nabh accreditation 4th edition std - orientation
TRANSCRIPT
NABH PROJECT
Mr. Kirankumar GhanapuramConsultant - Healthcare Management
[email protected]+91 9011017501
INTRODUCTION
Quality ?
• Degree to which a set of inherent characteristics fulfills requirements (as per ISO
9000:2000)
- Characteristics imply a distinguishing feature
- Requirement are a need or expectation that is stated generally implied or
obligatory
• Degree of adherence to pre-established criteria or standards
Quality Assurance ?
• Part of quality management focused on providing confidence that quality
requirements will be fulfilled
Quality Improvement?
• Ongoing response to quality assessment data about a service in ways that
improve the process by which the process by which services are provided to patients
“ Quality is not an act, it is a habit ”
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• The standard of something as measured against other things of a similar kind; the degree of
excellence of something.
• Meeting the needs and exceeding the expectations of the patients
• Delivering all and only the care that the patient and family needs
• A doctor may say: “The kind of care that may relive the pain and suffering and restore health
to the best possible level”
• A patient may say, “The best possible treatment that is timely, safe and affordable, and can
restore his health to his earning capacity at the earliest”
“ Quality is never an accident; it is always the
result of intelligent effort ”
QUALITY MANAGEMENT
PROGRAM
1. Commitment of Top Management
2. Educating the Management and Staff
3. Formation of Quality Management
Team
4. Awareness Campaign and
Development of Quality Culture
5. Defining Key Improvement Objectives
6. Development of Quality Policy and
Quality Manual
7. Training of Top Management
8. Training of Lower Level Staff
9. Identification and Mapping of all the
Hospital’s Process
10. Development of Hospital Information
System
11. Formulation of Criteria and Standards
12. Implementing the Program
13. Management Review of the QMS
14. Internal Audit/ Mock Survey
15. Detection of Non- Conformities
/effects
16. Implementation of Corrective
Measures
17. Review and Implementation of
Corrective Measures
18. External Certification/ Accreditation
Approaches : TQM, Lean Management, Six Sigma,
ISO 9001:2015, NABH, Safe – I, Nursing Excellence
Model, JCI, IMC RBNQA, National Quality Awards
etc..
NABH
• NABH - National Accreditation Board for Hospitals & Healthcare Providers
• Constituent board of Quality Council of India
• International Linkage – lSQua & ASQua
• Board Composition
• Objective - Enhancing health system & promoting continuous quality improvement and
patient safety.
• Vision : To be apex national healthcare accreditation and quality improvement body,
functioning at par with global benchmarks.
• Mission : To operate accreditation and allied programs in collaboration with stakeholders
focusing on patient safety and quality of healthcare based upon national/international
standards, through process of self and external evaluation.
• Objectives : Accreditation of healthcare facilities, Quality promotion, , IEC activities,
Education and Training, Recognition
“Quality gets attention”
• Accreditation is self-assessment and external peer review process used by the healthcare
organizations to accurately assess their level of performance in relation established standards
and to implement ways to continuously improve the healthcare system.
• Accreditation Assessment is the evaluation process for assessing the compliance of an
organization with the applicable standards for determining its accreditation status.
• Objective Element is that component of standard which can be measured objectively on a
rating scale. The acceptable compliance with the measurable elements will determine the
overall compliance with standard.
• Objective is a specific of a desired short-term condition or achievement includes measurable
end-results to be accomplished by specific teams or individuals within time limits.
• Standard is a statement of expectation that defines the structure and process that must be
substantially in place in an organization to enhance the quality of care.
“Quality is everyone's responsibility ”DEFINITIONS
That the organization ensures:
Commitment to create a culture of quality,
patient safety, efficiency and accountability
towards patient care.
Establishment of protocols and polices as
per National/ International Standards for
patient care, medication management,
consent process, patient safety, clinical
outcomes, medical records, infection
control and staffing.
Patients are treated with respect, dignity
and courtesy at all times.
