1

Hospitals-places of healing

Hospitals-places of potential harm or injury!!

Statistics & Perspectives

Harm from care

1 in every 10 patients are harmed during medical care - WHO

At any given time, 1.4 million people worldwide suffer from infections acquired in hospitals -WAPS Medication errors kill about 7,000 people/yr in the US and the estimated cost is $17-$29 billion/yr - To err is human, IOM 10 % of patients in acute care settings experience an adverse drug event -WHO An AHRQ-supported study discovered a rate of 1 in 112,994 cases of wrong-site surgery

Healthcare Acquired Infections

Medication Errors

Adverse Drug Events

Wrong Site Surgery

Patient Falls

2 -6% hospital patients suffer from falls during their stay - To err is human,IOM

How safe is healthcare ???

Deaths / year 100,000 10,000 Dangerous (>1/1000) Healthcare Driving Regular air transport European railways Nuclear power Risky Safe (<1/100K)

1000
100 10 1 Contacts / 1 death Mountain climbing Bungee jumping Chemical industry Charter flights

Earlier Simple, Ineffective and safe

Now.complex, effective and potentially dangerous!

- Sir Cyril Chantler, former Dean Guys, King and St. Thomass Medical and Dental School, Lancet 1999

Why Measure?

What we dont measure, we dont know. And we can only improve what we know
- access to care - process of care outcome of care patient experience of care

Real World Practice

Quality Gap
Quality Measurement

Quality Improvement

Optimal Practice

Perspectives on Quality

What is Quality?
Degree to which a set of inherent characteristics fulfill

requirements Quality is a set of attributes of a service Quality is conformance to the norms of Input, Process and Output Quality is conformance to the requirements and Customer Satisfaction

The Quality Continuum

Medical Quality Quality Assurance Continuous Quality
Less mature

Improvement
Total Quality Management
More mature

QUALITY ASSURANCE TRIANGLE

28

What is Accreditation
Accreditation is a voluntary process in which a

healthcare organization is assessed to determine if it meets a set of standards designed to improve the safety and quality of care.
Provides a visible commitment towards improving quality

of patient care ensuring a safe environment and reducing risk to staff.

Need for Accreditation

Increasing Awareness about Quality

Growing Insurance Coverage Medical Tourism

What is NABH ???

National Accreditation Board for Hospitals & Care Providers (NABH)
A constituent

board of Quality Council Of India

Mission is to focus on quality assurance and quality improvement of healthcare. It is structured to cater to much desired needs of the consumers and to set benchmarks for progress of health industry.

The board while being supported by all stakeholders including industry, consumers, government, have full functional autonomy in its operation.

31

Why NABH ???

Accreditation is a voluntary process in which QCI assesses a healthcare

organization to improve quality of care.

Provides a visible commitment towards improving quality of patient

care ensuring a safe environment.

32

Achievements and International Linkages

NABH- Institutional member of International Society for Quality in Healthcare (ISQua) ISQua is an International body which grants approval to accreditation bodies in India of Health Care as mark of equivalence of accreditation program of member countries ISQua has accredited Standards for Hospitals developed by NABH, India.

33

Hospital Standards of 11 Countries apart from India are accredited by ISQua

Australia Hong Kong United Kingdom Japan Canada Ireland

South Africa
Taiwan

Egypt
Kyrgyz Republic

Jordon

34

Manuals
Organizational manuals
NABH Quality Manual NABH Policy Manual Quality Improvement Manual Infection Control Manual Safety Manual

Departmental manuals

Committees
Quality Steering Committee

CPR Committee
Ethics Committee Infection Control Committee

Medical Services Committee

Pharmacy and Therapeutics Committee Safety Committee Credentialing and Privileging Committee

NABH CHAPTERS
CLINICAL CHAPTERS Access Assessment & Continuity of Care (AAC) Care Of Patients (COP) Management Of Medication (MOM) Patient Rights & Education (PRE) Hospital Infection Control (HIC) ORGANIZATIONAL CHAPTERS Continuous Quality Improvement (CQI) Responsibilities Of Management (ROM) Facility Management & Safety (FMS) Human Resources Management (HRM) Information Management & Security (IMS)

43

1. Access, Assessment & Continuity of Care (AAC)

44

Scope of services
> Broad specialities
> Superspecialities > Support services > Diagnostic services > Other clinical services

