A PROJECT REPORT ON

“A COMPARATIVE BENCH MARKING STUDY OF NABH

ACCREDITED AND NON-ACCREDITED HOSPITALS”

CONDUCTED AT

Mediqop Management Services LLP

SUBMITTED BY: XYZ

XTH SEMESTER

ROLL-,

REG.NO-

INSTITUTE NAME

1
ACKNOWLEDGMENT
Every successful work is backed by sincerity and hard work. During this two month
tenure of my work, I was able to gain a lot of knowledge both application and theory
wise. My training period would not have been possible without the wonderful support
and guide of respected trainers and official staffs.

I am very grateful to those people who have helped me in every ways of training report

I would like to express my warm and heart full gratitude towards

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DECLARATION
I do hereby declare that this project work entitled A COMPARATIVE
BENCH MARKING STUDY OF NABH ACCREDITED AND
NON-ACCREDITED HOSPITALS” at MEDIQOP MANAGEMENT
SERVICES LLP hospital for 4 months (7TH FEB 2022 TO 31ST MAY 2022),
submitted by me in practical fulfillment for the requirement of Bachelor
Degree in Hospital Management (BHM) from Jamia Hamdard (Hamdard
University) is the result of my original and independent research work
carried out under the supervision and guidance from…………...
I further declare this project work or any part of these has not been submitted
by me anywhere for the award of any degree or other similar title before
1. NAME-
2. ROLL NO.-
3. REG NO.-
4. DURATION OF TRAINING- 4 Month
5. (Signature of the Student) –
6. For office use only-
7. The project has been approve/ not -

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EXECUTIVE SUMMARY
As a part of a special internship program, I was allowed to get hands on experience of
working with trained professionals of the hospital industry and learning about the
nuances of handling and managing operations in the Quality Department.

Throughout my training period in ORGANISATION have learnt floor auditing. I have

checked every patient’s file, whether all the documents were properly arranged
according to the NABH guidelines or not. I used to check every record document
whether it has been clearly written with appropriate date, time & signature. I have also
checked Doctor’s initial assessment record whether it has been signed with proper date
and time or not. I have done time motion study in the Emergency & in USG department.
I have also calculated the average length of stay in ICU in this 4 months of training. I
used to organize Basic Life Support classes for the employees

Lastly, to summarize, my overall experience has been a very fruitful one. It was a good
learning experience for me and gave me the first exposure to gain knowledge about the
working of the hospital industry.

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TABLE OF CONTENTS
SERIAL TOPIC
NUMBER
1 Introduction
2 Company Profile
3 Review of Literature
4 Training Objective
5 About the Department
6 Research Methodology
7 Discussion & Findings
8 Conclusion

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INTRODUCTION
1. BACKGROUND

National Accreditation Board for Hospitals and Healthcare Providers (NABH) is a constituent
board of Quality Council of India (QCI), set up to establish and operate accreditation
Programme for healthcare organizations. NABH has been established with the objective of
enhancing health systems & promoting continuous quality improvement and patient safety.
The board while being supported by all stakeholders, including industry, consumers,
government, has full functional autonomy in its operation. NABH offers accreditation
services to hospitals and other clinical establishments. NABH provides accreditation in a non-
discriminatory manner regardless of their ownership, legal status, size, and degree of
independence. International Society for Quality in Healthcare (ISQua) has accredited NABH
as an Organization. The hospitals accredited by NABH have international recognition. This
provides boost to medical tourism in the country. NABH is an Institutional Member as well
as a member of the Accreditation Council of the International Society for Quality in
HealthCare (ISQua). NABH is one of the founder member of Asian Society for Quality in
Healthcare (ASQua). There has been demand from SAARC/ASIAN countries for NABH
accreditation and to meet this requirement, NABH has launched NABH International and to
begin with Philippines is the first overseas destination for extending NABH accreditation
services.

2. Benefits for Patients

• Patients are the biggest beneficiary among all the stakeholders.

• Accreditation results in high quality of care and patient safety.

• The patients are serviced by credentialed medical staff.

• Rights of patients are respected and protected. Patient’s satisfaction is regularly evaluated.

