Unit 4 TQM

TQM UNIT 4 QUALITY IN PATIENT CARE DSM-MHM
Contemporary quality improvement
Healthcare services, especially, the standard of medical care has always been prime concern in every
society and in every country. However, due to various factors such as paucity of resources, reluctance
on the part of health professionals to subject themselves to any scrutiny/external controls, lack : any
norms or the system of quality assessment and the lack of awareness among the public on health
matters, the quality of medical care never got the importance that it deserved. Of late, because of
market competition, increasing public awareness, criticism of the services being delivered and the
demand for high quality services, there has been a wakeup call to the healthcare providers. As a result,
the healthcare providers who have been hitherto insensitive have started paying attention to the
quality aspect of healthcare.
Quality in healthcare institutions is different from other organizations because the service, i.e. the
patient care, is a multifaceted and multidimensional service and is delivered personally to the
customer (the patient) by the doctors, nurses and other staff. Further, because of its role in improving
the efficiency of care as well as lowering the cost of treatment in the long run, it is the single most
important factor affecting the satisfaction of patients.
Essentials Of Quality Improvement In Healthcare Services
1. Well planned and meticulously executed.
2. It has to be organization wide covering all areas/departments without ignoring even a single
department or service. Since all services are interlinked and interdependent, poor quality of
even one service may affect the quality of services in other departments, e.g. poor quality of
housekeeping services (HK) may affect the quality of services in all other departments of the
hospital by unclean, unhygienic environment, spreading infections and displeasing the
patients, visitors as well as staff. Similarly poor quality sterilization in Central sterile supply
department (CSSD) may adversely affect the results of treatment in all wards/ departments.
3. It is a continuous ongoing process involving implementation and repeated cycles of review

and corrections.
4. Staff at all levels has to be trained, involved and committed to quality management.
5. There are no shortcuts. The program cannot be implanted in an organization. It has to be

planned, documented (organization specific), and implemented by the organization with full
knowledge, training, acceptance and participation of the staff.
6. Since it involves a major change in the ways of working, attitudes, in fact the entire work
culture in the organization, it is likely to cause a lot of resistance and resentment among staff.
The change has to be brought about in a way that is acceptable to the people. Often it is
advisable to bring in an expert outsider as a change agent who can help transform the
organization with minimum level of disturbance.
7. Hiring an outside consultant has other advantages also. In house administrators may not
have adequate knowledge or skills to implement the program successfully. Being an expert on
the subject, a professional consultant can guide the process so as to complete it with all the
Sumaiya Abdul Qadeer
Assistant professor Page 1
speed and efficiency. Besides, the senior administrators in the hospital would be too busy in
their day to day routine to spare adequate time for the program which may get delayed
indefinitely.
8. Board of management has a crucial role. Not only they have to be convinced and committed
themselves, they have to influence all the senior professionals to extend their full cooperation
and willing participation and share the responsibility' for successful implementation of the
program.
9. The program must follow a time schedule meticulously. Any slackness at any stage is likely
to send a wrong signal to the staff and break the momentum. Any delay has the potential to
cause further delays and danger of cynical employees reverting to the old ways thereby
derailing the entire program. It is also important because of the employee turnover factor.
Any delays may mean loss of trained employees and further delay because of training needs
of fresh recruits. For successful implementation it is imperative that the tempo of progress is
maintained in spite of all the hurdles.
Patient safety initiatives
Patient safety is prevention of avoidable errors and adverse effects to patients associated with health
care . the environment in which health care is delivered is fraught with risks, which are inherent to the
system They system is complex and has higher interdependencies with human.
The impact effects all the stakeholders: patient and families, staff, organization and society at large.
Several centuries ago Hippocrates stated “do no harm”. This aspect was not given importance in the
past but now since about two decades ,the fact that several patients were harmed or die by preventable
errors is getting global attention. The focus on patient safety has emerged as an important subject that
lays stress on safe practices, reporting the incidents, analysis, corrective and preventive actions. So it
is important for the health care providers to understand the concept and practices of patient safety and
integrate them into the patient care and leadership responsibilities.
Why Is Health Care Unsafe ?
Hospital complexity and system:
• Hospital is unsafe environment for both patient and staff. This is because the system is
complex system and has high variability.
• It has several people, several processes, equipment and are interdependent.
• Further, any invasive medical procedure has risk of complications for even a small deviation
in the process
• Ex:-Medication administration, patient identification.
• Most of these are due to poor communication, processes variation.

