ACCREDITATION PROCESS

By

Col (Dr) Pawan Kapoor

MBBS(AFMC), MHA(AIIMS)
DNB ( H&HA), MMS (Osmania), MBA (IGNOU)
 GOOD NEWS

I AM NOT GOING TO BORE YOU

 BAD NEWS

YOU WILL STILL HAVE TO

TOLERATE ME
FOR THE NEXT FEW HOURS
 THE GOOD NEWS

Ourclientele now knows the importance
of Good Health and values it

THE BAD NEWS

Ourclientele now knows the importance
of Good Health and values it AND-----

NOW HAS EXPECTATIONS

 AS A PATIENT WHAT QUALITY
LEVELS WOULD YOU ACCEPT FROM
YOUR HEALTH SERVICES?
90%
95%
96%

98%
99%

99.9%
 IF 99.9% IS ACCEPTABLE TO YOU, THEN…

•YOUR HEART FAILS * 20,000 WRONG

TO BEAT 32,000 DRUG
TIMES EACH YEAR PRESCRIPTIONS
MADE EVERY YEAR
* 500 SURGICAL
OPERATIONS ARE * 19,000
BABIES ARE
PERFORMED DROPPED BY
WRONGLY DOCTORS
EVERY WEEK AT BIRTH
WELL …..
“ THERE IS ONLY A 1 %

DIFFERENCE IN THE DNA

GENETIC CODE BETWEEN A

CHIMPANZEE AND A

HUMAN BEING”
•IN OUR PROFESSION THERE IS NO SCOPE
FOR ERROR. FOR ANY ERROR COMMITTED
IS ALL THE DIFFERENCE BETWEEN
LIFE AND DEATH, BETWEEN RELIEF AND
DISABILITY

•THERE IS NO SECOND CHANCE

Then …..
 HOW TO ACHIEVE
EXCELLENCE IN HEALTH

Please
wait…..
WHAT IS QUALITY ?

Appropriate application of medical
knowledge with due regard to the
balance between the hazard inherent
in every medical intervention and the
benefits expected from it

It is, however more complex than

this.
QUALITY FROM WHOSE
POINT OF VIEW ?

Provider of Health care Services

Recipient of the Health care

services

Organizer of the Health care

services
 PROVIDERS CONCERNS

To provide care as per established
norms

Adequate resources

Self satisfaction with the final
outcome

Should contribute to enhancement of
skills, competence and add to
experience
 RECIPIENTS 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
 ORGANISERS CONCERNS

Responsible to the Society for the funds
spent on health care

To ensure safety of public and prevent

inappropriate or suboptimal care

To meet the requirements of the recipient

and provider of the health care services at
Acceptable costs
 SIMPLE MEANING OF
QUALITY

Simply defined Quality is the degree of

adherence to predetermined standards

based on existing knowledge, principles

and practices
 What are Standards

A standard is a statement that defines the

structures and processes that must be

substantially in place in an organization to

enhance the quality of care

 COP.3
The ambulance services are
commensurate with the scope
of the services provided by the
organization
How to Measure the
standard ???
 Objective Elements

Objective element is a measurable

component of a standard

Acceptable compliance with objective

elements determines the overall

compliance with a standard

 COP.3
The ambulance services are
commensurate with the scope
of the services provided by the
organization

Objective elements
a) There is adequate access and space for
the ambulance(s)
b) Ambulance(s) is appropriately equipped
c) Ambulance(s) is manned by trained
personnel
 cont…

d) There is a checklist of all equipment and

emergency medications
e) Equipment are checked on a daily basis
f) Emergency medications are checked
daily and prior to dispatch
g) The ambulance(s) has a proper
communication system
 COP.4
Policies and procedures guide
the care of patients requiring
cardio-pulmonary resuscitation

Objective elements
a) Documented policies and procedures
guide the uniform use of resuscitation
throughout the organization
b) Staff providing direct patient care is
trained and periodically updated in
cardio pulmonary resuscitation
 cont…

c) The events during a cardio-pulmonary

resuscitation are recorded
d) An analysis of all cardiac arrests is done
e) A multidisciplinary committee monitors
the effectiveness of cardio-pulmonary
resuscitation
WHAT IS ACCREDITATION
 Accreditation is an external review of
quality with four principal components:

 It is based on written and published

standards
 Reviews are conducted by professional
peers
 The accreditation process is
administered by an independent body
 The aim of accreditation is to encourage
organizational development.
 Objectives of Accreditation

Assess Quality and Safety of Care

Assess a HCO ability to ensure continuous
improvement in Quality

Formulate Explicit Recommendations

Involve professionals at all stages of the
quality initiative

Provide external recognition of the Quality
of care in the HCO

Improve public confidence
 What Accreditation begets ?

