Case study of an accredited hospital final
Transcript of Case study of an accredited hospital final
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Case study of an Accredited Hospital- our experience
NSD RajuRanjini Eye Hospital (India’s first NABH
Accredited SHCO )
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• I have no financial interest or relationships to disclose
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Day care Ophthalmic surgical Center
Small Health Care Organization ( SHCO)
Ambulatory Ophthalmic Surgical Centre
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Our Ophthalmic Out patient surgical Centre
• Located in an open space• Accessibility• Parking facility• Built in area
5000 sq.ft
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Journey towards Accreditation
• NABH came into being in 2006• Applied for NABH in 2007• Pre assessment and final auditing done • Did not fully conform to the rigid standards
laid down for bigger institutions• Assessors impressed by the standard of
Patient care and other supportive and utility services
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Journey Continues
• NABH Set Standards• for Small Heath Care Org• Bed Strength up to 50• Appropriate supportive and utility services• Polyclinics and diagnostic centers not included• Specialty Day care centers included • Bed strength not mandatory
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The Final Accreditation
• Our center then came under the category of SHCO
• Centre Eligible for NABH accreditation
• Reapplied for NABH accerditation after a self assessment auditing
• Final auditing in 2009 –cleared for NABH accrditation
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Why NABH for Small Ophthalmology Hospitals
• Commitment to quality health care• Benchmark with international quality• Continuous improvement• Community confidence• Empanelment in government and insurance
schemes , medical tourism patronage
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Accreditation Standards- Patient Care Oriented
• 1.Access, Assessment and continuity of Care (AAC)
• In the care of patients rehabilitation excluded
• Management of Medications narcotics delete• Patients Rights and education• Hospital Infection Control
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Accreditation Standards- Organization Oriented
• Continuous Quality Improvement (CQI)
• Responsibilities of Management (ROM)
• Facility Management and Safety (FMS)
• Human Resource Management (HRM)
• Information Management System (IMS)
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Continuous Quality Continuous Quality Improvement Improvement
Structured quality improvement Monitor tools for continual improvement of
structures processes and outcomes Established system for clinical audit Analyze sentinel events
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Hospital Infection Control
• Well defined coordinated comprehensive HIC• Infection control manual• Measures to reduce hospital associated
infections – designing surgical suite• Documented Sterilization Procedures
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Information Management System
• Effective management of data
• Converted to complete and accurate EMR
• Paperless Office ensure continuity of service
• Documented procedure for safety and security
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Patient Rights and Education
• Protection of patient and family
• Documented policy for consent
• Right to information about their health care needs and cost of treatment
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Responsibilities of Management
Responsibilities of management well defined
Patient safety aspects and risk management issues forms an integral part of hospital management
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Other Measures
• MOU with Hospital for Patients needing admission/emergency
• Arrangement for ambulance Facility
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Conclusion
• NABH Benefits• Ongoing continuing process of
improvement
• Ensures best possible team work in a Health Care Organization
•
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Thank You