SCOPE OF THE STUDY

The study deals with the survey done online through Google forms with help of structured
questionnaire for General public comprising of patients as well.
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The questionnaire was prepared as such that it helps in understanding the behaviour pattern
of consumers while purchasing OTC drugs and helps to understand in which areas of
therapeutic segments the consumers are more inclined to go or purchase an OTC drugand at
the same time analysing how the recent pandemic has affected this buying decision.

3. PURPOSE AND SIGNIFICANCE OF THE STUDY

Goal of accreditation for healthcare organizations

Ultimately, the purpose of accreditation in healthcare is to strengthen your organization
and prove that you provide high-quality care. Achieving and maintaining accreditation
provides benchmarks for measuring how your organization is doing.

4. LIMITATIONS OF THE STUDY

The survey on the project was done with 100 OTC consumers and the sample size could have
been more for better results. The project could have also focused on a chemist’s perspective
along with that of the user’s perspective to validate the results in a stronger and significant
manner.

has progressive plans to change the healthcare delivery landscape in

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COMPANY PROFILE
Mediqop is a healthcare consulting organization focussed on supporting healthcare
organizations and institutions achieve their potential while enhancing quality in all
aspects of service delivery.

Our Mission
“To empower our Clients with expertise that makes them Cohesive & interdependent
leading to long term growth & success in an ever-changing healthcare scenario”

Our Vision
“To be a leader in providing end to end solutions to healthcare organizations”

The experts at Mediqop have been providing high quality expertise to several hospitals
whatever be their size and requirements. We have an experienced team committed
towards the objective to assist healthcare organizations grow by providing advisory and
consulting services for Quality Enhancement, Operations, Supply Chain Management,
Medico-legal Support, Human Resource Management, IT, Financial Management &
Capacity Building etc.

We also provide end to end business growth support including Business Analytics,
Banding, Marketing and Compliance to Rules, Regulations & Standards. Since healthcare
is an interplay of forces both private and government, we also provide services for
enhancing reach through public private partnerships through linkages with the public
health system.

We provide comprehensive, specialized & personalized services tailored to cater to needs

of varied clients.

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Effect of Hospital Accreditation on Quality of Care as Perceived by
Patients

Abstract

The study is aimed at understanding whether the accreditation of hospital in India (NABH) has
any effect on its quality, as perceived by the patients. Primary data was collected from patients
who took treatment in accredited and non-accredited hospitals, on their rating of Infrastructure,
process and outcome of care at their hospital. The data was statistically analysed to determine
if there is any significant difference in the rating given by accredited hospital's patients from
non-accredited hospital's patients.
The study found that except infrastructure component, the mean rating and percentage of high
rating were significantly higher for process and outcome component. The overall rating was
also significantly higher by accredited hospitals patients.
Keywords: Accreditation; Hospital; Healthcare Quality; Patient Care.

Introduction

Accreditation of hospitals is considered as one of the most successful mechanism to achieve

improvement in quality and safety of healthcare. Accreditation is the recognition of a certain
level of quality by an organization as assessed by a third party. It is a process of certifying the
credibility of an organization. In healthcare, accreditation recognize and certifies the capability
of a healthcare organization in delivering an acceptable standard of healthcare services, which
is based upon good and safe practices.
Accreditation is gaining prominence amongst healthcare organizations in India, Accreditation
by National Accreditation Board for Hospitals and Healthcare Providers (NABH) is the most
sought after accreditation by Indian hospitals. After the advent of NABH accreditation in India
in 2006, the number of hospital achieving NABH accreditation has been consistently
increasing. The process of getting accreditation by NABH involves application, pre-
assessment, final assessment and grant of accreditation. In between these stages the HCO is
required to prepare itself as per the requirements of accreditation standards.
Since its inception the NABH board has promoted accreditation of hospital as an effective
mean to improve quality and patient safety, Several benefits of accreditation for different
stakeholders of the hospital have been mentioned. Several other organizations specifically who
are in business of providing consultancy support to hospitals also promotes accreditation on
similar lines,
However, the recognition of accreditation as a means to healthcare quality have not been
sufficiently verified scientifically. Although there have been various researches and systematic
literature reviews conducted in other parts of the world, in India no such study has been done
till date. The concept of accreditation in hospitals started almost 60-70 years back and in last