Customer focus

Competitive advantage

Corporate environment

Confidence of Regulatory and paying
authorities

Minimisation of litigation losses
 Making of standards

Patient Safety

Staff and employee safety

Environment and community safety

Information Education and Communication

Simple and easy to comprehend

Measurable

Achievable

Organized around important functions

 What are the Important
functions ???

Patient Centered functions

Organisation Centered functions

Community Centered functions

Environment Centered functions

BENEFITS OF ACCREDITATION
 Benefits for Patients
 High quality of care
 Credentialed and privileged medical
staff
 Access to a quality focused
organization
 Rights are respected and protected
 Understandable education and
communication
 Patient Satisfaction is evaluated
 Benefits for Patients Contd..
 Involvement in care decisions and
care process
 Focus on patient safety

 Pain management

 Vulnerable patient

 Safe transport

 Continuity of care
 Benefits for the staff
 Improves professional staff
development
 Provides education on consensus
standards
 Provides leadership for quality
improvement within medicine and
nursing
 Increases satisfaction with continuous
learning, good working environment,
leadership and ownership
 Benefits for the Hospital

 Improves care

Stimulates continuous improvement

Demonstrates commitment to quality
care

Raises community confidence

Opportunity to benchmark with the
best
 Benefits to the Community

 Quality revolution

 Disaster preparedness

- epidemics
- physical
 Access to comparative database
MAKING OF STANDARDS
Technical Committee Members

Col (Dr) Pawan Kapoor (Armed Forces
Medial Services)- Convenor

Dr Umesh Gupta (Vascular Surgeon & Head
of QI, Indraprastha Apollo Hospital)

Dr Bidhan Das (COO, Rockland Hospital)

Dr Sidharth Satpathy (Addl Prof of HA,
AIIMS)

Dr S Murali (Neurologist & Clinical Co-
ordinater, Manipal Hospital)

Mr Deepak Bandhopadhyay (Quality
Consultant)
 METHODOLOGY FOLLOWED

Technical committee set up by QCI

Review of existing global standards

Perusal of available compliance data

Applicability aspects to Indian context

Amenable to international recognition

Not too difficult and stringent nor very
easy to achieve

Minimise Prescriptiveness

Consensus
 METHODOLOGY FOLLOWED

Draft standards forwarded to 32 Experts
across the country

Feedback received incorporated wherever it
was found to be feasible and implement able

Pilot study

Firming of the standards

Publication

Sensitisation Workshops
 METHODOLOGY FOLLOWED

Training of Assessors

Laying Down of Guideline Manuals

Implementation

Feedback from Assessors, Organisations,

Consumers, stakeholders

Revision
 NABH Standards

10 Chapters

100 Standards

503Objective Elements (512 in Revised

Edn 2007)
 Section I:
Patient-Centered Standards
Description Std OE REV

Access, Assessment and 15 78 78

Continuity of Care
Care of Patients 18 105 104
Mgmt of Medications 13 61 61
Patients Rights and 05 29 30
Education
Hospital Infection Control 09 44 46
Total 60 317 319
 Section II:
Organisation Centered Standards
Description Std OE REV

Continuous Quality 06 37 39
Improvement
Responsibilities of Mgmt 05 20 25
Facility Mgmt & Safety 09 41 41
Human Resource Mgmt 13 47 47
Information Mgmt System 07 41 41
Total 40 186 193
Accreditation Process
 WHO CAN APPLY

Any Health Care Organisation

Requirements

Currently in operation as a HCO

Preferably registered or licensed

Willingto assume responsibility for improving
quality of care

Shouldbe able to meet the prescribed
standards of the accrediting organisation
 HOW CAN ONE APPLY

Organisations apply on prescribed format
giving details as required

Submission of a self assessment form
indicating the outcomes of its QMS and
Internal Audits

Extent of adherence to the laid down
standards
 SCREENING OF APPLICATIONS

Completeness

Accuracy

Clarifications sought if required

 PREASSESSMENT SURVEY

To ascertain the readiness of the
organisation for Accreditation

Overview of the organizational
preparedness and commitment to quality
goals and consonance to laid down
standards

Deficiencies noticed informed to the
organisation

Advice rendered on the methodology to be
followed during the Accreditation Survey

Time frame worked out for the survey in
mutual consultation
 ACCREDITATION SURVEY

Carried out by a team of Assessors
depending upon the size, complexity and
facilities provided by the organisation

Scope will include all standards related
functions and all patient care settings

Onsitesurvey will consider specific cultural
and legal factors which may influence or
shape decisions regarding the provision of
care and /or policies and procedures
 METHODOLOGY OF SURVEY

