Drs Murli

Journey towards healthcare excellance
Tips to overcome most common

obstacles in Preparing for NABH
accreditation Achieve Service & Clinical Excellence
Healthcare Accreditation
Dr S Murali MD DM
Consultant Neurologist
Manipal Hospital
Bangalore Establish quality systems
1 2
National Accreditation Board for Hospitals & Healthcare Providers National Accreditation Board for Hospitals & Healthcare Providers
Perceived Obstacles Total Quality Management in a

Understanding by the TOP management Hospital
Who will drive it
Documentation
Legal
Infrastructure
Manpower
Clinician involvement
Others including certain grey areas viz End of Regulatory Compliance Regulations, Laws, Ethics
life care
3
Total Quality Management in a Total Quality Management in a

Hospital Hospital
Excellence in Complaint, Waste, and Defect

patient care Reductions, Elimination of Rework
Efficiency Efficiency
Documentation Documentation
Process Management Process Management
Regulatory Compliance Regulatory Compliance Regulations, Laws, Ethics

Regulations, Laws, Ethics
1
Total Quality Management in a TOP Management
Hospital
Should believe that having standard
Patient Satisfaction
Recog-
Employees' Satisfaction
quality through accreditation will add value
nition of
Quality
Management Satisfaction
Aim at improving quality and accreditation
Excellence in Complaint, Waste, and Defect
is a by product
patient care Reductions, Elimination of Rework
Unconditional support to the quality team
Efficiency Should understand its own role esp in
Documentation Process Management
context to mission, vision, operation and
Regulatory Compliance Regulations / Laws strategic plan
Track of all legal requirements 8
Who will drive it Documentation Pyramid

Team and not dependent on a single
1 Quality Manual (Apex Manual)
individual 2 Documented Policies & Procedures,
Accreditation co ordinater Patient Flow Diagrams, Organograms
Form subgroups involving relevant stake 3 - Work Instructions, SOPs where required
holders. 4 - Records, Formats, Registers, Forms
5 - External Documents, Statutory &
Educate the team - POI
Regulatory requirements
Ensure that the end user is involved in

9
documentation.
NABH ACCREDITATION NABH ACCREDITATION

Sample headings for Policies Committees Salient features
Composition
Scope / Aim / Objective
tenure
Definition
roles and responsibilities
Indications
objectives
Responsibilities
Contents / explanations / detailing or various processes functioning
Pre procedure / procedure / post procedures quoram
Resources Meetings / agenda
Training requirements minutes
Monitoring and analysis monitoring
Corrective and preventive action reporting pattern

References reports
action taken
11 12
2
Legal Infrastructure
Identify all legal requirements
Maintain a compliance registrar with the Identify all the infrastructure requirements
following Segregate them into essential and
Name desirable
Number Prioritise as per the essentiality and the
Status availability of resources.
One time or renewable( if renewable the next date) Consult experts in the field if required and
Responsibility for renewals and updating the start work early
amendments
Conditions if any
13 14
Manpower Clinician Involvement

Identify requirement and have an effective Educate on the benefits of accreditation to
manpower planning the clinician
Grey areas Educate on improvements in patient safety
Compliance that accreditation can provide
Reference Educate on what is the minimum
involvement of the clinician to ensure the
above
15 16
Other perceived Pain areas NABH ACCREDITATION

PAIN Identify teams
ADVERSE DRUG EVENTS Identify and form / merge relevant committees
Workshop
END OF LIFE CARE
Next deadline Identify gaps and prepare draft
AIR CONDITIONING document - date
MEDICAL AUDITS Next meeting / frequency
INDICATORS Training of various groups
TRAINING
PREVILEGING AND CREDENTIALING
17 18
3
NABH ACCREDITATION
NABH ACCREDITATION
Steps
Multidisciplinary team
Sensitisation of various professional Steering committee for NABH
Form Sub groups and delegate Understand the standards - workshops
Have the mandatory committees formed Form subgroups and Identify gaps from the existing
Identify and implement training requirements practices and from other quality management
systems in relation to the NABH standards
Identify and address all infracture,statuary and legal
Interact / educate the end users regarding the same
compliance
Help the relevant stake holders in preparation of the
Target dates for completing documentation and policies and procedures that complies with the
implementation NABH standard approved by the core committee
Periodic review /director medical / admin services/legal team and
19
implement 20
NABH ACCREDITATION
Steps Carry Home message
Prioritise
Ensure NABH standards are implemented and
integrated in the hospital functioning Give importance to processes
Do an internal audit At every point ensure that the standard is
Call for pre-assessment addressed
Corrective actions Make the process simple Have processes
Assessment that can be followed rather than what is ideal.
ACCREDITATION Identify and address crucial infrastructure and
Maintain quality improvement programme draw a plan for the rest
Train your group - POI
21 22
Carry Home message NABH ACCREDITATION

Manpower (IPHS) and bed occupancy Follow each objective element
Focus on training meticulously and accreditation will follow
Statutory obligations has to be met
Identify and implement completely all the
easily implementable processes
Difficult one go on a step by step manner.
Take 3 standards per week
Thank You
Accreditation levels
23 24

Drs Murli

Transféré par

Informations du document

Copyright

Formats disponibles

Partager ce document

Partager ou intégrer le document

Options de partage

Avez-vous trouvé ce document utile ?

Ce contenu est-il inapproprié ?

Droits d'auteur :

Formats disponibles

Drs Murli

Transféré par

Droits d'auteur :

Formats disponibles

Journey towards healthcare excellance

Tips to overcome most common

Perceived Obstacles Total Quality Management in a

Total Quality Management in a Total Quality Management in a

Excellence in Complaint, Waste, and Defect

Regulatory Compliance Regulatory Compliance Regulations, Laws, Ethics

Who will drive it Documentation Pyramid

Ensure that the end user is involved in

NABH ACCREDITATION NABH ACCREDITATION

Pre procedure / procedure / post procedures quoram

Resources Meetings / agenda

Training requirements minutes

Monitoring and analysis monitoring

Corrective and preventive action reporting pattern

Manpower Clinician Involvement

Other perceived Pain areas NABH ACCREDITATION

Carry Home message NABH ACCREDITATION

Vous aimerez peut-être aussi