Human Factors:
• Hospital offers services that are very people dependent. In a patient stay at hospital most of
the services will be delivered by human may be a nurse, a doctor or the ward boy etc.,
• It is the human factor such as stress, workload and complex work systems that causes
unintentional errors .
General Problems Reported:
• Medication related
• Infections
• Incorrect monitoring of patients
• Surgical complications
• Patient falls
• Pressure ulcers
• Patient identification errors
Impact:
Levels Of Harms To Patients:
Adverse events:
This is a type of medical complication that occurred as a result of medical care. It may be preventable
or non-preventable.
Near miss:
This aims to identify a failure in a process or action that may have led to harm, but was identified and
stopped.
No harm:
This term is self explanatory. A failure has taken place but did not have any impact on the patient.
Adverse drug event:
It is caused by an error in prescribing, dispensing, transcribing or administering.
Sentinel events:
It is term used for adverse events that leads to serious harm or death, and events that are considered
unacceptable.

Promoting Patient Safety:
Leader ship commitment :
 The leadership of the organization should make patient safety and important core
commitment.
 They can include this in the vision or mission of the organization.
 Budgets, resources, training, performance review, design of infrastructure should include
patient safety aspect.
 Monitoring, analysis and learning from adverse events should be an important part of any
leader’s work.
 Taking frequent rounds of the hospital to check on safety aspects is important.
 Patient safety goals such as correct identification proper hand washing, giving right
medication, reducing hospital acquired infection, reducing readmission, surgical safety,
communication and handovers, preventing patient fall can be announced and
implemented
Patient Safety Committee:
• A patient safety committee should be setup with multidisciplinary leadership

representation such as surgeons, radiologists, nursing, quality, laboratory, engineering,
pharmacy and security.
• Some hospitals include patients and their families to give inputs. Emphasis will be on
evaluating risks and reducing them.
Some of the key responsibilities are listed below:
• Ensure the development and approval of the organization's policies and procedures
related to patient safety.
• The committee will give direction for, and periodically review the training of staff related
to patient safety.
• The committee will formulate the institutional patient safety goals based on reviews of
national and international recommendations and internal reports that identify institution
specific priorities
• A patient safety audit of various departments and facilities will be performed periodically.
Risks will be identified and both clinical and nonclinical corrective and preventive actions
will be undertaken.
• The quality manager will be coordinating with the calendar of meetings, attendance,
minutes and action points.
• The chair person of the committee ,may be a senior leader of the hospital either clinical or
administrative.
System Approach:
A system approach rather than a person approach is required. This will reduce deviations, and bring in
controls.
Some Of The Key Check Points That Are Effective In Preventing Errors Are As Follows:

• Key checks while assessing patients.

• Verifying the identity of patients, their samples and reports.
• Checking that the right medicine is prescribed.
• Double checking the high risk medicines and active monitoring oif those patients.
• Hand hygiene, cleaning, disinfection and sterilization practices.
• Safe transfer and handovers.
• Prompt and timely response in emergency situations. use of disaster codes.
• Accurate and precise communication specially in documents.
• Involving patients in self medication, disease management, discharge planning.
Use Of Checklist:
This will help the person to verify that key actions has been taken, and will remove risk of missing a
step in the process.
Reporting of incidents and making improvements:
• The purpose of reporting is to raise alerts, learn from the mistakes, analyze, and make
improvements. Reports without improvement will not be of any relevance.
• It is important for the staff to report any events including near miss that they have
witnessed.
• This should be done in a work environment that promotes openness and accountability.
• Analysis of incidents is important. A system of peer should be placed and active
involvement of doctors and nurses should be made and should not be lest on
administration alone.
• Leaders has to manage the patients when they suffer loss, ensure root cause analysis is
regularly carried out and corrective, preventive actions are taken place.
Involving Patients And Their Families
• A new trend to bring in transparency and gain valuable inputs from the patients and their
family members. Many organizations seek routine inputs from them. They are invited to
participate in patient safety committee and share their concerns.
• In addition they were asked to be alert and participate in daily medication types, timing,
safeguarding patients from falling etc.,
• A strong focus on patient safety while delivering care, surveillance activities, reporting
and improving continuously can reduce these risks
• Leadership accountability and active participation of staff, patients and their families
ensures continuous focus.
• Innovation processes and technology will reduce the risks and incidents of adverse
events.