Initial presentation by the hospital

Document Review

Adherence to statutory obligations

Visits to various areas

Facility surveys and tours

Random structured interviews

 INITIAL PRESENTATION BY
THE HOSPITAL

Organogram

Quality management Team

Methodology followed for Quality
Improvement

Facilities provided

Inputs on resources provided for Quality
Improvement

Identified high Risk Areas for patient care
and safety

Sentinel Events being monitored
 INITIAL PRESENTATION BY
THE HOSPITAL

Key Monitoring Indicators

Resource

Volume

Utilization

Performance

Control charts

Problems faced and remedial measures
undertaken/ being undertaken
 DOCUMENT REVIEW

• Quality Manual
• Various Policies and Procedures
• Minutes of Meetings of various committees
• Medical Records
• Medical / Nursing Audit
• Adverse Events
• HAI
• Action Taken Reports
• Personal Records of Staff
 OBSERVATIONS
• Facility Safety
• Level of compliance with laid down policies and
procedures
• BMW Management
• Standard Precautions
• Patient care
• Fire Safety
• Equipment Management
 INTERVIEW
• Staff Interview
• To determine their level of awareness and
compliance with organisation policies and
procedures
• To assess their awareness levels of their
rights, privileges and patient rights
• To determine their satisfaction levels
• Patient and family Interview
• To assess their level of awareness of the
care process and their rights
• To determine their satisfaction levels
 SCORING PATTERN

NABH has laid down the following pattern

Non-compliance 0

Partial compliance 5

Full compliance 10

No standard can have more than one zero

The average for a standard must exceed 5

The overall average score must exceed 7

No zeros in legal requirements
OUTCOMES OF ACCREDITATION
SURVEYS

Accredited

HCO shows acceptable compliance with laid
down standards in all areas

Includes the scope of services for which
accredited

Any increase in scope the survey has to be
done for the increased scope

Accreditation denied

HCO is consistently non compliant with
standards

Accreditation withdrawn

HCO withdraws voluntarily

Due to consistent non compliance or non
adherence to safe and ethical practices
DURATION OF ACCREDITATION
AWARDS

Generally three years with one Reassessment
survey to ensure continued compliance and to
assess the CQI programme

If during accreditation NABH receives inputs that
the organisation is substantially out of compliance
with the current standards then Resurvey or
withdrawal of accredited decision may be resorted
to
 Summary of Accreditation
Process

 Applications
 Screening of the Applications
 Pre-assessment survey
 Assessment Survey
 Review of the recommendations of the
assessing body by the Accreditation
Committee
 Recommendations to the board
 Accreditation decision
Brief Explanation of Standards
 Access, Assessment and Continuity
Of Care (AAC)

The organization defines and displays the

services that it can provide.
Objective Elements
•The services being provided are clearly
defined.
•The defined services are prominently
displayed.
•The staff is oriented to these services.
 Admissions

* Patients are accepted only if the organization

can provide the required service.

* The policies and procedures also address

managing patients during non availability of beds.

 Transfer of patients

* Transfer of unstable patients

* Transfer of stable patients

* Staff responsible during transfer

* Summary of patient’s condition and

the treatment given.

 Assessment of patients
• Content of the assessments
• Time frame within which the initial assessment
is completed
• Initial assessment includes screening for
nutritional needs
• The initial assessment results in a documented
plan of care
• The plan of care also includes preventive
aspects of the care
 Re-assessment

• All patients are reassessed at appropriate

intervals.
• Staff involved in direct clinical care
document reassessments.
• Patients are reassessed to determine their
response to treatment and to plan further
treatment or discharge.
 Investigations
* Adequately qualified and trained personnel

perform and/or supervise the investigations.

* Collection, identification, handling, safe

transportation, processing and disposal of

specimens.

* Laboratory / imaging results time frame.

* Critical results reporting

 Investigations
• The laboratory / radiation safety program is
documented
• Handling and disposal of infectious and
hazardous materials
• Laboratory / imaging personnel are appropriately
trained in safe practices.
• Laboratory / imaging personnel are provided
with appropriate safety equipment / devices.
 Discharge

• Discharge process is planned

• A discharge summary is given to all the

patients leaving the organization (including

patients leaving against medical advice)

 Discharge

• Reasons for admission

• Significant findings

• Diagnosis

• Patient’s condition at the time of discharge

• Investigation results
 Discharge
• Procedure performed, medication and
other treatment given
• Follow up advice, medication and other
instructions in an understandable manner.
• Instructions about when and how to obtain
urgent care
• Patient records also contain a copy of the
discharge / case summary
Patient Rights and Education
(PRE)
The organization protects patient and family rights
during care
Objective Elements
• Patient and family rights are documented
• Patients and families are informed of their rights in
a format and language that they can understand
• The organization’s leaders protect patient’s and
family rights
• Staff is aware of their responsibility in protecting
patients and family rights
• Violation of patient and family rights is recorded,
reviewed and corrective/preventive measures
taken
 Rights
• Respect for personal dignity and privacy
• Protection from physical abuse or neglect
• Treating patient information as confidential
• Refusal of treatment
• Informed consent
• Information and consent before any research
protocol is initiated
• Information on how to voice a complaint
• Information on the expected cost of the
treatment
• Access to his / her clinical records
 Informed Consent
• Situations where informed consent is required
• Informed consent includes
• information on risks
• Benefits
• alternatives
• Who will perform the requisite procedure in a
language that they can understand
• Who can give consent when patient is
incapable of independent decision making
 Education
• Safe and effective use of medication
• Potential side effects of the medication
• Diet and nutrition
• Immunizations
• Specific disease process, complications and
prevention strategies
• Preventing infections
• Language and format that they can
understand
 Care Of Patients (COP)