Patients are involved in care planning and
decision making.
Patient are treated by qualified and trained
staff.
Feedback from patients is sought and
complaints (if any) are addressed
Transparency in billing and availability of
tariff list.
Continuous monitoring of its services for
improvement.
Commitment to prevent adverse events
that may occur.
“Quality is best business plan”
NABH ACCREDITATION
MEANS
BENEFITS OF ACCREDITATION
• Benefits for Patients
Biggest beneficiary
High quality of care and patient
safety
Rights of patients
Patients satisfaction
• Benefits for Hospitals
CQI
Commitment to quality care
Community confidence
Benchmarking
• Benefits for Hospital Staff
Staff satisfaction
Improves overall professional
development
• Benefits to paying and regulatory bodies
“It is quality rather than quantity that matters.”
NABH STANDARDS
• NABH Standards has 10 Chapters, 105 Standards &683 Objectives Elements
• Quality Indicators 70
• Outline of NABH Standards
“Quality is to understand (thoroughly),
communicate (adequately-from the front end of
the process to the back), and achieve
(consistently) patients' requirements."
Patient Centered Standards Chapters Std
1. Access, Assessment & Continuity of Care (AAC) 14
2. Care of Patient (COP) 20
3. Management of Medication (MOM) 13
4. Patient Right and Education (PRE) 07
5. Hospital Infection Control (HIC) 09
Organization Centered Standards Chapters Std
6. Continuous Quality Improvement (CQI) 08
7. Responsibility of Management (ROM) 06
8. Facility Management and Safety (FMS) 08
9. Human Resource Management (HRM) 10
10. Information Management System(IMS) 07
1. ACCESS, ASSESSMENT &
CONTINUITY OF CARE
AAC.1: The organisation
defines and displays the
healthcare services that
it provides.
AAC.2: The organisation
has a well-defined
registration and
admission process.
AAC.3: There is an
appropriate mechanism
for transfer (in and out)
or referral of patients.
AAC.4: Patients cared for
by the organisation
undergo an established
initial assessment.
AAC.5: Patients cared for
by the organisation
undergo a regular
reassessment.
AAC.6:Laboratory
services are provided as
per the scope of services
of the organisation.
AAC.7:There is an
established laboratory
quality assurance
programme.
“Give them quality. That’s the best kind of
advertising.”
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AAC.8:There is an established laboratory
safety programme.
AAC.9:Imaging services are provided as
per the scope of services of the
organisation.
AAC.10:There is an established quality
assurance programme for imaging
services.
AAC.11:There is an established safety
programme in the Imaging services.
AAC.12:Patient care is continuous and
multidisciplinary in nature.
AAC.13:The organisation has a
documented discharge process.
AAC.14: Organisation defines the
content of the discharge summary.
“Quality begins on the inside… then works its
way out.”
2. CARE OF PATIENTS
COP.1: Uniform care to patients is provided
in all settings of the organisation and is
guided by the applicable laws, regulations
and guidelines.
COP.2: Emergency services are guided by
documented policies, procedures,
applicable laws and regulations.
COP.3: The ambulance services are
commensurate with the scope of the
services provided by the organisation.
COP.4: The organisation plans for handling
community emergencies, epidemics and
other disasters.
COP.5: Documented policies and
procedures guide the care of patients
requiring cardio-pulmonary resuscitation.
COP.6: Documented policies and
procedures guide nursing care.
“Total quality management is a journey, not a
destination.”
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COP.7:Documented procedures guide the
performance of various procedures.
COP.8: Documented policies and
procedures define rational use of blood and
blood components.
COP.9: Documented policies and
procedures guide the care of patients in the
intensive care and high dependency units.
COP.10: Documented policies and
procedures guide the care of vulnerable
patients.
COP.11: Documented policies and
procedures guide obstetric care.
COP.12: Documented policies and
procedures guide paediatric services.
COP.13: Documented policies and
procedures guide the care of patients
undergoing moderate sedation.
