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The Official Scientific Journal of Delhi Ophthalmological Society
Accreditation of Eye Hospitals – A Review
Nirmal Fredrick T*, Sunitha Nirmal
Nirmals’ Eye Hospital Pvt. Ltd
Chennai, Tamil Nadu, India
Corresponding Author:
T. Nirmal Fredrick
Eye Surgeon & Managing Director
Nirmals’ Eye Hospital Pvt. Ltd
1058, Ayyasamy street, West Tambaram
Chennai 600045, TamilNadu, India    
&
Principal Assessor
National Accreditation Board for Hospital and Health Care Providers (NABH)
Quality Council of India.      
Email: nirmalfred@hotmail.com
Published Online: 01-DEC-2014
DOI: http://dx.doi.org/10.7869/djo.91
Abstract
Every day more than a million people are treated safely and successfully in our Hospitals. However the advances in technology and understanding of many diseases have created an immensely complex healthcare system. This complexity brings risks, and evidence shows that things will and do go wrong in our hospitals. Medical Errors can cause devastating emotional and physical consequences for patients and their families. For the staff involved too, incidents can be distressing, while members of their clinical teams can become demoralised and disaffected. Safety incidents also incur costs through litigation and extra treatment. Quality of health care and the initiatives taken to address various risk and safety issues in the hospitals have become a subject of debate. External assessment is increasingly used to regulate, improve and market health care providers, especially hospitals. The commonest models are peer review, accreditation, statutory inspection, ISO certification and evaluation against the ‘business excellence’ framework. Each of these is progressively adapting to meet the changing demands of public accountability, clinical effectiveness and improvement of quality and safety, but the most rapid development is in accreditation. This review article focusses on the standards for accreditation in India, approach to implementation, documentation, costs and Benefits. 
Keywords : • accreditation • standards • eye hospitals • quality of healthcare • structure • process • outcomes
Quality of health care and the initiatives taken to address various risk and safety issues in the hospitals have become a subject of debate. Many countries and organizations are exploring various means to improve the quality of health care services.  “Accreditation is a status that is conferred on an organization that has been assessed as having met particular standards. The two conditions for accreditation are an explicit definition of quality (i.e. standards) and an independent review process, aimed at identifying the level of congruence between practices and quality standards.”

Principle Features of Accreditation

Rooney and van Ostenberg define accreditation and contrast it with licensing. “Accreditation is usually a voluntary program, sponsored by a non-governmental agency (NGO), in which trained external peer reviewers evaluate a health care organization’s compliance with pre-established performance standards.[1]

Accreditation addresses organizational, rather than individual practitioner, capability or performance. Unlike licensing, accreditation focuses on continuous improvement strategies and achievement of optimal quality standards, rather than adherence to minimal standards intended to assure public safety”

Accreditation Process is intended to change the way the system operates, technical procedures of service delivery, in the appropriate use of available technologies, in the integration of relevant knowledge, in the way the resources are used, and in the efforts to ensure social participation.[2]

Thus the objective of accreditation is continuous improvement in the organizational and clinical performance of health services, not just the achievement of a certificate or award or merely assuring compliance with minimum acceptable standards (Figures 1-5). Accreditation decisions are made following a periodic on-site evaluation by a team of peer reviewers, typically conducted every three years.[3]

National Accreditation Board for Hospitals and Health Care Providers (NABH) is a constituent Board of Quality Council of India, set up with the co-operation of the Ministry of Health & Family Welfare, Government of India and the Indian Health Industry. National Accreditation Board for Hospitals and Healthcare providers [NABH] has designed an exhaustive healthcare standard for hospitals and healthcare providers. This standard consists of stringent 500 plus objective elements for the hospital to achieve in order to get the NABH accreditation. To comply with these standard elements, the hospital will need to have a process-driven approach in all aspects of hospital activities (Figures 3) – from registration, admission, pre-surgery, peri-surgery and post-surgery, discharge from the hospital to follow-up with the hospital after discharge (NABH, Guidebook to NABH Standards, 2012).[4]



NABH accreditation Standards - Criteria

To give an idea what NABH standards comprises of, some of the 500-plus objective elements are listed here. The requirements have been grouped for easy understanding and focus4:

Information to patients:
 

The patients and/or family members are explained about the proposed care, expected results, possible complications, and the expected costs.

Quality in investigations:
 

This is to be ensured by the following:
  • Adequately qualified and trained personnel perform and/or supervise the lab investigations.
  • Policies and procedures guide collection, identification, handling, safe transportation and disposal of lab specimens.
  • Laboratory and imaging results are available within a defined time frame. Critical results are intimated immediately to the concerned personnel.
  • The lab and imaging quality programme addresses verification and validation of test methods and includes periodic calibration and maintenance of all equipment’s.
  • The lab and imaging programme includes the documentation of corrective and preventive actions.


