Aditya Birla Memorial Hospital recently became the first multi-speciality care hospital in Pune to achieve a certification for quality standards from the Joint Commission International (JCI) in the US. Rekha Dubey, COO, Aditya Birla Memorial Hospital shares more details on this achievement and elaborates on the procedures of the JCI accreditation to Raelene Kambli
Congratulations on this most recent achievement. Could you give us details on the procedure and scope of the survey conducted by JCI prior to awarding the accreditation to the hospital? Also, what exactly did the survey involve, on a daily basis?
| Rekha Dubey |
It is a momentous occasion for all the employees of Aditya Birla Memorial Hospital (ABMH) to be the first JCI-accredited hospital in Pune. Applying for JCI accreditation was an ABMH initiative, to respond to the growing demand around the world for standard-based evaluation in healthcare. The main purpose of going for JCI accreditation is to meet our hospital mission and vision – ‘Compassionate quality healthcare and excellence first aid always’
Scope of survey: Three surveyors: a physician, nurse, and an administrator evaluated all the clinical and non-clinical departments’ performance, including the management of ABMH. Surveyors covered the entire hospital (capacity 500 beds) in three days. Their main emphasis was on patient care and patient safety. They intensively reviewed the nurse and doctor’s documentation in providing patient care. They tapped each and every corner of the hospital, e.g. hospital facility tour, patient care, infection control, medication management system, improvement in quality and patient safety system, closed patient record review staff qualification and education. The main focus was on medical staff and leadership interview.
Procedure: Every day, morning survey started at 7:30 am and stopped at 5 pm. JCI survey procedure started with documentation review. Surveyor tested and verified the hospital performance through tracers to evaluate the actual care that a patient receives.
During the stages mentioned above, they reviewed documentation, and role of various stakeholders (i.e. nurses, doctors, dietician, physiotherapists, patients and their family members) and systems (i.e. medication management, medical records, CSSD, F&B, house keeping, air conditioning system, patient counselling and education system) in providing patient care. Entire survey focused on the integration and coordination of patient care processes.
Every day they had a meeting with the management to discuss their findings, based on interviews, observations and document reviews.
On a daily basis, the survey involved day briefing, tracer activity as we mentioned above and hospital facility tours. Hospital staff and patients were interviewed during tracer and facility tours to know about their performance and the care given to patients.
When did the hospital apply for accreditation? How long did it take to achieve it?
The hospital applied for the accreditation in first week of September 2012 and it took approximately six months to achieve it. The hospital submitted an application for survey to JCI in August 2012 and the scheduled survey dates were December 10-14, 2012.
How much investment was made in order to achieve these quality standards for JCI accreditation?
Actual investment was nil as Aditya Birla Memorial Hospital is a multispecialty facility with state-of art infrastructure like advanced technology and international equipment. We only had to pay the accreditation fee which was approximately Rs 50 lakhs.
How will this achievement help the hospital to provide better care to its patients? Will this move help in achieving economies of scale for the hospital group?
Quality healthcare, patient’s safety and well-being has always been our priority. Implementation of the international patient safety goals has been one of the ‘top changes’ that has helped cultivate a culture of enhanced patient safety and quality of care. JCI accreditation is mainly to make our hospital a better and safer place for our patients. JCI has ‘a long-term international experience in quality and safety control as well as the highest standards of hospital processes.’ So it definitely helps in improving our hospital economies.
How do you plan to sustain the quality standards within the hospital? Will JCI keep a close watch on the quality standards separately?
To sustain the quality standards, we have adopted a philosophy of management that stimulates continuous quality improvement through the establishment of uniform quality measures, daily quality rounds, implementation of a quality assurance programme that includes both internal audits and training of personnel, creation of annual quality improvement goals, and the identification as well as use of clinical ‘best practices’ in an effort to achieve appropriate patient outcomes. And above all we have high-tech and dedicated staff to respond to the most demanding requirements of our patients.
Yes, JCI mentioned that they will visit the hospital at any point of time after accreditation to check hospital performance in implementing the quality standards.
What is your next move after achieving JCI accreditation?
Our next move will be to retain the JCI accreditation and Aditya Birla Memorial Hospital’s name and fame by focusing on continuous monitoring of organisational structure process and outcome and retain better managed leadership to increase our customer satisfaction.