Accreditation of health care organization

JCI, NABH

1. Accreditation of Health care organization Dr. Harpreet Kaur PG student Community Medicine Guru Gobind Singh Medical College, Faridkot

2. Learning Objective To know the basic structure of a ccreditation of health care organization

3. Lesson Plan Definition of accreditation Components of accreditation Purpose of accreditation Accreditation procedure Advantages of accreditation Different types of accreditation

4. Definition Accreditation may be defined as a formal process by which a recognized body, usually a non-governmental organization (NGO), assesses and recognizes that a healthcare organization meets pre-determined standards. It can also be defined as a system of external peer review of an organization for determining compliance against predetermined standards.

5. Accreditation standards are usually regarded as optimal and achievable and are designed to encourage continuous improvement in delivery of healthcare within accredited organizations. An accreditation decision about a specific healthcare organization is made following a periodic on-site evaluation by a team of peer reviewers, typically conducted every two to three years. It is usually a voluntary process in which organizations choose to participate, rather than one required by law and regulation.

6. Components of accreditation It is based on written and published standards. Reviews are conducted by professional peers. The accreditation process is administered by an independent body. The aim of accreditation is to encourage organizational development.

7. Purpose of Accreditation Improve the quality of healthcare by establishing optimal achievement goals in meeting standards for healthcare organizations. Stimulate and improve the integration and management of health services. Establish a comparative database of healthcare organizations able to meet selected structure, process and outcome standards or criteria. Reduce healthcare costs by focusing on increased efficiency and effectiveness of services.

8. e) Provide education and consultation to healthcare organizations, managers and health professionals on quality improvement strategies and “best practices” in healthcare. Strengthen the public’s confidence in the quality of healthcare and reduce risks associated with injury and infections for patients and staff. g) Accountability to professional bodies.

9. Accreditation Procedure There are many recognized bodies providing Accreditation to Healthcare Institutions. These have diverse policies and procedures. However, the common elements in a typical Accreditation procedure are:

10. Health care accrediting bodies use a variety of evaluation approaches during the on-site survey in order to determine the healthcare organization’s performance with predetermined standards.

11. These methods include any combination of the following: Interviews of the top level Administrators or the Managers of the organization Clinical and support staff interviews. Patient and family interviews. Observation of patient care and services provided. Tour of the building facilities, observation of patient care areas, equipment management and diagnostic testing services. Review of written documents such as policies and procedures, training documents, financial documents and quality assurance plans. Evaluation of the organization’s achievement of specific outcome measures (e.g. Immunization rates, hospital acquired infection rates, patient satisfaction). Evaluation of patients’ medical records.

12. Advantages of Accreditation Benefits to the Hospital It Improves delivery of medical care and enhances the image of the hospital. Thus, for private healthcare organizations it also results in more business. It stimulates a process of continuous improvement in delivery of medical care. Demonstrates commitment to quality care. Raises community confidence. Opportunity to benchmark with the best.

13. Advantages of Accreditation Benefits for the employees It helps in education, training and development of professional staff. Provides leadership for quality improvement within medical profession and nursing. Increases satisfaction of employees with working conditions and leadership. It aims for improved employee safety and security. It promotes team work.

14. Advantages of Accreditation Benefits for Patients Provides access to organizations providing quality medical care. Patient’s rights are respected and protected. It increases patient’s Involvement in medical care decisions. Focuses on patient safety.

15. Accreditation System in USA There are a number of organizations in US performing the function of accreditation of healthcare institutions: The Joint Commission on Accreditation of Healthcare Organizations (JCAHO). The National Committee for Quality Assurance (NCQA). The American Medical Accreditation Program (AMAP). The American Accreditation Health Care Commission / Utilization Review Accreditation Commission (AAHC/ URAC). Accreditation Association for Ambulatory Health Care (AAAHC).

16. JCAHO/JCI JCAHO is the largest and oldest accrediting body of USA. It is now more usually known as The Joint Commission . It is an independent, non government and not-for-profit organization. It has provided accreditation to more than 20,000 healthcare organizations both in US and outside.

17. The constitution of the JCI board includes : (a) Administrators, Physicians, Medical directors and Nurses (b) Consumers (c) Providers of care (d) Employers, Human Resource and quality expert (e) Health Insurance expert and expert in Ethics (f) Corporate and Public Members.

18. In 1997, Joint Commission initiated first step in establishing a link between accreditation and the outcomes of patient care, treatment and service issues. During on site survey, the Joint Commission team assesses performance improvement in conditions related to selected core measures with the help of data from the hospital. The JCI expects home health agencies to establish their own performance measures, which gives these organizations the freedom to develop their own quality assurance programs and outcome measures.