Surgical services:
 

Standards in surgical services areas follows:
  • Surgical patients have a pre-operative assessment and a provisional diagnosis, documented prior to surgery.
  • Documented policies and procedures exist to prevent adverse events like wrong site, wrong patient and wrong surgery.
  • The operating surgeon documents the post-operative plan of care.
  • There is a documented policy and procedure for the administration of anesthesia. All patients for anesthesia have a pre-anesthesia assessment by a qualified individual.
  • During anesthesia, monitoring includes regular and periodic recording of heart rate, cardiac rhythm, respiratory rate, blood pressure, oxygen saturation, airway security and level of anesthesia.
Medication Management:
 

Norms in medical management mandate the following:
  • Documented policies and procedures exist for prescription of medications.
  • The organization defines a list of high-risk medication.
  • High-risk medication orders are verified prior to dispensing.
Infection control:

Infection control practices of the hospital should include the following:
  • The hospital has an infection control team.
  • The hospital has designated and qualified infection control nurse[s] for this activity.
  • Hand-washing facilities in all patient care areas are accessible to health care providers.
  • Compliance regarding proper washing of hands is monitored regularly.
  • Isolation/ barrier nursing facilities are available.
  • Adequate gloves, masks, soaps, and disinfectants are available and used correctly.
Facility and maintenance:

Requirements on the facility and its maintenance include:
  • The organization’s environment and facilities operate to ensure safety of patients, staff and visitors.
  • There is a documented operational and maintenance [preventive and breakdown] plan.
  • Up-to-date drawings are maintained which detail the site layout, floor plans and fire escape routes.
  • The provision of space shall be in accordance with the available literature on good practices [Indian or International Standards] and directives from government agencies.
  • Maintenance staff is contactable round the clock for emergency repairs.


Step by step approach to NABH Accreditation of Eye Hospitals

1.  Director / Top Management must take a firm decision to implement Quality Management System based on NABH standards.
2.  Top Management must allocate proper resources (Human, Technology, Management support & Funds) to implement the above decision.
a.    uman Resources {Quality coordinator} & Core Team to “prepare, implement, maintain & improve” the Quality System.
b.    Time - minimum 2-3 hours per day (of core team) for initial three months, till achieving NABH Certification & afterwards at-least one to two hours per week (like every Monday - of core team).
c.    Financial Resources (Fees / charges for Training, documentation / consultancy (if outsourced) & NABH Certification / audit charges.
3.  Form a core team comprising minimum two employees (one senior & one junior) from each department / area and appoint one member of core team as a Quality coordinator to co-ordinate all Quality/NABH related activities.
4.    Establish a Training Plan.
a.    Awareness Training for all employees (on NABH standards and core Systems, as it is a team work and all employees are part of Quality Management System)
b.    Documentation training for core team &
c.    Internal Auditors training, to at-least three to four members of core team.
5.    Implement training plan / Conduct in-house training     programme
a.    Awareness Training for all employees
b.    Documentation training for core team.
6.  Review the Existing Eye Care Service Systems in the Hospital in comparison with NABH requirements. (Gap analysis exercise = either by your hospital team who has previous experience in NABH standards or by a third party team)
7.    Formulate Guiding document and Quality Objectives [functional / departmental targets / goals]
8.      Formulate the 10 major standards as required by NABH
9.    Formulate other:
-    Quality Procedures (QP),
-    Process flow charts (QFC),
-    Departmental work instructions (WI) &
-    Other documents i. e. forms / formats & etc. (QR, FM, FILE, REG., etc.) required to conduct the operations and complete the “Quality Manual”.
10.    Implement the Newly established “Management System” from a planned / fixed date.
11.    Arrange for “Internal Auditors Training” for at-least three to four members of Core Team. (Develop Self -assessment Capability)
12.    Conduct first Internal Quality Audit (After a gap of at-least 30 days from the date of implementation of system).
13.    Make Application for certification to NABH.
14.    Pre Assessment date will be given by NABH.
15.    Pre-Assessment by NABH Audit team – they will give a deficiency report. Close the deficiencies and send the report to NABH.
16.    NABH will schedule the date for final assessment.
17.    NABH team will assess the hospital again and give their report. If there are any deficiencies they     will give a report to the accreditation committee. If the Hospital closes all non-conformances effectively, accreditation committee will recommend Accreditation.
18.    Receive the Certificate and enjoy the fruits of hard work.
19.    Continue with the Accreditation work and reap the multiple benefits of the quality Journey.

Essential Documentation: Like all quality management systems, documentation is an essential component of NABH accreditation. NABH standards require documentation at every step and process. We suggest that the Hospital prepare an apex manual (quality manual) incorporating the various standards, objective elements with appropriate linkages. The apex manual could be distributed to all individuals in the first rung of the organogram. It is preferable that procedures and processes for various objective elements be incorporated in the apex manual or done separately depending on the size of hospital.