“Without changing our patterns of thought, we
will not be able to solve the problems”
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COP.14: Documented policies and
procedures guide the administration of
anaesthesia.
COP.15: Documented policies and
procedures guide the care of patients
undergoing surgical procedures.
COP.16: Documented policies and
procedures guide organ transplant
programme in the organisation.
COP.17: Documented policies and
procedures guide the care of patients
under restraints (physical and/or chemical).
COP.18: Documented policies and
procedures guide appropriate pain
management.
COP.19: Documented policies and
procedures guide appropriate rehabilitative
services.
“ Quality means doing it right when no one is
looking ”
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COP.20: Documented policies and procedures guide all research activities.
COP.21: Documented policies and procedures guide nutritional therapy.
COP.22: Documented policies and procedures guide the end of life care.
“People forget how fast you did a job – but they
remember how well you did it”
3. MANAGEMENT OF MEDICATION
MOM.1: Documented policies and procedures guide the organisation of pharmacy services
and usage of medication.
MOM.2. There is a hospital formulary.
MOM.3: Documented policies and procedures guide the storage of medication.
MOM.4: Documented policies and procedures guide the safe and rational prescription of
medications.
MOM.5: Documented policies and procedures guide the safe dispensing of medications.
MOM.6:There are documented policies and procedures for medication administration.
MOM.7: Patients are monitored after medication administration.
“http://www.ismp.org/”
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MOM.8: Near misses, medication errors
and adverse drug events are reported and
analysed.
MOM.9: Documented procedures guide
the use of narcotic drugs and psychotropic
substances.
MOM.10: Documented policies and
procedures guide the usage of
chemotherapeutic agents.
MOM.11: Documented policies and
procedures govern usage of radioactive
drugs.
MOM.12: Documented policies and
procedures guide the use of implantable
prosthesis and medical devices.
MOM.13: Documented policies and
procedures guide the use of medical
supplies and consumables.
“Anything you can achieve with a Quality”
4. PATIENT RIGHTS AND EDUCATION
PRE.1: The organisation protects patient
and family rights and informs them about
their responsibilities during care.
PRE.2: Patient and family rights support
individual beliefs, values and involve the
patient and family in decision making
processes.
PRE.3: The patient and/or family members
are educated to make informed decisions
and are involved in the care planning and
delivery process.
PRE.4: A documented procedure for
obtaining patient and/or family’s consent
exists for informed decision making about
their care.
PRE.5: Patient and families have a right to
information and education about their
healthcare needs.
“Patient is always right”
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PRE.6: Patients and families have a right to information on expected costs.
PRE.7: The organisation has a mechanism to capture patient’s feedback and redressal of
complaints.
PRE.8: The organisation has a system for effective communication with patients and /or
families.
“http://www.dmai.org.in/
Patient_Charter_DMAI.pdf”
5. HOSPITAL INFECTION CONTROL
HIC.1: The organisation has a well-
designed, comprehensive and coordinated
Hospital Infection Prevention and Control
(HIC) programme aimed at
reducing/eliminating risks to patients,
visitors and providers of care.
HIC.2: The organisation implements the
policies and procedures laid down in the
Infection Control Manual in all areas of the
hospital.
HIC.3: The organisation performs
surveillance activities to capture and
monitor infection prevention and control
data.
HIC.4: The organisation takes actions to
prevent and control Healthcare Associated
Infections (HAI) in patients.
“Once you adopt and communicate a quality
policy, stick with it, live it, and protect it. You
get only one chance!”
5. HOSPITAL INFECTION CONTROL
HIC.5: The organisation provides adequate
and appropriate resources for prevention
and control of Healthcare Associated
Infections (HAI).
HIC.6: The organisation identifies and takes
appropriate action to control outbreaks of
infections.
HIC.7: There are documented policies and
procedures for sterilization activities in the
organisation.
HIC.8: Biomedical waste (BMW) is handled
in an appropriate and safe manner.
