Accreditation: A Magic Wand ISQua Webinar July 10, 2014 B.K. Rana Joint Director, NABH Vice- Chairman, Accreditation Council of ISQua

Accreditation: A Magic Wand

ISQua WebinarJuly 10, 2014

B.K. RanaJoint Director, NABHVice- Chairman, Accreditation Council of ISQua

National Accreditation Board for Hospitals & Health Care Providers

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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


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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)


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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.


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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)


What is Accreditation?

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•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)


AccreditationIs a

processNot an event


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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.


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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.


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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.


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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.


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Various Accreditation Bodies


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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


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•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


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Various accreditation bodiesA. Developed AB:

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


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Various accreditation bodiesB. Developing AB:

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


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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


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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


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Case study of National Accreditation Board for Hospitals and Healthcare

Providers (NABH)

Indian ABEstablished in 2006, under Quality Council

of India, a not-for-profit Society.Independent Board comprising members

from various stakeholders


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.

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NABH Accreditation ProgramsAccreditation of Hospitals

Accreditation of SHCO/ Nursing Homes

Accreditation of Dental Centers

Accreditation of Blood Banks

Accreditation of Wellness Centers

Accreditation of PHC/CHCs

Accreditation of OST Centers

Accreditation of AYUSH hospitals

Accreditation of Medical Imaging Services

Allopathic Clinics


NABH Certification ProgramsSafe-I

Nursing Excellence

Medical Laboratory

Quality Improvement Initiatives


Quality Improvement Initiatives

Pre-Accreditation Entry Level Award

Pre-Accreditation Progressive Level Award

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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

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NABH is an institutional member of the International Society for Quality in Health Care (ISQua) since 2006

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ISQua Accreditation of NABH Standards for Hospitals 2nd ed., 2007(April 2008 – March 2012)

ISQua Accreditation of NABH Standards for Hospitals (April 2008 – March 2012)- 2nd Edition

(April 2012 – March 2016)- 3rd Edition

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ISQua Accreditation of NABH Standards for Hospitals 2nd ed., 2007(April 2008 – March 2012)

ISQua Accreditation of NABH (as an Organisation)

(September 2012 – August 2016)


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)


NABH International

Formed in July 2010

Four facilities accredited in Philippines

One application from Qatar


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Accreditation Standards for Hospitals

1) Chapters: 10

2) Standards: 102

3) Objective elements: 636


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Accreditation Standards for Hospitals1) Access, Assessment and Continuity of Care (AAC)2) Care of Patients (COP). 3) Management of Medication (MOM).4) Patient Rights and Education (PRE).5) Hospital Infection Control (HIC).6) Continuous Quality Improvement (CQI).7) Responsibility of Management (ROM).8) Facility Management and Safety (FMS).9) Human Resource Management (HRM)10) Information Management System (IMS).


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Accreditation Standards for Hospitals

Chapters Standards Objective Elements

AAC 14 86COP 20 136MOM 13 73PRE 7 46HIC 9 51CQI 8 57ROM 6 38FMS 8 54HRM 10 52IMS 7 43

Total 102 636


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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)

Application + Self-assessment + Documents

Accreditation Process


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


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Update

Yr 2006 Yr 2007 Yr 2008 Yr 2009 Yr 2010 Yr 2011 Yr 2012 Yr 2013 Yr 20140

100

200

300

400

500

600

700

800

900

1000

Applicant Hospitals (863)

Applicant Hospital


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Update on Activities

Yr 2006 Yr 2007 Yr 2008 Yr 2009 Yr 2010 Yr 2011 Yr 2012 Yr 2013 Yr 20140

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100

150

200

250

Accredited Hospitals (230)

Accredited Hospital


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Geographical Distribution of Hospitals --Applicants


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Accredited Hospitals


Linkage with Licensing/ Regulation


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..


Licensing / Registration/Regulation

• Healthcare facility to follow necessary Regulatory requirements e.g. Radiation Safety (AERB in India); Bio-Medical 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.


Voluntary vs Mandatory


• 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 Ex-Servicemen 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


Accreditation and Patient Safety


Patient Safety?

Quality?

Accreditation?(can not be achieved without patient safety & quality)


Accreditation standards include various aspects of quality and patient safety.


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


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


Accreditation supports...

•Quality improvement•Patient safety•Risk management•Change management

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Does accreditation make a difference?

• Better communication and collaboration

• Stronger teams

• Increased credibility and accountability

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Global Scenario and Role of ISQua



Why ISQua Accreditation?

•International Accreditation Programmes (IAP)

•ISQua accreditation helps to standardise by providing▫current evidence based standards, self-

assessment, peer review and consistent application

▫all organisations despite maturity level assessed against the same standards


Accrediting the Accreditors

International Accreditation Programmes (IAP)

• Accreditation of health care standards• Accreditation of external evaluation organisations • Accreditation of surveyor

training programmes


IAP Awards to Date

•26 accredited organizations•55 sets of standards•15 surveyor training programmes

Setting exemplary standards


Magic of Accreditation


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


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


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


•It is considered to fix anything & everything in a hospital▫All structures▫All legal requirements▫All process ▫All outcomes▫ZERO complaints


Patients/ Public consider Accreditation a Super Regulation (AB as Super Regulator) than a Tool for Improvement.


Can we live up to such expectations?


Thank You

[email protected] www.nabh.co