Accreditation Process Col Pawan Kapoor1

8/8/2019 Accreditation Process Col Pawan Kapoor1

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ACCREDITATION PROCESS

By

Col (Dr) Pawan Kapoor

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


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GOOD NEWSGOOD NEWS

I AM NOT GOING TO BORE YOU


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BAD NEWSBAD NEWS

YOU WILL STILL HAVE TO

TOLERATE ME

FOR THE NEXT FEW HOURS


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THE GOOD NEWSTHE GOOD NEWS

Our clientele now knows the importanceOur clientele now knows the importance

of Good Health and values itof Good Health and values it

THE BAD NEWSTHE BAD NEWS Our clientele now knows the importanceOur clientele now knows the importance

of Good Health and values it ANDof Good Health and values it AND----------

NOW HAS EXPECTATIONSNOW HAS EXPECTATIONS


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AS A PATIENT WHAT QUALITYAS A PATIENT WHAT QUALITY

LEVELS WOULD YOU ACCEPT FROMLEVELS WOULD YOU ACCEPT FROMYOUR HEALTH SERVICESYOUR HEALTH SERVICES??

90%90%

95%95%

96%96%

98%98%

99%99%

99.9%99.9%


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IF 99.9% IS ACCEPTABLE TO YOU, THEN

YOUR HEART FAILS

TO BEAT 32,000TIMES EACH YEAR

* 20,000 WRONG

DRUGPRESCRIPTIONS

MADE EVERY YEAR

* 500 SURGICALOPERATIONS AREPERFORMED

WRONGLYEVERY WEEK

* 19,000 BABIES AREDROPPED BY

DOCTORSAT BIRTH


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WELL ........

THERE IS ONLY A 1 %

DIFFERENCE IN THE DNA

GENETIC CODE BETWEEN A

CHIMPANZEE AND A

HUMAN BEING


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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 ..


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HOW TO ACHIEVEHOW TO ACHIEVE

EXCELLENCE IN HEALTHEXCELLENCE IN HEALTH

Pleasewait..


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WHAT IS QUALITY ?WHAT IS QUALITY ?


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Appropriate application of medical Appropriate application of medical

knowledge with due regard to theknowledge with due regard to the

balance between the hazard inherentbalance between the hazard inherent

in every medical intervention and thein every medical intervention and the

benefits expected from itbenefits expected from it

It is, however more complex thanIt is, however more complex thanthis.this.


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QUALITY FROM WHOSEQUALITY FROM WHOSE

POINT OF VIEW ?POINT OF VIEW ?


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Provider of Health care ServicesProvider of Health care Services

Recipient of the Health careRecipient of the Health care

servicesservices

Organizer of the Health careOrganizer of the Health care

servicesservices


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PROVIDERS CONCERNSPROVIDERS CONCERNS To provide care as per establishedTo provide care as per established

normsnorms

Adequate resourcesAdequate resources

Self satisfaction with the finalSelf satisfaction with the final

outcomeoutcome

Should contribute to enhancement ofShould contribute to enhancement of

skills, competence and add toskills, competence and add to

experienceexperience


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RECIPIENTS CONCERNSRECIPIENTS CONCERNSAccessibility

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


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ORGANISERS CONCERNSORGANISERS CONCERNS

Responsible to the Society for the fundsResponsible to the Society for the funds

spent on health carespent on health care

To ensure safety of public and preventTo ensure safety of public and prevent

inappropriate or suboptimal careinappropriate or suboptimal care

To meet the requirements of the recipientTo meet the requirements of the recipient

and provider of the health care services atand provider of the health care services at

Acceptable costsAcceptable costs


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SIMPLE MEANING OFSIMPLE MEANING OF

QUALITYQUALITY

Simply defined Quality is the degree ofSimply defined Quality is the degree of

adherence toadherence to predetermined standardspredetermined standardsbased on existing knowledge, principlesbased on existing knowledge, principles

and practicesand practices


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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


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COP.3COP.3The ambulance services areThe ambulance services are

commensurate with the scopecommensurate with the scope

of the services provided by theof the services provided by the

organizationorganization


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How to Measure the

standard ???


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Objective Elements

Objective element is a measurable

component of a standard

Acceptable compliance with objective

elements determines the overall

compliance with a standard


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COP.3COP.3

The ambulance services areThe ambulance services arecommensurate with the scopecommensurate with the scope

of the services provided by theof the services provided by theorganizationorganization

Objective elementsObjective elementsa)a) There is adequate access and space forThere is adequate access and space for

the ambulance(s)the ambulance(s)

b)b) Ambulance(s) is appropriately equippedAmbulance(s) is appropriately equipped

c)c) Ambulance(s) is manned by trained Ambulance(s) is manned by trained

personnelpersonnel


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contcont

d)d) There is a checklist of all equipment andThere is a checklist of all equipment and

emergency medicationsemergency medications

e)e) Equipment are checked on a daily basisEquipment are checked on a daily basis

f)f) Emergency medications are checkedEmergency medications are checked

daily and prior to dispatchdaily and prior to dispatch

g)g) The ambulance(s) has a properThe ambulance(s) has a proper

communication systemcommunication system


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COP.4COP.4

Policies and procedures guidePolicies and procedures guidethe care of patients requiringthe care of patients requiring

cardiocardio--pulmonary resuscitationpulmonary resuscitation Objective elementsObjective elements

a)a) Documented policies and proceduresDocumented policies and proceduresguide the uniform use of resuscitationguide the uniform use of resuscitation

throughout the organizationthroughout the organization

b)b) Staff providing direct patient care isStaff providing direct patient care istrained and periodically updated intrained and periodically updated in

cardio pulmonary resuscitationcardio pulmonary resuscitation


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contcont

c)c) The events during a cardioThe events during a cardio--pulmonarypulmonary

resuscitation are recordedresuscitation are recorded

d)d) An analysis of all cardiac arrests is doneAn analysis of all cardiac arrests is done

e)e) A multidisciplinary committee monitors A multidisciplinary committee monitors

the effectiveness of cardiothe effectiveness of cardio--pulmonarypulmonary

resuscitationresuscitation


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WHAT IS ACCREDITATIONWHAT IS ACCREDITATION


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Accreditation is an external review ofAccreditation is an external review of

quality with four principal components:quality with four principal components:

It is based on written and publishedIt is based on written and published

standardsstandards

Reviews are conducted by professionalReviews are conducted by professional

peerspeers The accreditation process isThe accreditation process is

administered by an independent bodyadministered by an independent body The aim of accreditation is to encourageThe aim of accreditation is to encourage

organizational development.organizational development.


