QUALITY, NABH & INTERNAL AUDIT

1. QUALITY, NABH & INTERNAL AUDIT Dr. Chandy Abraham M.S., DNB, MRCS, ADHA(Hosp.Adm.)

2. Quality Improvemint –

3. Quality Improvemint – unrealistically expecting that superficial changes will fix a product that leaves a bad taste in your mouth.

4. WHAT IS QUALITY ?

5. QUALITY • To the patients : Quality means being treated with empathy, respect and concern • To the professionals : Quality means delivering the most advanced knowledge and medical scientific skills to help/save the patient • To the medical audit : Quality means having the best achievable outcome for each patient • To the Organisation : Quality is “totality of characteristics of an entity that bear on its ability to satisfy stated and implied needs

6. Quality.. Degree to which a set of inherent characteristics fulfills requirements. Doing things right the first time and doing it better every time Quality is like love – You know it when you feel it

7. What does the customer look for? • “Fitness for purpose”

8. Some concepts • Quality Management System Management System to direct and control an organization with regards to quality • Quality Policy Overall intentions and directions of an organization related to quality as formally expressed by top management • Process Set of interrelated or interacting activities which transforms inputs into outputs • Procedure Specified way to carry out an activity or process (it may be documented or not)

9. Quality Management System • Vision • Mission • Quality Policies & Objectives • Processes • Procedures • Policies • Standards • Key Performance Indicators

10. An integrated approach • Top managements’ commitment and shared responsibilities among other staff • Well developed Vision and mission – staff subscription to the same • Professionally recognized standards • Focus on customers and professionalism rather than on documentation • Aiming for quality excellence and adherence to the standards rather than to accreditation

11. Core Processes Management Process Market Research Process Strategic Process Registration & Admission ProcessRegistration Process Admission Process (IP) Treatment, Discharge & Billing Process Treatment : Consultancy, diagnosis, palliative care and ALHS Services like Physiotherapy, Discharge and Billing Patient Support Process Further referrals Medi claims Re-appointments

12. Support Processes Purchase & Sub- contracting Process Provide & Manage People Process Core Business Process Provide & Manage Infrastructure Provision Process Monitor, Measure & Improve Process Manage Pharmacy Process Provide & Manage Information Process

13. Monitoring Methodology • Purpose: Conformance and Continual Improvement • Internal Audit every 3 months • External Audit every 6 months • Measurement of Quality: • Satisfaction Survey (Internal & External) • Quality Control • Calibration & AMC Schedule • Results of Audits

15. Standards

16. "A customer is the most important visitor on our premises. he is not dependent on us. We are dependent on him. He is not an interruption in our work. He is the purpose of it. He is not an outsider in our business. He is part of it. We are not doing him a favor by serving him. He is doing us a favor by giving us an opportunity to do so."

17. NATIONAL ACCREDITATION BOARD FOR HOSPITAL & HEALTH CARE PROVIDERS(NABH)

18. PROVIDERS CONCERNS To provide care as per established norms Adequate resources Self satisfaction with the final outcome Should contribute to enhancement of skills, competence and experience

19. RECIPIENTS CONCERNS Accessibility Affordability Prompt attention Less waiting time Early diagnosis and cure Return to Productivity as early as possible Humane Treatment ie to be treated with empathy , respect and concern

20. ORGANISERS CONCERNS Responsible to the Society for the funds spent on health care To ensure safety of public and prevent inappropriate or suboptimal care To meet the requirements of the recipient and provider of the health care services at Acceptable costs

21. WHAT IS ACCREDITATION

22. Accreditation is an external review of quality with four principal components: 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.

23. Focus of standards Patient Safety Staff and employee safety Environment and community safety Information Education and Communication

24. NABH STANDARDS

25. NABH Standards 10 Chapters 100 Standards 503 Objective Elements

26. Section I:Patient-Centered Standards STDOE Access, Assessment and Continuity of Care (AAC) 15 78 Patients Rights and Education (PRE) 05 29 Care of Patients (COP) 18 105 Management of Medications (MOM) 13 61 Hospital Infection Control (HIC) 09 44 60 317

27. Section II: Health Care Organization Management Standards STDOE Continuous Quality Improvement (CQI) 6 37 Responsibilities of Management (ROM) 5 20 Facility Management & Safety (FMS) 9 41 Human Resource Management (HRM) 13 47 Information Management Systems (IMS) 7 41 40 186

28. Accreditation Process Applications Screening of the Applications Pre-assessment survey Assessment Survey Review of the recommendations of the assessing body by the Accreditation Committee Recommendations to the board Accreditation decision

29. WHO CAN APPLY Any Health Care Organisation Requirements Currently in operation as a HCO Preferably registered or licensed Willing to assume responsibility for improving quality of care Should be able to meet the prescribed standards of the accrediting organisation