A suggested content for the Essential documentation is given below[4]:
  • Introduction of the organization
  • Management including ownership, vision, mission, ethical management, etc.
  • Quality policy and objectives including service standards
  • Scope of services provided by the organization and the details of services provided by every department.
  • Composition and role of various committees (in alphabetical order)
  • CPR analysis
    • Clinical audit
    • Ethics
    • Infection control
    • Pharmacy
    • Quality
    • Safety
  • Organogram
  • Statutory and regulatory requirements
  • Chapter-wise documentation
  • Annexure (if any)


Costs of Accreditation

Many doctors ask about the cost of accreditation and also have misconceptions on costs of accreditation. We have developed a list of frequently asked questions to help in decision making.



Approximately what is the cost of a NABH / Any accreditation survey for a hospital?

Varies, from agency to agency, certifying body to certifying body, the education/qualification/experience of the Consultant, the size of the Hospital, present status of the Hospital, Bed Strength, Core and Ancillary Services, Staffing Pattern, Commitment of the top management and the employees.

The total cost for accreditation would be: Consultancy charges + Cost of preparation for the Accreditation (employee training + changes to infra and superstructure) + initial Assessment + Actual Certification charges + Assessment charges (for the team).

Cost determination: The cost is determined by the size and complexity of the hospital. This determines the number of Auditors and the number of days needed to survey the standards.  The details found in an organization’s application for accreditation drive the formula to determine survey team size and survey length and this determines the cost.

Costs related to a sssessment: The cost for transportation of the team and hotel, food and local transportation costs on-site are not included. These are not included in the survey cost as they are extremely variable and subject to currency fluctuations.

The cost of an accreditation assessment does not include any training and consultation as the hospital prepares. While NABH/ISO/ JCI does offer accreditation preparation services through a separate division, many hospitals choose to prepare on their own or with assistance from other sources to maintain integrity.  

NABH standards for small health care organisations (SHCO):

Approximately 50,000 health care organizations are functioning in our country out of which significant number fall under the Small Health care Organizations which are less than 50 beds.

The SHCO standards, which are applicable to single specialty Eye hospitals, are a compilation of all applicable standards relevant to for small healthcare organizations. This will facilitate small Hospitals  in easy understanding and implementation of standards within their facilities. (Figure 4)

Lack of knowledge, High cost of Accreditation, Manpower issues and Poor insurance coverage are challenges faced by the SHCOs for Accreditation.  To be more inclusive and to encourage SHCOs to join quality journey, NABH has developed Pre Accreditation Entry Level standards. SHCO entry level requirements focus on the most critical elements important for patient safety. This makes accreditation affordable and will encourage the hospitals to adopt quality initiative,  to attain the next stage (progressive level) and eventually full accreditation.

Accreditation - Challenges of Implementing Quality in Eye Hospitals

The different challenges faced by the smaller hospitals in implementing national accreditation standards are:
a)    Escalating Costs

An accreditation system is a highly specialized, knowledge and cost-intensive endeavor. The acute need to cope with the advance in the medical technology, integrated hospital management system, sophisticated laboratory tests and equipment and implementing national standards, will lead to an increase in the overall hospital expenses.

b)    Infrastructural Deficiency

As many small hospitals in our country have seen a phased growth and have expanded from a smaller clinic, there is an acute shortage of space and a well-planned infrastructure. Different departments, including operation theatre, are not well planned and may not have the required infrastructural requirement for accreditation.

c)    Shortage of Healthcare Staff

There is an acute shortage of qualified and experienced healthcare professionals. Smaller set-ups don’t budget for competitive salary for healthcare staff including doctors, so it’s difficult for them to even acquire and then retain the talent. Thus the hospitals are always short of manpower for which staff end up doing extended shifts and ‘burnouts’ are very common.

d)    Inadequate Training

Most critical care staff are not BLS (Basic life Support) and ACLS (Advanced Cardiac Life Support) trained or certified. The healthcare staff, in many small and medium sized healthcare units, are not well versed with the biomedical waste, its management, hospital safety and risk management, infection control, medication management practices etc. which are critical not just patient safety, but also employee wellbeing.


e)    Increased Cost Pressure
The smaller hospitals are sandwiched between the increased cost of maintaining quality assurance and on the other side poor revenue cycle management and increased pressure from the insurance companies, TPAs and corporates in extending more discounts to patients.
 

f)    High-Customer Expectations

In recent years, productivity and efficiency of services in patient care have become a very important issue. With increased awareness and the emergence of consumerism, patients have become highly demanding and take an important role in the medical decision making process.

g)    Inadequate Licensing

Most hospitals do not have all the licenses applicable in the hospital. Thus implementation of the quality management system has become a challenging task for smaller hospitals as it comes with a big “price tag”. The solution that the hospital management is looking for is ‘how to strike a balance between cost reduction and maintaining/raising standards’.