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Objectives of AccreditationObjectives of Accreditation

Assess Quality and Safety of CareAssess Quality and Safety of Care

Assess a HCO ability to ensure continuousAssess a HCO ability to ensure continuousimprovement in Qualityimprovement in Quality

Formulate Explicit RecommendationsFormulate Explicit Recommendations Involve professionals at all stages of theInvolve professionals at all stages of the

quality initiativequality initiative

Provide external recognition of the QualityProvide external recognition of the Qualityof care in the HCOof care in the HCO

Improve public confidenceImprove public confidence


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What Accreditation begets ?What Accreditation begets ?

Customer focusCustomer focus

Competitive advantageCompetitive advantage

Corporate environmentCorporate environment

Confidence of Regulatory and payingConfidence of Regulatory and paying

authoritiesauthorities

MinimisationMinimisation of litigation lossesof litigation losses


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Making of standardsMaking of standards

Patient SafetyPatient Safety

Staff and employee safetyStaff and employee safety

Environment and community safetyEnvironment and community safety

Information Education and CommunicationInformation Education and Communication

Simple and easy to comprehendSimple and easy to comprehend

MeasurableMeasurable

AchievableAchievable

Organized around important functionsOrganized around important functions


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What are the Important

functions ???

Patient Centered functionsPatient Centered functions

Organisation Centered functionsOrganisation Centered functions

Community Centered functionsCommunity Centered functions

Environment Centered functionsEnvironment Centered functions


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BENEFITS OF ACCREDITATIONBENEFITS OF ACCREDITATION


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Benefits for PatientsBenefits for Patients High quality of careHigh quality of care

Credentialed and privileged medicalCredentialed and privileged medicalstaffstaff

Access to a quality focusedAccess to a quality focused

organizationorganization

Rights are respected and protectedRights are respected and protected

Understandable education andUnderstandable education andcommunicationcommunication

Patient Satisfaction is evaluatedPatient Satisfaction is evaluated


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Benefits for Patients Contd..Benefits for Patients Contd..

Involvement in care decisions andInvolvement in care decisions and

care processcare process

Focus on patient safetyFocus on patient safety

Pain managementPain management

Vulnerable patientVulnerable patient

Safe transportSafe transport

Continuity of careContinuity of care


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Benefits for the staffBenefits for the staff Improves professional staffImproves professional staff

developmentdevelopment

Provides education on consensusProvides education on consensus

standardsstandards

Provides leadership for qualityProvides leadership for qualityimprovement within medicine andimprovement within medicine and

nursingnursing

Increases satisfaction with continuousIncreases satisfaction with continuous

learning, good working environment,learning, good working environment,

leadership and ownershipleadership and ownership


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Benefits for the HospitalBenefits for the Hospital

Improves care

Stimulates continuous improvement

Demonstrates commitment to quality

care

Raises community confidence

Opportunity to benchmark with the

best


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Benefits to the CommunityBenefits to the Community

Quality revolutionQuality revolution

Disaster preparednessDisaster preparedness

-- epidemicsepidemics

-- physicalphysical

Access to comparative databaseAccess to comparative database


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MAKING OF STANDARDS


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Technical Committee Members

Col (Dr) Pawan Kapoor (Armed ForcesCol (Dr) Pawan Kapoor (Armed Forces

Medial Services)Medial Services)-- ConvenorConvenor

Dr Umesh Gupta (Vascular Surgeon & HeadDr Umesh Gupta (Vascular Surgeon & Head

of QI, Indraprastha Apollo Hospital)of QI, Indraprastha Apollo Hospital)

DrDr BidhanBidhan Das (COO, Rockland Hospital)Das (COO, Rockland Hospital)

DrDr SidharthSidharth Satpathy (Addl Prof of HA,Satpathy (Addl Prof of HA,

AIIMS)AIIMS)

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

Mr DeepakMr Deepak BandhopadhyayBandhopadhyay (Quality(Quality

Consultant)Consultant)


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METHODOLOGY FOLLOWED

Technical committee set up by QCITechnical committee set up by QCI

Review of existing global standardsReview of existing global standards

Perusal of available compliance dataPerusal of available compliance data

Applicability aspects to Indian contextApplicability aspects to Indian context

Amenable to international recognitionAmenable to international recognition

Not too difficult and stringent nor veryNot too difficult and stringent nor very

easy to achieveeasy to achieve MinimiseMinimise PrescriptivenessPrescriptiveness

ConsensusConsensus


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Draft standards forwarded to 32 ExpertsDraft standards forwarded to 32 Experts

across the countryacross the country

Feedback received incorporated wherever itFeedback received incorporated wherever it

was found to be feasible and implement ablewas found to be feasible and implement able

Pilot studyPilot study

Firming of the standardsFirming of the standards PublicationPublication

SensitisationSensitisation WorkshopsWorkshops


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Training of AssessorsTraining of Assessors

Laying Down of Guideline ManualsLaying Down of Guideline Manuals

ImplementationImplementation

Feedback from Assessors, Organisations,Feedback from Assessors, Organisations,

Consumers, stakeholdersConsumers, stakeholders

RevisionRevision


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NABH Standards

10 Chapters10 Chapters

100 Standards100 Standards

503 Objective Elements (512 in Revised503 Objective Elements (512 in Revised

EdnEdn

2007)2007)

Section I:Section I:


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Section I:Section I:

PatientPatient--Centered StandardsCentered Standards

3193193173176060TotalTotal

464644440909Hospital Infection ControlHospital Infection Control

303029290505Patients Rights andPatients Rights and

EducationEducation

616161611313Mgmt of MedicationsMgmt of Medications

1041041051051818Care of PatientsCare of Patients

787878781515Access, Assessment andAccess, Assessment andContinuity of CareContinuity of Care

REVREVOEOEStdStdDescriptionDescription

Section II:Section II:


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Section II:Section II:

Organisation Centered StandardsOrganisation Centered Standards

1931931861864040TotalTotal

414141410707Information Mgmt SystemInformation Mgmt System

474747471313Human Resource MgmtHuman Resource Mgmt

414141410909Facility Mgmt & SafetyFacility Mgmt & Safety

252520200505Responsibilities of MgmtResponsibilities of Mgmt

393937370606Continuous QualityContinuous QualityImprovementImprovement

REVREVOEOEStdStdDescriptionDescription


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Accreditation ProcessAccreditation Process


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WHO CAN APPLYWHO CAN APPLY

Any Health Care OrganisationAny Health Care Organisation

RequirementsRequirements

Currently in operation as a HCOCurrently in operation as a HCO

Preferably registered or licensedPreferably registered or licensed

Willing to assume responsibility for improvingWilling to assume responsibility for improving

quality of carequality of care Should be able to meet the prescribedShould be able to meet the prescribed

standards of the accrediting organisationstandards of the accrediting organisation


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HOW CAN ONE APPLYHOW CAN ONE APPLY

Organisations apply on prescribed formatOrganisations apply on prescribed format

giving details as requiredgiving details as required

Submission of a self assessment formSubmission of a self assessment form

indicating the outcomes of its QMS andindicating the outcomes of its QMS and

Internal AuditsInternal Audits

Extent of adherence to the laid downExtent of adherence to the laid down

standardsstandards


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SCREENING OF APPLICATIONSSCREENING OF APPLICATIONS

CompletenessCompleteness

AccuracyAccuracy

Clarifications sought if requiredClarifications sought if required

PREASSESSMENT SURVEYPREASSESSMENT SURVEY


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PREASSESSMENT SURVEYPREASSESSMENT SURVEY

To ascertain the readiness of theTo ascertain the readiness of theorganisation for Accreditationorganisation for Accreditation

Overview of the organizationalOverview of the organizationalpreparedness and commitment to qualitypreparedness and commitment to qualitygoals and consonance to laid downgoals and consonance to laid down

standardsstandards Deficiencies noticed informed to theDeficiencies noticed informed to the

organisationorganisation

Advice rendered on the methodology to beAdvice rendered on the methodology to befollowed during the Accreditation Surveyfollowed during the Accreditation Survey

Time frame worked out for the survey inTime frame worked out for the survey in

mutual consultationmutual consultation

ACCREDITATION SURVEYACCREDITATION SURVEY


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ACCREDITATION SURVEY ACCREDITATION SURVEY

Carried out by a team of AssessorsCarried out by a team of Assessors

depending upon the size, complexity anddepending upon the size, complexity and

facilities provided by the organisationfacilities provided by the organisation

Scope will include all standards relatedScope will include all standards related

functions and all patient care settingsfunctions and all patient care settings

Onsite survey will consider specific culturalOnsite survey will consider specific cultural

and legal factors which may influence orand legal factors which may influence orshape decisions regarding the provision ofshape decisions regarding the provision of

care and /or policies and procedurescare and /or policies and procedures


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METHODOLOGY OF SURVEYMETHODOLOGY OF SURVEY Initial presentation by the hospitalInitial presentation by the hospital

Document ReviewDocument Review

Adherence to statutory obligationsAdherence to statutory obligations

Visits to various areasVisits to various areas

Facility surveys and toursFacility surveys and tours

Random structured interviewsRandom structured interviews

INITIAL PRESENTATION BYINITIAL PRESENTATION BY


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THE HOSPITALTHE HOSPITAL OrganogramOrganogram

Quality management TeamQuality management Team

Methodology followed for QualityMethodology followed for QualityImprovementImprovement

Facilities providedFacilities provided Inputs on resources provided for QualityInputs on resources provided for Quality

ImprovementImprovement

Identified high Risk Areas for patient careIdentified high Risk Areas for patient careand safetyand safety

Sentinel Events being monitoredSentinel Events being monitored



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THE HOSPITALTHE HOSPITAL Key Monitoring IndicatorsKey Monitoring Indicators

ResourceResourceVolumeVolume

UtilizationUtilization

PerformancePerformance

Control chartsControl charts

Problems faced and remedial measuresProblems faced and remedial measures

undertaken/ being undertakenundertaken/ being undertaken


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OBSERVATIONSOBSERVATIONS


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OBSERVATIONSOBSERVATIONS

Facility SafetyFacility Safety

Level of compliance with laid down policies andLevel of compliance with laid down policies and

proceduresprocedures

BMW ManagementBMW Management

Standard PrecautionsStandard Precautions

Patient carePatient care

Fire SafetyFire Safety

Equipment ManagementEquipment Management

INTERVIEWINTERVIEW


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INTERVIEWINTERVIEW

Staff InterviewStaff Interview

To determine their level of awareness andTo determine their level of awareness and

compliance with organisation policies andcompliance with organisation policies andproceduresprocedures

To assess their awareness levels of theirTo assess their awareness levels of their

rights, privileges and patient rightsrights, privileges and patient rights

To determine their satisfaction levelsTo determine their satisfaction levels

Patient and family InterviewPatient and family Interview To assess their level of awareness of theTo assess their level of awareness of the

care process and their rightscare process and their rights

o determine their satisfaction levelso determine their satisfaction levels


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SCORING PATTERNSCORING PATTERN NABH has laid down the following patternNABH has laid down the following pattern

NonNon--compliancecompliance 00Partial compliancePartial compliance 55

Full complianceFull compliance 1010

No standard can have more than one zeroNo standard can have more than one zero

The average for a standard must exceed 5The average for a standard must exceed 5 The overall average score must exceed 7The overall average score must exceed 7

No zeros in legal requirementsNo zeros in legal requirements

OUTCOMES OF ACCREDITATIONOUTCOMES OF ACCREDITATION


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SURVEYSSURVEYS AccreditedAccredited

HCO shows acceptable compliance with laidHCO shows acceptable compliance with laid

down standards in all areasdown standards in all areas

Includes the scope of services for whichIncludes the scope of services for whichaccreditedaccredited

Any increase in scope the survey has to be Any increase in scope the survey has to be

done for the increased scopedone for the increased scope Accreditation deniedAccreditation denied

