Hosp Accreditation by DR Gayatri Direcotr Nabh

Video Conference on NABH Accreditation of Public Health Institutions

Centre for Innovations in Public Systems, Hyderabad

5 Jan 2013

Dr Gayatri Vyas Mahindroo

M.B.B.S., M.S., M.Phil.
Director, NABH Quality Council of India
National Accreditation Board for Hospitals and Healthcare Providers
Six aims for safe healthcare: 1. Safe: avoiding injuries to patients 2. Effective: service to be evidence based
3. Patient-centered: care to be respectful and responsive to

preferences, needs and values 4. Timely: reducing waits and sometimes harmful delays 5. Efficient: avoiding waste, including equipment, supplies, ideas, and energy 6. Equitable: same care for all sexes, ethnic groups, geographic location and socioeconomic status
Introduction of
National Accreditation Board for Hospitals and Healthcare Providers
History
March 2005 Reference from Ministry Of Health and Family Welfare (MOHFW), Government of India
March 10, 2005- Quality Council of India (QCI) Governing Board approved launch of Healthcare Accreditation program
April 11, 2005- QCI Governing Council adapted the approval of GB.
June 2005 Technical Committee Constituted
History
June 27 2005 President Indian Health Care Forum handed over material on Standard to TC NABH January 19, 2006- NABH Board approved Hospital standards February 2006 NABH Standards launched April 2008 ISQua accreditation to the standards March 2012 ISQua re accreditation to the standards Sept 2012 ISQua accreditation to the NABH organisation
Constituent Board of
Quality Council of India (QCI)
Structure of Quality Council of India

Council
Governing Body Secretariat
Accreditation
National Accreditation Board for Certification Bodies (NABCB)
Quality Promotion
National Board for Quality Promotion (NBQP) Quality Information and Enquiry Service (QIES)
National Accreditation Board for Education and Training (NABET)
National Accreditation Board for Hospitals and Healthcare Providers (NABH)
National Accreditation Board for Testing and Calibration Laboratories (NABL)
Structure of NABH
Quality Council of India
National Accreditation Board for Hospitals & Healthcare Providers
Appeals Committee Secretariat Technical Committee Panel of Assessor/Expert
Accreditation Committee
Vision
To be apex national healthcare accreditation and quality improvement body, functioning at par with global benchmarks.
Mission
To operate accreditation and allied programs in collaboration with stakeholders focusing on patient safety and quality of healthcare based upon national/international standards, through process of self and external evaluation.
10
COMPOSITION OF BOARD
1. Chairman 2. Indian Medical Association 3. Consumer Co-ordination Council 4. Insurance Regulatory & Development Authority 5. Indian Nursing Council 6. Secretary AYUSH 7. Director General, Armed Forces Medical Services 8. Directorate General of Health Services 9. Academic Institute(MaulanaAzad Medical College) 10.Ministry of Tourism
11
COMPOSITION OF BOARD
11. Chair Health Committee CII 12. Chair Health Committee ASSOCHAM 13. Chair Health Committee FICCI 14. Academy of Hospital Administration (AHA) 15. Indian Health Care Quality Forum Academic partner 16. Chair Accreditation Committee NABH 17. Chair Hospital Technical Committee NABH 18. Chair Appeals Committee NABH 19. Drug Controller General of India 20. CEO NABH Member Secretary
12
NABH is an institutional member of the International Society for Quality in Health Care (ISQua) since 2006
13
Member of ISQua Accreditation Council (2007, 2008-2012)
Member of ISQua Board (2009-2011, 2011-2014)
14
ISQua Accreditation of NABH Standards for Hospitals

April 2008 March 2012 - 2nd Edition April 2012 March 2016 - 3rd Edition
ISQua Accreditation of NABH as an Organization
Core Activities of NABH

Operate Accreditation Programs Develop accreditation improvement standards and quality
Conduct Assessor/ Surveyor training programs Conduct educational workshops and training programs for participating organizations
Accreditation is a quality improvement process that seeks to improve patient care and outcomes through systematic review of care against explicit criteria and the implementation of change. Accreditation is a process of external review of the quality of the health care being provided by a healthcare organization against pre determined set of standards.
NABH Accreditation Programs

Accreditation of Hospitals Accreditation of Blood Banks Accreditation of SHCO Accreditation of PHC Accreditation of CHC Accreditation of AYUSH hospitals Accreditation of Wellness Centers Accreditation of Medical Imaging Services Accreditation of Dental Centers Accreditation of Allopathic Clinics
Capacity Building Programs

