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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