Use of root cause analysis in evaluating the challenges posed by clinical v/s operational patient
flow
1. Flow chart

2. Fish bone diagram
Failure-Mode Analysis and Failure-Mode-Cause Analysis
• Failure mode analysis would involve a detailed critical analysis as to which sub-process went
wrong and then doing the failure-mode-cause analysis of the sub-process to locate the element
responsible for it, such as:
1. Mistakes in Prescribing the Medication: The doctor’s orders may be verbal or written.
Verbal orders are prone to be misunderstood. Written orders ,too, could be the cause of errors.
There may be mistakes in writing the name of the drug, the dosage, the route, the frequency
of administration or the precautions to be taken.
2. Mistakes in Interpreting the Prescription: The doctor's handwriting may not be legible.
The nurse may decipher it incorrectly, particularly if she is not an experienced nurse.
3. Mistakes in Noting Down the Orders: There may be a mistake by the sister in writing down
the orders on the nurse’s record or the nurse's work book.
4. Mistakes in Drug Identification: While getting the drug ready, the nurse can make a mistake
and take out the wrong drug (sound-alike, look-alike drug), the wrong strength or the wrong
route drug (intramuscular instead of intravenous).
5. Failure to Identify the Correct Patient: The nurse may fail to correctly identify the patient.
It may be the wrong bed or the room. She may fail to check the patient's name, the CR

number or the ID band. The hospital may not be having the system of using ID band, or the
band may not have been fixed on that patient or may have been fixed at the wrong place on
the body of the patient.
6. Mistakes in Medication Administration: Administration of drug to the patient may be

faulty. The nurse may fail to check/test for allergy to the drug or may prepare the drug in the
wrong strength. She may administer the drug at the wrong time, in the wrong dose, by the
wrong route. The nurse may fail to brief the patient about the signs of adverse effects and may
fail to caution him/her about it.
7. Failure to Observe for Adverse Effects: The nurse may fail to observe the patient after
administering the drug.
8. Delay in Detecting the Problem: There may be a delay in the nurse's response to the
patient’s complaint of symptoms. The nurse may fail to realize that wrong drug has been
administered to the patient or may fail to realize that the patient has developed adverse effects
of the drug administered.
9. Delay in Response: The counter measures by the nurse may be delayed or inadequate. The
ward may not be having all the requisite equipment, the anaphylactic tray may not be ready or
the oxygen cylinder may be empty. The doctor’s phone may be busy or he may not be readily
available to respond to the emergency call.
3. Corrective Measures to be Implemented All the weak points mentioned herewith is the
potential failure-mode causes. To ensure that the process of medication administration is
hazard-free, after identification of the failure mode and cause, the corrective measures as per
the best practices protocol) must be incorporated.
4. Review and evaluation of the protocol after incorporating the relevant corrective measures
in the process at the right place, the effectiveness of the process is eliminating the medication
errors must be re-evaluated.
Why & What Is Streamlining Of Patients
The health care system in our country had to cover large amount of population with only limited
number of doctors, nurses and the infrastructure within the hospitals.
• Due to which we need to effectively use the availability of these resources.

• Waiting time for the patients for various services increases due to unavoidable reasons.
• Also there arises dissatisfaction among the patients for delays in treatment with in the
hospitals.
• This leads to bottle necks
• One short and simple path to achieving that goal is streamlining and optimizing patient flow.
• The expeditor LEAN patient flow system combines sophisticated automated browser based
communication and visual cues ….a fundamental LEAN management tool.
• This system tracks all patients from check in- check out, from when they arrive to when they
leave the practice.
• Automated analysis and reporting combined with informed consulting leads to better results.