Services not provided

Burns Care when burns are >20%
Cardiac transplantation Liver transplantation Diagnosed open Tuberculosis Chicken pox Rabies

Focus Areas
Initial Assessment and regular reassessment by

Physician, Nurses and dietician. Lab Services & Safety, Quality Assurance Imaging Services & Safety, Quality Assurance Documented Discharge Process Defined Discharge Summary

47

Access of Care
Registration and admission as o out-patient, o in-patient or o emergency patients Transfer of unstable / stable patient Summary of patients condition and treatment

48

Color Code in Triage

Red: Yellow:

Green:
Black:

Most urgent Urgent Non-urgent Dead

49

Patient Identifiers
Use at least two patient Inpatient &

identifiers (neither to be the patient's room number) whenever taking any samples, administering medications, or blood products

Outpatient: Patient Name and MRN No. Emergency admit with no ID: Unknown 1/2/3 with MRN No

50

Nonavailability of beds
Initial care and stabilization to be done Sent to the nearest hospital by choice with the required facilities.

Lab Services Quality & Safety

Lab tests not available in organization are outsourced Periodical calibration and maintenance of all equipments, which is

to be documented properly. Documentation of corrective and preventive action Safety at workplace

52

Imaging Services
Imaging tests not available in the organization are outsourced Safe transportation of patient to imaging services Documentation of corrective and preventive action Radiation safety for all.

53

2. Care of Patients (COP)

54

 Policies guide uniform care Areas:

Care of Patients

Emergency and ambulance Cardio pulmonary resuscitation Use of Blood and blood products Intensive Care Vulnerable patients High risk obstetrical patients Pediatric Moderate sedation Anesthesia & Surgical Restraint Physiotherapy Nutrition Pain management End of life care

55

Care of Patients
Emergency Service Ambulance Service

Equipped & manned by trained personnel Checklist for equipment and medications present Daily checks present

56

Vulnerable Patient
Child, <16 years

Elderly, >65 years

Physically challenged Terminally ill

Women in labor
Patients with emotional or psychiatric disorders Any patient Who cannot perform ADLs CPS Scoring (Scores =/> 45)

57

Vulnerable Patient
Different H&P for women, children

Side rails
Safety measures: Safety First Program Bed sore, Ulcer and DVT precautions

Frequent assessments
Document all this

58

Code Blue
Code Blue: Emergency mode of alerting all

medical, nursing, paramedical and allied healthcare service personnel for CPR following sudden collapse of patient, for example MI, Shock, etc. Call 80 Team concept Team leader is Anesthesia registrar. Crash carts locked & stocked by pharmacy

59

3. Management of Medication (MOM)

61

Focus Areas
Pharmacy services and usage of medication Hospital Formulary Storage Prescription Dispensing Administration Documentation Patient & family Education Monitoring

62

 Medication

management encompasses selecting, procuring, storing, ordering/prescribing, transcribing, distribution, dispensing, administering. Medication administered is documented Authorized personnel to administer medication Patient identification to be done. Medication, Dosage, Route & Timing to verify from the drug order sheet Policy & procedure govern patients self administration & patients medications brought from outside the organization Documenting, and monitoring of medication therapies

Medication Management and Use

63

Medication Policy
Medication in discharge summary should be in

laymans language. Nurses will administer the medicines after cross checking:
Right patient Right drug Right dose Right time Right method

Right documentation

All Medications shall be administered by nurses

64

Medication Policy
Self Administration By Patients: Hospital policy does not allow self administration. Self administration of Insulin , Inhalers, Syrups/

suspensions for paediatric/ neonatal patients to be taught under supervision

65

Medication Policy
Why? : To reduce medication errors Doctor signs a medicine order sheet Refer to the hospital drug formulary In case of doubt, the resident will call up the

consultant and confirm the correct information

66

Medication Errors (MEs)

1. Prescription 2. Transcription 3. Dispensing 4. Administration & Documentation

Wrong Drug (Look alike)

Adverse Drug Reactions (ADR)

ADR: any response to a drug that is unintended and

/ or noxious at a dose that is normally used in humans Please report suspected or confirmed ADRs on ADR Form or Incident form.

