

Monitoring and Implementation Visits

- Review of pending gaps

- Implementation Review Rounds of Hospital

- Staff interviews / knowledge assessment

- Review of implementation registers / forms

- Medical Record completion reviews

- Review of CQI Documentation and Minutes etc.

- Within 30 – 45 Days of enrollment

- Timeslot will be intimated through

phone and email

- Cancellations and postponement will

be charged additional visits

- Implementation Review Visit Report

will be submitted with action points

(PDF and Online)

Completion of Implementation Review Action

Points

- 30 Days time. Evidence of corrective action to be

uploaded by hospital and reviewed by consultant /

project coordinator

- Next implementation review visits scheduled only

on substantial completion of previous visit gaps


- Additional visits would be charged post exhausting of planned implementation support visits


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Online Application & Desktop Review Support

Application to NABH

- Online process to be done by hospital as per guidance of

technical support team

- 2 Stages:

1-Creation of user name & password,

2- completion of application form, documentation upload and

payment of fees on HOPE portal.

Desktop Review by NABH Secretariat

- All evidences would be reviewed by NABH team based on a

desktop process and non-conformities shared to hospital

- Technical team will guide in closure of the NCs and uploading

of corrective action evidence to NABH

- Onsite Assessment date only provided by NABH after

clearance of desktop review NCs

- No separate visits provided for same. Application filing and evidence uploading covered in first implementation visit

- Online / telephonic guidance provided. Hospital required to provide Login ID & Password for checking


-20 Days overall provided for completion of online application process stage one and up to 45 days for corrective action

clearance based on Desktop Review non-conformities

-Undue Delay / non-payment of NABH application and accreditation fee after advise from technical team would lead to de-

enrollment of the hospital. Hospital would be sent one reminder and grace period of 10 days provided. If payments still not

done hospital will be automatically de-enrolled by IMA - HBI


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Mock Assessment

Mock Assessment Visit

- Review of hospital and staff readiness to face

assessment

- Will be scheduled on confirmation of assessment

dates or intimation of possible assessment

schedule by NABH

- Ideally planned 15-20 days before NABH

assessment

- Date and Timeslot will be intimated

through phone and email

- Cancellations and postponement will

be charged additional visits

- Mock Assessment Report will be

submitted with action points (PDF and

Online)

Completion of Mock Assessment Non-

Conformities

-2 Weeks time. Evidence of corrective action to be

uploaded by hospital and reviewed by consultant /

project coordinator



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Post Assessment Guidance

Post Assessment Support

- Corrective Action Report Filing along with

Evidences and support for NABH Accreditation

Committee Presentation Preparation and answering

Committee queries / clarifications

- One visit planned for support of evidence

preparation and review onsite

- Corrective Action Report (CAR) draft and evidence advice provided

- Additional reviews other than one on site visits done through mail / phones

- Each evidence needs to be submitted for review and approval of technical team before uploading by hospital to NABH


-IMA – HBI technical team would not be responsible for CAR clearance by assessor / NABH secretariat in case

same not submitted for review and approval of technical team

-In such cases additional time taken for clearance will be charged as additional visits


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NABH Process Digitalization Software

HQ Pulse Software

- Enables hospitals to digitize and automate NABH

activities using a cloud based software accessible

through browsers and android based custom app.

-Automates NABH checklists / audits, Incident

Reporting, QI Tracking / graphing and mandatory

registers

- All NABH data is digitized and stored - Digital registers automatically

tracking Quality Indicators and graphing

- Android phone / tablets based reporting of incidents and keeping digital registers

- Dynamic dashboards for hospital MD / CEO

- Control screen for NABH Coordinator to track all activities and compliances

Pricing Information

-Will be offered inclusive with IMA HBI program for 12 months congruous with the period of support. Post

period subscriptions fee would be applicable


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Timeframe for Support Activities

Activities / Milestones Months

1 2 3 4 5 6 7 8 9 10 11 12

Initial Assessment & Training

Documentation

Implementation

Online Application & Desktop Review Stage

Mock Assessment

Onsire NABH Assessment & Post Assessment Clearance

Hospital Level Time Frame

Total Time frame for each hospital – 10-12 Months

Note

- Period of Support be for 12 months from the date of initial assessment of the hospital.