HCO is consistently non compliant withHCO is consistently non compliant with

standardsstandards

Accreditation withdrawnAccreditation withdrawn

HCO withdraws voluntarilyHCO withdraws voluntarily

Due to consistent non compliance or nonDue to consistent non compliance or non

adherence to safe and ethical practicesadherence to safe and ethical practices

DURATION OF ACCREDITATIONDURATION OF ACCREDITATION


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DURATION OF ACCREDITATIONDURATION OF ACCREDITATION

AWARDSAWARDS

Generally three years with one ReassessmentGenerally three years with one Reassessment

survey to ensure continued compliance and tosurvey to ensure continued compliance and to

assess the CQI programmeassess the CQI programme

If during accreditation NABH receives inputs thatIf during accreditation NABH receives inputs thatthe organisation is substantially out of compliancethe organisation is substantially out of compliance

with the current standards then Resurvey orwith the current standards then Resurvey or

withdrawal of accredited decision may be resortedwithdrawal of accredited decision may be resorted

toto

Summary of AccreditationSummary of Accreditation


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ProcessProcess

ApplicationsApplications Screening of the ApplicationsScreening of the Applications

PrePre--assessment surveyassessment survey

Assessment SurveyAssessment Survey

Review of the recommendations of theReview of the recommendations of the

assessing body by the Accreditationassessing body by the AccreditationCommitteeCommittee

Recommendations to the boardRecommendations to the board

Accreditation decisionAccreditation decision


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Brief Explanation of StandardsBrief Explanation of Standards

Access, Assessment and Continuity


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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 clearlydefined.

The defined services are prominentlydisplayed.

The staff is oriented to these services.

Admissions


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** Patients are accepted only if the organizationPatients are accepted only if the organization

can provide the required service.can provide the required service.

** TThe policies and procedures also addresshe policies and procedures also address

managing patients during non availability of beds.managing patients during non availability of beds.

Admissions

Transfer of patients


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* Transfer of unstable patients

* Transfer of stable patients

* Staff responsible during transfer

* Summary of patients condition and

the treatment given.

Assessment of patients


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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


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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


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* 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


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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


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Discharge process is planned

A discharge summary is given to all the

patients leaving the organization (including

patients leaving against medical advice)

Discharge


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Reasons for admission

Significant findings

Diagnosis

Patients condition at the time of discharge

Investigation results

Discharge


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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


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Patient Rights and EducationPatient Rights and Education

(PRE)(PRE)


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The organization protects patient and family rightsduring care

Objective Elements

Patient and family rights are documented

Patients and families are informed of their rights ina format and language that they can understand

The organizations leaders protect patients andfamily rights

Staff is aware of their responsibility in protectingpatients and family rights

Violation of patient and family rights is recorded,reviewed and corrective/preventive measures

taken

Rights

Respect for personal dignity and privacy


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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 researchprotocol is initiated

Information on how to voice a complaint

Information on the expected cost of thetreatment

Access to his / her clinical records

Informed Consent


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Situations where informed consent is required

Informed consent includes

information on risks

Benefits

alternatives

Who will perform the requisite procedure in alanguage that they can understand

Who can give consent when patient isincapable of independent decision making

Education


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Safe and effective use of medication

Potential side effects of the medication

Diet and nutrition

Immunizations

Specific disease process, complications andprevention strategies

Preventing infections

Language and format that they canunderstand

Care Of Patients (COP)


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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 practiceguidelines are adopted to guide patient care

whenever possible

Emergency servicesEmergency services


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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 patientsfor 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


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COP.3.The ambulance services are commensurate withthe 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 emergencymedications

Equipment are checked on a daily basis

Emergency medications are checked daily and prior todispatch

The ambulance(s) has proper communication system

CPR


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Documented policies and procedures guide theuniform 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 isdone by a multidisciplinary committee

Corrective and preventive measures are taken

n h - v n n l i

Blood transfusion


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Documented policies and procedures are usedto guide rational use of blood and bloodproducts

The transfusion services are governed by theapplicable laws and regulations

Informed consent is obtained for donation and

transfusion of blood and blood products

Informed consent also includes patient andfamily education about donation

Staff is trained to implement the policies

Transfusion reactions are analyzed for

preventive and corrective actions

ICUThe organization has documented admission and


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discharge criteria for its intensive care and highdependency units

Staff is trained to apply these criteria

Adequate staff and equipment are available

Defined procedures for situation of bed shortagesare followed

Infection control practices are followed

The unique needs of end of life patients are identifiedand cared for

A quality assurance program is implemented

Vulnerable patients Policies and procedures are documented and are


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in accordance with the prevailing laws and thenational and international guidelines

Care is organized and delivered in accordancewith 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 legalrepresentative

Staff is trained to care for this vulnerable group

Obstetrics

P li i d d id h f hi h i k


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Policies and procedures guide the care of high riskobstetrical 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 patients 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

Th i ti d fi d di l th f


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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,


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growth, psychosocial and immunization

assessment

Policies and procedures prevent child/ neonate

abduction and abuse

The childrens family members are educated about

nutrition, immunization and safe parenting and this is

documented in the medical record

Sedation

Competent and trained persons perform sedationTh d i i t i d it i


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The person administering and monitoringsedation is different from the person performingthe procedure

Intra-procedure monitoring includes at a minimumthe 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


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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


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periodic recording of heart rate, cardiac rhythm,

respiratory rate, blood pressure, oxygen saturation,

airway security and patency and level of anesthesia

Each patients 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


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Surgical patients have a preoperative assessmentand a provisional diagnosis documented prior tosurgery

An informed consent is obtained by a surgeon prior tothe procedure

Documented policies and procedures exist to preventadverse events like Wrong site, wrong patient and

wrong surgery

Persons qualified by law are permitted to perform theprocedures that they are entitled to perform

Surgery


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A brief operative note is documented prior totransfer out of patient from recovery area

The operating surgeon documents the post-operative plan of care

A quality assurance program is followed for thesurgical services

Standard

Policies and procedures guide the care of patients

Restraints


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Policies and procedures guide the care of patientsunder restraints (physical and / or chemical)

Objective Elements Documented policies and procedures guide the care of

patients under restraints

These include both physical and chemical restraintmeasures

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


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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 careStandard

COP 18 Policies and procedures guide the end of life


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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


