Quality Council of India

Report
Accreditation: A Magic Wand
ISQua Webinar
July 10, 2014
B.K. Rana
Joint Director, NABH
Vice- Chairman, Accreditation Council of ISQua
2
Topics to be covered
▫ What is accreditation?
▫ Benefits of accreditation
▫ Various accreditation bodies – case study of
NABH
▫ Linkage with licensing/regulation
▫ Voluntary vs Mandatory
▫ Accreditation and Patient Safety
▫ Global Scenario & Role of ISQua
▫ Magic of Accreditation
National Accreditation Board for Hospitals & Health Care Providers
3
What is accreditation?
• Procedure by which an authoritative body gives
formal recognition that an organization is
competent to carry out specific tasks.
(ISO 15189:2012- Medical Laboratories:
Requirements for Quality and Competence)
National Accreditation Board for Hospitals & Health Care Providers
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What is accreditation(AB Accreditation)?
• A public recognition of the achievement of the
standards by a healthcare organisation,
demonstrated through an independent external
peer assessment (by AB) of that body’s
organisational performance in relation to the
standards.
National Accreditation Board for Hospitals & Health Care Providers
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What is accreditation (ISQua
Accreditation)?
• A public recognition of the achievement of the
standards by a healthcare external
evaluation body, demonstrated through an
independent external peer assessment (by
ISQua) of that body’s organisational
performance in relation to the standards.
(ISQua 2013)
National Accreditation Board for Hospitals & Health Care Providers
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What is Accreditation?
• Strategic change and risk
management tool
• Proactive and continuous
• Transparent and rigorous analysis
of service provision
• Addresses current and future
patient needs facilitated by:
▫ Independent third party
▫ Quality Improvement focus
▫ Objectivity
(slide from Phil Hassen’s webinar)
National Accreditation Board for Hospitals & Health Care Providers
Accreditation
Is a
process
Not an event
National Accreditation Board for Hospitals & Health Care Providers
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Benefits of accreditation
Benefits for Patients
Patients are the biggest beneficiary among all the
stakeholders. Accreditation results in high
quality of care and patient safety. The patients
are serviced by medical staff with established
credentials. Rights of patients are respected and
protected. Patients satisfaction is regularly
evaluated.
National Accreditation Board for Hospitals & Health Care Providers
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Benefits of accreditation
Benefits for Hospitals
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.
National Accreditation Board for Hospitals & Health Care Providers
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Benefits of accreditation
Benefits for Hospital Staff
The staff in an accredited hospital is more satisfied
as it provides for continuous learning, good
working environment, leadership and above all
ownership of clinical processes. It improves
overall professional development of Clinicians,
Nurses and Para Medical Staff and provides
leadership for quality improvement.
National Accreditation Board for Hospitals & Health Care Providers
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Benefits of accreditation
Benefits to paying and regulatory bodies
Finally, accreditation provides an objective system
of empanelment by insurance and other third
parties. Accreditation provides access to reliable
and certified information on facilities,
infrastructure and level of care.