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two decades have gained high momentum, the quantum of researches done on accreditation is
relatively limited, Due to the growing need of accreditation in healthcare and amount of efforts
involved in it, questions are being raised on value that accreditation brings in to healthcare
quality. Several studies conducted on few prominent accreditation systems to see its effect on
healthcare and since these accreditation system differs in their structure, system and
implementation mechanism, the results of these studies are expected to be varying.
Effect of accreditation has been researched by several researchers using different methods.
These studies have been done on different accreditation system in world and hence there is a
limitation with generalizing their finding on other accreditation systems. While most studies
found evidence of accreditation havinga positive impact on healthcare outcomes, the level and
consistency of effect have not been sufficiently verified. Also these studies have majorly
shown that different component of a healthcare organization had different level of impact on
its quality.
Existing studies on healthcare accreditation shows differential result with different
accreditation system. Also, as different accreditation system has their own set of standards,
assessment and accreditation method, generalizing result of study of on one accreditation
system on other may be limited. Several studies have also found contradicting findingseven
with same accreditation system. This explains that while accreditation may have sufficient
association on some parameters it may not be associated with other parameters.
While most studies observed and compared accreditation's impact on clinical care components,
very few shows an overall impact on hospital as an organization.Clinical care although is a
vital component of healthcare the non-clinical aspects also plays an important role in overall
healthcare quality. Things like infrastructure, human resource capability, patient care
processes, client satisfaction etc. constitutes and important part of overall quality and whether
or not accreditation has any effect on them, is not reflecting from literatures reviewed.
With regards to NABH accreditation no significant literature could be found on studies relating
accreditation with quality, patient safety or healthcare outcome. In one intra-institutional
experience study that was conducted to evaluate the change of attitude toward acceptance of
NABH guidelines by medical practitioner, it was reported that medical staff had a positive
attitude and improved knowledge about accreditation after 6 months working in a hospital on
the way to NABH, However, no link with healthcare performance, quality, safety or outcome
were made. Hence there is a need to study how NABH is associated with healthcare delivery
and what is its effects/impacts on healthcare outcome, quality and safety.
Accreditation requires significant amount of financial resources and efforts on part of the
hospitals. Financial implications for accreditation are both direct and indirect, Direct costs are
those in form of accreditation fee and cost involved in process of accreditation such as external
assessments. These costs are recurring in nature. Indirect costs are those that are required to be
done in hospital in-order to comply with accreditation requirements. These costs are variable
and to large extent depend upon existing status of the hospital and how much work is involved
in meeting accreditation requirements. Although there is no authentic data explaining
expenditure on accreditation, it can range from moderate to high.
Since these expenditure and efforts are being done primarily to improve patient care quality, it
is imperative to have an evidence to ascertain the same. One of the most important stakeholder
for hospitals are its patient and hence it is imperative to know, if there is a difference in the
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way patients' perceive accredited and non-accredited hospitals.
Quality Indicators are the backbone on which quality assurance Programme of a hospital relies. NABH
(National Accreditation Board for Hospitals & Healthcare Providers. Click here to know more)
accreditation expects hospitals to calculate several quality indicators and use it for monitoring the
quality of care. These are the list of quality indicators, which a hospital preparing for accreditation
must necessarily monitor.

