nabh hco entry level pre-accreditation standards orientation
TRANSCRIPT
NABH ENTRY LEVEL PROJECT
By: Mr. Kirankumar GhanapuramConsultant - Healthcare Management
[email protected]+91 9011017501
ABOUT NABH• NABH - National Accreditation Board for Hospitals & Healthcare
Providers• Constituent board of Quality Council of India• International Linkage – lSQua & ASQua• NABH standards are in consonance with the global benchmarks• 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
ABOUT ENTRY LEVEL• A stepping stone for enhancing
the quality of patient care and safety
• Aim : To introduce quality and accreditation to the HCOs as their first step towards awareness and capacity building
• Objectives : To operate accreditation and allied programs in collaboration with stakeholders focusing on patient safety and quality of healthcare
• Next stage - Progressive Level
and finally to Full Accreditation
• Practical methodology provides a step by step and staged approach for the HCOs face challenges and difficulties in implementing all the Accreditation Standards
• Self-assessment against NABH Pre Accreditation Entry Level standards after implementing it for at least 3 months before submission of application
Entry Level Pre-Accreditation
Progressive Level Pre-Accreditation
NABH Accreditation
QUALITY DEFINITION• 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
Continue..• 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”
IMPORTANT DEFINITIONS• 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.
BENEFITS OF PRE ACCREDITATION ENTRY LEVEL STANDARDS• Benefits for Patients
– Patients are the biggest beneficiary among all the stakeholders
– Pre Accreditation Entry Level standards result in improved quality care and patient safety
– The patients are serviced by trained & skilled medical staff
– Rights of patients are respected and protected
• Benefits for Hospitals– Pre Accreditation Entry
Level Standards for a hospital will stimulate a journey towards continuous improvement
– It enables hospital in demonstrating commitment to quality care. It raises community confidence in the services provided by the hospital
– International recognition– Provide boost to medical
tourism
Continue…• Benefits for Hospital Staff
– The staff in a Pre Accreditation Entry Level certified hospital is sensitized over the quality & patient safety & is satisfied as it provides for continuous learning, good working environment, leadership and above all ownership of clinical processes
– It improves overall professional development of Clinicians and Para Medical Staff and provides leadership for quality improvement with medicine and nursing
• Benefits to paying and regulatory bodies– Finally, Pre Accreditation Entry Level Certification provides an
objective system of empanelment by insurance and other third parties
– It provides access to reliable and certified information on facilities, infrastructure and level of care
ORGANIZATIONAL STRUCTURENational Accreditation Board for Hospitals and
Healthcare Providers (NABH)
Appeals Committee
Secretariat Panel of
Assessors & Experts
TechnicalCommittee
AccreditationCommittee
Continue…• Accreditation Committee : The main functions of Accreditation
Committee are as follows:– Recommending to Board about grant of Certification or
otherwise based on evaluation of assessment reports & other relevant information
– Approval of the major changes in the scope of Certification– Recommending to the board on launching of new initiatives
• Technical Committee : The main functions of Technical Committee are as follows:– Drafting of standards and associated documents– Periodic review of standards
• NABH Secretariat : The Secretariat coordinates the entire activities related to NABH Accreditation to hospitals and healthcare organizations
• Panel of Assessors and Experts : NABH has a panel of trained and qualified assessors for assessment of hospitals
ENTRY LEVEL STANDARDS • NABH Pre Accreditation Entry Level Standards for Hospitals has 10
chapters incorporating 45 standards and 167 objective elements• Outline of NABH Chapters
Patient Centered Standards
• Access, Assessment and Continuity of Care (AAC)
• Care of Patient (COP)• Management of Medication
(MOM)• Patient Right and
Education (PRE)• Hospital Infection Control
(HIC)
Organization Centered Standards
• Continuous Quality Improvement (CQI)
• Responsibility of Management (ROM)
• Facility Management and Safety (FMS)
• Human Resource Management (HRM)
• Information Management System(IMS)
PREPARING FOR NABH PRE ACCREDITATIONENTRY LEVEL
Obtain a copy of NABH Pre Accreditation Entry Level Standards for hospitals
(From NABH office)
Get accustomed to the standard & implement them (By health care organization)
Fill the Application Form online (On NABH web site)
Submit the Application Form + Self- Assessment toolkit + Application Fee + Document
(to NABH Secretariat)
Pay the Certification fee before the final assessment
PREPARING FOR NABH PRE ACCREDITATIONENTRY LEVEL
Application form + Self-Assessment Tool Kit + Documents + Application Fee
Acknowledgment and Scrutiny of application (by NABH Secretariat)
Certification Fee submitted to NABH Secretariat before Final Assessment
Final Assessment of hospital (by Assessment Team)
Review of Assessment Report (by NABH Secretariat)
Review of report & Recommendation for Pre Accreditation Entry Level Certificate
(by Accreditation Committee)Issue of Pre Accreditation Entry Level Certificate for 2 years, 6 monthly report on defined indicators to be submitted to NABH
SecretariatRenewal, Go for Pre Accreditation Progressive Level/ Full
Accreditation (by NABH Secretariat)
Feedback to Health careOrganizationAndNecessary Corrective Action Taken By Healthcare Organization
Chapter 1: ACCESS, ASSESSMENT AND CONTINUITY OF CARE (AAC)• AAC.1: The organization defines
and displays the services that it can provide.
