Journey towards healthcare excellance Tips to overcome ... · PDF file1 National Accreditation...
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National Accreditation Board for Hospitals & Healthcare Providers
Tips to overcome most common obstacles in Preparing for NABH
accreditation
Dr S Murali MD DMConsultant Neurologist
Manipal Hospital
Bangalore
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National Accreditation Board for Hospitals & Healthcare Providers
Journey towards healthcare excellance
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Achieve Service & Clinical Excellence
Healthcare Accreditation
Establish quality systems
National Accreditation Board for Hospitals & Healthcare Providers
Perceived Obstacles• Understanding by the TOP management
• Who will drive it
• Documentation
• Legal
• Infrastructure
• Manpower
• Clinician involvement
• Others including certain grey areas – viz End of
life care3
National Accreditation Board for Hospitals & Healthcare Providers
Regulatory Compliance
Total Quality Management in a Hospital
Regulations, Laws, Ethics
National Accreditation Board for Hospitals & Healthcare Providers
Documentation
Regulatory Compliance
Total Quality Management in a Hospital
Efficiency
Process Management
Regulations, Laws, Ethics
National Accreditation Board for Hospitals & Healthcare Providers
Excellence in patient care
Documentation
Regulatory Compliance
Total Quality Management in a Hospital
Complaint, Waste, and Defect
Reductions, Elimination of Rework
Efficiency
Process Management
Regulations, Laws, Ethics
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National Accreditation Board for Hospitals & Healthcare Providers
Recog-
nition of
Quality
Excellence in patient care
Documentation
Regulatory Compliance
Total Quality Management in a Hospital
Patient Satisfaction
Employees' Satisfaction
Management Satisfaction
Complaint, Waste, and Defect
Reductions, Elimination of Rework
Efficiency
Process Management
Regulations / Laws
National Accreditation Board for Hospitals & Healthcare Providers
TOP Management
• Should believe that having standard
quality through accreditation will add value
• Aim at improving quality and accreditation
is a by product
• Unconditional support to the quality team
• Should understand its own role – esp in
context to mission, vision, operation and
strategic plan
• Track of all legal requirements8
National Accreditation Board for Hospitals & Healthcare Providers
Who will drive it
• Team and not dependent on a single
individual
• Accreditation co ordinater
• Form subgroups involving relevant stake
holders.
• Educate the team - POI
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National Accreditation Board for Hospitals & Healthcare Providers
Documentation Pyramid
• 1 – Quality Manual (Apex Manual)
• 2 – Documented Policies & Procedures, Patient Flow Diagrams, Organograms
• 3 - Work Instructions, SOPs where required
• 4 - Records, Formats, Registers, Forms
• 5 - External Documents, Statutory &
Regulatory requirements
Ensure that the end user is involved in documentation.
National Accreditation Board for Hospitals & Healthcare Providers
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NABH ACCREDITATIONSample headings for Policies
• Scope / Aim / Objective
• Definition• Indications• Responsibilities• Contents / explanations / detailing or various processes • Pre procedure / procedure / post procedures
• Resources• Training requirements• Monitoring and analysis• Corrective and preventive action• References
National Accreditation Board for Hospitals & Healthcare Providers
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NABH ACCREDITATIONCommittees – Salient features• Composition
• tenure
• roles and responsibilities
• objectives
• functioning
• quoram
• Meetings / agenda
• minutes
• monitoring
• reporting pattern
• reports
• action taken
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National Accreditation Board for Hospitals & Healthcare Providers
Legal• Identify all legal requirements
• Maintain a compliance registrar with the
following
– Name
– Number
– Status
– One time or renewable( if renewable the next date)
– Responsibility for renewals and updating the
amendments
– Conditions if any13
National Accreditation Board for Hospitals & Healthcare Providers
Infrastructure
• Identify all the infrastructure requirements
• Segregate them into – essential and
desirable
• Prioritise as per the essentiality and the
availability of resources.
• Consult experts in the field if required and
start work early
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National Accreditation Board for Hospitals & Healthcare Providers
Manpower
• Identify requirement and have an effective
manpower planning
• Grey areas
• Compliance
• Reference
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National Accreditation Board for Hospitals & Healthcare Providers
Clinician Involvement
• Educate on the benefits of accreditation to
the clinician
• Educate on improvements in patient safety
that accreditation can provide
• Educate on what is the minimum
involvement of the clinician to ensure the
above
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National Accreditation Board for Hospitals & Healthcare Providers
Other perceived Pain areas
• PAIN
• ADVERSE DRUG EVENTS
• END OF LIFE CARE
• AIR CONDITIONING
• MEDICAL AUDITS
• INDICATORS
• TRAINING
• PREVILEGING AND CREDENTIALING17
National Accreditation Board for Hospitals & Healthcare Providers
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NABH ACCREDITATION
• Identify teams
• Identify and form / merge relevant committees
• Workshop
• Next deadline – Identify gaps and prepare draft
document - date
• Next meeting / frequency
• Training of various groups
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National Accreditation Board for Hospitals & Healthcare Providers
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NABH ACCREDITATION
• Sensitisation of various professional
• Form Sub groups and delegate
• Have the mandatory committees formed
• Identify and implement training requirements
• Identify and address all infracture,statuary and legal
compliance
• Target dates for completing documentation and implementation
• Periodic review
National Accreditation Board for Hospitals & Healthcare Providers
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NABH ACCREDITATIONSteps
• Multidisciplinary team
• Steering committee for NABH
• Understand the standards - workshops
• Form subgroups and Identify gaps from the existing practices and from other quality management systems in relation to the NABH standards
• Interact / educate the end users regarding the same
• Help the relevant stake holders in preparation of the policies and procedures that complies with the NABH standard – approved by the core committee /director medical / admin services/legal team and implement
National Accreditation Board for Hospitals & Healthcare Providers
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NABH ACCREDITATIONSteps
• Ensure NABH standards are implemented and integrated in the hospital functioning
• Do an internal audit
• Call for pre-assessment
• Corrective actions
• Assessment
• ACCREDITATION
• Maintain quality improvement programme
National Accreditation Board for Hospitals & Healthcare Providers
Carry Home message• Prioritise
• Give importance to processes
• At every point ensure that the standard is
addressed
• Make the process simple – Have processes
that can be followed rather than what is ideal.
• Identify and address crucial infrastructure and
draw a plan for the rest
• Train your group - POI22
National Accreditation Board for Hospitals & Healthcare Providers
Carry Home message
• Manpower (IPHS) and bed occupancy
• Focus on training
• Statutory obligations has to be met
• Identify and implement completely all the
easily implementable processes
• Difficult one go on a step by step manner.
• Take 3 standards per week
• Accreditation levels23
National Accreditation Board for Hospitals & Healthcare Providers
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NABH ACCREDITATION
Follow each objective element meticulously and accreditation will follow
Thank You