1. Average time taken for initial Sum of time taken for initial The time taken can be taken from time
assessment of patients assessment of all admitted when patient was registered for
admitted in IPD patients in a period / total admission till the time at which initial
number of patients admitted in assessment was completed and
that period documented
2. Percentage of IPD patients (Number of patients for whom Timeframe for initial assessment of
for whom the initial the initial assessment was patient getting admitted must be
assessment was completed completed within a defined time defined by the hospital
within defined timeframe frame / total number of patients
admitted) x 100
3. Average time taken for initial Sum of time taken for initial The time taken can be taken from time
assessment of patients assessment of all patients who at which patient arrived at emergency
coming to emergency accessed emergency services department till the time at which initial
in a period / total number of assessment was completed and
patients who accessed documented.
emergency services in that
period
4. Percentage of emergency (Number of patients in Timeframe for initial assessment of
patients for whom the initial emergency for whom the initial emergency patients must be defined
assessment was completed assessment was completed by the hospital
within defined timeframe within a defined time frame /
total number of patients
admitted) x 100
5. Percentage of in-patients (Number of case records in This can be further broken down into
wherein the plan of care with which plan of care with desired subcomponents such as case records
desired outcomes is outcomes is documented and with documented plan of care,
documented and countersigned by the clinicians / documented desired outcomes and
countersigned by the Total number of case records countersigned
clinicians checked) x 100
6. Percentage of in-patients (Number of admitted patients Nutritional screening format can be
wherein screening for who has been screened for used and is required for all admitted
nutritional needs has been nutritional requirements / Total patients
done number of patients admitted) x
100
7. Reporting error rates (per (Number of lab reports in which The error rates can be separately
1000) in laboratory errors detected / Number of lab calculated for each unit of laboratory
reports checked) x 1000
8. Percentage of re-dos in (Number of lab tests which has Only those repeat test shall be
laboratory to be repeated in a period/ Total considered in calculation, where the
lab tests conducted in that reason of repeating is related to errors,
period) x 100 mistake or quality issues
9. Percentage of lab reports (Number of lab reports in which While higher correlation shall be
co-relating with clinical the diagnosis matches with the expected, it may not necessarily be
diagnosis clinical diagnosis of the doctor / 100%
Total lab tests conducted) x 100
10.Percentage of adherence to (Number of observations that Safety precautions must be clearly
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safety precautions by indicates adherence to safety defined. Data must be gathered
employees working in labs precautions in a period / Total through random monitoring of practices
number of observations made in followed by staff. Most safety
that period) x 100 precautions shall be related safety
from infection, bio-medical waste and
safety from chemicals.
11.Reporting error rates (per (Number of lab reports in which The error rates can be separately
1000) in Imaging errors detected / Number of lab calculated for each imaging modality
reports checked) x 1000
12.Percentage of re-dos in (Number of Imaging tests that Only those repeat test shall be
Imaging has to be repeated in a period / considered in calculation, where the
Total Imaging tests conducted in reason of repeating is related to errors,
that period) x 100 mistake or quality issues
13.Percentage of Imaging (Number of Imaging reports in While higher correlation shall be
reports co-relating with which the diagnosis matches expected, it may not necessarily be
clinical diagnosis with the clinical diagnosis of the 100%
doctor / Total Imaging tests
conducted) x 100
14.Percentage of adherence to (Number of observations that Safety precautions must be clearly
safety precautions by indicates adherence to safety defined. Data must be gathered
employees working in precautions in a period / Total through random monitoring of practices
Imaging number of observations made in followed by staff. Most safety
that period) x 100 precautions shall be radiation safety
and infection control
15.Medication error rate (Number of medication errors For data on medication error a strong
OR reported in a period / Total medication error reporting system must
Medication error per 1000 number of medication be in place.
patient days administration events) x 100
OR This indicator can further be divided
(Number of medication errors into various types of medication errors,
reported in a period / Total such as administration error,
patient days in that period) x dispensing error, error of route, error of
1000 dose etc.
16.Percentage of adverse drug (Number of patients who Adverse drug reaction and medication
reactions suffered adverse drug reactions error shall be defined and should not
in a period / Number of admitted overlap with each other
patients in that period) x 100
17.Percentage of adverse drug (Number of patients developing List of high-risk medicines shall be
reaction due to high-risk adverse drug reaction from specified by the hospital and any
medicine high-risk medicines in a period / adverse reaction happening due to
Number of patients given high- these medicines shall be counted for
risk medicine in that period) x this indicator
100
18.Percentage of medical (Number of medical records List of accepted abbreviations shall be