• Care delivery is uniform when similar care is

provided in more than one setting
• The care and treatment orders are signed,
named, timed and dated by the concerned doctor
• The care plan is countersigned by the clinician in-
charge of the patient within 24 hours
• Evidence based medicine and clinical practice
guidelines are adopted to guide patient care
whenever possible
 Emergency services
• Policies and procedure for emergency care are
documented
• Policies also address handling of medico-legal cases
• The patients receive care in consonance with the
policies
• Policies and procedures guide the triage of patients
for initiation of appropriate care
• Staff is familiar with the policies and trained on the
procedures for care of Emergency patients
• Admission or discharge to home or transfer to another
organization is also Documented
 Ambulance
COP.3.The ambulance services are commensurate with
the scope of the services provided by the organization
Objective Elements
• There is adequate access and space
• Ambulance (s) is appropriately equipped
• Ambulance (s) is manned by trained personnel
• There is a checklist of all equipment and emergency
medications
• Equipment are checked on a daily basis
• Emergency medications are checked daily and prior to
dispatch
• The ambulance(s) has proper communication system
 CPR
• Documented policies and procedures guide the
uniform use of resuscitation throughout the
organization
• Staff providing direct patient care is trained and
periodically updated in cardio pulmonary
resuscitation
• The events during a cardio-pulmonary
resuscitation are recorded
• A post-event analysis of all cardiac arrests is
done by a multidisciplinary committee
• Corrective and preventive measures are taken
based on the post-event analysis
 Blood transfusion
• Documented policies and procedures are used
to guide rational use of blood and blood
products
• The transfusion services are governed by the
applicable laws and regulations
• Informed consent is obtained for donation and
transfusion of blood and blood products
• Informed consent also includes patient and
family education about donation
• Staff is trained to implement the policies
• Transfusion reactions are analyzed for
preventive and corrective actions
 ICU
•The organization has documented admission and
discharge criteria for its intensive care and high
dependency units

•Staff is trained to apply these criteria

•Adequate staff and equipment are available

•Defined procedures for situation of bed shortages

are followed

•Infection control practices are followed

•The unique needs of end of life patients are identified

and cared for
•A quality assurance program is implemented
 Vulnerable patients
• Policies and procedures are documented and are
in accordance with the prevailing laws and the
national and international guidelines

• Care is organized and delivered in accordance

with the policies and procedures

• The organization provides for a safe and secure

environment for this vulnerable group

• A documented procedure exists for obtaining

informed consent from the appropriate legal
representative

• Staff is trained to care for this vulnerable group

 Obstetrics
PPolicies and procedures guide the care of high risk
obstetrical patients
•The organization defines and displays whether high
risk obstetric cases can be cared for or not
•Persons caring for high risk obstetric cases are
competent
•High risk obstetric patient’s assessment also
includes maternal nutrition
•The organization caring for high risk obstetric cases
has the facilities to take care of neonates of such
cases
 Pediatrics
•The organization defines and displays the scope of

its pediatric services

•The policy for care of neonatal patients is in

consonance with the national/ international guidelines

•Those who care for children have age specific

competency

•Provisions are made for special care of children

 Pediatrics
•Patient assessment includes detailed nutritional,

growth, psychosocial and immunization

assessment

•Policies and procedures prevent child/ neonate

abduction and abuse

•The children’s family members are educated about

nutrition, immunization and safe parenting and this is

documented in the medical record

 Sedation
• Competent and trained persons perform sedation
• The person administering and monitoring
sedation is different from the person performing
the procedure
• Intra-procedure monitoring includes at a minimum
the heart rate, cardiac rhythm, respiratory rate,
blood pressure, oxygen saturation, and level of
• sedation
• Patients are monitored after sedation
• Criteria are used to determine appropriateness of
discharge from the recovery area
• Equipment and manpower are available to
rescue patients from a deeper level of sedation
than that intended
 Anesthesia
• All patients for anesthesia have a pre-anesthesia

assessment by a qualified individual

• The pre-anesthesia assessment results in formulation

of an anesthesia plan which is documented

• An immediate preoperative reevaluation is

documented

• Informed consent for administration of anesthesia is

obtained by the anesthetist

 Anesthesia
• During anesthesia monitoring includes regular and
periodic recording of heart rate, cardiac rhythm,
respiratory rate, blood pressure, oxygen saturation,
airway security and patency and level of anesthesia
• Each patient’s post-anesthesia status is monitored
and documented
• A qualified individual applies defined criteria to
transfer the patient from the recovery area
• All adverse anesthesia events are recorded and
monitored
 Surgery
• Surgical patients have a preoperative assessment
and a provisional diagnosis documented prior to
surgery