69

Read Back Policy

Read back, verify, document verbal orders Applicable for;

a) Code Blue Situation b) Critical Lab Values: The staff nurse has to read the value back to confirm and duly sign her name and clock no. and write the name and emp no. of the person who has given the report. c) Insulin orders: Eg: 29/04/08 6:00am 40 units Read back to Dr. -----------, signature, name of the staff and emp no.

4.Patient Rights & Education (PRE)

71

 Identify,

Focus Areas Protect and Promote Patient

rights &

responsibilities Patients family in decision making Informed Consent Right to information and education

72

Patient Rights

In patient guide Any special preferences Dignity Privacy Confidentiality Refusal of Treatment Informed consent Voice a complaint Expected cost Access to medical records

73

Informed Consent
Important to fill completely Has improved patient and family education

regarding the procedure and the expected outcomes. This will decrease the rate of dissatisfaction of the patient and family Anesthesia consent by Anesthetist Consent of Blood/ Blood products Consent for Specific blood tests

74

Right to Information & Education

About safe & effective use of medication Diet and nutrition

Immunizations
Preventing infections Financial implications, in case, there is a change in

patient condition or treatment setting

75

5. Hospital Infection Control (HIC)

76

Prevention and Control of Infection

Everyone can prevent infection All of us are equally concerned

Hand hygiene is the single most important factor

Carry out hand hygiene before & after patient

contact, bathroom use, handling patient files Hand wash, hand rub (sanitizer) Infection control committee & manual

77

BSI UTI VAP

ALL HAI!

78

Infection Control
Restricted antibiotics policy Monitoring of Healthcare Associated Infection

Catheter related Urinary tract infections ( CR-UTI) Respiratory infections (Ventilator Associated Pneumonia- VAP) Central line associated Blood stream infection (CA-BSI) Surgical site infections (SSI)

79

5 Moments of hand hygiene

WHAT AFTER NEEDLE STICK INJURY?

The affected area should be rinsed and washed

thoroughly with soap and water; The practice to "milk out not recommended by the CDC.[1] Lab tests of the recipient are obtained for baseline studies: HIV, acute hepatitis panel (HAV IgM, HBsAg, HB core IgM, HCV) and for immunized individuals HB surface antibody.

Staff exposure to patients blood / body fluids

Treat as if needle stick injury Report to Emergency Send appropriate samples Inform the infection control Committee or your Senior Fill out Incident Form

83

Waste Management Policy

S.No 1 2 3 4 5 Container Yellow Bag Red Bag Red Bag Black Bag Disposable Sharps container Waste Description Organic/ contaminated waste Plastics Glassware All general waste Needles & Blades

Disposable Sharps container

Broken glass

84

Photograph showing segregation of Bio-medical waste in the Hospital premises

6. Continuous Quality Improvement(CQI)

86

 Quality improvement and continuous monitoring

Focus Areas

programme Key indicators to monitor clinical structures, processes and outcomes Near Miss & Sentinel events analysis

87

CQI

Quality steering committee PDCA cycle Patient Satisfaction Root Cause Analysis for unexpected
Deaths Transfusion reactions Significant ADR Significant meds errors Significant anesthesia events Significant difference in pre & post op diagnosis

88

CQI
NABH Project is a Quality Improvement initiative

89

Clinical Indicators
Patient assessment Diagnostic services

Invasive procedures
Adverse drug events Use of anesthesia Use of blood & blood products

Availability and content of medical records

Infection Control activities Data collection to support further improvements Data collection to support evaluation of these improvements

90

Managerial Indicators
Procurement of medication essential to meet patient needs. Reporting of activities as required by laws and regulations. Risk management. Utilisation of space, manpower and equipment. Patient satisfaction including waiting time for services. Employee satisfaction. Adverse events and near misses. Data collection to support further study for improvements. Data collection to support evaluation of these improvements.

 Variance - defined as any event or circumstance not

consistent with the standard routine operations of the hospital and its staff or the routine care of a patient/visitor. Error - an unintended act, either of omission or commission, or an act that does not achieve its intended outcome.

Sentinel events

(Contd)

(Contd)

Causes of Sentinel events

Adverse Events
Any unanticipated, undesirable or potentially dangerous occurrence

in a healthcare organization. eg- medication error, patient fall, transfusion reaction etc

Near Miss Events

A Near Miss is defined as any process variation

which did not affect the outcome but for which a recurrence carries a significant chance of a serious adverse outcome.