Benefits of Accreditation

Standardization of all processes and procedures, helps through six important factors, namely:
1. Enhanced efficiency
2. Reduced complications
3. Improved monitoring
4. Cost effectiveness
5. Replication
6. Costing and budgeting (NABH, 2012)

Benefits of Accreditation (a system oriented approach) to Patients and Staff

The benefits of accreditation (Figure 5) include[3]:
  • As all members of a team are trained and aware of standard protocols, they are able to identify deviations as soon as they occur, and rectify the same.
  • In absence of a team leader, the team can continue to work efficiently by adhering to the standard protocols.
  • Regular monitoring of results helps quality enhancement, as early detection of complications and their causes can help in timely and relevant interventions.
  • On most occasions, complications occur due to deviations from protocols. When protocols and procedures are standardized and implemented, even minor deviations can be identified and steps for rectification introduced. Timely identification and immediate management of complications can help in reducing morbidity.5
Effect of Accreditation / Standardization on Hospital Management

The effect of accreditation / standardization on hospital management can be summarized as follows[1]:
  • Standardization increases cost effectiveness and helps costing and budgeting.
  • Accreditation helps to know the vital signs of Hospital performance - KEY PERFORMANCE INDICATORS (KPI) The implementation of Key Performance Indicators (KPIs) is one of the hallmarks of Accreditation and Good Management Practice  to assess the overall performance of the Hospital.
  • KPIs can also include non-clinical areas such Business Development and financial management, which are also important factors in the performance of an organization.
  • Updates to accreditation standards are common and NABH training sessions impart continued education on the standards and policies, procedures and practices.
  • Along with the quality improvement, the insurance companies, TPAs and corporate may extend better rates to accredited hospitals which may serve as ‘boon in disguise’.
  • If all the international standards are met, the healthcare facility operators can contract with foreign governments (as some Indian hospitals have done) to provide services with superior outcome and lower costs. Medical tourists could potentially bring in hundreds of millions dollars as they do for Thailand, Malaysia and  Singapore
  • Accreditation provides a powerful policy tool which makes the healthcare providers accountable and potentially a “win win” situation for all parties — particularly patients.
Best Time to start Accreditation Process

Before a hospital starts accreditation process, it is better to assess the response from all stakeholders by a thorough internal review before committing with the external agency for the following aspects: gain expected, risks and costs, incentives, or benefits to the staff, patients and Hospital, choice of provider and committement from Senior management, General staff and Medical staff.[1]

Conclusion

Accreditation is basically a framework, which helps Hospitals to establish objective systems aimed at quality & patient safety. The standards provide a basic format for Hospitals to organise and develop a quality management system that is focused on error prevention and continuous improvement. Accreditation emphasizing participation of various stakeholders has the potential to be more successful than regulation.  There is a growing realization that without the commitment of Hospital Owners, Consultants, the changes needed within our health care institutions to improve patient safety will not be made. By focusing on creating systems that support both quality and safety, Ophthalmologists can transform the eye care system and improve the lives of the patients and communities they serve.

Financial & competing interest disclosure

The authors do not have any competing interests in any product/procedure mentioned in this study. The authors do not have any financial interests in any product / procedure mentioned

References
  1. www.who.int/hrh/documents/en/quality_accreditation.pdf. Quality and accreditation in health care services A GLOBAL REVIEW. Evidence and Information for Policy, Department of Health Service Provision (OSD) World Health Organization, 1211 Geneva 27, Switzerland. 2003.
  2. Kimberley A, Galt K A:  Foundation in Patient safety for Health Professionals. Jones & Bartlett Publishers, LLC, 2011.
  3. nabh.co/Images/PDF/nabh_gib_hos.pdf:National Accreditation Board for Hospitals and Healthcare Providers General Information Brochure, 2013.
  4. nabh.co/images/pdf/all-gib.pdf:  National Accreditation Board for Hospitals and Healthcare Guidebook to NABH Standards 2012.
  5. Myers S A. Patient Safety and Hospital accreditation A model for ensuring success.  Springer Publishing Company, LLC, New York, 2012.
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Nirmal Fredrick T, Nirmal SAccreditation of Eye Hospitals – A Review.DJO 2014;25:118-124
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Nirmal Fredrick T, Nirmal SAccreditation of Eye Hospitals – A Review.DJO [serial online] 2014[cited 2018 Nov 17];25:118-124. Available from: http://www.djo.org.in/articles/25/2/accreditation-of-eye.html
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