• An informed consent is obtained by a surgeon prior to

the procedure

• Documented policies and procedures exist to prevent

adverse events like Wrong site, wrong patient and
wrong surgery

• Persons qualified by law are permitted to perform the

procedures that they are entitled to perform
 Surgery

• A brief operative note is documented prior to

transfer out of patient from recovery area

• The operating surgeon documents the post-

operative plan of care

• A quality assurance program is followed for the

surgical services
 Restraints
Standard
• Policies and procedures guide the care of patients
under restraints (physical and / or chemical)

Objective Elements
• Documented policies and procedures guide the care of
patients under restraints
• These include both physical and chemical restraint
measures
• These include documentation of reasons for restraints
• These patients are more frequently monitored
• Staff receive training and periodic updating in control
and restraint techniques
 Pain management
• Documented policies and procedures guide the

management of pain

• The organization respects and supports the

appropriate assessment and management of pain for

all patients

• Patient and family are educated on various pain

management techniques
 End of life care
Standard
COP.18. Policies and procedures guide the end of life
care
Objective Elements
• Documented policies and procedures guide the end of
life care
• These policies and procedures are in consonance with
the legal requirements
• These also address the identification of the unique
needs of such patient and family
• These also include sensitively addressing issues such
as autopsy and organ donation
• Staff is educated and trained in end of life care
•
 Management of
Medication (MOM)
 Drug committee
Standard
•Policies and procedures guide the organization of
pharmacy services and usage of medication
Objective Elements
•There is a documented policy and procedure for
pharmacy services and medication usage
•These comply with the applicable laws and
regulations
•A multidisciplinary committee guides the formulation
and implementation of these policies and procedures
 Formulary
Objective Elements
•A list of medication appropriate for the
patients and organization’s resources is
developed
•The list is developed collaboratively by the
multidisciplinary committee
•There is a defined process for acquisition of
these medications
•There is a process to obtain medications not
listed in the formulary
 Storage of medication
Objective Elements
•Documented policies and procedures exist for
storage of medication
•Medications are stored in a clean, well lit and
ventilated environment
•Sound inventory control practices guide
storage of the medications
•Medications are protected from loss or theft
 Storage of medication
Objective Elements
•Sound alike and look alike medications are
stored separately
•There is a method to obtain medication when
the pharmacy is closed
•Emergency medications are available all the
time
•Emergency medications are replenished in a
timely manner when used
 Prescription of medications
Objective Elements
•Documented policies and procedures exist for
prescription of medications
•The organization determines who can write
orders
•Orders are written in a uniform location in the
medical records
•Medication orders are clear, legible, dated,
named and signed
 Prescription of medications

Objective Elements

•Policy on verbal orders is documented and

implemented

•The organization defines a list of high risk

medication

•High risk medication orders are verified prior to

dispensing
 Safe dispensing of medications
Objective Elements
•Documented policies and procedures guide
the safe dispensing of medications
•The policies include a procedure for
medication recall
•Expiry dates are checked prior to
dispensing
•Labeling requirements are documented and
implemented by the organization
 Medication administration
Objective Elements
•Medications are administered by those who are
permitted by law to do so
•Prepared medication are labeled prior to preparation
of a second drug
•Patient is identified prior to administration
•Medication is verified from the order prior to
administration
•Dosage is verified from the order prior to
administration
 •Medication administration
•Objective Elements
•Route is verified from the order prior to
administration
•Timing is verified from the order prior to
administration
•Medication administration is documented
•Polices and procedures govern patient’s self
administration of medications
•Polices and procedures govern patient’s
medications brought from outside the
organization
 Medication education