records with error-prone which contains error-prone determined by the hospital and any
abbreviations abbreviations / Number of abbreviation other than that shall be
medical records screened) x considered as error prone
100
19.Percentage of modification (Number of patients in whom Each patient must undergo pre-
of anaesthesia plan anaesthesia plan was modified anaesthesia check-up in which
immediately before induction of anaesthesia plan (type of anaesthesia
anaesthesia / Number of and anaesthetic agent) is determined.
patients that have undergone Any change in this plan shall be
anaesthesia) x 100 considered as a modification
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20.Percentage of unplanned (Number of patients who Unplanned ventilation is the situation in
ventilation following required unplanned ventilator which patient has to be put on the
anaesthesia support following anaesthesia / ventilator after surgery, due to
Number of patients who were complications resulting from
given anaesthesia) x 100 anaesthesia
21.Percentage of re-scheduling (Number of planned surgeries This indicator can further be classified
of surgeries re-scheduled or cancelled / as per causes of re-scheduling for the
Number of surgeries planned) x management to take appropriate
100 corrective and preventive measures
22.Compliance rate to surgical (Number of surgical patients in For surgical safety practices, ‘WHO
safety practices which all surgical safety surgical safety checklist can serve
practices where adhered / as a good reference material’.
Number of surgical patients’
cases reviewed) x 100 The compliance rate of individual
practices can also be calculated for
detailed analysis
23.Percentage of cases who (Number of surgical patients The hospital must define the time-
received prophylactic who has received prophylactic frame for giving prophylactic antibiotic.
antibiotic within specified antibiotic / Total number of The documentation of administration of
time-frame patient undergone surgery) x antibiotics and the time shall be done
100 for getting data
24.Percentage of transfusion (Number of patients who To get data for this indicator a
reactions developed blood or blood transfusion administration form must
component transfusion reaction be filled for each transfusion, which
/ Number of patients who shall have a column for indicating
underwent blood or component reactions if any
transfusion) x 100
25.Percentage of blood and (Units of blood and blood Blood and blood components being
blood components wasted components wasted or discarded because of unfit in lab tests,
discarded in a period / Total shall not be counted as wastage.
units of blood and blood Wastage shall be because of reasons
components under storage of expiry, errors, poor storage
during that period) x 100 conditions etc.
26.Percentage of blood (Total units of blood The percentage should be high
component usage components transfused to
patients / Total units of whole
blood plus blood components
transfused to patients) x 100
27.Turn-around time for the Sum of time taken for issuing The time taken shall be considered
issue of blood and blood blood and blood taken in each from the time of receipt of requisition till
components requisition / Total number of the time of dispatch of blood or blood
requisition received for blood component
and blood component
28.Percentage of blood and (Number of blood and blood The time frame must be defined by the
blood components issued component requisitions that organization
within defined time frame were issued within defined time-
frame / Total number of
requisition received for blood
and blood component) x 100
29.Catheter associated Urinary (Number of patients developing CA-UTI shall be determined clinically
Tract Infection (CA-UTI) rate CA-UTI in a period / Total (CDC guidelines must be followed)
urinary catheterization days in The catheterization days shall be
that period) x 1000 calculated as sum of number of days
each patient spent with urinary
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catheter in the period of calculation
30.Ventilator associated (Number of patients developing VAP shall be determined clinically
pneumonia (VAP) rate VAP in a period / Total ventilator (CDC guidelines must be followed)
days in that period) x 1000 The ventilator days shall be calculated
as sum of number of days each patient
spent on ventilator in the period of
calculation
31.Central line catheter (Number of patients developing CA-BSI shall be determined clinically
associated blood stream CA-BSI in a period / Total (CDC guidelines must be followed)
infection (CA-BSI) rate central line days in that period) x The central line days shall be
1000 calculated as sum of number of days
each patient spent with central line
catheter in the period of calculation
32.Surgical site infection (SSI) (Number of patients developing CA-BSI shall be determined clinically
rate SSI in a period / Total number of (CDC guidelines must be followed)
clean surgeries performed in This can be further bifurcated in
that period) x 100 superficial, deep and organ/space
infections due to surgeries
33.Gross mortality rate (Total number of deaths All deaths (including deaths in
happened in the hospital in a emergency and ICU) shall be counted.
period / Total number of deaths In denominator all types of discharges
discharges during that period) x shall be considered
100
34.Net mortality rate (Total number of deaths that Deaths happening within 48 hours of
happened after 48 hours of discharge should also be counted in
admission of the patient / Total numerator
number of deaths and
discharges during that period) x
100
35.ICU specific mortality rate (Total number of deaths in ICU On similar lines, condition specific or
patients in a period / Total speciality specific deaths rates can
number of patients discharged also be calculated
