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Quality Accreditation In Hospitals

Leaders of quality assurance programmes must be able to generate interest and commitment without burdening clinical and administrative staff with an activity they neither understand nor believe in

"The success of any quality assurance programme depends almost entirely on the commitment and interest of the administrators, nurses, paramedical staff and physicians" - Dr Rashi Agarwal Director PRAXIS - A New Dimension to Healthcare Mumbai

Hospital accreditation has been defined as 'A self-assessment and external peer assessment process used by healthcare organisations to accurately assess their level of performance in relation to established standards and to implement ways to continuously improve'. Hospital quality assurance systems are operational control systems intended to fulfill specific expectations for treating patients.

Clinicians have customarily enjoyed a great deal of autonomy in their practices. The mechanisms for monitoring and assuring quality of the care provided have tended to be based on internal peer review. Time, however, has torn away much of the curtain of professional mystique. The changing healthcare environment with revised hospital accreditation guidelines have sharpened the clinical and administrative hospital staff's concern for evaluating the quality of care they provide. Clinicians now see accreditation standards as a framework by which organisational processes will be improved and their patients are better cared for. Physicians and administrators now must face the challenge of establishing comprehensive and vigorous systems of quality assurance and learn to avoid the traps that impede implementation of such systems. Quality assurance is a very simple process that deals with finding problems and fixing them.

A comprehensive definition of quality health care would be 'The optimal achievable result for each patient, the avoidance of physician-induced (iatrogenic) complications, and attention to patient and family needs in a manner that is both cost effective and reasonably documented'.

Importance of Accreditation In Hospitals

Accredited hospitals offer higher quality of care to their patients. Accreditation also provides a competitive advantage in the healthcare industry and strengthens community confidence in the quality and safety of care, treatment and services. Overall it improves risk management and risk reduction and helps organise and strengthen patient safety efforts and creates a culture of patient safety. Not only does it enhance recruitment and staff education and development, but it also assesses all aspects of management and provides education on good practices to improve business operations. International accreditation like JCI creates a mark on the world map and increases business through medical tourism.

Few Quality Accreditation Programmes for Hospitals

There are several quality accreditation standards. However, few that are common to hospitals are Joint Commission International (JCI) , National Accreditation Board for Hospitals (NABH), ISO 9001-2000, Malcolm Baldridge etc. The most common ones being ISO and NABH. Other ones being departmental specific like NABL etc.

Difference Between the Accreditation Standards

ISO is more process driven and is better for back-end departments like Accounts, HRD etc, while NABH and JCI are clinically oriented standards to directly impact patient care.

Accreditation Standards (NABH and JCI):

Patient Centered Standards (Functions related to providing patient care)

• Access to Care and Continuity of Care/ Access, Assessment and Continuity of Care (AAC).
• Patient and Family Rights/ Patient Rights and Education (PRE).
• Patient and Family Education.
• Assessment of Patients/ Management of Medication (MOM).
• Care of Patients/ Care of Patients (COP).

Healthcare Organisation and Management Standards: (Functions related to providing a safe, effective and well-managed organisation)

• Quality Improvement and Patient Safety/ Continuous Quality Improvement (CQI).
• Prevention and Control of Infection/ Hospital Infection Control (HIC).
• Governance, Leadership, and Direction/ Responsibilities of Management (ROM).
• Facility Management and Safety/ Facility Management and Safety (FMS).
• Staff Qualifications and Education/ Human Resource Management (HRM).
• Management of Information/ Information Management System (IMS).

The Accreditation Process

Begin with accreditation process by education: Educate the leaders and the managers and explain the benefits, advantages, process, timeline, etc. of the accreditation.

Baseline Assessment: Use knowledgeable and credible evaluators (either internal or external consultants) (PRAXIS takes on consulting assignments for accreditation process) who will critically and objectively assess each area and conduct a detailed baseline assessment of the organisation's current adherence to the standards and each measurable element. Score as Met, Partially Met, or Not Met and cite specific findings and recommendations. Also collect and analyse baseline quality data as required by the quality monitoring standards e.g. medication errors, hospital-associated infection rates, antibiotic usage, surgical complications, etc. Establish an ongoing monitoring system for data collection (e.g. monthly, with quarterly data analysis) to identify problem areas and track progress in improvement.

Action Planning: Using the findings of the baseline assessment, develop a detailed project plan starting first with priority areas of the core standards. Responsibilities, deliverables, and timeframes should be assigned. E.g. Revise informed consent policy, develop a new informed consent statement, educate staff in the next two month time period.

Chapter Assignment: Look for good people skills, time management skills, and consensus building skills and assign oversight of each chapter of standards to such a respected champion/leader who will identify team members from throughout the hospital and carry out the process.

Policies and Procedures: In addition to overall project plan, it is often helpful to compile a list of all required policies and procedures that will need development and revision.

Continue to monitor your progress in meeting the standards, such as through a mini-evaluation of each chapter at regular intervals (e.g. quarterly).

Final Mock Survey: Plan for a final 'mock survey' at least 4-6 months in advance of the target date of the actual accreditation survey. Use evaluators (internal or external consultants) who were not involved in the baseline assessment and preparation, who will look at the organisation with a fresh and objective eye. Need to plan final revisions and corrections based on the findings of the final mock survey.

Final Survey

The success of any quality assurance programme depends almost entirely on the commitment and interest of the administrators, nurses, paramedical staff and physicians. Leaders of quality assurance programmes must be able to generate interest and commitment without burdening clinical and administrative staff with an activity they neither understand nor believe in. This will help move quality assurance out of its current paralysis in some hospitals. Quality assurance is to succeed in its goal to identify and correct problems and to improve the quality of patient care.

rashi@praxishc.com