Objective Elements

•Patient and family are educated about safe and

effective use of medication

•Patient and family are educated about food-

drug interactions
 Medication effects
Objective Elements
•Patients are monitored after medication
administration and this is documented
•Adverse drug events are defined
•Adverse drug events are reported within a
specified time frame
•Adverse drug events are collected and analyzed
•Policies are modified to reduce adverse drug
events when unacceptable trends occur
 Narcotic drugs and psychotropic
substances
Objective Elements
•Documented policies and procedures guide
the use of narcotic drugs and psychotropic
substances
•These policies are in consonance with local
and national regulations
•A proper record is kept of the usage,
administration and disposal of these drugs
•These drugs are handled by appropriate
personnel in accordance with policies
 Chemotherapeutic agents
Objective Elements
•Documented policies and procedures guide
the usage of chemotherapeutic agents
•Chemotherapy is prescribed by those who
have the knowledge to monitor and treat the
adverse effect of chemotherapy
•Chemotherapy is prepared and administered
by qualified personnel
•Chemotherapy drugs are disposed off in
accordance with legal requirements.
 Radioactive or investigational drugs
Objective Elements
•Documented policies and procedures govern
usage of radioactive or investigational drugs
•These policies and procedures are in
consonance with laws and regulations
•The policies and procedures include the safe
storage, preparation, handling, distribution
and disposal of radioactive and investigational
drugs
•Staff, patients and visitors are educated on
safety precautions
 Implantable prosthesis
Objective Elements
•Documented policies and procedures govern
procurement and usage of implantable
prosthesis
•Selection of implantable prosthesis is based
on scientific criteria and internationally
recognized approvals
•The batch and serial number of the
implantable prosthesis are recorded in the
patient’s medical record and the master
logbook
 •Medical gases
Objective Elements
•Documented policies and procedures govern
procurement, handling, storage, distribution,
usage and replenishment of medical gases.
•The policies and procedures address the
safety issues at all levels
•Appropriate records are maintained in
accordance with the policies, procedures and
legal requirements.
Hospital Infection Control (HIC)
 Infection control program
Standard
The organization has a well-designed, comprehensive
and coordinated Hospital Infection Control (HIC)
programme aimed at reducing/ eliminating risks to
patients, visitors and providers of care.
Objective Elements
•The hospital has a multi-disciplinary infection control
committee.
•The hospital has an infection control team.
•The hospital has designated and qualified infection
control nurse(s) for this activity
•The hospital infection control programme is
documented.
 Infection control manual
•The manual identifies the various high-risk
areas.
•It outlines methods of surveillance in the
identified high-risk areas.
•Focuses on adherence to standard
precautions at all times.
•Equipment cleaning and sterilisation practices
•An appropriate antibiotic policy is established
and implemented.
 •Infection control manual

•Laundry and linen management processes

are also included.

•Kitchen sanitation and food handling issues

are included in the manual

•Engineering controls to prevent infections

•Mortuary practices and procedures are

included as appropriate to the organization
 Surveillance
Objective Elements
•Surveillance activities are appropriately directed
towards the identified high-risk areas.
•Collection of surveillance data is an ongoing
process.
•Verification of data is done on regular basis by the
infection control team.
•In cases of notifiable diseases, information (in
relevant format) is sent to appropriate authorities.
•Scope of surveillance activities incorporates
tracking and analysing of infection risks, rates and
trends
 Hospital Associated Infections (HAI)
Objective Elements
•The organization monitors urinary tract infections.
•The organization monitors respiratory tract
infections.
•The organization monitors intra-vascular device
infections.
•The organization monitors surgical site infections.
•Appropriate feedback regarding HAI rates are
provided on a regular basis to medical and nursing
staff.
 Resources
•Hand washing facilities in all patient care
areas are accessible to health care
providers.
• Compliance with proper hand washing is
monitored regularly.
•Isolation/ barrier nursing facilities are
available.
•Adequate gloves, masks, soaps, and
disinfectants are available and used
correctly.
 Outbreaks of infections
•Hospital has a documented procedure for handling
such outbreaks.
•This procedure is implemented during outbreaks.
•After the outbreak is over appropriate corrective
actions are taken to prevent recurrence.
CSSD
•There is adequate space available for sterilization
activities
•Regular validation tests for sterilisation are carried
out and documented.
•There is an established recall procedure when
breakdown in the sterilisation system is identified.
 Bio-medical waste management

•Proper segregation and collection of Bio-

medical Waste from all patient care areas of
the hospital is implemented and monitored

•Appropriate personal protective measures

are used by all categories of staff handling
Bio-medical Waste.
 Staff training

•The hospital regularly earmarks adequate funds

from its annual budget in this regard.
•It conducts regular pre-induction training for
appropriate categories of staff before joining
concerned departments
•It also conducts regular “in-service” training
sessions for all concerned categories of staff at
least once in a year.
•Appropriate pre and post exposure prophylaxis is
provided to all concerned staff members.
And You Thought You Had a
Migraine …

Unfortunately
There is
More
To
Follow

SORRY !!!!!!
This is for all of you - our
friends .

20.09.2008 10:32
Sometimes the pressure
Is so high...
The hours are so long...
The problems so big...
The whole world seems to
be against you...
Do you know what you
should do?
Pretend that all that is not happening to you!

Have fun!
Act silly!
Don’t listen to the ones who make
you feel depressed!
Smile!
Ignore your problems!
Do what you enjoy!
Stop worrying!
Be warm and loving!
Make time
for the things
you love!
Make fun of
trouble!
Leave your fears
aside and...