30. HOW CAN ONE APPLY Basic Ingredients Organisations apply on prescribed format giving details as required Submission of a self assessment form indicating the outcomes of its QMS and Internal Audits Extent of adherence to the laid down standards

31. SCREENING OF APPLICATIONS Completeness Accuracy Clarifications sought if required

32. PREASSESSMENT SURVEY To ascertain the readiness of the organisation for Accreditation Overview of the organizational preparedness and commitment to quality goals and consonance to laid down standards Deficiencies noticed informed to the organisation Advice rendered on the methodology to be followed during the Accreditation Survey Time frame worked out for the survey in mutual consultation

33. ACCREDITATION SURVEY Carried out by a team of Assessors depending upon the size, complexity and facilities provided by the organisation Scope will include all standards related functions and all patient care settings Onsite survey will consider specific cultural and legal factors which may influence or shape decisions regarding the provision of care and /or policies and procedures

34. METHODOLOGY OF SURVEY Initial presentation by the hospital Document Review Adherence to statutory obligations Visits to various areas Facility surveys and tours Random structured interviews

35. INITIAL PRESENTATION BY THE HOSPITAL Organogram Quality management Team Methodology followed for Quality Improvement Facilities provided Inputs on resources provided for Quality Improvement Identified high Risk Areas for patient care and safety Sentinel Events being monitored

36. INITIAL PRESENTATION BY THE HOSPITAL Key Monitoring Indicators Resource Volume Utilization Performance Control charts Problems faced and remedial measures undertaken/ being undertaken

37. DOCUMENT REVIEW Quality Manual Various Policies and Procedures Minutes of Meetings of various committees Medical Records Medical / Nursing Audit Adverse Events Action Taken Reports Personal Records of Staff

38. OBSERVATIONS Facility Safety Level of compliance with laid down policies and procedures BMW Management Standard Precautions Patient care Fire Safety Equipment Management

39. INTERVIEW Staff Interview To determine their level of awareness and compliance with organisation policies and procedures To assess their awareness levels of their rights, privileges and patient rights To determine their satisfaction levels Patient and family Interview To assess their level of awareness of the care process and their rights To determine their satisfaction levels

40. SCORING PATTERN NABH has laid down the following pattern Non-compliance 0 Partial compliance 5 Full compliance 10 No standard can have more than one zero The average for a standard must exceed 5 The overall average score must exceed 7 No zeros in legal requirements

41. OUTCOMES OF ACCREDITATION SURVEYS Accredited HCO shows acceptable compliance with laid down standards in all areas Includes the scope of services for which accredited Any increase in scope the survey has to be done for the increased scope Accreditation denied HCO is consistently non compliant with standards Accreditation withdrawn HCO withdraws voluntarily Due to consistent non compliance or non adherence to safe and ethical practices

42. DURATION OF ACCREDITATION AWARDS Generally three years with one Reassessment survey to ensure continued compliance and to assess the CQI programme If during accreditation The Accreditation organisation receives inputs that the organisation is substantially out of compliance with the current standards then Resurvey or withdrawal of accredited decision may be resorted to

43. AUDIT “systematic, independent and documented process for obtaining evidence and evaluating it objectively to determine the extent to which audit criteria are fulfilled”

44. Audit/Assessment---examines a system • Stage 0: Is the hospital system based • Stage 1: Has the system incorporated NABH standards? • Stage 2: Is the new system implemented and understood by all? • Stage 3: Is this system helping the hospital meet its objectives?

45. GENERAL PRINCIPLES OF AUDIT: • Audits are authorised • Have a systematic approach • Objective • Independent • Provide information on which the management can act • Use established methods and techniques to ensure that findings are relevant, reliable and reproducible

46. GENERAL PRINCIPLES--- Contd. • Should cover all elements of the standards and all the personnel in each cycle • The scope, objectives and audit criteria of each audit are clearly defined and agreed prior to commencing the audit • Team members and managers are competent for the tasks they perform • Audit team members act professionally and with integrity and confidentiality.

47. INTERNAL AUDIT ( First Party audit) • A requirement of accreditation criteria of NABH. • Management discovers any internal weaknesses before these are detected by external assessors. • Powerful management tool to aid quality improvement. • Verify effectiveness of corrective actions/ (corrective – to prevent recurrence preventive– to prevent occurrence)

48. INTERNAL AUDIT– Contd. • Predetermined schedule • Comply with standards laid down • Trained and qualified personnel. (Where resources permit- independent) • Maintain records of audit findings and corrective actions.

49. Accreditation Coordinator: • Hospital should have one person designated • Responsible for planning records Involvement of experts to complete the audit

50. Requirements for Internal Audits • Internal audit part of quality system • Nominated persons responsible • Procedures for auditing are documented • Implementation actually done • According to preplanned program • Results recorded • Non conformities identified and corrective action initiated within a reasonable time scale • Effective and prompt remedial action which is documented.