• “Invest 4 minutes to eliminate 30-40 minutes of wasted time per physician per day that
translates to 2-3 more patients seen per day per physician”.
Financial Benefits After Streamlining
The financial benefits after quickly and efficiently place patients in the right treatment path, the first
time include:
• Added Capacity: More efficient utilization of the resources and faster turnover of the
existing capacity. Thus without expanding physically.
• Increased Revenue: By providing care for more patients without adding resources.
• Reduced Costs: By optimizing use of hospital resources and proactively managing length of
the stay.
• Improved Staff Productivity: minimizing the “work queuing” by cutting down the time of
teams such as transport, emergency, transfer, nursing and others.
• Improved Patient Health And Satisfaction: By reducing waiting time and timeliness of
definitive care.
• Shorter Length Of Stay & Fewer Readmissions: It can be achieved by right level of care
and coordinated discharge process.
Nine Rules To Achieve Low Cycle Time:
• Cycle time must include treatment complications
• The constraint should be referral, the first process step
• Cycle time must be regularly monitored
• Once the constraint has been identified, that step should be sped up
• Process steps should be completed in parallel whenever possible
• Treatment should be standardized as possible
• Protocols should be followed for the standard treatment process
• The most expensive process step may justify the creation of a buffer to ensure that it is always
in use
EXAMPLE: OPERATION THEATER – KNEE REPLACEMENT SURGERIES
In operation theater due to improper functioning of the cautery machine leads to less number
of surgeries per day thus increasing the waiting list of patients ought for surgery.And this
number goes on increasing if unnoticed and thus the cost of the operation theater usage also
increases.
Rectification Here by monitoring the cycle time we could check the total number of surgeries
that could happen in a single day and the reason for less number of surgeries.

Total Cycle Time: Total cycle time is defined as the number of minutes between a patient
arrives and when he or she leaves.
Waiting Time Shortening By: Murray
Mark Murray had pointed out six principles for improving access,
STEP 1: understanding the balance between supply and demand External demand and Internal
demand
STEP 2: recalibrating the system
STEP 3: applying queuing theory based upon supply we need to decide about the number and ways of
queue required
STEP 4: creating contingency plans in case of variations in supply and demand what should be the
contingency plan ex: seasonal FLU.
STEP 5: influencing the demand patients visiting the regular doctor usually gives better outcomes
and lower system costs
STEP 6:managing the problems proper work allocation usually leads to proper utilization of man
power.
WOODCOCK, MOORE: BETTER PATIENT FLOW AND CYCLE TIME
According to them , the management should be thorough with the following things
• A deep understanding of patient flow process

• Identifying the problems
• Developing the concept of ideal system
• Changes through small steps for achieving the goal
Two methods were proposed by Moore for charting the flow
1.Flow mapping customer service, paper work, equipment and space inadequacies, duplication and
rework, correction and value added and non value added services.
2.Cycle time measurement: this is build based upon flow mapping and involves measuring and
charting the time associated with various parts of the patient visit
• Flow mapping, cycle-time measurement and interruption lists can help practices identify
bottlenecks.
• Using small tests of change, practices have discovered solutions to their patient flow
problems.
• Visit planning, co-location, efficient office design, exam room standardization,
documentation shortcuts and streamlined check-in and checkout processes have proven
successful.
Sample Cycle-Time For A 15-Minute Office Visit

Step Time (minutes)
Wait at check-in 2
Complete check-in 6
Wait in waiting room 14
Move to exam room 4
Wait for physician 10
Interaction with 19
physician
Move to checkout 3
Wait at checkout 3
Check out 4
Total cycle time 65 minutes
• Allocating resources effectively to handle bottle necks – look up on Google
Improving the efficiency of patient care administration and coordination

Patient Turnaround Time

1. Assign a check-in clerk whose sole duty is to check in patients.
2. Give patients a medical history form that is self-explanatory and easy to fill out.
3. Assign a medical assistant to take vitals and prep charts. This way, there will be no delay in
charts being brought to the back clinical area.
4. Post an order board in a common area to prevent delays in patients waiting for common office
procedures such as injections.
5. Implement an efficient practice management system that seamlessly guides you between check-in
and checkout without a hitch. PMSs that process pre-insurance checks are useful too as they
facilitate the check-in process.
6. Request resident physicians to review patient charts prior to patient visits.
7. Make sure your electronic medical record is easy to use and fast to navigate. This will decrease
the amount of time the doctor spends inputting data and increases his or her time talking to the
patient.
8. Finally, align your practice with a culture of service. Clinical staff that is aware of and cares
about service and patient satisfaction will work to improve patient flow.
Patient Safety And Quality

