Journey towards healthcare excellance Tips to …

1 1 National accreditation Board for Hospitals & healthcare ProvidersTips to overcome most common obstacles in preparing for NABH accreditationDr S Murali MD DMConsultant NeurologistManipal HospitalBangalore1 National accreditation Board for Hospitals & healthcare ProvidersJourney towards healthcare excellance2 Achieve Service & Clinical ExcellenceHealthcare AccreditationEstablish quality systemsNational accreditation Board for Hospitals & healthcare ProvidersPerceived 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 ProvidersRegulatory ComplianceTotal Quality Management in a HospitalRegulations, Laws, EthicsNational accreditation Board for Hospitals & healthcare ProvidersDocumentationRegulatory ComplianceTotal Quality Management in a HospitalEfficiencyProcess ManagementRegulations, Laws, EthicsNational accreditation Board for Hospitals & healthcare ProvidersExcellence in patient careDocumentationRegulatory ComplianceTotal Quality Management in a HospitalComplaint, Waste, and DefectReductions, Elimination of ReworkEfficiencyProcess ManagementRegulations, Laws, Ethics2 National accreditation Board for Hospitals & healthcare ProvidersRecog-nition of QualityExcellence in patient careDocumentationRegulatory ComplianceTotal Quality Management in a HospitalPatient SatisfactionEmployees' SatisfactionManagement SatisfactionComplaint, Waste.

2 And DefectReductions, Elimination of ReworkEfficiencyProcess ManagementRegulations / LawsNational accreditation Board for Hospitals & healthcare ProvidersTOP 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 ProvidersWho will drive it Team and not dependent on a single individual accreditation co ordinater Form subgroups involving relevant stake holders. Educate the team - POI9 National accreditation Board for Hospitals & healthcare ProvidersDocumentation Pyramid 1 Quality Manual (Apex Manual)

3 2 Documented Policies & Procedures, Patient Flow Diagrams, Organograms 3 - Work Instructions, SOPs where required 4 - Records, Formats, Registers, Forms 5 - External Documents, Statutory & Regulatory requirementsEnsure that the end user is involved in accreditation Board for Hospitals & healthcare Providers11 NABH ACCREDITATIONS ample 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 ReferencesNational accreditation Board for Hospitals & healthcare Providers12 NABH ACCREDITATIONC ommittees Salient features Composition tenure roles and responsibilities objectives functioning quoram Meetings / agenda minutes monitoring reporting pattern reports action taken3 National accreditation Board for

4 Hospitals & healthcare ProvidersLegal 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 ProvidersInfrastructure 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 early14 National accreditation Board for Hospitals & healthcare ProvidersManpower Identify requirement and have an effective manpower planning Grey areas Compliance Reference15 National accreditation Board for Hospitals & healthcare ProvidersClinician 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 above16 National accreditation Board for Hospitals & healthcare ProvidersOther perceived Pain areas PAIN ADVERSE DRUG EVENTS END OF LIFE CARE AIR CONDITIONING MEDICAL AUDITS INDICATORS TRAINING PREVILEGING AND CREDENTIALING17

5 National accreditation Board for Hospitals & healthcare Providers18 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 groups4 National accreditation Board for Hospitals & healthcare Providers19 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 reviewNational accreditation Board for Hospitals & healthcare Providers20 NABH ACCREDITATIONS teps 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 implementNational accreditation Board for Hospitals & healthcare Providers21 NABH ACCREDITATIONS

6 Teps 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 programmeNational accreditation Board for Hospitals & healthcare ProvidersCarry 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 ProvidersCarry 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.

7 Take 3 standards per week accreditation levels23 National accreditation Board for Hospitals & healthcare Providers24 NABH ACCREDITATIONF ollow each objective element meticulously and accreditation will followThank You