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Management ofManagement of

Medication (MOM)Medication (MOM)

Drug committeeStandard


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Standard

Policies and procedures guide the organization of

pharmacy services and usage of medication

Objective Elements

There is a documented policy and procedure forpharmacy services and medication usage

These comply with the applicable laws and

regulations

A multidisciplinary committee guides the formulation

and im lementation of these olicies and rocedures

Formulary

Objective Elements


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Objective Elements

A list of medication appropriate for the

patients and organizations resources isdeveloped

The list is developed collaboratively by themultidisciplinary committee

There is a defined process for acquisition of

these medicationsThere is a process to obtain medications notlisted in the formulary

Storage of medication

Objective Elements


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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


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Objective Elements

Sound alike and look alike medications are

stored separately

There is a method to obtain medication when

the pharmacy is closedEmergency medications are available all thetime

Emergency medications are replenished in atimely manner when used

Prescription of medications

Objective Elements


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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

Obj ti El t


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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


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Safe dispensing of medicationsObjective Elements

Documented policies and procedures guidethe safe dispensing of medications

The policies include a procedure for

medication recall

Expiry dates are checked prior to

dispensingLabeling requirements are documented andimplemented by the organization

Medication administration

Objective Elements


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Objective Elements

Medications are administered by those who are

permitted by law to do soPrepared medication are labeled prior to preparationof 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 toadministration

Medication administration

Objective Elements


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j

Route is verified from the order prior to

administrationTiming is verified from the order prior toadministration

Medication administration is documented

Polices and procedures govern patients selfadministration of medications

Polices and procedures govern patientsmedications brought from outside the

organization

Medication education


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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


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j

Patients are monitored after medication

administration and this is documentedAdverse drug events are defined

Adverse drug events are reported within aspecified time frame

Adverse drug events are collected and analyzedPolicies are modified to reduce adverse drugevents when unacceptable trends occur

Narcotic drugs and psychotropicsubstances

Objective Elements


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Objective Elements

Documented policies and procedures guidethe use of narcotic drugs and psychotropicsubstances

These policies are in consonance with localand national regulations

A proper record is kept of the usage,

administration and disposal of these drugsThese drugs are handled by appropriatepersonnel in accordance with policies

Chemotherapeutic agents

Objective Elements


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Documented policies and procedures guidethe usage of chemotherapeutic agents

Chemotherapy is prescribed by those whohave the knowledge to monitor and treat the

adverse effect of chemotherapy

Chemotherapy is prepared and administered

by qualified personnelChemotherapy drugs are disposed off inaccordance with legal requirements.

Radioactive or investigational drugs

Objective Elements


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Documented policies and procedures governusage of radioactive or investigational drugs

These policies and procedures are inconsonance with laws and regulations

The policies and procedures include the safestorage, preparation, handling, distributionand disposal of radioactive and investigationaldrugs

Staff, patients and visitors are educated on

safety precautions

Implantable prosthesis

Objective Elements


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Documented policies and procedures governprocurement and usage of implantableprosthesis

Selection of implantable prosthesis is based

on scientific criteria and internationallyrecognized approvals

The batch and serial number of the

implantable prosthesis are recorded in thepatients medical record and the masterlogbook

Medical gases

Objective Elements


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Documented policies and procedures govern

procurement, handling, storage, distribution,usage and replenishment of medical gases.

The policies and procedures address thesafety issues at all levels

Appropriate records are maintained inaccordance with the policies, procedures andlegal requirements.


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Hospital Infection Control (HIC)

Infection control programStandard

The organization has a well-designed, comprehensiveand coordinated Hospital Infection Control (HIC)


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and coordinated Hospital Infection Control (HIC)programme aimed at reducing/ eliminating risks topatients, 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 activityThe hospital infection control programme isdocumented.

Infection control manual

The manual identifies the various high-riskareas


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areas.

It outlines methods of surveillance in the

identified high-risk areas.

Focuses on adherence to standardprecautions at all times.

Equipment cleaning and sterilisation practices

An appropriate antibiotic policy is establishedand implemented.

Infection control manual

Laundry and linen management processes


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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


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pp p y

towards the identified high-risk areas.

Collection of surveillance data is an ongoingprocess.

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 incorporatestracking and analysing of infection risks, rates and

Hospital Associated Infections (HAI)

Objective Elements

The organization monitors urinary tract infections.


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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 areprovided on a regular basis to medical and nursing

staff.

Resources

Hand washing facilities in all patient careareas are accessible to health care


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areas are accessible to health careproviders.

Compliance with proper hand washing ismonitored regularly.

Isolation/ barrier nursing facilities areavailable.

Adequate gloves, masks, soaps, anddisinfectants are available and usedcorrectly.

Outbreaks of infections

Hospital has a documented procedure for handlingsuch outbreaks.


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This procedure is implemented during outbreaks.

After the outbreak is over appropriate correctiveactions are taken to prevent recurrence.

CSSD

There is adequate space available for sterilizationactivities

Regular validation tests for sterilisation are carried

out and documented.

There is an established recall procedure whenbreakdown in the sterilisation system is identified.

Bio-medical waste management


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Proper segregation and collection of Bio-medical Waste from all patient care areas ofthe 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


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p g y q

from its annual budget in this regard.

It conducts regular pre-induction training forappropriate categories of staff before joiningconcerned departments

It also conducts regular in-service trainingsessions for all concerned categories of staff atleast once in a year.

Appropriate pre and post exposure prophylaxis isprovided to all concerned staff members.

And You Thought You Had aAnd You Thought You Had a

MigraineMigraine


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UnfortunatelyUnfortunately


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UnfortunatelyUnfortunately

There isThere isMoreMore

ToTo

FollowFollow

SORRY !!!!!!SORRY !!!!!!

This is for all of youThis is for all of you--ourour


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yy

friends .friends .

20.09.2008 10:3220.09.2008 10:3220.09.2008 10:3220.09.2008 10:3220.09.2008 10:3220.09.2008 10:3220.09.2008 10:3220.09.2008 10:32

Sometimes the pressureSometimes the pressure

Is so highIs so high


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Is so high...Is so high...

The hours are so long...The hours are so long...The problems so big...The problems so big...

The whole world seems toThe whole world seems to

be against you...be against you...Do you know what youDo you know what youshould do?should do?

