REVIEW OF LITERATURE

For the purpose of the research the following literature are considered as useful
for the study. Hence the literatures are;
1)Vivek Hittinahalli and Saroj Golia; National Accreditation Board for
Hospitals and Healthcare Providers (NABH) is a national body responsible for
providing accreditation to the hospitals. General accreditation programs appear to
improve the structure and process of care, with a good body of evidence showing
that accreditation programs improve clinical outcomes. General accreditation
programs of health organizations and accreditation of subspecialties should be
encouraged and supported to improve the quality of healthcare services. One of
the most important barriers to the implementation of accreditation programs is the
skepticism of healthcare professionals in general and physicians in particular
about the positive impact of accreditation programs on the quality of healthcare
services. However with quality in healthcare an important aspect, healthcare
accreditation has become a most important tool for improving the standard of the
hospitals and thereafter benchmarking.

2)Mandeep, Naveen Chitkara, Sandeep Goel; the study revealed that medical
staff had a positive attitude and improved knowledge about accreditation after 6
months working in a hospital on the way to NABH. The attitude reflected in their
positive approach in managing patients under better work atmosphere thus,
indirectly reflecting on the benefit to the society as whole. The sound knowledge
and a positive attitude toward NABH accreditation among the medical staff are
very important. And the same can be accomplished with proper training and good
hospital environment.

3)Quality Council of India; the rapid changes in the healthcare system, with
revolutionary advancements in imaging, along with the lack of any existing
imaging standards in our country, have raised the need for
an accreditation structure. The Quality Council of India (QCI) has therefore
introduced standards for medical imaging services, focusing on the control of
services, personnel, imaging processes and procedures, facility and environment,
equipment, and documentation, as well as risk control and safety. This article
deals briefly with the standards structured by the QCI for accreditation of imaging
services.

4)Bogh SB, Falstie-Jensen AM, Bartels P, Hollnagel E, Johnsen SP; the

overall opportunity-based composite score improved for both non-accredited and
accredited hospitals (13.7% and 9.9%, respectively), but the improvements were
significantly higher for non-accredited hospitals (absolute difference: 3.8%). No
significant differences were found at disease level. The overall all-or-none score
increased significantly for non-accredited hospitals, but not for
accredited hospitals. The absolute difference between improvements in the all-or-
none score at non-accredited and accredited hospitals was not significant.
Participating in accreditation was not associated with larger improvement in
performance measures for acute stroke, heart failure or ulcer.

5) Dr Kalra; said the biggest beneficiaries of accreditation were patients as the

certification ensured best quality services to them. Although there are 19 major
criteria to be followed by any hospital seeking accreditation, there are 150 minor
objectives that the unit should fulfil, he informed. NABH accreditation was not
mandatory yet but it was also not an easy affair. The process involved many pre-
assessment procedures and inspections but was mainly patient centric."It is aimed
at providing the best possible care to patients. Beginning from small things like
hand washing to post operative care, everything has a definite protocol monitored
extensively. We conduct even surprise inspections,"
The American College of Surgeons woke up to the fact that ―All hospitals are
accountable to the public for their degree of success....if the initiative is not taken
by the medical profession, it will be taken by the lay public.‖ The seeds of
healthcare quality and patient safety were sown – it would culminate in the
formation of Joint Commission International (JCI).
6) D.Shreedevi; Indian health care system is currently operating within an
environment of rapid social, economical and technical changes and hospitals are
an integral part of health care system. Accreditation would be the single most
important approach for improving the quality of hospitals. National accreditation
system for hospitals ensures that hospitals, whether public or private,
national or expatriate, play their expected roles in national
health system. Accreditation results in high quality of care and patient safety.
Patient rights encompass legal and ethical issues in the provider-patient
relationship, including a Person’s right to privacy, right to quality medical
care without prejudice, right to make informed decisions about care and treatment
options, and right to refuse treatment. This study assesses the NABH
Accreditation preparedness of the hospital with respect to the patient rights and
education. The results of this study reveal that existing patient’s right practices are
not on par with the NABH standards. Concrete steps in terms of initiating a
mechanism of action to ensure strict adherence to patients’ rights and up-gradation
of the existing practices is necessary.