Patient safety is the prevention of avoidable errors and adverse effects to patients associated with health
care. Patient safety is a fundamental principle of health care. Every point in the process of care-giving
contains a certain degree of inherent unsafely.
Adverse events may result from problems in practice, products, procedures or systems. Patient safety
improvements demand a complex system-wide effort, involving a wide range of actions in performance
improvement, environmental safety and risk management, including infection control, safe use of
medicines, equipment safety, safe clinical practice and safe environment of care.{WHO}
Patient safety is the absence of preventable harm to a patient during the process of health care.
The discipline of patient safety is the coordinated efforts to prevent harm caused by the process of health
care itself. It is generally agreed upon that the meaning of patient safety is….please do not harm”

Quality of process
1. There must be a documented program of patient safety management in the hospital.
2. The programme must include each and every activity of The program must include each and
every activity that bearing on the patients' safety.
3. There must be a formal Patient Safety Management Program (PSMP Committee) with a
documented charter of duties and staff functioning. The committee need not be too large as it
would hamper the functioning.
4. There must be a documented policy and procedure for regular and periodic inspections of the
facility by the administrator along with the chief of maintenance services. The observations must
be documented along with the corrective actions taken.
5. A documented procedure for regular planned maintenance facility along with the allocation of
adequate funds.
6. A documented procedure for planned preventive maintenance of all the equipment. To make it
effective there must be an updated inventory of all the equipments and a history sheet for each
and every equipment and a history sheet for each and every equipment unit.
7. Display of warning signs to fore warn the people about the possible hazards.
8. A well planned and documented hospital security system detailed protocols for safety/security of
patients, particularly the vulnerable groups.
9. A well documented fire safety program, with special emphasis on training of staff in fire fighting
drills, periodic mock drills and record of observation/actions recommended and a system of
planned preventive maintenance of fire fighting equipment.
10. Policy and procedure for ensuring hazard free power supply.
11. There should be a documented policy and procedure for purchases. Materials purchased,
especially the drugs and dietary items must be of assured high quality and their storage system
should be good enough to prevent deterioration.
12. There should be a documented policy and procedure for eliminating medical errors.
Accreditation and accrediting organization – NABH, NABL and JCI
History of Accreditation
 The early 20th century was a period of very rapid change

 The Flexner Report, the formation of the American College of Surgeons (ACS), the formation of
their “ Hospital Standardization Committee” and the publication of articles on scientific
management. The Flexner Report was a study of the them current state of American medical
education sponsored by the Carnegie Foundation and carried out by Abraham Flexner, a
professional educator with no previous experience in health care. He visited medical schools
throughout the country, observing that only a limited number were in any sense equal to that of
Johns Hopkins which was a widely accepted “ gold standard” in education.
 In 1910, Dr Codman revealed his “End Result Idea”, the concept that surgeons and hospitals
ought to follow patients after discharge in order to understand exactly what the effects of
treatment were. He added the important corollary that all results should be made public. A

“Hospital Standardization Committee” was formed with Codman as its Chair; once the ACS was
chartered it became a standing committee of the college.
 Ernest A Codman: His concept of the End Result Idea was “merely the common-sense notion
that every hospital should follow every patient it treats, long enough to determine whether or not
the treatment has been successful, and then to inquire ‘if not, why not?’ with a view to preventing
a similar failure in the future.”
The hospital standardization committee
This committee continues its work to develop a minimum set of standards for hospitals. Initially only five
standards were promulgated. They were:-
 That the medical staff should be organized

 That the staff be restricted to physicians who licensed graduates, competent and of good moral
character
 That the medical staff adopt rules including a requirement that there be a review and analysis of
clinical performance
 That accurate and complete records be maintained for all patients
 That diagnostic and therapeutic services “under competent supervision” be available
Development of the Joint Commission: The Joint Commission on Accreditations of Hospitals, which
was incorporated in 1951. The board consisted of seven members from the AMA seven from the AHA
and three each from the ACS and the American College of Physicians as well as a representative of the
Candian Medical Society
 The term accreditation means the systematic assessment of hospitals against accepted standards
 After Joint Commission in USA. Canada and later Australia launched their accreditation
Programs. The number of programs around the world has doubled every 5 years since 1990.
Development has been especially marked in Europe. There are 11 active programs (Bulgaria,
France, Germany, Ireland, Italy (regional), Netherlands, Poland, Portugal, Spain, Switzerlands,
and UK.
 To promote development and compatibility in world, the International Society for Quality in
Health care (ISQua) launched Agenda for Leadership in Programs in Health care Accreditation
(ALPHA) in 1999. ALPHA offers services for healthcare standards and accreditation bodies:

Survey and international standards for accordance with international standards for national
healthcare accreditation bodies and standards assessment against international principles for
national health care
 Accreditation standards are available for different types of healthcare organization such as
hospitals, clinic laboratories homecare and nursing care ambulatory care providers, transport care,
providers, etc. These standards are applicable in public healthcare organization as well as in
private healthcare sectors.
 Many benefits of accreditation, such as establishment of uniform policies, procedures and records,
measurement of indicators of performances, management system and clinical system, etc, attract
healthcare decision makers to adopt this program.
The list of the chapters in the JCI hospital accreditation program is as follows:
Section I: patient –Centered Standards
a) Patient Safety Goals(IPSG)

b) Access to Care and Continuity of Care (ACC)
c) Patient and Family Rights(PER)
d) Assessment of Patients (AOP)
e) Care of Patients(COP)
f) Anesthesia and Surgical Care (ASC)
g) Medication Management and Use (MMU)
h) Patient and Family Education(PPE)
Section II: Healthcare Organization Management Standards

a) Quality Improvement and Patient Safety (QPS)
b) Prevention and control of Infections(PCI)
c) Governance, Leadership, and Direction (GLD)
d) Facility Management and Safety(FMS)
e) Staff Qualification and Education(SQE)
f) Management of Communication and Information(MCI)
Other International Healthcare Accreditation Organizations
• The Canadian Council on Health Service Accreditation (CCHSA), Canada.

• The Australian Council on Healthcare Standards (ACHS), Australia.

• Health Quality Services (HQS). The King’ fund Centre, England

• Council Health Services Accreditation for South Africa (COHSASA)
• The Irish Health Services Accreditation Board (IHSAB), Ireland
• The Malaysian Society for Quality in Health (MSQH), Malaysia.
• New Zealand Council on Healthcare Standards (NZCHS). New Zealand.
• Trent Accreditation Scheme, Trent based in UK-Europe and Hong Kong
• Community Health Accreditation Program (CHAP) – based in the USA.
• Accreditation Commission for HealthCare Inc. (ACHC) – based in the USA.
• Healthcare Quality Association on Accreditation (HQAA) – based in the USA
• Many other countries including Thailand, Jordan, Taiwan and others have their own accreditation
bodies.
Evolution of NABH and its present status
In India the quality of services provided to the population by both public and private sector is
questionable. The National Accreditation Board for Hospitals and Healthcare Providers(NABH)
accreditation system is one of the methods for commitment to quality enhancement throughout the whole
of the healthcare system in India
History
• The current structure of the health care delivery system in our country does not provide enough
incentives for improvement in efficiency.
• Mechanisms used in other countries to produce greater efficiency, accountability, and more
responsible governance in hospitals are not yet deployed in India.
• The profit private sector has received relatively less attention from the policy makers as compared
to the public sector.
• Thus, the private sector healthcare delivery system in India has remained largely fragmented and
uncontrolled, and there is a clear evidence of serious quality of care deficiencies in their practices.
• There is a need to establish bodies and systems to monitor clinical and non-clinical effectiveness
of the service offered in the public and private facilities.
What is NABH? National Accreditation Board for Hospitals and Health Care Providers (NABH) is a
constituent Board of QCI, set up with cooperation of the Ministry of Health and Family Welfare,
Government of India and the Indian Health Industry.