National Accreditation Board for Hospitals & Health Care Providers
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Various Accreditation Bodies
National Accreditation Board for Hospitals & Health Care Providers
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Various accreditation bodies
Across the globe, in healthcare domain, several
Accreditation Bodies (AB) are functional. There
is no classification, however on the basis of
length of their operation and credibility of their
programs, I have classified them into:
• Developed AB
• Developing AB
• Struggling AB
National Accreditation Board for Hospitals & Health Care Providers
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Various accreditation bodies
• Developed AB (Long length of operations and
ISQua accredited organisation, standards and
surveyor training )
• Developing AB (Couple of years of operations
and ISQua accredited organisation/standards/
surveyor training )
• Struggling AB (No ISQua accreditation*)
* Exceptions may be there e.g. The Joint Commission, USA; China
National Accreditation Board for Hospitals & Health Care Providers
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Various accreditation bodies
A. Developed AB:
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Accreditation Canada
ACHS, Australia
HAS, France
Joint Commission International, USA
COHSASA, South Africa
TJCHA, Taiwan
MSQH, Malaysia
CHKS, UK
NIAZ, The Netherlands
AABB, USA
IKAS, Denmark
National Accreditation Board for Hospitals & Health Care Providers
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Various accreditation bodies
B. Developing AB:

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NABH, India
HCAC, Jordan
DAP BC, Canada
Healthcare Accreditation Institute, Thailand
Australian General Practice Accreditation Ltd
Australian Aged Care Quality Agency
DNV, Norway
HDAA, Australia
HDANZ, New Zealand
Japan Council for Quality Health Care
National Accreditation Board for Hospitals & Health Care Providers
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Various accreditation bodies

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Quality Improvement Council
DAA Group Limited, New Zealand
Health Accreditation Service (ICONTEC), Columbia
Canadian Accreditation Council of Human Services
Global Mark, Australia
QHA Trent, UK
 CQA Canada; RACGP Australia; KOIHA Korea;
HKAG Hong Kong; CBAHI Saudi Arabia; MOH
Kazakhstan; CPQ UAE; ONA Brazil; ALIAD Spain;
MOH Turkey; CPSA Canada
National Accreditation Board for Hospitals & Health Care Providers
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Various accreditation bodies
C. Struggling AB:
Rest of the accreditation organizations not
listed in A & B (with exceptions*)
 PCAHO, Philippines
 Pakistan is trying to develop one
 Sri Lanka
National Accreditation Board for Hospitals & Health Care Providers
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Case study of
National Accreditation
Board for Hospitals and Healthcare Providers
(NABH)
Indian AB
Established in 2006, under Quality Council of
India, a not-for-profit Society.
Independent Board comprising members from
various stakeholders
National Accreditation Board for Hospitals & Health Care Providers
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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.
National Accreditation Board for Hospitals & Health Care Providers
NABH Accreditation Programs
Accreditation of Hospitals
Accreditation of Blood Banks
Accreditation of SHCO/ Nursing Homes
Accreditation of OST Centers
Accreditation of PHC/CHCs
Accreditation of AYUSH hospitals
Accreditation of Wellness Centers
Accreditation of Medical Imaging Services
Accreditation of Dental Centers
Allopathic Clinics
National Accreditation Board for Hospitals & Health Care Providers
Quality Improvement Initiatives
NABH Certification Programs
Safe-I
Medical Laboratory
Nursing Excellence
National Accreditation Board for Hospitals & Health Care Providers
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Quality Improvement Initiatives
Pre-Accreditation Entry Level Award
Pre-Accreditation Progressive Level Award
National Accreditation Board for Hospitals & Health Care Providers
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Objective of these awards
Provide a framework for quality improvement
Focus on patient safety
Set basic standards that all Organizations must
achieve
National Accreditation Board for Hospitals & Health Care Providers
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NABH is an institutional member of
the International Society for Quality
in Health Care (ISQua) since 2006
National Accreditation Board for Hospitals & Health Care Providers
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ISQua Accreditation of NABH
Standards for Hospitals
(April 2008 – March 2012)- 2nd Edition
(April 2012 – March 2016)- 3rd Edition
National Accreditation Board for Hospitals & Health Care Providers
ISQua Accreditation of NABH (as an
Organisation)
(September 2012 – August 2016)
National Accreditation Board for Hospitals & Health Care Providers
Elected Member of ISQua Board (2009-2011,
2011-2013)
Elected Member of ISQua Accreditation
Council
(2007, 2008-2012, 2013-)
NABH is founder member of Asian Society
for Quality in Healthcare (ASQua)
National Accreditation Board for Hospitals & Health Care Providers
NABH International
Formed in July 2010
Four facilities accredited in Philippines
One application from Qatar
National Accreditation Board for Hospitals & Health Care Providers
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Accreditation Standards for Hospitals
1) Chapters: 10
2) Standards: 102
3) Objective elements: 636
National Accreditation Board for Hospitals & Health Care Providers
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Accreditation Standards for Hospitals
1)
2)
3)
4)
5)
6)
7)
8)
9)
10)
Access, Assessment and Continuity of Care (AAC)
Care of Patients (COP).