7)Dr. Eesha Arora, Dr. Prakash P; in healthcare it came in for some serious
discussion only in late nineties in our country. Quality specific to healthcare
evolved after some serious effort coming from college of Surgeons in USA. This
was largely based on establishing clinical protocols & outcome indicators. This
effort later got formalized in terms of healthcare accreditation. Multidisciplinary
healthcare organizations of today need to be managed in terms of integrating
clinical services with the support services. The current generation of accreditation
standards have optimum mix of managerial elements with supporting clinical
components. Quality assurance by way of formal accreditation is being considered
as a necessary part of the operation of any healthcare organization these days.
Accreditation is structured to cater to much desired needs of the consumers and to
set benchmarks for progress of health industry.
8)Ms Bandita Thakur, Dr Purnima S Rao, Dr Sumesh T Rao; hospitals
currently operate in an environment of rapid socioeconomic and technical changes
that raise concern for the quality of health care. Accreditation would be the single
most important approach for improving the quality of care in hospitals. Rights of
patients in a hospital are to be respected and protected. Patient rights encompass
legal and ethical issues in the provider-patient relationship, including right to
privacy, quality medical care without prejudice, the right to make informed
decisions about treatment options, and the right to refuse treatment.

9)Dr Pandit; ―Earlier, the government has asked hospitals to get the accreditation
certificate by December 2014, but after the request of the hospitals, it has been
extended up to 2015. Currently, only one hospital—Bombay Hospital—has the
NABH accreditation in the city, but many of them have applied to get the
accreditation‖.

10) Rita Dutta; the swelling demand for an accreditation that comes under the
purview of the quasi-Government body, Quality Council of India is quite an
interesting phenomenon. And to think that most of the board members are veteran
administrators from private and public sectors doing honorary work and the
assessors also don’t get major monetary benefit! But the most interesting
development in recent times has been change of the old guard and constitution of
a new board.

11)Dr Praneet Kumar, Chairman, Technical Committee, NABH; after making

NABH standards ISQUA (the International Society for Quality in Health Care)
compliant in 2008, the technical committee is working on attaining accreditation
of NABH from ISQUA. ―This would ensure that NABH's systems and processes
are compliant with an international organization, thus guaranteeing better
documentation and process orientation,‖ It is expected that an ISQUA-accredited
NABH would give a boost to medical value travel, especially from the US and the
UK. ―It would bring in more transparency and clarity in processes involved for
medical value travel‖. So far, hospital standards of only 11 countries are
accredited by ISQUA.

12)Dr Narottam Puri, Chairman, NABH Committee; most Government-led

initiatives are plagued by slow processes and lack of transparency. NABH wants
to address these challenges by more effective use of IT. ―Though the status of
NABH registration can be viewed online, hospitals can neither apply nor get
queries answered online. We also have a space crunch to stack all this paper in the
office. Right now, the use of IT is very rudimentary. Going forward, we need a
robust IT system.‖

13)Dr Kumar; IT would also empower the accredited hospitals. It is planning to

make a daily update of data on some key parameters mandatory for the hospital.
―For instance, if updating an accredited hospital's score on HAI is made
mandatory, then all hospitals would be made more accountable and responsible
towards quality compliance. This would help hospitals get a snapshot of where
they stand and enable them to learn from each other. It would also empower
patients to choose the hospitals they want to seek treatment from by noting
comparative scores on key parameters‖.

