Leveraging Accreditation Program for Patients Well Being

Girdhar J Gyani Secretary General, QCI CEO, NABH

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Quality Council of India (QCI)

QCI is an autonomous body set up by Govt. of India to establish and operate accreditation structure in the country and promote quality through National Quality Campaign under the overall mission; Quality for National Well Being.

Quality Council of India

Structure of QCI
Quality Council of India

National Accreditation Board for Certification Bodies (NABCB)

National Accreditation Board for Testing and Calibration Laboratories (NABL)

National Registration Board for Personnel and Training (NRBPT)

National Accreditation Board for Hospitals & Healthcare Providers (NABH)

National Board for Quality Promotion (NBQP)

Quality Information and Enquiry Service

Quality Council of India

National Accreditation Board for Hospitals & Healthcare Providers (NABH)

Set up in association with Govt. of India and the Indian Health Industry. Catering to the needs of the consumers and setting standards for progress of the health industry. Supported by all stakeholders and having full functional autonomy in its operations

Quality Council of India

Structure of NABH
Quality Council of India National Accreditation Board for Hospitals & Healthcare Providers
Appeals Committee Secretariat Technical Committee Panel of Assessor/Expert
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Accreditation Committee

Quality Council of India

Composition of Board

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15.

Chairman Indian Medical Association Consumer Co-ordination Council Insurance Regulatory & Development Authority (IRDA) Indian Nursing Council Sree Chitra Tirunal Institute for Medical Science & Technology Director General, Armed Forces Medical Services Department of Bio-Technology Postgraduate Education Institute (on rotation basis) 1. PGI Chandigarh CEO NABH (member secretary) Confederation of Indian Industry (CII) The Associated Chambers of Commerce and Industry of India (ASSOCHAM) Federation of Indian Chambers of Commerce and Industry (FICCI) Academy of Hospital Administration (AHA) Ex Officio Members 1. Secretary General - QCI 2. Chair Accreditation Committee NABH 3. Chair Technical Committee NABH 4. Chair Appeal Committee NABH
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Quality Council of India

Composition of Technical Committee (Hospitals)

1. 2. 3. 4. 5. 6. 7. 8. Col (Dr.) Pawan Kapoor (O/o DGAFMS) Dr. Siddhartha Satpathy (AIIMS) Col (Dr.) S. K. M. Rao (O/o DGAFMS) Dr. Bidhan Das Dr. S Murali (Manipal Hosp, Bangalore) Dr. Vikram Kashyap (Neurosurgeon, Bangalore) Dr. Aniruddha Mukherjee (Min. of Health, Govt of WB) Mrs. Kawaljeet Oberoi (Gen. Mgr. Nursing Kokilaben Dhirubai Ambani Hospital , Mumbai)

Quality Council of India

Composition of Accreditation Committee (Hospitals)

1. 2. 3. 4. 5. 6. Dr. Nandkumar Jairam (Columbia Asia, Bangalore) Dr. Praneet Kumar (Fortis Healthcare Limited, Jaipur) Dr. Tilak Suvarna ( Asian Heart Institute, Mumbai) Prof.(Dr.) A.K. Agarwal (IGNOU, Delhi) Dr. Lloyd Nazareth, Wockhardt Hospitals, Bangalore Dr. Pawan Kapoor-Convener TC (Hospital)-By Invitation

Quality Council of India

Accreditation
Accreditation relies on establishing technical competence of healthcare organization in terms of accreditation standards in delivering services with respect to its scope. It focuses on learning, self development, improved performance and reducing risk. Accreditation is based on optimum standards, professional accountability and encourages healthcare organization to pursue continual excellence
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Quality Council of India

International Linkages
NABH is an institutional member of the International Society for Quality in Health Care (ISQua). NABH is also a member of ISQua Accreditation Council. NABH is a member of International Steering Committee of WHO Collaborating Centre for Patient Safety as a nominee of ISQua Accreditation Council. NABH is on board of Asian Society for Quality in Healthcare (ASQua), Kualalampur. This initiative is to strengthen the Asian representation at international level. NABH represents on the Advisory Board of Medical Tourism Association, USA (MTA).
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Quality Council of India

NABH Standards for Hospital, 2nd Edition

NABH hospital standards, 2nd edition, November 2007 have been accredited by International Society for Quality in Healthcare (ISQua) under its International Accreditation Program (IAP) for a cycle of 4 years (April 2008 to March 2012)

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Quality Council of India

Standards
Patient Centered Standards:
1.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)

Organization Centered Standards:

6. Continuous Quality Improvement (CQI) 7. Responsibilities of Management (ROM) 8. Facility Management and Safety (FMS) 9. Human Resource Management (HRM) 10.Information Management System (IMS)
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Quality Council of India

Current status on Accreditation (as on 15th December, 2008)

Accredited Hospitals: Applicant Hospitals: Accredited SHCOs: Applicant SHCOs: Applicant Blood Banks: (Final assessment planned for 04 blood banks)
Quality Council of India

23 55 01 08 08

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New Initiatives.
Other Accreditations Program Accreditation of Blood Banks Accreditation of Small Health Care Organizations (SHCO) Accreditation of Health and Wellness Centres Accreditation Under Launch Accreditation program for Oral Substitution Therapy (OST) centres. Accreditation of Diagnostic Centres (Radiology) Accreditation of Dental Centres Accreditation of Ayurvedic Hospitals/Clinics
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Quality Council of India

Some of the prominent Accreditation Bodies operating in other parts of World

1. The Australian council on Healthcare Standards ACHS/ACHSI. 2. Accreditation Canada/ International. 3. Council for Health Service Accreditation of Southern Africa. 4. CHKS Healthcare Accreditation Quality Unit UK. 5. Joint Commission/ JCI. 6. Malaysian Society for Quality in Health. 7. Japan Council for Quality in Health.

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Quality Council of India

Benefits of Accreditation

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Quality Council of India

Patients

Accreditation benefits all stake holders. Patients are the biggest beneficiary. Accreditation results in high quality of care and patient safety. The patients get services by credentialed medical staff. Rights of patients are respected and protected. Patient satisfaction is regularly evaluated.

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Quality Council of India

Healthcare Organizations

Accreditation to a healthcare organization stimulates continuous improvement. It enables the organization in demonstrating commitment to quality care. It raises community confidence in the services provided by the organization. It also provides opportunity to healthcare unit to benchmark with the best.

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Quality Council of India

Healthcare Organization

Staff in an accredited healthcare organization are satisfied lot as it provides for continuous learning, good working environment, leadership and above all ownership of clinical processes. It improves overall professional development of Clinicians and Paramedical staff and provides leadership for quality improvement within medicine and nursing.

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Quality Council of India

Third parties

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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Quality Council of India

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Driving Factors for Accreditation

Consumer Protection Act Clinical Establishment Act Insurance Companies regulation Empanelment by CGHS, ECHS, Corporate etc. Community Awareness & Response Health Tourism

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Quality Council of India

Challenges & Opportunities Awareness on Accreditation a) Health industry b) Consumers c) Regulators Creating enabling mechanism to assist hospitals on accreditation

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Quality Council of India

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Challenges & Opportunities

How do we add value to accredited hospitals -Clinical indicator program - Quality tools; Six Sigma, Lean etc. - HR, HIS (MIS) - Education Programs Knowledge sharing with
-ACHS, JCI -ISQua, Others

Ownership of accreditation program by Health industry Acceptance of accreditation program by Consumers

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Quality Council of India

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Quality Council of India

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