98

7. Responsibilities of Management (ROM)

99

Focus Areas
Defined & documented responsibilities of qualified

and experienced Head Of Organization Ethical management Scope of Service of each department is documented Risk Management
Resources for proactive risk management Risk reduction activities Systems for internal & external reporting of system or process failures

102

8. Facility Management and Safety (FMS)

103

Critical Areas of Facility Management

Safety

Utility

Security

Medical Equipment

Facility Mgmt

Hazardous Materials

Fire Safety

Emergency

Focus Areas
Facility inspection

Safety of patients, their families, staff & visitors

Clinical and support equipment management Emergencies / Disaster Management

Smoking limitation policy

Management of hazardous material Safe and secure environment

106

Facility Management and Safety

Safety Committee Safety Rounds

Safety Manual
Disaster plan Mock drills for external & internal disasters

Policy for Hazardous materials

107

Emergency codes
Event Code Code Number
80 Individual Disaster/ Cardiac Code Blue Arrest

Security Threat
Child Abduction Hazardous material spill Internal disaster including Fire Bomb threat External disaster

Code Purple
Code Pink Code Yellow Code Red Code Black Code Orange

81
81 81 81 81 82

Safety Issues
In case of fire. First inform 81 and then remember the

mnemonic: RACE
R A

C
E

: : : :

Rescue Alarm Confine the fire Extinguish (if trained) and Evacuate

110

Fire Safety mock drill

External disaster mock drill

Safety Issues
Mercury spill
Formalin & Cidex spill Any Hazardous Material Spill HAZMAT (Hazardous Materials) Team will

be available round the clock Safety Manuals are kept on all nursing stations for ready reference PPE at every floor / ward for use

113

Mercury spill
Major spills : All Mercury spills
To be taken as hazardous material and To be collected in sealed containers

114

Minor Spill
Minor spill: < 30 ml
Place tissue /paper over spill Wear gloves, goggles, face mask (PPEs) Place in plastic bag. Seal and Label Housekeeping to mop area & Dispose Incident Report

115

Major spill
Major spill: > 30 ml
Place tissue / paper over the spill Place inverted trash can over the spill Inform HAZMAT team at 81 Incident Report

116

Infectious material Spill

All body fluid spill is potentially infectious, for eg. blood,

urine, vomit, serous fluid etc. In case of infectious material spillage use spill kit to manage it. Wear PPE Pour 1% sodium hypochlorite solution over the spillage area. Place tissue paper over the spillage to confine the spillage. Leave it for 20 minutes Pick up the soiled material with the pair of tongs and dispose into yellow bag. Mop the area with sodium hypochlorite solution. Remove the gloves and wash the hands.

117

PPE
PPE : personal protective equipment Each floor has two sets of PPEs for use in cases of

spillage Gloves, goggles, face mask, apron, gumboots, etc Use and replace

118

MSDS (Material Safety Data Sheets)

Outline purpose, potential harmful effects and first aid

for all chemicals in the hospital

Present on each nursing station and computer.

119

No Smoking Policy
Smoking in hospital premises is not allowed by law (public place)

120

Equipment Management
All medical equipment should be having a

Biomedical/engineering/biochemical sticker with date of calibration, due date, checked by __ (Initials).

Please inform Nursing

supervisor, if absent

121

9. Human Resource Management (HRM)

123

Areas of Focus
Manpower Planning Recruitment Orientation and education

Appraisal
Grievance Discipline

Safety at work place

Health Needs Source Verification and Credentialing- Medical &

Nursing Staff Privileging- Consultants Work assignments- Nursing staff

125

10. Information Management System (IMS)

126

Information Management
This chapter talks of

Information Plan, Confidentiality, Security, and Integrity of data, Policy on Policies, standardized and accessible Patient Clinical Records. Confidentiality: It is a Patients right. Discussing a patient in the lifts (if identifiable information is being discussed) can be a violation of this! Patient records are sacrosanct

128

Medical Record
Up-to date chronological account patient care records Contents of medical record identified & recorded

Contents :

- Reason for admission, diagnosis & plan of action

- Operative & other procedures performed - Discharge note - In case of death, copy of death certificate

Care providers have an access to medical records Retention of medical records

Safeguarding data
Periodical review
129

Some important issues

Patient identification Patient care Clinical pathways and protocols Documentation date, time , name, signature Plan of care Pain management Verbal orders Cardiopulmonary Resuscitation (CPR/ Code Blue) Surgical safety- time out Patient rights and education