Pretend that all that is not happening to you!Pretend that all that is not happening to you!


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Have fun!Have fun!

Act silly!Act silly!


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DonDont listen to the ones who maket listen to the ones who make

you feel depressed!you feel depressed!


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Smile!Smile!

Ignore your problems!Ignore your problems!


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Do what you enjoy!Do what you enjoy!


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Stop worrying!Stop worrying!

Be warm and loving!Be warm and loving!


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Make timeMake timefor the thingsfor the things


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for the thingsfor the things

you love!you love!

M k f fM k f f


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Make fun ofMake fun of

trouble!trouble!

Leave your fearsLeave your fears

aside and...aside and...


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Be a bit ridiculous!Be a bit ridiculous!

Fight forFight for

perfection...perfection...


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...but not to exhaustion!...but not to exhaustion!

Life is better when we have fun...Life is better when we have fun...


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...so do anything you like....so do anything you like.

And the mostAnd the most

importantimportant::


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Life doesnLife doesntt

end today...end today...

And doesnAnd doesnt start tomorrowt start tomorrow......


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DonDont stop!!t stop!!


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pp

Each minute of stressEach minute of stress

is wasted timeis wasted time

This is why I wish you:This is why I wish you:


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A little madness and a littleA little madness and a little

imagination, so you can see life betterimagination, so you can see life betterthan usual!!than usual!!

The End showThe End showThe End showThe End showThe End showThe End showThe End showThe End show20.09.2008 10:3220.09.2008 10:3220.09.2008 10:3220.09.2008 10:3220.09.2008 10:3220.09.2008 10:3220.09.2008 10:3220.09.2008 10:32


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And donAnd dont forgett forget::

Smile!Smile!In life everything is nicer whenIn life everything is nicer when

you cheer up.you cheer up.

Because The Show Must GO ON!Because The Show Must GO ON!


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Continuous Quality ImprovementContinuous Quality Improvement

Structured Quality ImprovementStructured Quality Improvement


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ProgrammeProgramme-- Documented, developed ,maintainedDocumented, developed ,maintained

and updated by a multi disciplinaryand updated by a multi disciplinarycommitteecommittee

-- Communicated and coCommunicated and co ordinatedordinatedamongst all employeesamongst all employees


Key Indicators to monitor ClinicalKey Indicators to monitor ClinicalStructures , Processes and OutcomesStructures , Processes and Outcomes


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Structures , Processes and OutcomesStructures , Processes and Outcomes

-- Invasive ProceduresInvasive Procedures-- Diagnostic servicesDiagnostic services

--

Adverse drug EventsAdverse drug Events

-- Use ofUse ofAnaesthesiaAnaesthesia

-- Use of blood and Blood ProductsUse of blood and Blood Products

-- Infection control ActivitiesInfection control Activities-- Clinical researchClinical research


Key Indicators to monitor ManagerialKey Indicators to monitor Managerial


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Structures , Processes and OutcomesStructures , Processes and Outcomes

-- Medication ProcurementMedication Procurement

-- UtilisationUtilisation of facilitiesof facilities

-- Patient and Employee satisfactionPatient and Employee satisfaction

-- Adverse EventsAdverse Events


Established system of Clinical AuditEstablished system of Clinical Audit


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-- Participation of Medical StaffParticipation of Medical Staff

-- Defining of parametersDefining of parameters

-- Maintenance of patient and clinicianMaintenance of patient and clinician

anonymityanonymity

-- Documentation of AuditsDocumentation of Audits

-- Institution of remedial measuresInstitution of remedial measures


Sentinel events are intensivelySentinel events are intensively analysedanalysed


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-- Defining of sentinel eventsDefining of sentinel events

-- Established processes for intenseEstablished processes for intense

analysisanalysis

-- Corrective and Preventive measures areCorrective and Preventive measures are

undertaken based upon the analysisundertaken based upon the analysis

RESPONSIBILITIES OFRESPONSIBILITIES OF

MANAGEMENTMANAGEMENT

Responsibilities are definedResponsibilities are defined


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-- Documented organogramDocumented organogram

-- Appoint senior leadersAppoint senior leaders

-- Support QIPSupport QIP

-- Org complies with statutory obligationsOrg complies with statutory obligations

-- Address the org social responsibilitiesAddress the org social responsibilities



Services provided by each department areServices provided by each department are


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documenteddocumentedEach org programme ,service,Each org programme ,service,

department has effective leadershipdepartment has effective leadershipScope of services are definedScope of services are defined

AdmAdm policies and procedures arepolicies and procedures aremaintainedmaintained



Org is managed in an ethical mannerOrg is managed in an ethical manner


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-- Org discloses its ownershipOrg discloses its ownership

-- Honestly portrays the services that itHonestly portrays the services that it

can or cannot providecan or cannot provide

-- Accurately bills based upon a standardAccurately bills based upon a standard

tarifftariff


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FACILITIES MANAGEMENT ANDFACILITIES MANAGEMENT AND

SAFETYSAFETY

Org has a programme for clinical andOrg has a programme for clinical andsupport servicesupport service eqpteqpt managementmanagement


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-- Plans forPlans for eqpteqpt in a collaborative mannerin a collaborative mannerin accordance with the services providedin accordance with the services provided

-- AllAll eqpteqpt are inventoried and proper logsare inventoried and proper logs

maintainedmaintained-- Qualified and trained personnel operateQualified and trained personnel operateand maintain theand maintain the eqpteqpt

-- EqptEqpt are periodically inspected andare periodically inspected andcalibratedcalibrated

-- Preventive and breakdown MaintenancePreventive and breakdown MaintenancePlanPlan

FACILITIES MANAGEMENT ANDFACILITIES MANAGEMENT AND

SAFETYSAFETY

Org has provisions for safe water,Org has provisions for safe water,

electricity, medical gases and vacuumelectricity, medical gases and vacuum


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electricity, medical gases and vacuumelectricity, medical gases and vacuum

systemssystems

Org has plans for fire and non fireOrg has plans for fire and non fire

emergenciesemergencies

Org has plans for handlingOrg has plans for handling

communitycommunity emergencies,epidemicsemergencies,epidemicsand other disasters.and other disasters.