14)Dr. Puri; the demand for NABH accreditation has gone beyond Indian shores.
It has recently launched its international arm NABH International, similar to JCI
of JCAHO. It has already signed an agreement with the Philippines Government
to launch NABHI in Philippines. NABHI has also been approached by countries
like Bangladesh, Pakistan and the UAE. About the rationale of launching its
international arm. ―These countries respect the clinical acumen of Indian doctors.
We also get a regular stream of patients from these countries. So, we are tapping a
business opportunity here‖. ―Depending on the country we are working in, we
would tweak our standards‖.
15)Abdullah Alkhenizan and Charles Shaw; there is consistent evidence that
shows that general accreditation programs improve the process of care provided
by healthcare services. There is considerable evidence to show that general
accreditation programs improve clinical outcomes of a wide spectrum of clinical
conditions. There is also considerable evidence to show that accreditation
programs of subspecialties improve clinical outcomes. Accreditation programs
should be supported as a tool to improve the quality of healthcare services.

16)Akash Rajpal; more important than the infrastructure, it is essential to know if

the hospital has a documented process for its healthcare activities. Patient care not
only involves the core clinical care, but also other support activities like
requisition of tests, medicines, nurse doctor coordination, infection control
practices, training, and so on. These need to run seamlessly in the background to
provide the best experience to the patient and the relatives.
A quality-conscious hospital should define all such activities internally, document
the same, and impart necessary training to the staff. These documented activities
include detailed job responsibilities, work instructions, checklists and quality
indicators for the staff to follow.

17)Stephanie Bennett, Clinical Editor at Elsevier/MC Strategies; ―Voluntary

accreditation helps hospitals demonstrate commitment to high-quality
performance, which benefits patients and healthcare professionals alike. With new
players offering more flexibility, hospitals now have opportunities to tailor their
quality systems and develop programs focused on specific needs‖.

18)The Joint Commission; the advantages of being commission-accredited

include better risk management and risk reduction, the provision of education on
best practices to improve business operations, and improved staff recruitment and
development. Some insurers look for commission accreditation. Accreditation
costs range from $1,780 to $36,845, depending on the hospital’s size and
complexity of services.
19)Det Norske Veritas Healthcare; its accreditation services are unique because
it uses the hospital’s own practices as the basis for written policies and
procedures, so hospital administrators can determine areas of focus and write
individualized action plans. The organization has 27 hospitals in 22 states
participating in its accreditation program. It is working to build its reputation and
gain support from insurers.

20)Dr Rakesh Parashar (Consultant, Activist and Entrepreneur in Health

Care); there is a need to take early actions to escape a „lost credibility‟ scenario
for the board. This would mean looking into and defining the relevance for
various HCOs, redefining the standards to remove vagueness and to include many
other possible areas including relevant use of Information Technology, making the
process more transparent and put in place a strict monitoring system to measure
the outcomes of the NABH certification at a broad level. Also, there should be
recommendations about how NABH can utilize the monetary returns better for the
health service delivery in India.

21)June Gibbs Brown Inspector General; unquestionably, the Joint

Commission is the central force in the external review of hospital quality. It
accredits about 80 percent of the hospitals in the country and, for Medicare
purposes, it has a congressionally granted deeming status that is unique among
accrediting bodies. Medicare beneficiaries and others who rely upon hospital
services have much at stake in how and how well the Joint Commission does its
job. Our review underscores that the core element of the Joint Commission’s
approach to accreditation is the announced, on-site survey of hospitals a survey
that is heavily oriented toward educational and performance improvement
objectives. The other elements of external review unannounced surveys, responses
to complaints and serious incidents, and standardized performance measures play
relatively minor roles in the Joint Commission’s accreditation process.
22) David Greenfield, Jeffrey Braithwaite; the health care accreditation
industry appears to be purposefully moving towards constructing the evidence to
ground our understanding of accreditation. The analysis reveals a complex
picture. In two categories consistent findings were recorded: promote change and
professional development. Inconsistent findings were identified in five categories:
professions' attitudes to accreditation, organizational impact, financial impact,
quality measures and program assessment. The remaining three categories
consumer views or patient satisfaction, public disclosure and surveyor issues did
not have sufficient studies to draw any conclusion. The search identified a number
of national health care accreditation organizations engaged in research activities.