• AAC.2: The organization has a documented registration, admission and transfer process.
• AAC.3 Patients cared for by the organization undergo an established initial assessment.
• AAC.4 Patient care is continuous and all patients cared for by the organization undergo a regular reassessment.
• AAC.5 Laboratory services are
provided as per the scope of the hospital’s services and laboratory safety requirements.
• AAC.6 Imaging services are provided as per the scope of the hospital’s services and established radiation safety programme.
• AAC.7 The organization has a defined discharge process.
Chapter 2: CARE OF PATIENTS (COP)• COP.1: Care of patients is
guided by accepted norms & practice.
• COP.2: Emergency services including ambulance are guided by documented procedures.
• COP.3: Documented procedures define rational use of blood and blood products.
• COP.4: Documented procedures guide the care of patients as per the scope of services provided by hospital in Intensive care and high dependency unit.
• COP.5: Documented procedures guide the care of obstetrical patients as per the scope of services provided by hospital.
• COP.6: Documented procedures guide the care of pediatric patients as per the scope of services provided by hospital.
• COP.7: Documented procedures guide the administration of anesthesia.
• COP.8: Documented procedure guides the care of patients undergoing surgical procedures.
Chapter 3: MANAGEMENT OF MEDICATION (MOM)• MOM.1: Documented procedures guide the organization of
pharmacy services and usage of medication.• MOM.2: Documented policies & procedures guide the storage of
medications.• MOM.3: Documented procedures guide the prescription of
medications.• MOM.4: Policies & procedures guide the safe dispensing of
medications.• MOM.5: There are defined procedures for medication
administration.• MOM.6: Adverse drug events are monitored.• MOM.7: Documented policies & procedures govern usage of
radioactive drugs.
Chapter 4: PATIENT RIGHTS AND EDUCATION (PRE)• PRE.1: Patient rights are documented displayed and support
individual beliefs, values and involve the patient and family in decision making processes.
• PRE.2: Patient and families have a right to information and education about their healthcare needs.
Chapter 5: HOSPITAL INFECTION CONTROL (HIC)• HIC.1: The hospital has an infection control manual, which is
periodically updated and conducts surveillance activities.• HIC.2: The hospital takes actions to prevent or reduce the risks of
Hospital Associated Infections (HAI) in patients and employees.• HIC.3: Bio-medical Waste (BMW) management practices are
followed.
Chapter 6: CONTINUOUS QUALITY IMPROVEMENT (CQI)• CQI.1: There is a structured quality improvement, patient safety
and continuous monitoring programme in the organization.• CQI.2: The organization identifies key indicators to monitor the
structures, processes and outcomes which are used as tools for continual improvement.
Chapter 7: RESPONSIBILITIES OF MANAGEMENT (ROM)• ROM.1: The responsibilities of the management are defined• ROM.2: The organization is managed by the leaders in an ethical
manner.• ROM.3: The organization has set up multi-disciplinary committees
to oversee specific areas of quality and patient safety.
Chapter 8: FACILITY MANAGEMENT
AND SAFETY (FMS)• FMS.1: The organization’s environment and facilities operate to
ensure safety of patients, their families, staff and visitors.• FMS.2: The organization has a program for clinical and support
service equipment management.• FMS.3: The organization has provisions for safe water, electricity,
medical gas and vacuum systems.• FMS.4: The organization has plans for fire and non-fire
emergencies within the facilities.
Chapter 9: HUMAN RESOURCE MANAGEMENT (HRM)• HRM.1: The organization has staffing commensurate with patient
care needs.• HRM.2: There is an ongoing programme for professional training
and development of the staff.• HRM.3: The organization has a well-documented disciplinary and
grievance handling procedure.• HRM.4: The organization addresses the health needs of the
employees• HRM.5: There is documented personal record for each staff
member
Chapter 10: INFORMATION MANAGEMENT SYSTEM (IMS)• IMS.1: The organization has a complete and accurate medical
record for every Patient• IMS.2: The medical record reflects continuity of care.• MS.3: Documented policies and procedures are in place for
maintaining confidentiality, integrity and security of records, data and information.
• IMS.4: Documented procedures exist for retention time of records, data and information.
ONSITE ASSESSMENT ACTIVITIES • Opening Meeting • Orientation of assessors to the organization’s services• Document review• Functional interview• Visit to patient care areas and selected department• Facility tour • Special interview/ issue resolution• Closing Meeting
ENTRY LEVEL AWARD MEANSThat 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.• Patients 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.
CONTACT US FOROur consulting services are
• NABH (All Level)• NABH Safe I• ISO 9001:2015• Nursing Excellence• Medical Laboratory Programme• Emergency Department Standards• Medical Facilitator Programme
IT’S VERY SIMPLE
“Success is a Journey, Not a Destination!”
“In order to succeed, we first believe that we can!”
“Alone we can do so little, Together we can do so much!”
“The achievements of an organization are the results of the combined effort of each and every individual!”
“As there is nothing training cannot do, Nothing is above its reach, Training can turn bad morals to good, Destroy bad principles & recreate good ones, It can lift men to performing excellence!”