from ICU in that period) x 100
36.Return to ICU within 48 (Number of patients who were The patients who were discharged
hours re-admitted to ICU within 48 against medical advice from ICU
hours of being discharged from should be ignored
ICU / Total number of patients
discharged from ICU) x 100
37.Return to emergency within (Number of patients who The patients who were discharged
72 hours with similar returned to emergency within 72 against medical advice from
presenting complaints hours with similar presenting emergency should be ignored
complaints / Total number of
patients discharged from
emergency) x 100
38.Re-intubation rate (Number of patients who has to Data on re-intubation and ex-tubation
be re-intubated after ex-tubation shall be taken from individual medical
/ Total number of ex-tubation record or a master register
done during the period) x 100
39.Percentage of research (Number of research activities Applicable to hospital undertaking
activities approved by ethics approved by ethics committee / clinical research
committee Number of research proposal
submitted to ethics committee) x
100
40.Percentage of patients (Number of patients withdrawing Applicable to hospital undertaking
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withdrawing from clinical from research study / Number of clinical research
research patients originally enrolled in the
study) x 100
41.Percentage of protocol (Incidence of protocol Applicable to hospital undertaking
violations/deviations in violations/deviations observed in clinical research
clinical research study clinical research study / Number
of observations made) x 100
42.Percentage of serious (Number of serious adverse Applicable to hospital undertaking
events in clinical research events reported to ethics clinical research
study reported to ethics committee / Number of serious
committee adverse events identified) x 100
43.Error rates during shift hand- (Number of errors detected in A handover checklist must be available
overs patient handovers during shift against which errors can be detected
changes / Number of hand over
records reviewed) x 100
44.Percentage of medical (Number of medical errors A robust system of medical
error due to reported that happened due to error reporting must be in place to get
wrong identification of wrong identification of patient / appropriate data
patient Total number of medical errors
reported) x 100
45.Hand hygiene compliance (Number of observations in Hand hygiene guidelines must be
rate which staff complied with hand specified.
hygiene guidelines / Total Data shall be gathered through
number of observations made) x monitoring
100
46.Compliance rate to (Number of prescriptions in Not applicable, if prescription is
medication prescription in which medications are written in computerized
capitals capital letters / Total number of
prescriptions checked) x 100
47.Percentage of procurement (Value of drugs and Local purchases are unplanned,
through local purchase consumables purchased emergency purchases which increase
through local purchase / Total the cost of purchasing
value of drugs and consumables
purchased in that period) x 100
48.Percentage of stockouts for (Number of emergency drugs on Stock out is a situation when the
emergency drugs the stock-out / Total number of inventory level of the medicine has
emergency drugs) x 100 gone below the defined minimum level
49.Percentage of drugs and (Number of drugs and The data can be taken through a
consumables rejected before consumables rejected before random sample of items that were
preparation of goods receipt preparation of goods receipt checked
note note / Total number of drugs
and consumables received) x
100
50.Percentage of variation from (Number of times standard A standard operating process for
procurement process procurement process was not procurement must be in place to
followed / Total number of calculate this indicator
procurements done) x 100
51.Percentage of variations (Number of variations observed This should be separately calculated
observed in mock drills in mock drills / Total number of for different mock drills such as code
observations made) x 100 blue, code red, code pink, disaster
handling etc.
52.Patient fall rate per 1000 (Number of patient fall reported Patient fall must be defined. Generally,
patient days in a period / Total patient days all kind of fall (fall from bed, in
in that period) x 1000 washroom, on stairs, while walking
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etc.) must be counted
53.Hospital-associated (Number of patients developing Criteria for determining pressure ulcers
pressure ulcer rate hospital associated pressure shall be specified.
ulcers / Number of bedridden Patients at risk of developing pressure
patient days) x 1000 ulcers must be identified
54.Percentage of staff provided (Number of staff who received Pre-exposure prophylaxis can be given
pre-exposure prophylaxis pre-exposure prophylaxis / Total for different conditions such as
healthcare staff) x 100 Hepatitis, certain kinds of Pneumonia
etc.
55.Bed Occupancy Rate (Total patient days in a period / Total patient days is the sum of days
Total bed days available during spent by each admitted patient in
that period) x 100 hospital
Total bed days is the product of
number of functional beds in hospital
with the number of days in that period
56.Average Length of Stay Sum of length of stay of ALOS must be separately calculated
(ALOS) individual patients / Total for different disease conditions,
number of patients whose specialities and ICU/Non-ICU cases
length of stay has been taken
57.OT utilization rate (Total hours for which actual Total hours of surgeries can be
surgeries were performed in OT calculated by summing up the duration
/ Total OT hours available) x of each surgeries performed in the
100 period