1. Awareness and Program On Implementation Programs 2. Educational Workshops 3. Empanelled Courses
20
Number of Applicant Hospitals

700 628 600 577
500 No. of Applicants
460
400
360
300
200
100 56 29 0 2006 2007
86
2008
2009 Year
2010
2011
2012
21
Number of Accredited Hospitals

140 150 120 114
100 Nos of Accredited Hospitals
80
60
57
40
35
20 10 2 0 2006 2007
18
2008
2009 Year
2010
2011
2012
22
Accreditation to a hospital stimulates continuous improvement. It enables hospital in demonstrating commitment to quality care. It raises community confidence in the services provided by the hospital. It also provides opportunity to healthcare unit to benchmark with the best.
Although accreditation benefits all stake holders, patients are the biggest beneficiary. Accreditation results in high quality of care and patient safety. The patients get services by credentialed medical staff. Rights of patients are respected and protected. Patient satisfaction is regularly evaluated.
Staff in an accredited hospital are satisfied lot as it provides for continuous learning, good working environment, leadership and above all ownership of clinical processes. It improves overall professional development of Clinicians and Paramedical staff and provides leadership for quality improvement within medicine and nursing.
NABH Standards for Hospitals

10 Chapters 104 Standards
636 Objective Elements
First Five Chapters are Patient-Centered Standards

Access, Assessment and Continuity of Care (AAC) Patients Rights and Education (PRE) Care of Patients (COP) Management of Medications (MOM) Hospital Infection Control (HIC)
Next Five Chapters are HealthCare Management Standards

Continuous Quality Improvement (CQI)
Responsibilities of Management (ROM)
Facility Management & Safety (FMS)

Human Resource Management (HRM)
Information Management Systems (IMS)
What are Standards

A standard is a statement that defines the structures and processes that must be substantially in place in an organization to achieve outcome and enhance the quality of care
A standard is an explicit statement describing the quality of care to be achieved, which is definable and measurable.
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
Accreditation is an external review of quality with four principal components:

1. It is based on written and published standards 2. Reviews are conducted by professional peers 3. The accreditation process is administered by an independent body
4. The aim of accreditation is to encourage organizational development.
Quality Indicators for NABH accredited hospitals NABH accreditation is life long, mutually beneficial relationship with the
accredited facilities. All NABH accreditation hospitals are required to share data for following 10 Quality Indicators: 1. Percentage of medication errors. 2. Percentage of transfusion reactions 3. Urinary tract infection rate 4. Respiratory infection rate 5. Intra-vascular device infection rate 6. Surgical site infection rate 7. Incidence of falls 8. Incidence of bed sores after admission 9. Bed occupancy rate and average length of stay 10.Incidence of needle stick injuries
32
Accreditation is a Journey.
Not a Destination
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Video Conference on NABH Accreditation of Public Health Institutions

Centre for Innovations in Public Systems, Hyderabad

Dr Gayatri Vyas Mahindroo

Director, NABH Quality Council of India

National Accreditation Board for Hospitals and Healthcare Providers

3. Patient-centered: care to be respectful and responsive to

June 2005 Technical Committee Constituted

Quality Council of India (QCI)

Structure of Quality Council of India

National Accreditation Board for Education and Training (NABET)

National Accreditation Board for Hospitals and Healthcare Providers (NABH)

National Accreditation Board for Testing and Calibration Laboratories (NABL)

Member of ISQua Accreditation Council (2007, 2008-2012)

Member of ISQua Board (2009-2011, 2011-2014)

ISQua Accreditation of NABH Standards for Hospitals

ISQua Accreditation of NABH as an Organization

Core Activities of NABH

NABH Accreditation Programs

Capacity Building Programs

Number of Applicant Hospitals

500 No. of Applicants

100 56 29 0 2006 2007

Number of Accredited Hospitals

100 Nos of Accredited Hospitals

NABH Standards for Hospitals

636 Objective Elements

First Five Chapters are Patient-Centered Standards

Next Five Chapters are HealthCare Management Standards

Facility Management & Safety (FMS)

Information Management Systems (IMS)

What are Standards

Accreditation is an external review of quality with four principal components:

4. The aim of accreditation is to encourage organizational development.

Thank You Thank You

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