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Transcript of NABH
ACCREDITATION STANDARD FOR
MEDICAL IMAGING SERVICES
ASHISH RANJAN
AASTHA SERVICE INTERNATIONALF-17, IIND FLLOR , SUBASH CHOWK , LAXMI NAGAR,
DELHI-110092
What is Accreditation?What is Accreditation?
Public recognition of the achievement of accreditation standards by a healthcare organization, demonstrated through an independent external assessment of that organization’s level of performance in relation to the standard.
(ISQua)
Hospital Accreditation in IndiaHospital Accreditation in India
Started in India in the year 2005 by National Accreditation Board for Hospitals & Healthcare Providers (NABH)
NABH is a constituent board of Quality Council of India (QCI) set up to establish and operate accreditation programme for healthcare organizations.
QCI is an Autonomous body jointly set up by the Government of India and Indian industries to establish and operate National Accreditation Structure.
The board while being supported by all stakeholders including industry, consumers, government, has full functional autonomy in its operations.
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A constituent board of Quality Council
of India (QCI)
To provide accreditation services to hospitals and healthcare providers
Structure of QCIStructure of QCI
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Quality Council of India
National Accreditation Board
for Certification Bodies (NABCB)
National Board for Quality Promotion
(NBQP)
National Accreditation Board for Testing and
Calibration Laboratories (NABL)
National Accreditation Board for Education and Training (NABET)
National Accreditation Board for Hospitals & Healthcare Providers
(NABH)
Quality Information and Enquiry Service
(QIES)
StructureStructure of of NABHNABH
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National Accreditation Board for Hospitals & Healthcare Providers
Technical Committee Panel of
Assessor/Expert
Accreditation Committee
Appeals Committee
Quality Council of India
Secretariat
NABH ActivitiesAccreditation of Hospitals
Accreditation of SHCO/ Nursing Homes
Accreditation of Dental Centers (Ready for launch)
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(Ready for launch)
International Recognition International Recognition
NABH is an institutional member NABH is an institutional member of the International Society for of the International Society for Quality in Health Care (ISQua) Quality in Health Care (ISQua) since 2006.since 2006.
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ISQua Board Member
Member of Accreditation Council
ASQua Board Member
International RecognitionInternational Recognition
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ISQua Accreditation of NABH Standards for Hospitals (April 2008 – March 2012)
International RecognitionInternational Recognition
Basic Principles of Basic Principles of AccreditationAccreditation
Statutory/ Regulatory/ Licensing – Compliance Must
It is based on structure, process and outcomes
Focused on Patient Care and Safety
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Accreditation Standards
Accreditation Standards for Medical Accreditation Standards for Medical Imaging ServiceImaging Service
1) Control of Service (CS)2) Control Of Imaging Processes And Procedures
(CPP) 3) Control Of Personnel(CP)4) Control Of Equipment (CE)5) Control Of Documents And Record (CDR) 6) Risk Control and Safety (RCS)7) Control Of Services(CS)8) Control Of Imaging Process And Procedures (CPP)9) Human Resource Management (HRM)
10 chapters,100 standards,514 objective elements.
Objective of the studyObjective of the study
To analyze the improvements in the quality of services rendered by different hospitals, accredited under the accreditation program of NABH, based on certain service and clinical standard indicators.
MethodologyMethodologyThe hospitals were provided with questionnaire related to some service and clinical standards. They were requested to provide information on benefits of accreditation in terms of improvement in performance under different standards provided.
The standards selected are:
Service standards: a) Registration desk b) Pharmacy c) IT and Billing
Clinical Standards: a) OPD standards b) Diagnostic (Laboratory and
Radiology) c) OT and Nursing
The data from hospitals accredited under NABH accreditation program
was collected, analyzed and following
observations were made
RESULTSRESULTS
SERVICE STANDARDSINDICATORS
Scope of services well defined and understood by staff
Job responsibilities of staff clearly
defined
Patients rights and responsibilities are identified and respected
Admission process streamlined, admission
counseling startedIncreased
patient satisfaction and quality
of care
Increase in staff strength in areas like enquiry, doctors
booking & console as per work load
Staff review meetings for discussion complaints & suggestions
REGISTRATION DESK
Procurement, storage & dispensing policies/procedures
for medications well defined
Special care taken in handling,storing and dispensing sound alike, look alike and high risk
medicines
Improved inventory practices as a result of
training of staff
Regular medical audits
Policies defined for handling of narcotic, radioactive& chemotherapeutic drugs.
Adverse drug reactions & medication error tracking & review has been reinforced
Lower incidents of medication related adverse events in care
PHARMACY
IT &BILLING
Auto stoppage of medication which have serious side effects unless reordered by the physician
New out patient and in patient billing counters to meet up additional workload.
Introduction of billing counseling
Auto log& limitation on viewing privileges
IT generated discharge summary
Schedule of charges displayed through kiosk and handouts
Safety of patient data & decrease in waiting time for billing
CLINICAL STANDARDSINDICATORS
Corrective steps taken to reduce OPD consultation waiting time
More emphasis on preventive care through patient education.
Protocols for preventive health checks, cardiac evaluation, pre operative anesthesia, angiography have been reinforced
Monthly review of statistics on mortality, code blue occurrence, capacity utilization, doctor’s performance etc.
Increased patient satisfaction
OPD Consultation
Procedures and policies for pathology & radiology depts. implemented with
standardized processes
Wastages identified and corrective actions
taken. Biomedical waste practices improved
Regular training of staff in
radiation safety
Continuous monitoring of clinical tests
results
Staff with requisite qualifications and
experience is employed
Increased patient safety and enhanced quality of
services provided
DIAGNOSTICS
Policy to prevent adverse events like wrong site, wrong patient &wrong surgery is defined and
implemented
Sterilization and disinfection practices are monitored and are in place
Infection and environmental surveillance carried out regularly
Rational use of blood and blood products in OT
Proper documentation of OT notes and sign offs by treating surgeons are in place
Improved practices in OT and reduced chances
of error
OT & Nursing
Registration: Staff awareness about various policies,
procedures and services improved considerably. Patient’s rights are now recognized and respected.Turn around time reducedPharmacy: Waiting time reducedReady stock of emergency drugs at all times Improved inventory practices.
CONCLUSION
IT and Billing: Security policy for the access of data and OPD
records.Restricted control and access to patient’s data.
OPD Consultations: Mandatory nutritional assessment .Patient rights regarding privacy and
confidentiality reinforced.
Diagnostics: Equipment calibration/preventive maintenance
schedule monitored regularly.Quality assurance programme implemented.Corrective actions identified & implemented.OT and Nursing: Fumigation policy and hands washing is
continuously monitored in OT.Better Infection controlContinuous training, incidental teaching and
supervision to ensure quality nursing service.Motivation to nursing staff to be a partner in
delivery of healthcare.