Way to Quality: Accreditation Process

National SightFirst Conclave 2018

October 7, 2018, Siliguri

Dr. B.K. Rana

Founding CEO
Introduction of QAI

 QAI- Quality & Accreditation Institute

Change Adapt Improve

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Introduction of QAI

 Vision: Nurturing the largest global pool of organisations

and people through quality improvement and
accreditation framework.

 Mission: To conceive and deliver education, training,

accreditation and related programs in partnership with
stakeholders using an approach of co-design and co-
creation.

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Introduction of QAI

Values:
 Listener: Seek continuous feedback from stakeholders
to address their concerns
 Competitive: Look for viable options to benefit users of
our services
 Transparency: Clearly defined policies made available
in public domain
 Innovation: Continuously evolve using co-design and
co-creation

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Organisation Structure of QAI

Board of Directors
Advisory Board
CEO

Centre for Centre for Centre for Centre for Centre for
Education and Laboratory Accreditation Accreditation of Proficiency
Training (CET) of Veterinary Testing (CPT)
Accreditation
Accreditation Facilities (CAVF)
(CLA)
(CAHSC)

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Structure of CAHSC

Governing Board

Chairman
Appeals Committee
CEO

Technical Committees Accreditation Committee

Heads of Programs Administration & Accounts

Panel of Assessors/ Experts

Executive

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Centre for Accreditation of
Health & Social Care (CAHSC)

 Board constituted- Prof M.C.Misra, Chair

 Accreditation of ART including IVF Centres

 Accreditation of Home Healthcare

 Accreditation of Dialysis centres

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

 Dr. B.K. Rana, Founding CEO is a member of the

Board of Directors (2017-2019)

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8
Quality & Accreditation Institute
Accreditation Mark of Quality and Accreditation
Institute
 Global Operations
 Global Associates:
 Ghana
 Nigeria
 Nepal
 Maldives
 Bangladesh
 Philippines
 UAE
 Bahrain
 Mexico
 UK QAI 10
QAI Journal of Healthcare Quality &
Patient Safety
www.qaij.org
Accreditation

Public recognition of the achievement of accreditation

standards by a healthcare organisation, demonstrated
through an independent external assessment of that
organisation’s level of performance in relation to the
standard.
(ISQua)

Quality & Accreditation Institute

Accreditation

 Accreditation relies on establishing technical competence

of a HCO in terms of 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
organisation to pursue continual excellence.
Quality & Accreditation Institute
Why accreditation?

 One study found that only 20% of eligible patients

received β-blockers following a heart attack, despite the
fact that they have been proven to be an effective
intervention, reducing mortality by 43%.

 Another study found that antibiotics are frequently over-

prescribed; contributing to microbial resistance to these
drugs. Such resistance could cost as much as $7.5 billion
a year for more expensive healthcare interventions.

QAI-CAHSC/Home Care/Standards 14
Cataract-operated left eye
got infected, man lost eye Hospital
due to medical negligence gets fined
Rs 5 lakh relief (TOI) for
botched
eye
surgery
after 12
Five lose sight after years
surgery at X hospital
(The Telegraph)
(TOI)
 Why accreditation??

 Improves care and enhances public confidence.

 Ensures transparency in the functioning.

 Provides the framework for an integrated and

focused management structure.

 Recognition by payers, government and

vendors.
 Why accreditation?

 Financial Transparency
 Role model to other hospitals.
 Recognition of services.
 Helps in promoting Medical Tourism.
 Awakening of patients about their rights
 Reduced ALOS
 Increase in revenue?
 Consumer’s Perspective
 Patient safety of prime importance.
 Increased patient involvement in care
 Open disclosure.
 Patient rights and responsibilities clearly
defined.
 Protocol based treatment.
Characteristics of a Quality Healthcare
System

 It is safe
 It is effective
 It is efficient
 It is patient centered
 It is equitable
 It is timely
Institute of
Medicine
2001

19
Building a Culture of
Quality & Safety
What does it mean?

 Not just a certificate

 Not just preparation for an assessment/survey

 Not just someone else is responsible

 Intention to improve under every circumstances

What is needed?

• Engaging leaders
• Link quality with outcomes
• Adopt quality management tools
• Building capacity through training &
consulting organizations
• Promoting recognition system for healthcare
quality professionals
What is needed?

• Patient / People centered care

 Remember that Bad system
not bad people are responsible
for most errors.
What is needed?

Outcomes!
 Change-Adapt-Improve

• Change Management
• Change culture
• Change attitude Change Adapt

• Adapt to these changes

• Practice
• Stabilize Improve

• Improvement
• Move on……….
Specific Issues to Eye Care
Facilities
Adverse Events

 Wrong site

 Wrong patient

 Wrong procedure

 Medication errors
Care of vulnerable patients

 Infants

 Children

 Physically challenged/ Disabled individuals

 Mentally challenged

 Elderly
Accreditation/Certification
Standards

30
Chapters Std. OE
Access, Assessment and Continuity of 7 32
Care (AAC)
Care of Patients (COP) 11 52
Management of Medications (MOM) 6 32

Patients Rights and Education (PRE) 7 33

Hospital Infection Control (HIC) 6 28

QUALITY & ACCREDITATION INSTITUTE

Chapters Std. OE
Continuous Quality Improvement (CQI) 6 31

Responsibilities of Management (ROM) 3 17

Facility Management & Safety (FMS) 4 17

Human Resource Management (HRM) 10 26

Information Management Systems 6 34

(IMS)
Total 66 302
QUALITY & ACCREDITATION INSTITUTE
 Process for accreditation/ Certification

Submission of application (online)

Review
Feedback
To
Pre/ Final assessment
Health care
Organization
And
Review of Assessment Report
Necessary
(by Secretariat)
Corrective
Action
Taken
Accreditation committee
By
Health care
Organization
Approval for accreditation/ Certification

Issue of certificate
Why all this?
 ……I want to
Build a culture of
Quality & Safety
Thank you
bkrana@qai.org.in

www.qai.org.in

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