Informed Consent
End of life care Medication process

Some important issues (contd)

Standard precautions Hospital acquired infections

Biomedical waste management

Quality Indicators Facility safety & Disaster codes Fire Safety

Spill management
External disaster Statutory compliance Medical Record management

JOINT COMMISSION INTERNATIONAL ( JCI)

JCI
JCI is the international arm of The Joint Commission

(USA)
JCIs mission is to improve the quality of healthcare The Joint Commission and JCI are both NGO and not-

for-profit USA corporations.

JCI: PURPOSE & GOAL

The purpose is to offer standards-based, objective processes for evaluating health care organizations. The goal is to stimulate demonstration of continuous, sustained improvement in health care organization by applying:
1. 2.

International Standards International Patient Safety Goals

JCI Standards
Patient-centered chapters
1. International Patient Safety Goals ( IPSGs)

2. Access to Care and Continuity of Care (ACC)

3. Patient and Family Rights (PFR) 4. Assessment of Patients(AOP) 5. Care of Patients (COP) 6. Anesthesia and Surgical Care

(ASC) 7. Medication Management and Use (MMU) 8. Patient and Family Education (PFE)

Organization-centered chapters 1. Quality Improvement and Patient Safety (QPS) 2. Prevention and Control of Infections (PCI) 3. Governance, Leadership, and Direction (GLD) 4. Facility Management and Safety (FMS) 5. Staff Qualifications and Education (SQE) 6. Management of Communication and Information (MCI)

Each Standard has Measurable elements (MEs)

JCI Accreditation Process

Quality Management System Standards:

ISO 9001: 2008 (E)

Standards: ISO

1987

1994 2000 2008

Content

9000
9001

*
*

*
*

*
*

*
*

Fundamentals & Vocabulary Selection of Standards

(QMS Requirement) Design, Manufacturing, Inspection, Service Manufacturing, Inspection, Service Inspection

9002 9003

* *

* *

9004 (IS 15551:2003)

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QMS Guidelines for Process Improvement in Health Service Organization

Contractual Requirement s for QMS & Non-contractual Standards

Shift in Quality Approach

ISI to ISO
Product Quality to Process Quality

What is an Audit?
Audit is an independent assessment of the functionality to evaluate conformance. Or,

Audit is not a fault finding exercise, but an opportunity

to identify the gap / deficiencies for improvement.

Audit is carried out to ascertain whether,

Documented system is complying with standards (ISO

9001:2008)

Planned arrangement is adequate to realize the objectives

Objectives are met with Results comply with the set targets

Process of correction, prevention & improvement is

effective

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Why Audit?
Approach

ADARR : Implementation Strategy (Step-by-step approach)

Deploy Form Teams - Cross functional, multi skilled, over lapping Divide in to small manageable areas Establish the Ownership concept Equip Teams-with tools& techniques

Create awareness to all Propagate concept across the orgn Ensure understanding of concept, practices, tools & techniques Assess performance Monitor activity progress as per plan Identify the gaps through audits Compare with bench marks Improve through Action plans Re-audit. Dont move on to next till satisfactory level is achieved

Review of Results at each step Record all related data Consolidate the gains

Compare audit score with bench

marks Continuous improvements till reaching the goal of Parlor status

When & Who?

Pre - Implementation

RADAR : Assessment Strategy (Step-by-step approach)

Self Third party

Gap Analysis between desired &

existing
During - Implementation Self

Self Audit: Verify compliance Peer Audit: Transparency

During - Certification

Peer Department Supplier / Customer Certified Auditors

Unbiased & Transparent

Post Certification

Self Certifying Body

Sustenance & Improvement

Audit Process Pre-audit activities

In-process activities Post-audit activities Plan & Schedule for Audit Prepare the Audit Checklist Communicate in advance to both Auditee & Auditor Make it more lively & transparent during audit

Interact & Involve all concerned in the department not only HOD, so as to explore the facts & figures. Record & share the audit findings with concerned Follow up for closing NCs & Improvement plans Maintain confidentiality of records & findings

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Types of Systems Audit

There are 3 types of Audits
Adequacy Audit : Examining the documents whether they meet the specified clauses

of the standards.

