13 vikram kashyap-quality-management-systems_ncas_2011

Ambulatory Surgical Centres

Quality Management Systems Accreditation to

NABH SHCO Standards

Managing Quality

• START a Quality Dept.: Team, Resources, Authority, Competence, Internal Audits

•Structure •Process •Outcome

COMPLIANCE • Legal, statutory, regulatory requirements

• Patients' requirements: stated and implied

• Employees' requirements, especially safety

• Hospital's own policies and procedures

• Start preparing for N A B H Accreditation

NABH organisation

National Accreditation Board for Hospital &

Health Care Providers

Technical

Committee Panel of

Assessors

Accreditation

Committee

Appeals

Committee

Quality Council of India

S e c r e t a r i a t

N A B H Accreditation Programmes

• Hospitals : 51 + beds

• Small Health Care Organisations

• Ayurveda, Yoga, Unani, Siddha, Homoepathy

• Wellness

• Imaging

• Blood Banking

• Clinical Laboratories

S H C O Standards • Small Health Care Organisations

• 20 – 50 beds, & Day care and ambulatory surgical centres

• 10 chapters, 258 requirements

• Exclusions clamed must be justified

• 'Apex' Quality Manual, Documented Policies, Standard Operating Procedures, System of maintaining patient records

Patient Centred

• Access, Assessment & Continuity of Care

• Care of Patients

• Management of Medication

• Patients’ Rights & Responsibilities

• Hospital infection Control

Organisation Centred

• Continuous Quality Improvement

• Responsibilities of Management

• Facilities Management and Safety

• Human Resources Management

• Information Management System

Top Management • Identify and follow all applicable laws

• Establish & support the Quality Dept

• Identify & monitor key indicators of volume, quality and performance

• Standard billing practices

• Conduct mock drills: Fire, CPR, disaster

• Conduct internal quality audits

Take Home Messages • Quality Management Team > integral to the

practice of medicine and surgery today

• Compliances: Legal, Patient requirements, Employee related, Hospital policies

• Management: Material, Medicines, Methods, Manpower (their motivation), Machines, Milieu, MONEY !

• Visit the website: www.nabh.co

Patient satisfaction is the best accreditation

Thank you very much