Total OT hours can be calculated by

multiplying functional hours available
for each OT with the number of OT
58.ICU utilization rate (Total ICU patient days in a This is similar to calculation bed
period / Total ICU bed days occupancy rate, but only for ICU
available in that period) x 100
59.Percentage of downtime of Total duration (in days or hours) A list of critical equipment shall be
Critical equipment for which a critical equipment made.
was down / Total duration (in This indicator shall be calculated
days or hours) in that period separately for each critical equipment
60.Nurse patient ratio for wards Total number of nurse working An average ratio of the month can be
in a shift / Total number of taken. This should be separately
patient in that shift calculated for each shift and each ward
61.Nurse patient ratio for ICU Total number of nurse working An average ratio of the month can be
in ICU in a shift / Total number taken. This should be separately
of patient in that shift calculated for each shift and each ICU
62.Out-patient satisfaction Average rating given by patient A standard patient satisfaction
index of OPD to the hospital feedback form can be used for
obtaining rating from patients. Number
of feedback collected should be
statistically significant
63.In-patient satisfaction index Average rating given by patient A standard patient satisfaction
of IPD to the hospital feedback form can be used for
obtaining rating from patients. Number
of feedback collected should be
statistically significant
64.Average waiting time for Total waiting time of all patients Average waiting time shall be
services for a particular service / Total separately calculated for OPD
number of patients whose consultation, Billing, Pharmacy and
waiting time has been taken diagnostics
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65.Average discharge time Sum of time taken for Time taken for discharge shall be
discharging patients / Total taken from the time when the
patients whose discharge time discharged was ordered by the doctor
is taken till the time when patient was relieved
from room/bed
66.Employee satisfaction index Average rating given by An employee satisfaction study must
employee to the organization be conducted for this.
The index can be calculated for
different categories of employees
67.Employee attrition rate (Number of employee who This should be calculated overall as
resigned during a period / Total well as category wise
number of employee on roll) x
100
68.Employee absenteeism rate (Total number of absenteeism of Absenteeism shall be considered as
employee in a period / Total absent without information.
employee days) x 100
This indicator shall also be calculated
category wise
69.Percentage of employee (Number of employee aware of Category-wise calculation shall be
aware of employee rights employee rights / Total number done
of employee) x 100
70.Percentage of sentinel (Number of sentinel events Timeframe and sentinel events must
events analysed within a analysed within defined time be defined
defined time frame frame / Number of sentinel
events reported) x 100
71.Percentage of near misses (Number of near misses A robust system of reporting errors and
reported / Total number of near misses must be in place
errors and near-miss reported) x
100
72.Needlestick injury rate (Number of needle stick injury Needlestick injury reporting and data
reported / Total patient days in collection mechanism must be in place
that period) x 100
73.Percentage of medical (Number of medical records not Sufficient sample size must be ensured
records not having discharge having discharge summary /
summary Total number of medical records
screened) x 100
74.Percentage of medical (Number of medical records not Sufficient sample size must be ensured
records not having ICD having ICD codes / Total
codes number of medical records
screened) x 100
75.Percentage of medical (Number of medical records Standard process of informed consent
records having incomplete having incomplete and improper must be in place to determine what
and improper consent consent / Total number of constitutes incomplete or improper
medical records where consent consent
was applicable
76.Percentage of missing (Number of medical records A definition of missing shall be
records missing / Total number of available. Generally, any medical
medical records in MRD) x 100 record which has been able to be
traced for last 3 days shall be
considered missing. In case, a missing
record has been found it shall be
removed from the missing data

