HOSPITAL ACCREDITATION & RETAINING QUALITY Dr. Bidhan Das

Definition of Accreditation “A system of external peer review for determining compliance with a set of standards” World Health Organisation 2003

What is healthcare accreditation? “A public recognition by a healthcare accreditation body of the achievement of accreditation standards by a healthcare organization, demonstrated through an independent external peer assessment of that organization's level of performance in relation to the standards.” The International Society for Quality in Health Care, Organization Survey Handbook.

Accreditation What it is: Acting in the best interests of patients A commitment to minimising risks A commitment to maximising quality and safety Being a ‘learning’ organisation (Evaluating)

Accreditation Standards Why standards? They can provide an integrated and structured framework for managing an organization's performance and its quality program. Standards: Address a recognized need Evidence based (as far as practicable) Developed through a transparent and consultative process Outcome focused Achievable Measurable

Models of External Evaluation Certification or Licensing Regulatory: Government - minimum standards. Compliance checking by Government to minimum standards based on the quality level for safe delivery of health services Accreditation Peer review: Government and/or Industry - Continuous Quality Improvement (CQI)

Comparison Accreditation Licensure Based on optimum standards, professional accountability and cooperative relationships and public accountability Based on minimum standards, investigation, enforcement Improved performance and reducing risk General review of internal systems In-depth probe of conditions and activities Focus on education, self-development Compliance checking as a direct response to complaints and adverse events

Accreditation: Demand Factors Risk management and litigation Accountability and transparency Performance improvement Marketing (Medical tourism)

Accreditation: Benefits Improved quality of care Increased public / consumer confidence Increased efficiency, cost reduction, credibility with insurers External, objective evaluation

Performance Measurement Objectives Why measure performance? What are performance indicators?

Why measure performance? Provide objective feedback Provide basis for comparison Define & ensure minimum standard Focus action for improvement Evaluate improvement strategies Demonstrate improvement over time Monitor risks & their control

What is the difference? Incidents – what actually happens Indicators – what usually happens

Incidents, Sentinel Events, Complaints Individual events What has happened Can be collated for trends May inform future situations

Performance Indicators Act as a “flag” Measure what is happening MOST of the time Can be quantitative or qualitative

Qualities of Good Indicators NOT TOO MANY! Definable Clear – easily understood Relevant Accessible Reliable Valid

More…. Useful Responsive – timely for action Comparable Robust – despite change Integrated into day to day business Cost effective

INDICATOR A statistical measure of the performance of functions, systems or processes over time.

INDICATOR Clinical Indicator Managerial Indicator

MONITORING OF INDICATORS Benchmark every indicator Apply statistical and managerial tools whenever required: RCA FMEA PERT CPM Take appropriate action

Clinical indicators Continuous monitoring of clinical activity Improve care

Patient assessment Time for initial assessment of Indoor Patients- Time of generation of face sheet - time the initial assessment of patient was started by the doctor (Sum of time taken/Total number of patients(sample size) Time for initial assessment of Emergency Patients- Wheel in time in the emergency -time the initial assessment was started by the CMO

Safety/Quality for Diagnostics Services (Lab & Radiology) Number of reporting errors/1000 investigations- No. of reporting errors (Typing error, wrong patient, wrong test etc )/sample size X1000 Percentage of Re-do's- No. of Re do's(QNS, hemolysed sample, wrong sample etc) in a month /no of tests done in a month X 100

Medication Management Percentage of admissions with adverse drug reaction(s) - No. of adverse drug reactions/No. of discharges & deaths*100 Percentage of patients receiving high risk medications developing adverse drug event- No. of patients receiving high risk medications who have an adverse drug event/No. of patients receiving high risk medicines X 100

Anaesthesia Percentage of adverse anaesthesia events- No. of patients who developed adverse anesthesia events /No. of patients who underwent anesthesia X100 Anaesthesia related mortality rate- No. of patients who died due to anesthesia/no. of patients who underwent anesthesia X 100

Surgical Services Percentage of unplanned return to OT- No. of unplanned return to OT (i.e. re entry into OT within 48 hours ) /no. of patients operated X 100 Percentage of re-scheduling of surgeries-No. of cases re- scheduled/no. of surgeries performed X 100

Use of Blood and Blood products Percentage of transfusion reactions- No. of transfusion reactions/Total no. of units transfused X 100 Percentage of blood component usage- No. of units of components used /no. of units issued by the blood bank X 100 Turnaround time for issue of blood and blood components- Time of generation of bill of blood - time of issue of blood

Infection Control Urinary tract infection rate- No. of catheter associated UTIs in a month /no. of urinary catheter days in a month X 1000 Pneumonia rate- No. of pneumonias in a month /no. of ventilator days in a month X 1000

Mortality & Morbidity Mortality rate - No. of deaths/No. of discharges & deaths*100 Return to ICU within 48 hours- No. of returns to ICU within 48 hours/No. of discharges and deaths in the ICU

Clinical Research Percentage of research activities approved by ethics committee- No. of research activities approved by ethics committee/No. of research protocols submitted to ethics committee Percentage of serious adverse events (which have occurred in the organization) reported to the Ethics committee within the defined time frame - Number of serious adverse events reported/Total number of patients enrolled X 100

Patient Satisfaction Out patient satisfaction index- For Hospitals with < 20 patients/day: 100% For Hospitals with 21-50 patients/day: 50% For Hospitals with 51-100 patients/day: 20% For Hospitals with 101-200 patients/day: 10% For Hospitals with 201-400 patients/day: 5% For Hospitals with > 400 patients/day: 2%

Adverse events and near misses Number of sentinel events reported, collected and analysed within the defined time frame- No. of sentinel events reported, collected and analysed within the defined timeframe/No. of sentinel events reported, collected & analysed*100

Medical Records Percentage of medical records not having discharge summary- No. of medical records not having discharge summary/No. of discharges & deaths X 100 Percentage of missing records- No. of missing records/No. of records X 100