HIC.9: The infection control programme is
supported by the management and
includes training of staff.
‘Benchmarking means out-maneuvering your
competitors”
6. CONTINUAL QUALITY
IMPROVEMENT
CQI.1: There is a structured quality
improvement and continuous monitoring
programme in the organisation.
CQI.2: There is a structured patient-safety
programme in the organisation.
CQI.3: The organisation identifies key
indicators to monitor the clinical structures,
processes and outcomes, which are used as
tools for continual improvement.
CQI.4: The organisation identifies key
indicators to monitor the managerial
structures, processes and outcomes which
are used as tools for continual
improvement.
“Continuous improvement is nothing but the
development of ever better methods”
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CQI.5: There is a mechanism for validation
and analysis of quality indicators to
facilitate quality improvement.
CQI.6: The quality improvement
programme is supported by the
management
CQI.7: There is an established system for
clinical audit.
CQI.8: Incidents are collected and analysed
to ensure continual quality improvement.
CQI.9: Sentinel events are intensively
analysed.
“It is the quality of our work which will please
God and not the quantity.”
7. RESPONSIBILITIES OF MANAGEMENT
ROM.1: The responsibilities of those
responsible for governance are defined.
ROM.2: The organisation is responsible for
and complies with the laid down and
applicable legislations, regulations and
notifications.
ROM.3: The services provided by each
department are documented.
ROM.4: The organisation is managed by
the leaders in an ethical manner.
“Good management is the art of making
problems so interesting and their solutions so
constructive that everyone wants to get to
work and deal with them”
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ROM.5: The organisation displays professionalism in management of affairs.
ROM.6: Management ensures that patient-safety aspects and risk-management issues are an
integral part of patient care and hospital management.
“Management is doing things right; leadership
is doing the right things”
8. FACILITY MANAGEMENT AND
SAFETY
FMS.1: The organisation has a system in
place to provide a safe and secure
environment.
FMS.2: The organisation’s environment and
facilities operate in a planned manner to
ensure safety of patients, their families,
staff and visitors and promotes
environment friendly measures.
FMS.3: The organisation has a programme
for engineering support services and utility
system.
FMS.4: The organisation has a programme
for bio-medical equipment management.
FMS.5: The organisation has a programme
for medical gases, vacuum and compressed
air.
FMS.6: The organisation has plans for fire
and non-fire emergencies within the
facilities.
FMS.7: The organisation has a plan for
management of hazardous materials.
“Unity is strength... when there is teamwork
and collaboration, wonderful things can be
achieved”
9.HUMAN RESOURCE
MANAGEMENT
HRM.1. The organisation has a
documented system of human resource
planning.
HRM.2. The organisation has a
documented procedure for recruiting staff
and orienting them to the organisation’s
environment.
HRM.3. There is an on-going programme
for professional training and development
of the staff.
HRM.4. Staff are adequately trained on
various safety-related aspects.
“Great vision without great people is
irrelevant”
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HRM.6. The organisation has documented
disciplinary and grievance handling policies
and procedures.
HRM.7. The organisation addresses the
health needs of the employees.
HRM.8. There is documented personal
information for each staff member.
HRM.9. There is a process for credentialing
and privileging of medical professionals,
permitted to provide patient care without
supervision.
HRM.10. There is a process for
credentialing and privileging of nursing
professionals, permitted to provide patient
care without supervision.
HRM.5. An appraisal system for evaluating
the performance of an employee exists as
an integral part of the human resource
management process.
“You can’t teach employees to smile. They have
to smile before you hire them”
10. INFORMATION MANAGEMENT
SYSTEM
IMS.1. Documented policies and
procedures exist to meet the information
needs of the care providers, management
of the organisation as well as other
agencies that require data and information
from the organisation.
IMS.2. The organisation has processes in
place for effective control and management
of data.
IMS.3. The organisation has a complete and
accurate medical record for every patient.
IMS.4. The medical record reflects
continuity of care.
