Explaining A-Z of hospital accreditation
M3 India Newsdesk Apr 03, 2018
Accreditation helps in assessing a hospital’s level of service delivery. It not only brings an improved level of community confidence and trust but also safety and quality into focus.
National Accreditation Board for Hospitals and Healthcare Providers (NABH) was established in 2006 to enhance health system, promote continuous quality improvement and patient safety.
If a hospital or a clinic showcases NABH accreditation, it indicates that they are offering enhanced services and higher quality of care, which enables the patient to have faith in their clinical judgments. Naturally, this will bring them more business.
“Accreditation is currently the best objective criteria to judge the level of quality of any healthcare organisation. Just by seeing the logo of accreditation mark, we can know whether the organisation has qualified for entry-level standards or has got advanced-level accreditation. In this era of tech-savvy and well-informed consumers, patients prefer accredited hospitals for their treatment. Accreditation is also a stepping stone for hospitals willing to venture into medical tourism. A sense of accountability and responsibility is key to quality.”
-Garima Tripathi, a certified Internal Counsellor for NABH standards (4th edition)
According to the NABH website, the staff of an accredited healthcare organisation is highly satisfied as it provides for continuous learning, good working environment, leadership and ownership of clinical processes. "It stimulates continuous improvement, demonstrates a commitment to quality care, and raises community confidence in the services provided by the healthcare organisation. It also provides an opportunity to healthcare unit to benchmark with the best," the website reads.
Accreditation is not a one-time phenomenon. Once the organisation gets accredited, the rating shall be valid for a defined period. The NABH conducts a regular surveillance of the accredited hospital to ensure. It is an institutional member of International Society for Quality in Healthcare (ISQua) as well as the member of its Board and Accreditation Council. NABH standards for hospitals have been approved by ISQua.
Currently, The NABH is offering accreditation programmes for hospitals, small healthcare organisations/nursing homes, blood banks and transfusion services, oral substitution therapy centres and primary and secondary healthcare centres.
Getting good ratings
Accreditation depends on various factors, such as:
Ø Size and complexity of the healthcare organisation
Ø Existing condition of the applicant
Ø Level for which the applicant has applied i.e. entry-level or advanced level
Ø Management’s support and commitment
Doctors running a private clinic need:
Ø To follow a process that involves repeated gap analysis
Ø Prepare organisation structurally
Ø Large-scale recruitment
Ø Identification and standardisation of processes
Ø Extensive documentation
Ø Regular training programs and audits
Ø Conduct root-cause analysis
Ø Continuous and prompt corrective and preventive actions for anything adverse that comes up or may come up
Ø Regular and detailed monitoring to check for root-level implementation, the establishment of a mechanism to capture, analyze and work on quality indicators
Ø Assessment of satisfaction (both patient and employees) with a 360-degree approach,
Ø Rigorous working on dissatisfaction points
Ø Putting every endeavour to reduce infection rates and development of effective information management system.
Keen on getting the accreditation at the earliest?
A separate internal committee comprising of Quality Control manager, Infection control manager, NABH coordinator (all in-house), etc will be put in place to check the necessary modifications in the hospital before, during and after applying for the accreditation. It should not take more than 15 to 17 months from the date of pre-assessment.
The most common accreditation bodies in India are Joint Commission International and NABH. Other organisations like the Indian Confederation for Health Care Accreditation have also started accreditation of health institutions.
7 steps to get NABH accreditation
a. Undertaking a self-assessment
b. Making an initial application
c. Desk-based document review by the accreditation body
d. On-site pre-assessment meeting
e. Initial on-site full assessment
f. Grant of accreditation (or otherwise)
g. Follow up, on-site assessment
The article is contributed by Elizabeth Mani, a member of 101Reporters, a pan-India network of grassroots reporters.
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