23)Kirsten Brubakk, Gunn E. Vist, Geir Bukholm, Paul Barach and Ole
Tjomsland; Accreditation continues to grow internationally but due to scant
evidence, no conclusions could be reached to support its effectiveness. Our review
did not find evidence to support accreditation and certification of hospitals being
linked to measurable changes in quality of care as measured by quality metrics
and standards. Most studies did not report intervention context, implementation,
or cost. This might reflect the challenges in assessing complex, heterogeneous
interventions such as accreditation and certification. It is also may be magnified
by the impact of how accreditation is managed and executed, and the varied
financial and organizational healthcare constraints. The strategies hospitals should
implement to improve patient safety and organizational outcomes related to
accreditation and certification components remains unclear.

24)Stephen P Schmaltz, Scott C Williams, Mark R Chassin, Jerod M Loeb,

and Robert M Wachter; hospitals accredited by The Joint Commission tended to
have better baseline performance in 2004 than non-accredited hospitals.
Accredited hospitals had larger gains over time, and were significantly more
likely to have high performance in 2008 on 13 out of 16 standardized clinical
performance measures and all summary scores.
25)Jack Needleman, Peter Buerhaus, Soeren Mattke, Maureen Stewart and
Katya Zelevinsky; it is uncertain whether lower levels of staffing by nurses at
hospitals are associated with an increased risk that patients will have
complications or die. A higher proportion of hours of nursing care provided by
registered nurses and a greater number of hours of care by registered nurses per
day are associated with better care for hospitalized patients.

26)CASPE Research, London, UK; this paper is a summary of the operation,

findings and conclusions of a European Union project on external peer review
techniques, termed 'ExPeRT', to research the scope, mechanisms and use of
external quality mechanisms in the improvement of health care. Many of the
themes outlined are described in detail in other papers that have been prepared
specifically for this issue of The International Journal for Quality in Health Care.
Although the emphasis of this project and of this issue of the Journal is on Europe,
the conclusions are more widely relevant.

27)Braithwaite J; inconsistent findings were identified in five categories:

professions' attitudes to accreditation, organizational impact, financial impact,
quality measures and program assessment. The remaining three categories-
consumer views or patient satisfaction, public disclosure and surveyor issues-did
not have sufficient studies to draw any conclusion. The search identified a number
of national health care accreditation organizations engaged in research activities.
The health is accreditation industry appears to be purposefully moving towards
constructing the evidence to ground our understanding of accreditation.

28)Bukonda N, Tavrow P, Abdallah H, Hoffner K, Tembo J; having a

developing country sustain an accreditation program requires dedicated funds,
government and donor commitment, continual adaptation, ongoing technical
assistance to hospitals, and a functioning accreditation body. In Zambia, the
accrediting Council was stymied by a heavy workload, lack of legitimacy and
budget authority, and the government's indecision on incentives and feedback.
Long delays arose between accreditation surveys and feedback of written results.
Zambia has now begun to include some accreditation standards in performance
audits and is considering decentralizing survey functions.

29)Duckett SJ; participation in the Australian Council on Hospital Standards’

accreditation program provides one of the important stimuli for change in
Australian hospitals. This article analyses the impact of the accreditation program
upon a random sample of 23 Australian hospitals which were monitored for two
years. At the conclusion of the study, those hospitals which had applied for
accreditation were compared and contrasted with those hospitals which had not
applied. It was found that those hospitals which applied could be differentiated
from those hospitals which had not by significant changes in six areas. The areas
which showed the least change were those most directly associated with the
medical staff. 'Nursing Organization' and 'Physical Facilities and Safety' were the
area’s most affected by accreditation.

