Professional Documents
Culture Documents
Healthcare Accreditation
Dr S Murali MD DM
Consultant Neurologist
Manipal Hospital
Bangalore Establish quality systems
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National Accreditation Board for Hospitals & Healthcare Providers National Accreditation Board for Hospitals & Healthcare Providers
life care
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National Accreditation Board for Hospitals & Healthcare Providers National Accreditation Board for Hospitals & Healthcare Providers
Efficiency Efficiency
Documentation Documentation
Process Management Process Management
National Accreditation Board for Hospitals & Healthcare Providers National Accreditation Board for Hospitals & Healthcare Providers
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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
National Accreditation Board for Hospitals & Healthcare Providers National Accreditation Board for Hospitals & Healthcare Providers
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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
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National Accreditation Board for Hospitals & Healthcare Providers National Accreditation Board for Hospitals & Healthcare Providers
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National Accreditation Board for Hospitals & Healthcare Providers National Accreditation Board for Hospitals & Healthcare Providers
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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
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implement 20
National Accreditation Board for Hospitals & Healthcare Providers National Accreditation Board for Hospitals & Healthcare Providers
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
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National Accreditation Board for Hospitals & Healthcare Providers National Accreditation Board for Hospitals & Healthcare Providers