Management of Medication (MOM).
Patient Rights and Education (PRE).
Hospital Infection Control (HIC).
Continuous Quality Improvement (CQI).
Responsibility of Management (ROM).
Facility Management and Safety (FMS).
Human Resource Management (HRM)
Information Management System (IMS).
National Accreditation Board for Hospitals & Health Care Providers
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Accreditation Standards for Hospitals
Chapters
Standards
Objective
Elements
AAC
COP
MOM
PRE
HIC
CQI
ROM
FMS
HRM
IMS
14
20
13
7
9
8
6
8
10
7
86
136
73
46
51
57
38
54
52
43
Total
102
636
National Accreditation Board for Hospitals & Health Care Providers
Accreditation
Process
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Application + Self-assessment + Documents
Acknowledgment and Scrutiny of application
(By NABH Secretariat)
Pre - Assessment visit
(By Assessment team)
Final Assessment
(By Assessment team)
Review of Assessment Report
(By NABH Secretariat)
Recommendation for Accreditation
(By Accreditation Committee)
Approval for Accreditation
(By Chairman, NABH)
Issue of Accreditation certificate
(By NABH Secretariat)
National Accreditation Board for Hospitals & Health Care Providers
What after Accreditation?
Accreditation Cycle: 3 years
Surveillance Assessment: at 18 months
Renewal Assessment: within 6 months before expiry of
current accreditation
Surprise checks: one hospital/ month
Performance Indicators: Data submission every quarter for
11 indicators
National Accreditation Board for Hospitals & Health Care Providers
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Update
Applicant Hospitals (863)
1000
900
800
700
600
500
Applicant Hospital
400
300
200
100
0
Yr 2006
Yr 2007
Yr 2008
Yr 2009
Yr 2010
Yr 2011
Yr 2012
Yr 2013
Yr 2014
National Accreditation Board for Hospitals & Health Care Providers
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Update on Activities
Accredited Hospitals (230)
250
200
150
Accredited Hospital
100
50
0
Yr 2006
Yr 2007
Yr 2008
Yr 2009
Yr 2010
Yr 2011
Yr 2012
Yr 2013
Yr 2014
National Accreditation Board for Hospitals & Health Care Providers
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Geographical Distribution of
Hospitals --Applicants
National Accreditation Board for Hospitals & Health Care Providers
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Accredited Hospitals
National Accreditation Board for Hospitals & Health Care Providers
Linkage with Licensing/ Regulation
National Accreditation Board for Hospitals & Health Care Providers
Licensing / Registration/ Regulation
•
•
•
•
•
A mandatory process
Operated by the Government
Prescribe certain basic requirements- mostly structural
and may include some processes
Healthcare facility to be licensed/ registered: not uniform
in India, States have their own Acts, if any, central Act yet
to be in place
Healthcare facility to obtain necessary licenses for
different activities e.g. to procure and store alcohol,
narcotics etc..
National Accreditation Board for Hospitals & Health Care Providers
Licensing / Registration/Regulation
•
Healthcare facility to follow necessary Regulatory
requirements e.g. Radiation Safety (AERB in India); BioMedical Waste Handling (BMW Act in India); Narcotic
Drugs (NDPS Act in India) etc…….
In India, Hospitals require to obtain and comply with all
applicable licenses and regulations as a requirement
to sign up for NABH Accreditation as these have
been appropriately prescribed in Accreditation
Standards.
National Accreditation Board for Hospitals & Health Care Providers
Voluntary vs Mandatory
National Accreditation Board for Hospitals & Health Care Providers
•
•
•
•
By virtue of its definition, Accreditation is a voluntary
process
Government may prescribe it as a mandatory condition
for hospitals to function e.g. HAS, France accreditation is
mandatory for a hospital
Government / Paying organisation like insurance can
prescribe it as a condition for empanelment
In India, Central Government Health Scheme and ExServicemen Contributory Health Scheme prescribed as
one of the conditions for private hospitals to be
empanelled with them.