HUMAN RESOURCES MANAGEMENTHUMAN RESOURCES MANAGEMENT

Org has documented system ofOrg has documented system of

Human resource PlanningHuman resource Planning


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Human resource PlanningHuman resource Planning

-- Maintains an adequate number and mixMaintains an adequate number and mix

of staff to meet the needs of patientsof staff to meet the needs of patients

-- The required job specifications andThe required job specifications anddescriptions are well defined for eachdescriptions are well defined for each

category of staffcategory of staff

-- Org verifies the antecedents of theOrg verifies the antecedents of the

potential employeepotential employee


SocialisationSocialisation and Orientation of theand Orientation of the

new employeesnew employees


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new employeese e p oyees

-- Orientation to the OrgOrientation to the Org

-- Awareness of hospital and departmentalAwareness of hospital and departmental

policies and procedurespolicies and procedures-- Awareness of his and patients rightsAwareness of his and patients rights

and responsibilitiesand responsibilities

-- Orientation to the service standards ofOrientation to the service standards of

the orgthe org


Ongoing Programme for professionalOngoing Programme for professionaltraining and development of stafftraining and development of staff


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Performance Appraisal systemPerformance Appraisal systemDisciplinary ProceduresDisciplinary Procedures

Grievance handling MechanismGrievance handling MechanismHealth needs of employeesHealth needs of employees

Personal record of each staff memberPersonal record of each staff member Credentialing and PrivilegingCredentialing and Privileging

INFORMATION MANAGEMENTINFORMATION MANAGEMENT

SYSTEMSYSTEM

Info needs of the organisation areInfo needs of the organisation areidentifiedidentified


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Policies and procedures to meet thePolicies and procedures to meet theneeds exist and are in accordanceneeds exist and are in accordance

with the prevailing laws andwith the prevailing laws and

regulationsregulations

Org contributes to the data base ofOrg contributes to the data base of

other organisations in accordanceother organisations in accordancewith the law of the land.with the law of the land.


SYSTEMSYSTEM

Effective Management of dataEffective Management of data

-- Formats areFormats are standardisedstandardised


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-- Procedures laid down for timely andProcedures laid down for timely and

accurateaccurate dissemination,storagedissemination,storage andand

retrieval of dataretrieval of data

-- Participation of staff in selecting,Participation of staff in selecting,

integrating andintegrating and utilisingutilising datadata


SYSTEMSYSTEM

Complete and accurate MedicalComplete and accurate Medicalrecord for each patientrecord for each patient


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-- Every Record has a unique identifierEvery Record has a unique identifier-- Every entry is dated and timedEvery entry is dated and timed

-- The author of the entry can beThe author of the entry can be

identifiedidentified

-- The record provides chronological andThe record provides chronological and

updated account of patient careupdated account of patient care


SYSTEMSYSTEM

Policies and procedures addressPolicies and procedures address

Confidentiality, Integrity and SecurityConfidentiality, Integrity and Security


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of Informationof Information

Policies and Procedures exist forPolicies and Procedures exist for

retention time of recordsretention time of records

Medical Audits are carried outMedical Audits are carried out

regularly.regularly.


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WHAT SHOULD WE DO?WHAT SHOULD WE DO?


Quality ManualQuality Manual

Various Policies and ProceduresVarious Policies and Procedures

Identify High Risk Areas for patientIdentify High Risk Areas for patient


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care and safetycare and safety Identify Sentinel Events forIdentify Sentinel Events for

monitoringmonitoring

Provide resources for QualityProvide resources for QualityImprovementImprovement

Alter Mind setAlter Mind set Identify gaps between what isIdentify gaps between what is

expected and what existsexpected and what exists


THE HOSPITALTHE HOSPITAL OrganogramOrganogram



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Methodology followed for QualityMethodology followed for QualityImprovementImprovement

Facilities providedFacilities provided

Inputs on resources provided for QualityInputs on resources provided for QualityImprovementImprovement

Identified high Risk Areas for patient careIdentified high Risk Areas for patient care

and safetyand safety Sentinel Events being monitoredSentinel Events being monitored

DOCUMENT REVIEWDOCUMENT REVIEW

Quality ManualQuality Manual

Various Policies and ProceduresVarious Policies and Procedures


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Minutes of Meetings of various committeesMinutes of Meetings of various committees

Medical RecordsMedical Records

Medical / Nursing AuditMedical / Nursing Audit Adverse EventsAdverse Events

HAIHAI

Action Taken ReportsAction Taken Reports

OBSERVEOBSERVE

Facility SafetyFacility Safety

Level of compliance with laid downLevel of compliance with laid down

policies and procedurespolicies and procedures


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CPRCPR BMW ManagementBMW Management

Standard PrecautionsStandard Precautions

Patient carePatient care

HAIHAI

Fire SafetyFire Safety

Equipment ManagementEquipment Management

INTERVIEWINTERVIEW

Staff InterviewStaff Interview To determine their level of awareness andTo determine their level of awareness and

compliance with organisation policies andcompliance with organisation policies and

dd


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proceduresprocedures To assess the awareness levels of theirTo assess the awareness levels of their

rights, privileges and patient rightsrights, privileges and patient rights


Patient and family InterviewPatient and family Interview

To assess their level of awareness of theTo assess their level of awareness of thecare process and their rightscare process and their rights


Key Monitoring IndicatorsKey Monitoring Indicators ResourceResource

V lV l

MONITORMONITOR


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VolumeVolume UtilizationUtilization

PerformancePerformance

Control chartsControl charts

Problems faced and remedialProblems faced and remedial

measures undertaken/ beingmeasures undertaken/ being

undertakenundertaken


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STRENGTHSSTRENGTHS

Professionally competent staffProfessionally competent staff

W ll l id d li i dW ll l id d li i d


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Well laid down policies andWell laid down policies and

proceduresprocedures

Disciplined work forceDisciplined work force

By and Large known clienteleBy and Large known clientele

Supportive Top managementSupportive Top management

CHALLENGESCHALLENGES

Attitudinal ChangeAttitudinal Change

Removing blind spotsRemoving blind spots


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Creating a holistic approach toCreating a holistic approach to medimedi

care.care.