Be a bit ridiculous!
 Fight for
perfection...

...but not to exhaustion!

Life is better when we have fun...

...so do anything you like.

And the most
important:

Life doesn’t
end today...
And doesn’t start tomorrow...
 Don’t stop!!
Each minute of stress
is wasted time”
 This is why I wish you:

A little madness and a little

imagination, so you can see life better
than usual!!
The End show
20.09.2008 10:32

And don’t forget:

Smile! In life everything is nicer when

you cheer up.
Because The Show Must GO ON!
Continuous Quality Improvement

Structured Quality Improvement

Programme
- Documented, developed ,maintained
and updated by a multi disciplinary
committee
- Communicated and co ordinated
amongst all employees
Continuous Quality Improvement

Key Indicators to monitor Clinical
Structures , Processes and Outcomes
- Invasive Procedures
- Diagnostic services
- Adverse drug Events
- Use of Anaesthesia
- Use of blood and Blood Products
- Infection control Activities
- Clinical research
Continuous Quality Improvement

Key Indicators to monitor Managerial

Structures , Processes and Outcomes
- Medication Procurement
- Utilisation of facilities
- Patient and Employee satisfaction
- Adverse Events
Continuous Quality Improvement

Established system of Clinical Audit

- Participation of Medical Staff
- Defining of parameters
- Maintenance of patient and clinician
anonymity
- Documentation of Audits
- Institution of remedial measures
Continuous Quality Improvement

Sentinel events are intensively analysed

- Defining of sentinel events

- Established processes for intense

analysis

- Corrective and Preventive measures are

undertaken based upon the analysis

 RESPONSIBILITIES OF
MANAGEMENT

Responsibilities are defined
- Documented organogram
- Appoint senior leaders
- Support QIP
- Org complies with statutory obligations
- Address the org social responsibilities
 RESPONSIBILITIES OF
MANAGEMENT

Services provided by each department are
documented

Each org programme ,service,
department has effective leadership

Scope of services are defined

Adm policies and procedures are
maintained
 RESPONSIBILITIES OF
MANAGEMENT

Org is managed in an ethical manner

- Org discloses its ownership

- Honestly portrays the services that it

can or cannot provide

- Accurately bills based upon a standard

tariff
 FACILITIES MANAGEMENT AND
SAFETY

Org environment and facilities operate to
ensure safety of patients, families,visitors
and staff
- Documented operational and
maintenance plan
- Designated Individuals responsible for
maintenance of facilities
- Maintenance staff is contactable round
the clock
- Response times are monitored
 FACILITIES MANAGEMENT AND
SAFETY

Org has a programme for clinical and
support service eqpt management
- Plans for eqpt in a collaborative manner
in accordance with the services provided
- All eqpt are inventoried and proper logs
maintained
- Qualified and trained personnel operate
and maintain the eqpt
- Eqpt are periodically inspected and
calibrated
- Preventive and breakdown Maintenance
Plan
 FACILITIES MANAGEMENT AND
SAFETY

Org has provisions for safe water,
electricity, medical gases and vacuum
systems

Org has plans for fire and non fire
emergencies

Org has plans for handling
community emergencies,epidemics
and other disasters.
HUMAN RESOURCES MANAGEMENT

Org
has documented system of
Human resource Planning
- Maintains an adequate number and mix
of staff to meet the needs of patients
- The required job specifications and
descriptions are well defined for each
category of staff
- Org verifies the antecedents of the
potential employee
 HUMAN RESOURCES MANAGEMENT

Socialisation
and Orientation of the
new employees
- Orientation to the Org
- Awareness of hospital and departmental
policies and procedures
- Awareness of his and patients rights
and responsibilities
- Orientation to the service standards of
the org
HUMAN RESOURCES MANAGEMENT

Ongoing Programme for professional
training and development of staff

Performance Appraisal system

Disciplinary Procedures

Grievance handling Mechanism

Health needs of employees

Personal record of each staff member

Credentialing and Privileging
 INFORMATION MANAGEMENT
SYSTEM

Info needs of the organisation are
identified

Policies and procedures to meet the
needs exist and are in accordance
with the prevailing laws and
regulations

Org contributes to the data base of
other organisations in accordance
with the law of the land.
 INFORMATION MANAGEMENT
SYSTEM

Effective Management of data
- Formats are standardised
- Procedures laid down for timely and
accurate dissemination,storage and
retrieval of data
- Participation of staff in selecting,
integrating and utilising data
 INFORMATION MANAGEMENT
SYSTEM

Complete and accurate Medical
record for each patient
- Every Record has a unique identifier
- Every entry is dated and timed
- The author of the entry can be
identified
- The record provides chronological and
updated account of patient care
 INFORMATION MANAGEMENT
SYSTEM

Policies and procedures address
Confidentiality, Integrity and Security
of Information

Policies and Procedures exist for
retention time of records

Medical Audits are carried out
regularly.
WHAT SHOULD WE DO?