30)Dean Beaulieu N, Epstein AM; Accreditation of health care organizations has

traditionally been considered a building block of quality assurance. However, the
differences between accredited and non-accredited health plans and the impact
of accreditation on plan enrollment are not well understood. Accredited plans
have higher (Health Plan Employer Data and Information Set) HEDIS scores but
similar or lower performance on patient-reported measures of health plan quality
and satisfaction. Furthermore, a substantial number of the plans in the bottom
docile of quality performance were accredited suggesting that accreditation does
not ensure high quality care. Receipt of accreditation has been associated with
increased enrollment in the early years of the accreditation program; however,
plans denied (National Committee on Quality Assurance) NCQA accreditation do
not appear to suffer enrollment losses. NCQA accreditation is positively
associated with some measures of quality but does not assure a minimal level of
performance. Efforts now underway to incorporate plan performance on HEDIS
into criteria for accreditation seem warranted.
31)Griffith JR, Knutzen SR, Alexander JA; outcomes performance measures
are increasingly important in health care. The Joint Commission
on Accreditation of Healthcare Organizations (Joint Commission) continues to
rely on structure and process measures based on accepted good practice. One of
the first tasks in moving to a more outcomes-oriented approach is to compare the
two measurement approaches. This article compares seven non-federal general
hospital performance measures derived from Medicare against Joint Commission
scores. Joint Commission measures are generally not correlated with outcome
measures. The few significant correlations that appear are often counterintuitive.
We conclude that a potentially serious disjuncture exists between the outcomes
measures and Joint Commission evaluations.

32)Miller MR, Pronovost P, Donithan M, Zeger S, Zhan C, Morlock

L, Meyer GS; this study examined the association between the Joint Commission
on Accreditation of Healthcare Organizations (JCAHO)accreditation scores and
the Agency for Healthcare Research and Quality's Inpatient Quality Indicators and
Patient Safety Indicators (IQIs/PSIs). JCAHO accreditation data from 1997 to
1999 were matched with institutional IQI/PSI performance from 24 states in the
Healthcare Cost and Utilization Project. Most institutions scored high on JCAHO
measures despite IQI/PSI performance variation with no significant relationship
between them. Principal component analysis found 1 factor each of the IQIs/PSIs
that explained the majority of variance on the IQIs/PSIs. Worse performance on
the PSI factor was associated with worse performance on JCAHO scores (P=.02).
No significant relationships existed between JCAHO categorical accreditation
decisions and IQI/PSI performance. Few relationships exist between JCAHO
scores and IQI/PSI performance. There is a need to continuously reevaluate all
measurement tools to ensure they are providing the public with reliable, consistent
information about health care quality and safety.
33)Hadley TR, McGurrin MC; data on 216 state psychiatric hospitals were
analyzed to determine whether accreditation by the Joint Commission on
Accreditation of Healthcare Organizations (JCAHO) or certification by the Health
Care Financing Administration (HCFA) were related to seven hospital
characteristics generally accepted as reflecting quality of care. The characteristics
were average cost per patient, per diem bed cost, total staff hours per patient,
clinical staff hours per patient, percent of staff hours provided by medical staff,
bed turnover, and percent of beds occupied. While a majority of the hospitals had
either JCAHO accreditation, HCFA certification, or both, analysis revealed a
weak relationship between accreditation or certification status and the indicators
of quality of care. Accredited or certified hospitals were, however, more likely to
have higher values on specific indicators than hospitals without accreditation.

34)Al Tehewy M, Salem B, Habil I, El Okda S; mean patient satisfaction scores

were significantly higher among the accredited non-governmental health units
regarding: cleanliness, waiting area, waiting time, unit staff and overall
satisfaction. No significant differences were noticed in provider satisfaction
except for the overall satisfaction score. Most of the checked standards had
compliance above 90% in the accredited units and were significantly higher than
in the non-accredited units.
Accreditation of the non-governmental health units has a positive effect regarding
patient satisfaction and the continuation of performance according to the
accreditation standards compared with non-accredited health units. This short-
term effect was shown within the first year from accreditation. Future research is
needed to assess long duration effects of applying accreditation in non-
governmental health units.