IMS.5. Documented policies and
procedures are in place for maintaining
confidentiality, integrity and security of
records, data and information.
IMS.6. Documented policies and
procedures exist for retention time of
records, data and information.
IMS.7. The organisation regularly carries
out review of medical records.
"Alone we can do so little, together we can do
so much"
ACCREDITATION PROCEDURE
Self-Assessment
Application for accreditation
Pre - Assessment visit
Final Assessment of hospital
Issue of Accreditation Certificate
Surveillance
Re assessment
"Coming together is a beginning. Keeping
together is progress. Working together is
success"
PREARATION FOR ACCREDITATION
Make a definite plan of action for obtaining
accreditation
Nominate a responsible person to co-
ordinate all activities related to
accreditation.
Must have conducted self-assessment
against NABH standards at least 3 months
before submission of application and must
ensure compliance
"The strength of the team is each individual
member. The strength of each member is the
team"
PRE ASSESSMENT
NABH appoints a Principal Assessor/
Assessment Team
Application form, documents, procedures,
Self assessment toolkit
The objective is to
• Check the preparedness of the
hospital for final assessment
• Commitment to quality goals and
consonance to laid down standards
• Review of the documentation system
of the hospital
• Explain the methodology to be
adopted for assessment.
http://nabh.co/h-doc.aspx
FINAL ASSESSMENT
Corrective actions
Compliance with the NC’s pointed out
during the pre-assessment
Comprehensive review of hospital
functions and services
New assessment team including Principal
assessor (already appointed) and the
assessors
Assessors number depend on the
number of beds and services provided
Final assessment report
“We = power”
NABH JOURNEY “The journey of a thousand miles begins with
one step”
Progressive Level
Entry Level
Medical Laboratory, Safe I, Nursing Excellence etc..
NABH Accreditation
Pre Accreditation
LEVEL - ACCREDITATION
1. ENTRY LEVEL ACCREDITATION
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.
Validity period min 6 months to max 18
months.
Cannot apply for assessment before 6
months.
“Sometimes it's the journey that teaches you a
lot about your destination”
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2. PROGRESSIVE LEVEL
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.
Validity period min 3 months to max of 12
months.
Cannot apply for assessment before 3
months.
“Focus on the journey, not the destination”
Continue…
3. ACCREDITATION
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 standards
must not be less than 5.
The average score for individual chapter
must not be less than 7.
The overall average score for all standards
must exceed 7.
Validity period is 3 years
“To sustain longevity, you have to evolve”
SURVEILLANCE & RE-ASSESSMENTS
One surveillance visit in one accreditation
cycle of three years.
Will be planned during the 2nd year i.e.
after 18 months of accreditation.
May apply for renewal of accreditation at
least six months before the expiry of
validity
NABH may call for un-announced visit,
based on any concern or any serious
complaint or incident reported
“The foundation stones for a balanced success
are honesty, character, integrity, faith, love and
loyalty.”
METHODOLOGY
1. Random Structured interviews
To determine their level of awareness and
compliance with organization policies and
procedures.
To assess their awareness levels of their
rights, privileges and patient rights.
To determine their satisfaction levels
2. Observation
Visits to various areas
Facility surveys and tours
3. Documenters
Review of documents
Adherence to statutory obligations
“Success is how high you bounce when you hit
bottom”
STAFF RESPONSE “Progress is impossible without change, and
those who cannot change their minds cannot
change anything”
Expected Response
Response of Medical Fraternity
CONTACT US
• Please contact us for Healthcare Quality Assurance & Certifications consulting services
•Our consulting services are –
NABH (All Level)
NABH Safe I
ISO 9001:2015
Nursing Excellence
Medical Laboratory Programme
Emergency Department Standards
Medical Facilitator Programme
“iHEALTHcare - Availability of Healthcare
required all facilities under one roof is
what “Makes us Different”
• Mr. Kirankumar Ghanapuram• Consultant - Healthcare Management• [email protected]• +91 9011017501