Quality management Team

Quality Manual

Various Policies and Procedures

Identify High Risk Areas for patient
care and safety

Identify Sentinel Events for
monitoring

Provide resources for Quality
Improvement

Alter Mind set

Identify gaps between what is
expected and what exists
 INITIAL PRESENTATION BY
THE HOSPITAL

Organogram

Quality management Team

Methodology followed for Quality
Improvement

Facilities provided

Inputs on resources provided for Quality
Improvement

Identified high Risk Areas for patient care
and safety

Sentinel Events being monitored
 DOCUMENT REVIEW

• Quality Manual
• Various Policies and Procedures
• Minutes of Meetings of various committees
• Medical Records
• Medical / Nursing Audit
• Adverse Events
• HAI
• Action Taken Reports
 OBSERVE
• Facility Safety
• Level of compliance with laid down
policies and procedures
• CPR
• BMW Management
• Standard Precautions
• Patient care
• HAI
• Fire Safety
• Equipment Management
 INTERVIEW
• Staff Interview
• To determine their level of awareness and
compliance with organisation policies and
procedures
• To assess the awareness levels of their
rights, privileges and patient rights
• To determine their satisfaction levels
• Patient and family Interview
• To assess their level of awareness of the
care process and their rights
• To determine their satisfaction levels
 MONITOR

Key Monitoring Indicators

Resource

Volume

Utilization

Performance

Control charts

Problems faced and remedial
measures undertaken/ being
undertaken
 CONSTRAINTS

Manpower

Architecture

Logistics

Coordination with multiple agencies

Turnover of trained manpower

 STRENGTHS

Professionally competent staff

Well laid down policies and

procedures

Disciplined work force

By and Large known clientele

Supportive Top management

 CHALLENGES

Attitudinal Change

Removing blind spots

Creating a holistic approach to medi
care.

Overcoming constraints

Making benchmarks for services
provided

Implementing QA programmes
 EXPERIENCES

HCOs are very enthusiastic

Ill prepared

Initial preparation is shoddy

Resources required initially

Benefits have a longer gestation

period
PROBLEMS AND CHALLENGES

Quality Consciousness at all levels will take
time

Sustenance and consistency of efforts will
be required

Commitment on a consistent basis

High rates of attrition will require repeated
and continual training

Public Sector will take a longer time to get
into the process

Quality and consistency of assessors and
assessments
These May Look Difficult

Initially, But the First

steps are Never easy.

Also Nothing Is

Impossible

For,
Impossible

Means

I’ M Possible
Quality Norms and Accreditation??

Response of Medical Fraternity

Expected Response
There was a man who
had four sons.
He wanted his sons to
learn not to Judge
things too quickly.
So he sent them each
on a quest,in turn,to
go and look at a pear
tree that was a great
distance away
The first son went in the
winter,
the second in the spring,
the third in summer,
and the youngest son in the
fall.
When they had all gone and
come back, he called them
together to describe what they
had seen
The first son said that the tree was ugly,
bent, and twisted.
The second son said no it was covered
with green buds and full of promise.
The third son disagreed; he said it was laden with blossoms
that smelled so
sweet and looked so beautiful, it was the most graceful
thing he had ever
seen.
The last son disagreed with all of them; he said it was ripe
and
drooping with fruit, full of life and fulfilment.
fulfilment.
The man then explained to his sons that they were
all right, because they
had each seen but only one season in the tree's
life.
He told them that you cannot judge a tree, or a
person, by only one season,
and that the essence of who they are and the
pleasure, joy, and love that
come from that life can only be measured at
the end, when all the seasons
are up.
 If you give up when it's
winter,
you will miss the promise of
your
spring, the beauty of your
summer,
fulfillment of your fall.
Don't let the pain of one season destroy the
joy of all the rest.
Don't judge life by one difficult season.
 Persevere through the
difficult patches
and better times are sure
to come
some time.
Aspire to Inspire Before You Expire
Live Simply Love Generously. Care
Deeply. Speak Kindly.
Leave the Rest to God.
Happiness keeps You
Sweet,
Trials keep You Strong,
Sorrows keep You Human
Failures keep You Humble
Success keeps You Glowing,
But Only Effort and Faith keeps You Going
Take the first steps
And
Keep the Effort Going
U WILL SOON FIND THE PATH
And the
sunshine will
follow
 THE CURRENT STATUS OF
ACCREDITATION IN INDIA

Initializing phase is over.

Phase of consolidation.

The initial steps have been difficult but

the journey has begun.

The journey has to continue……….

Especially since ---------------------------

ACCREDITATION IS A JOURNEY

AND

NOT A DESTINATION.
BON VOYAGE !!!!!