Compliance Audit : Examining whether they are being carried out as mentioned and giving results as expected. Surveillance (Verification) Audit: Questioning implemented system, Sustenance & Improvement. the Effectiveness of the

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Four Tier: Quality Manual & Common procedures Department Procedure Manuals Procedure,Protocol,SOP,Work Instructions Forms, Formats, Checklists & Records

Documents:
1 2

3 4

Identification number
Revision number Approval Effective date Whether it is controlled Correctness and completeness of content Related amendment record Entry in master list Legibility Validity in case of temporary document

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Retention period of Record

Quality Management System Requirements Clauses of ISO 9001:2008

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148

1. Quality Management System

1.1. 1.2.

General Application

2. Normative Reference
3. Terms & Definitions

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149

4. Quality Management System

4.1. 4.2.

General Requirement Documentation Requirements 4.2.1. General 4.2.2 . Quality Manual 4.2.3. Control of Documents 4.2.4. Control Of Records

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5. Management Responsibilities
5.1. 5.2. 5.3

Management Commitment Customer Focus Quality Policy

5.4. Planning 5.4.1. Quality Objectives 5.4.2. Quality Management

System Planning

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5. Management Responsibilities
5.5. Responsibility, authority &

Communication 5.5.1 Responsibility and authority 5.5.2 Management Representative

5.5.3 Internal Communication

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5. Management Responsibilities
5.6 Management Review

5.6.1. 5.6.2 5.6.3

General Review Input Review Output

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6. Resources Management
6.1. Provision of Resources 6.2 Human Resources

6.2.1. General 6.2.2. Competence, training & awareness

6.3. Infrastructure 6.4. Work Environment

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7. Product Realization
7.1. 7.2.

Planning of product realization

Customer-related processes 7.2.1. Determination of requirement related to the product. 7.2.2 Review of Requirement related to the product. 7.2.3. Customer communication.

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7. Product Realization
7.3 Design & Development

7.3.1. Design and Development planning 7.3.2. Design and Development Inputs 7.3.3. Design and Development Outputs 7.3.4 Design and Development Review 7.3.5. Design and Development Verification 7.3.6 Design and Development Validation 7.3.7 Control of design & development changes

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7. Product Realization
7.4 Purchasing

7.4.1. Purchasing Process

7.4 .2. Purchasing Information

7.4.3. Verification of purchased product

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7. Product Realization
7.5 Production and Service Provision

7.5.1 Control of production & service provision 7.5.2 Validation of processes for production and service provision 7.5.3 Identification and traceability 7.5.4 Customer Property 7.5.5 Preservation of product
7.6 Control of monitoring & measuring equipment

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8. Measurement, analysis and improvement

8.1 8.2.
8.2.1. 8.2.2. 8.2.3. 8.2.4.

General Monitoring and Measurement

Customer Satisfaction Internal Audit Monitoring & measurement of process Monitoring and measurement of product

8.3
8.4.
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Control of nonconforming Product

Analysis of Data
159

8. Measurement, analysis and improvement

8.5 Improvement 8.5.1. Continual Improvement 8.5.2. Corrective action 8.5.3. Preventive action

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NABL

National Accreditation Board for Testing and Calibration Laboratories (NABL)

NABL is an autonomous body under the Department of Science

& Technology, Government of India, and is registered under the Societies Act. NABL has been established with the objective to provide Government and Industry with a scheme for third-party assessment of testing calibration and medical laboratories assessment of testing, calibration and medical laboratories Program started in 1981. First Accreditation granted in 1992. Autonomous Body registered under societies Act in 1998. The sole accreditation body for Testing and Calibration laboratories authorized by the Government of India.

NABL
NABL grants accreditation to testing & calibration laboratories

as per ISO/IEC 17025 and medical laboratories as per ISO 15189. NABL operates its own system as per ISO/IEC 17011. It requires the applicant and the accredited laboratories to take part in recognized Proficiency Testing Programmes in accordance with ISO/IEC Guide 43 An applicant laboratory has to satisfactorily participate in atleast one Proficiency Testing programme, while the accredited laboratories are expected to cover the major scopes of accreditation in a cycle time of four years.