- Hospitals will be dropped or charged additionally for technical support post 12 months

- In case of any delays in visits / services by technical support team same must be duly informed to IMA – HBI team

Hospitals will have to work as per timeframe and Micro Plan developed during Initial Assessment of the

Hospital


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Proposed Categories & Professional Fee Rates for Hospitals

Categorisation and Professional Fees

Small Healthcare Organizations – SHCO Category Healthcare Organizations – HCO Category

Category I

Hospitals

1 to 25 beds

Category II

Hospitals

25 to 50 beds

Category III

Hospitals

51 to 75 beds

Category IV

Hospitals

76 – 100 beds

Category V

Hospitals

101 – 150 Beds

Category VI

Hospitals

151 – 200 Beds

Rs. 75,000/- Rs. 100,000/- Rs. 125,000/- Rs. 150,000/- Rs.2,00,000 Rs.2,50,000

- GST will be charged extra - Additional Visits will be made available on a monthly basis @ Rs. 11,000 /- + GST per visit consisting of two visits. - For additional visits peripheral areas hospital would be charged 15 % extra for travel and other incidental expenses - Hospital bed numbers will be based on Hospital Registration Certificate as per Mumbai Nursing Home Act


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Pattern of Onsite Visits

Technical Support Activities

Hospital Categories Vas No of Onsite Visits

I 1-25 Beds

II

26-50 Beds

III 51-75

IV 76-100

V 101-150

VI 151 -200

Initial Assessment 1 1 1 1 1 1

Training 1 1 1 1 2 3

Documentation Support 1 1 1 1 1 1

Implementation Support 2 3 4 5 6 7

Mock Assessment 1 1 1 1 1 1

Post Assessment Support 1 1 1 1 1 1

Total 7 8 9 10 12 14


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General Terms & Conditions

- A hospital site visit is 4-5 hours at site. The overall time frame includes time for travel, visit preparation and report preparation done back office. Training visits is 6 hours.

- Technical Support team works only on weekdays. No visits activities can be scheduled on weekends and holidays. - Visits will be scheduled only on confirmed dates. Cancelations are not possible and the visits will be deemed done

and deducted from hospitals planned visits. Additional visits will be charged when visits is same repeated. - In case the hospital fail to confirm visit schedule despite schedule requests / dates provided by technical team or

postpones activities beyond time frame approved for each stage; additional visits charges will be charged. - All additional visits will be charged – clarifications, additional infrastructure reviews, revisits due to cancellation,

non-availability of owner / key personal - No printouts / hard copies provided of reports, model documentation etc. All transmission through email or IMA –

HBI portal only - All communication only through specified phone number and emails. - IMA-HBI Technical Team will coordinate with owner / doctors and specified accreditation coordinators. Will not

coordinate with local / private consultants - The programs support provides only technical guidance, review of progress, advice, training, documentation first

drafts and clarifications. The technical team will not prepare CQI data, minutes of meetings or PPTs required by NABH. Hand holding at site is not duty of technical team. In case same is required sufficient additional visits may be availed on payment after discussing with IMA HBI Program Coordinator.

- Visit reports have to be duly signed and stamped by the hospital. They will be provided a PDF copy through mail. - All grievances / complaints have to addressed through online portal provided by IMA-HBI. Same is monitored by

IMA-HBI office bearers.


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For Further Information

Dr. Mangesh Pate National Coordinator – IMA NABH Accreditation Initiative + 91 98200 64054 [email protected] Ranjith R Menon Team Leader – IMA HBI NABH Technical Support Team +91 96633 96111 [email protected]