19. Accreditation system in Australia The Australian Council on Healthcare Standards (ACHS) is an institutional accreditation body established in 1974. It is an independent not for profit company. It is neither government funded nor government owned. Dedicated to improving safety and quality through continual review of performance, assessment and accreditation. The council consists of Professional colleges Industries bodies- private & public Governments Consumers

20. Accreditation system in INDIA Quality Council of India (QCI) QCI is an autonomous body set up jointly by Government of India and Industry to establish and operate accreditation structure in the country. It offers services like certification, inspection, testing, calibration and registration. Initially it started with product certification and inspection under ISO 9001 series.

21. Objectives of QCI include: Establish & operate accreditation structure in the country. Provide right & unbiased information on quality & related standards. Spread quality movement in India. Represent India’s interest in international platform. Help establish brand equity of Indian products. QCI developed standards for accreditation of laboratories and the Hospital as different boards- National Accreditation Board for Testing and Calibration Laboratories (NABL) National Accreditation Board for Hospitals and Healthcare providers (NABH)

22. National Accreditation Board for Testing and Calibration Laboratories (NABL) NABL is an autonomous body under the aegis of Department of Science & Technology, Government of India and is registered under the Societies Act. Government of India has authorized NABL as the sole accreditation body for Testing and Calibration laboratories.

23. NABL provides laboratory accreditation services to laboratories that are performing tests / calibrations. These services are offered in a non-discriminatory manner and are accessible to all testing and calibration laboratories in India and abroad, regardless of their ownership, legal status, size and degree of independence. The accreditation granted to a laboratory is valid for a period of 3 years subject to satisfactory annual surveillance.

24. National Accreditation Board for Hospitals and Healthcare providers (NABH) NABH is a constituent board of QCI set up with cooperation of the Ministry of Health and Family Welfare, Government of India and the health Industry. The board while being supported by all stakeholders including industry, consumers, government, but board have full autonomy in its operation. The Technical Committee of NABH had formulated first edition of standards for hospitals in 2005 which have been revised and in November 2007 second edition of standards have been published.

25. Vision of NABH To be the apex national healthcare accreditation and quality improvement body, functioning at par with global benchmarks. Mission of NABH To operate accreditation and allied programs in collaboration with stakeholders focusing on patient safety and quality of healthcare based upon national/international standards, through process of self and external evaluation.

26. Values of NABH Credibility:  Provide credible and value addition services Responsiveness:  Willingness to listen and continuously improving service Transparency: Openness in communication and freedom of information to its stakeholders Innovation:  Incorporating change, creativity, continuous learning and new ideas to improve the services being provided

27. NABH is a member of International Society for Quality in healthcare ( ISQua ). ISQua is an international body which grants approval to Accreditation bodies in the area of healthcare as mark of equivalence of accreditation programme member countries. So far hospital standards of 11 countries viz. Australia, Canada, Egypt, Hong Kong, Ireland, Japan, Jordan, Kyrgyz Republic, South Africa, Taiwan, United Kingdom. India becomes the 12 th country to join in this group. The hospitals accredited by NABH will have international recognition.

28. Standards of NABH There are 10 chapters in NABH document including 100 standards. The standards can be classified as : (a) Patient Centered standards : These include : (i) Access, Assessment and Continuity of Care (AAC) (ii) Care of patients (COP) (iii) Management of medication (MOM) (iv) Patient Rights and Education (PRE) (v) Hospital Infection Control (HIC)

29. (b) Organization Centered Standards : These include : ( i ) Continuous Quality Improvement (CQI) (ii) Responsibilities of Management (ROM) (iii) Facility Management and Safety (FMS) (iv) Human Resource Management (HRM) (v) Information management System (IMS) Each standard is further divided into variable number of objective elements. Objective elements frame the guidelines for achieving a particular standard.

30. SUMMARY Accreditation can be regarded as one of the most attractive form of tool for External Quality Assessment of healthcare organizations. Joint Commission Resources now provides consultation by Joint Commission worldwide on healthcare issues and Joint Commission International is the largest Accreditation body, concerned with global accreditation. One of the chief purposes of Accreditation is to Improve the quality of healthcare by establishing optimal achievement goals in meeting standards for healthcare organizations. Health care accrediting bodies use a variety of evaluation approaches during the on-site survey in order to determine the healthcare organization’s performance with predetermined standards.

31. References Bhalwar R, Health Policy & Health Care Systems , Textbook of Public Health and Community Medicine, 1 st ed. Department of community medicine, AFMC, Pune in collaboration with WHO, India office, New delhi ; 2009. p.420-26. Kishore J , Health care delivery system in India , J. Kishore’s National Health Programs of India, 12 th ed. Century Publications; 2017.p.108-09.

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