Some other examples: in USA, Australia, Taiwan
insurance
providers
require
accreditation
for
empanelment
National Accreditation Board for Hospitals & Health Care Providers
Accreditation and Patient Safety
National Accreditation Board for Hospitals & Health Care Providers
Patient Safety?
Quality?
Accreditation?
(can not be achieved without patient safety & quality)
National Accreditation Board for Hospitals & Health Care Providers
Accreditation standards include various
aspects of quality and patient safety.
National Accreditation Board for Hospitals & Health Care Providers
Patient Safety Encounters
• Patient safety information
▫ Informed consent for procedures
▫ Patient and family education
• Clinical safety
▫ CPR, Code blue
▫ prevention against wrong side, wrong
patient and wrong procedure
• Medication management
▫ Labeling of drugs
▫ Labeling of prepared drugs
▫ High risk medication awareness
National Accreditation Board for Hospitals & Health Care Providers
Patient Safety Encounters
• Environment of care
▫ Straps of trolleys, ill maintained wheel
chairs, bed rails, disability friendly toilets
▫ Surveillance of environment
▫ Calibration of equipment
▫ Neonatal abduction prevention
• Infection control
▫ Manual, policies, procedures
▫ Compliance of hand washing
National Accreditation Board for Hospitals & Health Care Providers
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Accreditation supports...
•
•
•
•
Quality improvement
Patient safety
Risk management
Change management
National Accreditation Board for Hospitals & Health Care Providers
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Does accreditation make a difference?
• Better communication and
collaboration
• Stronger teams
• Increased credibility and
accountability
National Accreditation Board for Hospitals & Health Care Providers
Global Scenario and Role of ISQua
National Accreditation Board for Hospitals & Health Care Providers
National Accreditation Board for Hospitals & Health Care Providers
Why ISQua Accreditation?
• International Accreditation Programmes (IAP)
• ISQua accreditation helps to standardise by
providing
▫ current evidence based standards, selfassessment, peer review and consistent
application
▫ all organisations despite maturity level assessed
against the same standards
National Accreditation Board for Hospitals & Health Care Providers
Accrediting the Accreditors
International Accreditation
Programmes (IAP)
•
•
•
Accreditation of health care
standards
Accreditation of external
evaluation organisations
Accreditation of surveyor training
programmes
National Accreditation Board for Hospitals & Health Care Providers
IAP Awards to Date
• 26 accredited organizations
• 55 sets of standards
• 15 surveyor training programmes
Setting exemplary standards
National Accreditation Board for Hospitals & Health Care Providers
Magic of Accreditation
National Accreditation Board for Hospitals & Health Care Providers
Why I call it a magic wand?
• It is perceived to be doing everything.
For Hospital:
• Good reputation
• Better income
• Doing everything Right
• The Best
For Patients:
• Less expenditure
• Best care
• Everything MUST be in place
• Any shortcoming/error not acceptable
National Accreditation Board for Hospitals & Health Care Providers
Why I call it a magic wand?
For Staff:
• Good reputation
• Better income
• Right to get what they want (best in the market/
govt.)
For Paying Agencies:
• Best care
• Less expenditure
• Transparency in billing/ claims
National Accreditation Board for Hospitals & Health Care Providers
If anything missing?
• Accreditation/ Accreditation Body is responsible
• If a hospital is not accredited: People are happy
even basic services are not available but it
changes once it is accredited
National Accreditation Board for Hospitals & Health Care Providers
• It is considered to fix anything & everything in a
hospital
▫
▫
▫
▫
▫
All structures
All legal requirements
All process
All outcomes
ZERO complaints
National Accreditation Board for Hospitals & Health Care Providers
Patients/ Public consider Accreditation a Super
Regulation (AB as Super Regulator) than a Tool
for Improvement.
National Accreditation Board for Hospitals & Health Care Providers
Can we live up to such expectations?
National Accreditation Board for Hospitals & Health Care Providers
Thank You
[email protected]
www.nabh.co
National Accreditation Board for Hospitals & Health Care Providers

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