Calibration Laboratories:
Electro-Technical Mechanical Radiological Thermal & Optical Fluid-Flow

NABL grants Accreditation in the following disciplines

Medical Laboratories:
Clinical Biochemistry Clinical Pathology Cytogenetics Cytopathology Haematology Histopathology Immunology Microbiology & Serology Nuclear Medicine

Five Stages of NABL Accreditation Process

Stage I: Application for NABL accreditation. NABL 153 is to be used by Medical Laboratories for applying to NABL Secretariat for accreditation.

Stage II: Pre-Assessment audit (One day) by Lead Assessor. A copy of Pre Assessment Report is provided to Laboratory for taking necessary corrective action on the concerns.The laboratory shall submit Corrective Action Report to NABL Secretariat. After laboratory confirms the completion of corrective actions, Final Assessment of the laboratory shall be organised by NABL. Stage III: Final Assessment audit (two days or more) by the NABL team one Lead Assessor and other Technical Assessor(s). Nonconformances pointed out the laboratory, with opportunity to correct them. The report is given to the Lab and the NABL Secretariat.

Stage IV After satisfactory corrective action by the laboratory, the Accreditation Committee examines the findings of the Assessment Team and recommend additional corrective action, if any, by the laboratory, and takes decision on the basis of the actions taken. Stage V Accreditation to a laboratory shall be valid for a period of 2 years and NABL shall conduct periodical Surveillance of the laboratory at intervals of one year. Laboratory shall apply for Renewal of accreditation to it at least 6 months before the expiry of the validity of accreditation

IMC Ramakrishna Bajaj Awards

The IMC Ramkrishna Bajaj National Quality Awards was instituted in 1997 to encourage Indian Industry to be alert to the importance of quality in the context of global competitiveness. The objectives of this award are: Promote quality awareness and practices in Indian Business Recognize achievements of Indian companies in the field of quality Publicize successful quality strategies and programs

IMC Ramakrishna Bajaj

Criteria Framework & Categories

Criteria & Requirements

Leadership
HOW organizations SENIOR LEADERS personal action guide and sustain organization Organizations GOVERNANCE system and HOW organization fulfills its legal, ethical and societal responsibilities and support its KEY communities. HOW organization develops STRATEGIC OBJECTIVES and ACTION PLANS HOW chosen STRATEGIC OBJECTIVES and ACTION PLANS are DEPLOYED and changed if circumstances require and HOW progress is measured.

Strategic Planning

Customer Focus

HOW organization engages its CUSTOMERS for long-term marketplace success. HOW organization builds a CUSTOMER-focused culture HOW organization listens to the VOICE OF ITS CUSTOMERS and uses this information to improve and identify opportunities for INNOVATION. HOW organization selects, gathers, analyzes, manages and improves its data, information and KNOWLEDGE ASSETS and HOW it manages its information technology HOW organization reviews and uses reviews to improve its PERFORMANCE.

Measurement, Analysis and Knowledge Management

Workforce Focus

HOW your organization engages, manages and develops your WORKFORCE to utilize its full potential in ALIGNMENT with your organizations overall MISSION, strategy and ACTION PLANS ability to assess WORKFORCE CAPABILITY and CAPACITY needs and to build a WORKFORCE environment conducive to HIGH PERFORMANCE.

Process Management

HOW your organization designs its WORK SYSTEMS HOW it designs, manages and improve its KEY PROCESSES for implementing those WORK SYSTEMS to deliver CUSTOMER VALUE and achieve organizational success and SUSTAINABILITY Readiness for emergencies

Results

organizations PERFORMANCE and improvement in all KEY areasproduct outcomes, CUSTOMER-focused outcomes, financial and market outcomes, WORKFORCE-focused outcomes, PROCESS-EFFECTIVENESS outcomes and leadership outcome

In conclusion.

Accreditation is a journey and not a destination

References
ISO
http://www.bis.org.in/cert/faqmscd.htm

NABH
www.qcin.org/nabh/

NABL
http://www.nabl-india.org/nabl/html/about-lab-acc.asp

JCI
http://www.jointcommissioninternational.org/

IMC Ramakrishna Bajaj

http://www.imcrbnqa.com/

QUALITY AND PATIENT SAFETY

Quality & Patient Safety

What makes for a successful team?

Effective teams possess the following features: o a common purpose o measurable goals o effective leadership and conflict resolution o good communication o good cohesion and mutual respect o situation monitoring o self-monitoring o flexibility

Thank you