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Methodology

The methodology aimed at understanding whether or not hospital accreditation affects the
quality of healthcare, as perceived by the Patients. For this, response of patients, who took
treatment in accredited and non-accredited hospitals were collected through a standard
instrument created for the purpose of this study.
Framework of the study: Since the concept of quality in healthcare has been explained in
numerous ways and there are different models available for its description, identifying one for
the purpose for this research is essential to avoid confusion and to bring in uniformity in
measuring and stating quality. There are significantly large number of different models in
healthcare for quality which indicates that modelling the healthcare quality correctly is near
impossible or it is a fiction not a reality. After reviewing the popular models, Donabedian's
conceptual model of quality of care has been chosen for this study.
The model proposed by Avedis Donabedian is arguably the most widely accepted method to
design the main dimensions of healthcare quality, In his work published in 1988, Donabedian
defined the quality and described its parameters in healthcare organization. According to the
model, understanding about quality of care can be drawn from three categories: "structure,"
"process," and "outcomes." Structure describes the context in which care is delivered,
including hospital buildings, staff, financing, and equipment. Process denotes the transactions
between patients and providers throughout the delivery of healthcare. Finally, outcomes refer
to the effects of healthcare on the health status of patients and populations.
The study utilizes Donabedian's quality of care model to describe and assess quality in
healthcare organization. The instruments used for data collection are constructed based on
components described under this model. The concept of quality in healthcare given in this
model has been adopted for analysis, discussion and findings in this study.
Accordingly, the response of quality of healthcare were collected and analysed under following
components-
Infrastructure of hospital - This includes facility, equipment and human resources of the
hospital, as perceived by patients
1. Process - This includes policies and processes used at hospital for clinical and non-
clinical work, as perceived by patients
2. Outcome - The outcome of treatment, as perceived by the patient
3. Overall - This is the overall response on quality of the hospital by the patient
Study design: Cross sectional exploratory study design is used for the purpose of this research
work. The data from sample belonging to accredited hospitals was compared with the data
from sample belonging to non-accredited hospitals. The samples were matched in all other
parameters except their belonging to accredited or non-accredited hospital. The data from 2
samples were analysed to observe of significant differences.
Study group (respondent patients): The respondents were sourced from 2 hospitals who are
accredited by NABH and 2 hospitals that were not accredited at the time of collection of data.
The comparison of hospitals from where respondents were sampled is given in table 1 below.

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As the Chi-square value is 7.780 and corresponding P value is 0.005, the result is significant at p < 0.05.
Hence, null hypothesis - HO-l is rejected.

Conclusion

• The data and its analysis shows following result the mean rating given to infrastructure
component by patients of accredited hospital do not significantly differ from the mean
rating given by patients of non-accredited hospital. The distribution of high and not high
rating also do not differ between patients of accredited and non-accredited hospital
The analysis of process component of hospital, shows significant difference in ratings
given by patients of accredited and non-accredited hospital
• Differences in mean rating of outcome by respondents from accredited and by
respondents from non-accredited hospitals was also found to be statistically significant,
with rating by respondents from accredited group being significantly higher
The analysis of overall rating has shown significant difference in ratings by respondents
from accredited and non-accredited hospital in both the categories. The distribution of
'high' rating was also found to be higher in accredited group respondents
Thus, it could be concluded that except for infrastructure, the other components of quality,
i.e. process and outcome, has been perceived better by patients from accredited hospital in
comparison to non-accredited hospitals. The overall response on hospital was also better
for accredited hospitals.

Recommendation
While the accreditation system do seem to improve process and outcomes in view of
patients and healthcare providers, the infrastructure component is not effected. As
infrastructure is also a basic component of quality of care, the accreditation system must
focus more on improving this component of the hospital.
Limitation
The study has some limitations which should be taken into consideration while interpreting
the resultsThe effect on quality has been measured by the rating given by patients. This
may differ from the technical data on infrastructure, process and outcome.
The study is based on a cross sectional data and do not features in time series data. Hence
study cannot comment upon whether the data collected at the time of collection holds true
across the time.

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