NABH assessment process in general
 The NABH standards for hospitals have been drafted by Technical Committee of NABH
 The standards focus on patient safety and quality of care.
 The standards call for continuous monitoring of sentinel events and comprehensive corrective
action plan leading to building of quality culture at all levels and across all the functions.
 The main purpose of NABH accreditation is to help the planners to promote, to implement, to
monitor and to evaluate the robust practice in the healthcare system.
 The problems range from inadequate and inappropriate treatments to excessive use of higher
technologies and wastage of scare resources to serious problems of medical malpractice and
negligence.
 Quality assurance has to help improve the effectiveness, efficiency and cost containment and
should also address the accountability and the need to minimize the errors and increase the safety
in healthcare system.
 The standards provide a framework for quality assurance and quality for quality assurance and
quality improvement for Hospital.
 The accreditation standard requirements make sure that the owners, managers and staff comply
with appropriate technical and professional standards regardless of cost pressures and avoidance
of the personnel.
 Patient Centered Standard :-
1. Access, Assessment and Continuity of Care(ACC)
2. Care Of Patient(COP)
3. Management of Medication(MOM)
4. Patient Right and Education(PRE)
5. Hospital Infection Control(HIC)
Organization Centered Standards:-
1. Continuous Quality of Improvement(CQI)
2. Responsibilities of Management (ROM)
3. Facility Management and Safety(PRE)
4. Human Resources Management(HRM)
5. Information Management(IMS)
Cardinal Principles of assessment are:

1. Hospital operations are based on sound principles of system based organization.

2. NABH standards are implemented and institutionalize into hospital functioning.

3. Patient safety and quality of care, as core values, are established and owned by management
and staff in all functions and at all levels.
4. There is structured quality improvement program based continuous monitoring of patient care
services.
Why NABH?
The main purpose of NABH accreditation is to help planners to promote, implement, monitor and
evaluate robust practice in order to ensure that occupies a central place in the development of the
healthcare system.
Benefits Of Accreditation
1. Patient focus leads to better quality services and satisfaction/delight of the patients.
2. Wasteful expenses and activities are minimized and the efficiency is enhanced.
3. Gainful activities are optimized and outcomes improved.
4. The reputation for professional excellence provides the organization an edge over the
competitors and brings in better business.
5. It enhances the confidence of patients, public and insurance agencies as well as the regulatory
authorities in the quality of services provided by the organization.
6. It minimizes the chances of negligence, improves the safety standards and enhances the image
of the organization.
National Accreditation Board for Testing and Calibration Laboratories
National Accreditation Board for Testing and Calibration Laboratories (NABL) is an autonomous body
under the aegis of Department of Science & Technology, Government of India. NABL has been
established with the objective to provide Government, Regulators and Industry with a scheme of
laboratory accreditation through third-party assessment for formally recognizing the technical competence
of laboratories. The accreditation services are provided for testing, calibration and medical laboratories in
accordance with International Organization for Standardization (ISO) Standards. Accreditation assists the
Indian industries to enhance the quality and reliability of Indian goods in the domestic market and exports,
thereby, catalyses the growth of Indian economy. WTO has identified non-acceptance of test results and
measurement data as Technical Barrier to Trade (TBT) and accreditation is considered to be the first
essential step towards removing such technical barriers.
NABL went a step further in removing technical barriers to trade and achieved the status of signatory to

Asia Pacific Laboratory Accreditation Cooperation (APLAC) Mutual Recognition Arrangement (MRA) and
International Laboratory Accreditation Cooperation (ILAC) Arrangement based on a peer evaluation by
APLAC in 2000. This was a major step towards mutual acceptance of test results and measurement data
across Indian borders. NABL went through the peer APLAC evaluation in 2004 & 2008 and reaffirmed its
APLAC / ILAC signatory status with extension of scope for Medical Testing as per the new standard ISO
15189. Today, the test results and measurement data produced by Indian accredited laboratories are
acceptable amongst 64 economies. NABL accredited laboratories have therefore emerged members of
global family of more than 40,000 accredited laboratories.
NABL provides accreditation in all major fields of Science and Engineering such as Biological,
Chemical, Electrical, Electronics, Mechanical, Fluid-Flow, Non-Destructive, Photometry, Radiological,
Thermal & Forensics under testing facilities and Electro-Technical, Mechanical, Fluid Flow, Thermal,
Optical & Radiological under Calibration facilities. NABL also offers accreditation for medical testing
laboratories.
The major sectors in which NABL has granted accreditation are Textiles, Automobiles, Power, Telecom,
Petroleum, Food, Health and Environment. As on date, more than 1600 laboratories have NABL
accreditation, out of which 20% are Government laboratories.
Benefits of accreditation
1. Formal recognition of competence of a laboratory by an Accreditation body in accordance