Overcoming constraintsOvercoming constraints

Making benchmarks for servicesMaking benchmarks for services

providedprovided

Im lementin A ro rammesImplementing QA programmes

EXPERIENCESEXPERIENCES

HCOsHCOs are very enthusiasticare very enthusiastic

Ill preparedIll prepared


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Ill preparedIll prepared

Initial preparation is shoddyInitial preparation is shoddy

Resources required initiallyResources required initially

Benefits have a longer gestationBenefits have a longer gestation

periodperiod

PROBLEMS AND CHALLENGESPROBLEMS AND CHALLENGES

Quality Consciousness at all levels will takeQuality Consciousness at all levels will taketimetime

Sustenance and consistency of efforts willSustenance and consistency of efforts will

be requiredbe required


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be requiredbe required Commitment on a consistent basisCommitment on a consistent basis

High rates of attrition will require repeatedHigh rates of attrition will require repeatedand continual trainingand continual training

Public Sector will take a longer time to getPublic Sector will take a longer time to get

into the processinto the process

Quality and consistency of assessors andQuality and consistency of assessors andassessmentsassessments


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Also Nothing IsAlso Nothing Is

ImpossibleImpossible


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For,For,


MeansMeans


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MeansMeans

IIM PossibleM Possible

Quality Norms and Accreditation??


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Response of Medical Fraternity

Expected ResponseExpected Response


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There was a man whoThere was a man who

had four sons.had four sons.

He wanted his sons toHe wanted his sons to

learn not to Judgelearn not to Judge


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learn not to Judgelearn not to Judge

things too quickly.things too quickly.

So he sent them eachSo he sent them each

on aon a quest,inquest,in turn,toturn,to

go and look at a peargo and look at a pear

tree that was a greattree that was a great

distance awaydistance away

The first son went in the

winter,

the second in the spring,th thi d i


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the second in the spring,the third in summer,

and the youngest son in the

fall.


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When they had all gone andWhen they had all gone and

come back, he called themcome back, he called them

together to describe what theytogether to describe what they

had seenhad 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.


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The third son disagreed; he said it was laden with blossomsThe third son disagreed; he said it was laden with blossomsThe third son disagreed; he said it was laden with blossomsThe third son disagreed; he said it was laden with blossomsthat smelled sothat smelled sothat smelled sothat smelled so

sweet and looked so beautiful, it was the most gracefulsweet and looked so beautiful, it was the most gracefulsweet and looked so beautiful, it was the most gracefulsweet and looked so beautiful, it was the most graceful

thing he had everthing he had everthing he had everthing he had ever

seen.seen.seen.seen.

The last son disagreed with all of them; he said it was ripeThe last son disagreed with all of them; he said it was ripeThe last son disagreed with all of them; he said it was ripeThe last son disagreed with all of them; he said it was ripe

andandandand

drooping with fruit, full of life anddrooping with fruit, full of life anddrooping with fruit, full of life anddrooping with fruit, full of life and fulfilmentfulfilmentfulfilmentfulfilment....


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p gp gp gp g

The man then explained to his sons that they wereThe man then explained to his sons that they wereThe man then explained to his sons that they wereThe man then explained to his sons that they were

all right, because theyall right, because theyall right, because theyall right, because they

had each seen but only one season in the tree'shad each seen but only one season in the tree'shad each seen but only one season in the tree'shad each seen but only one season in the tree's

life.life.life.life.


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He told them that you cannot judge a tree, or aHe told them that you cannot judge a tree, or aHe told them that you cannot judge a tree, or aHe told them that you cannot judge a tree, or aperson, by only one season,person, by only one season,person, by only one season,person, by only one season,

and that the essence of who they are and theand that the essence of who they are and theand that the essence of who they are and theand that the essence of who they are and the

pleasure, joy, and love thatpleasure, joy, and love thatpleasure, joy, and love thatpleasure, joy, and love thatcome from that life can only be measured atcome from that life can only be measured atcome from that life can only be measured atcome from that life can only be measured at

the end, when all the seasonsthe end, when all the seasonsthe end, when all the seasonsthe end, when all the seasons

are up.are up.are up.are up.


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pppp

If you give up when it'sIf you give up when it'sIf you give up when it'sIf you give up when it's

winter,winter,winter,winter,

you will miss the promise ofyou will miss the promise ofyou will miss the promise ofyou will miss the promise of

youryouryouryourspring, the beauty of yourspring, the beauty of yourspring, the beauty of yourspring, the beauty of your

summer,summer,summer,summer,

fulfillment of your fall.fulfillment of your fall.fulfillment of your fall.fulfillment of your fall.


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Don't let the pain of one season destroy theDon't let the pain of one season destroy theDon't let the pain of one season destroy theDon't let the pain of one season destroy the

joy of all the rest.joy of all the rest.joy of all the rest.joy of all the rest.

Don't judge life by one difficult season.Don't judge life by one difficult season.Don't judge life by one difficult season.Don't judge life by one difficult season.


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Persevere through thedifficult patches

and better times are sureto come

some time.


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Aspire to Inspire Before You Expire


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Live Simply Love Generously. Care

Deeply. Speak Kindly.Leave the Rest to God.

Happiness keeps YouSweet,

Trials keep You Strong,


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Sorrows keep You Human


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Success keeps You Glowing,


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But Only Effort and Faith keeps You Going


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Take the first stepsAndKeep the Effort Going

U WILL SOON FIND THE PATH


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And thesunshine willfollow

THE CURRENT STATUS OFTHE CURRENT STATUS OFACCREDITATION IN INDIAACCREDITATION IN INDIA

Initializing phase is over.Initializing phase is over.

Phase of consolidation.Phase of consolidation.

The initial steps have been difficult butThe initial steps have been difficult but


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The initial steps have been difficult butThe initial steps have been difficult but

the journey has begun.the journey has begun.

The journey has to continueThe journey has to continue..

Especially sinceEspecially since ------------------------------------------------------

ACCREDITATION IS A JOURNEYACCREDITATION IS A JOURNEY

ANDAND


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ANDAND

NOT A DESTINATION.NOT A DESTINATION.

BON VOYAGE !!!!!BON VOYAGE !!!!!


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BON VOYAGE !!!!!BON VOYAGE !!!!!


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Accreditation Process Col Pawan Kapoor1

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Transcript of Accreditation Process Col Pawan Kapoor1