35)Quimbo SA, Peabody JW, Shimkhada R, Woo K, Solon O; it is unclear

whether health provider accreditation ensures or promotes quality of care. Using
baseline data from the Quality Improvement Demonstration Study (QIDS) in the
Philippines we measured the quality of pediatric care provided by private and
public doctors working at the district hospital level in the country's central region.
We found that national level accreditation by a national insurance program
influences quality of care. However, our data also show that insurance payments
have a similar, strong impact on quality of care. These results suggest
that accreditation alone may not be sufficient to promote high quality of care.
Further improvements may be achieved with properly monitored and well-
designed payment or incentive schemes.

36)Chen J, Rathore SS, Radford MJ, Krumholz HM; we examined the

association between JCAHO accreditation of hospitals, those hospitals' quality of
care, and survival among Medicare patients hospitalized for acute myocardial
infarction. Hospitals not surveyed by JCAHO had, on average, lower quality (less
likely to use aspirin, beta-blockers, and reperfusion therapy) and higher thirty-day
mortality rates than did surveyed hospitals. However, there was considerable
variation within accreditation categories in quality of care and mortality among
surveyed hospitals, which indicates that JCAHO accreditation levels have limited
usefulness in distinguishing individual performance among accredited hospitals.
These findings support current efforts to incorporate quality of care in
accreditation decisions.

37)Wells R, Lemak CH, Alexander JA, Nahra TA, Ye Y, Campbell CI;

licensing and accreditation are widely used to improve and convey organizational
quality. The objective of this study was to provide substance abuse treatment
stakeholders with better evidence about how well licensing
and accreditation actually correlate with staffing and treatment practices.
Regressions using data from national surveys of outpatient substance abuse
treatment facilities indicated that no form of licensing or accreditation was
associated with better staff-to-client ratios or with one important aspect of
comprehensive treatment the percentage of clients receiving routine medical care.
There were several positive associations between licensing/accreditation and other
aspects of treatment comprehensiveness. Three categories of
licensure/accreditation were also positively associated with use of after-treatment
plans. Post hoc analyses revealed that accreditation was associated with units'
organizational contexts and referral sources as well as the nature of the
competitive environment. Licensing/accreditation may reveal as much about units'
institutional environments as about the quality of treatment provided.

38)Sekimoto M, Imanaka Y, Kobayashi H, Okubo T, Kizu J, Kobuse

H, Mihara H, Tsuji N, Yamaguchi A; in Japan, hospital Infection Control (IC)
programs are frequently under-resourced, whereas their improvement is
considered a pressing issue. Hospital accreditation may have a positive impact on
IC program performance. The Japan Council for Quality Health Care (JCQHC) is
a hospital accreditation organization that now prescribes broad elements of IC as
part of its accreditation standards. Hospital accreditation had a significant impact
on hospitals' IC infrastructure and performance.
39)Menachemi N, Chukmaitov A, Brown LS, Saunders C, Brooks RG; little is
known about quality outcomes in accredited and non-accredited Ambulatory
Surgical Centres (ASCs). Quality outcomes in ASCs accredited by either the
Accreditation Association for Ambulatory Health Care (AAAHC) or The Joint
Commission were compared with those of non-accredited ASCs in Florida. With
the exception of one procedure, systematic differences in quality of care do not
exist between ASCs (non-accredited ambulatory surgical centers) that are
accredited by AAAHC (Accreditation Association for Ambulatory Health Care),
those accredited by the Joint Commission, or those not accredited in Florida.

40) Schmaltz SP, Williams SC, Chassin MR, Loeb JM, Wachter RM;
hospitals accredited by the Joint Commission tended to have better baseline
performance in 2004 than non-accredited hospitals. Accredited hospitals had
larger gains over time, and were significantly more likely to have high
performance in 2008 on 13 out of 16 standardized clinical performance measures
and all summary scores.