with international criteria provides a ready means for customers to identify and select reliable
testing, measurement and calibration services.
2. Marketing advantage: Accreditation body publish directory of their accredited laboratories- a
potential means of promoting a laboratories accredited services to potential clients.
3. Savings in terms of time and money due to reduction or elimination of the need for re-testing
of products. The uniform approach for determining laboratory competence encourages
laboratories to adopt internationally accepted testing and measurement practices. This
effectively reduces costs for both the manufacturer and the importer, as it reduces or
eliminates the need for products to be retested in another country.
4. Better control of laboratory operations: Incorporation of the systematic approach of relevant
standard in working of laboratory provides better control of laboratory operations.
5. Benchmark for performance: A regular assessment by an accreditation body as per
international standard checks all aspects of facility’s operation consistently producing
accurate and dependable data. Therefore raises the performance level to the appropriate
international standard.
6. Ease of operation: Customers can search and identify the laboratories accredited by NABL
for their specific requirements from the Directory of Accredited Laboratories.
7. Users of accredited laboratories will enjoy greater access for their products, in both
domestic and international markets, when the products are tested by accredited laboratories

as the test data is accepted in the national and international markets. This can lead to
potential increase in business due to enhanced customer confidence and satisfaction.
8. International recognition for laboratory: Laboratory accreditation is highly regarded both
nationally and internationally as reliable indicator of technical competence. Mutual recognition
agreements (MRAs) among the countries enable test and calibration data produced by
accredited laboratories to be accepted between these countries.


Unit 4 TQM

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TQM UNIT 4 QUALITY IN PATIENT CARE DSM-MHM

Contemporary quality improvement

Essentials Of Quality Improvement In Healthcare Services

1. Well planned and meticulously executed.

3. It is a continuous ongoing process involving implementation and repeated cycles of review

5. There are no shortcuts. The program cannot be implanted in an organization. It has to be

Patient safety initiatives

Why Is Health Care Unsafe ?

Hospital complexity and system:

• It has several people, several processes, equipment and are interdependent.

• Ex:-Medication administration, patient identification.

• Most of these are due to poor communication, processes variation.

Sumaiya Abdul Qadeer

General Problems Reported:

• Incorrect monitoring of patients

• Patient identification errors

Levels Of Harms To Patients:

Adverse drug event:

It is caused by an error in prescribing, dispensing, transcribing or administering.

Sumaiya Abdul Qadeer

Promoting Patient Safety:

Leader ship commitment :

Patient Safety Committee:

• A patient safety committee should be setup with multidisciplinary leadership

Some of the key responsibilities are listed below:

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• Key checks while assessing patients.

Reporting of incidents and making improvements:

Involving Patients And Their Families

Sumaiya Abdul Qadeer

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2. Fish bone diagram

Failure-Mode Analysis and Failure-Mode-Cause Analysis

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6. Mistakes in Medication Administration: Administration of drug to the patient may be

Why & What Is Streamlining Of Patients

• Due to which we need to effectively use the availability of these resources.

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Financial Benefits After Streamlining

Nine Rules To Achieve Low Cycle Time:

• Cycle time must include treatment complications

• The constraint should be referral, the first process step

• Cycle time must be regularly monitored

• Process steps should be completed in parallel whenever possible

• Treatment should be standardized as possible

• Protocols should be followed for the standard treatment process

EXAMPLE: OPERATION THEATER – KNEE REPLACEMENT SURGERIES

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Waiting Time Shortening By: Murray

STEP 2: recalibrating the system

WOODCOCK, MOORE: BETTER PATIENT FLOW AND CYCLE TIME

• A deep understanding of patient flow process

Two methods were proposed by Moore for charting the flow

Sample Cycle-Time For A 15-Minute Office Visit

Sumaiya Abdul Qadeer

Step Time (minutes)

• Allocating resources effectively to handle bottle necks – look up on Google

Improving the efficiency of patient care administration and coordination

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Patient Turnaround Time

Patient Safety And Quality

Sumaiya Abdul Qadeer

Accreditation and accrediting organization – NABH, NABL and JCI