Quality in Healthcare Beyond Accreditation Dr Y P Bhatia

Defining Quality “ The degree to which health services for individuals and populations increases the likelihood of desired outcomes and are consistent with current professional knowledge” Institute of Medicine

Medical Quality (Avedis Donabedian1970’s) Measurement of quality Structure Stable characteristics of the providers of care, tools and resources at their disposal Process Activities that go on between and within the practitioners and patients Outcome Changes in health status attributable to antecedent health care

FOOD FOR THOUGHT I Should Quality Initiatives lead to Accreditation OR II Should Accreditation lead to quality initiatives (TAKE YOUR PICK)

Quality Aspects Less mature More mature Conformance to standards An ongoing process of building and sustaining relationships and properties of deliverables by assessing, anticipating and fulfilling stated and implied needs Error-free, value added care that meets or exceeds the needs and legitimate expectations of the served and serving Less mature More mature

The Quality Continuum Less mature More mature Medical Quality Quality Assurance Continuous Quality Improvement Total Quality Management Less mature More mature

Approaches to Quality Initiatives The Quality Continuum Vision Current Strategic Perspective Involvement Local Global Focus Niche Processes Complete Processes Scope Organisation Wide Community Wide Triggers External Internal Less mature More mature

QUALITY ASSURANCE TRIANGLE Defining Quality Policy Making Structural Reorganization Quality Redesigning Incentives Benchmarking Motivation QUALITY ASSURANCE Problem Solving Standards setting Management Actions Monitoring systems Supervision Improving Quality Measuring Quality Regulation Audit Quality Evaluation Accreditation QUALITY ASSURANCE TRIANGLE

Importance Effectiveness Community And confidence Efficiency Improved Health Outcomes Waste Reduction Optimum Utilization of Resources Reduced Cost of Healthcare Safety and risk reduction Uniformity In Processes

HEALTHCARE ACCREDITATION Frame work for Quality Assurance A Voluntary Act Organisational Commitment HEALTHCARE ACCREDITATION Defined Standards Frame work for Quality Assurance Assessment by External Agency Unbiased approach An Effective Quality Improvement Tool

Vision VOLUNTARY ACT Involvement Focus Triggers

Structural Standards Physical facility and spatial associations Equipments Structural Standards Materials Human resource

Policies Processes Process Standards Guidelines Programmes/Plans

Benefits of Accreditation A visible commitment by organisation towards quality of patient care Safe working environment Benefits of Accreditation Resource Optimisation Stimulates continuous improvement Benefits all stake holders Raises community confidence

*NOW MAKE YOUR CHOICES* FOOD FOR THOUGHT (REVISITED) I Quality initiatives should lead to Accreditation (Philosophy leading to the goals) II Accreditation should lead to Quality initiatives (The goal prompting and directing philosophy) *NOW MAKE YOUR CHOICES*

Process of Accreditation Quality Improvement Process of Accreditation Decision NO YES Obtain Standards Comprehensive Review P D C A Identify Gaps and Bridge it Is standards Implemented and Integrated satisfactorily Yes No Apply NABH for Assessment Apply for re-assessment Assessments by NABH Is Assessment Result satisfactory No Receive recommendation & act accordingly Yes NABH Accreditation

Applying Accreditation Standards for Quality Improvement - A systematic approach Initiation Documentation Implementation Monitoring

Initiation Initiation Sensitization Constitution of teams Understanding Standards Customising Applicability Action Plan

Documentation Policies Processes Guidelines Criteria and protocols Programmes Roles and Responsibilities Formats for records and documents Manuals Organisational and departmental line of hierarchy

Documentation topics Registration policy and procedure Admission policy and procedure Transfer of unstable patients to another facility Transfer of stable patients to another facility Standardized initial assessment of patients in the OPD, emergency and IPD. Processing and disposal of specimens in laboratory. Handling and disposal of infectious materials Identification and safe transportation of patients to imaging services. Handling and disposal of radio-active and hazardous materials. Safe use of radioactive isotopes for imaging services. Referral of patients to other departments / specialties. Discharge policy and process LAMA policy and process Informed Consent policy and process Pricing Policy Uniform care policy and processes Emergency care policy and processes Medico-legal cases Triaging of patients Uniform use of resuscitation Rational use of blood and blood products Care of patients in ICU and HDU Situation of bed shortage in ICU/HDU Care of vulnerable patients Care of high risk obstetrical patients Care of paediatric patients Prevention of child/neonate abduction or abuse Care of patients undergoing moderate sedation Administration of anaesthesia Care of patients undergoing surgical procedures Prevention of adverse events

Procurement of implantable prosthesis Procurements, handling, storage, distribution, usage and replenishment of medical gases. Antibiotic policy Laundry and linen management Kitchen sanitation and food handling Engineering controls for infection control Mortuary practices an procedures Surveillance, data collection and monitoring of HAI Isolation/barrier nursing Outbreak control procedures Quality control for sterilization Handling of bio-medical waste Quality assurance programmes Operational and maintenance plan Smoking policy Human resource planning Restraints techniques Pain management guidelines Rehabilitative services polices Research activities policies and protocols Nutritional assessment and reassessment End of life care Procurement, Storage, prescription and dispensing of Medications Administration of medications Monitoring of medications Patient’s self administration of medication Medication brought from outside the organisation Adverse drug events Use of narcotic drugs and psychotropic substance Usage of chemotherapeutic agents Usage of radioactive and investigational drugs Safe storage, preparation, handling, distribution and disposal or radioactive and investigational drugs.

Committees Medical audit / death audit committee Infection control committee Resuscitation committee Sentinel event committee Committees Fire and non-fire emergency committee Equipment management committee Pharmaco-therapeutic committee Ethics committee Safety committee Quality assurance committee

Training of Staff Central Vs. Departmental Internal Vs. External Theoretical Vs. Practical Mock drills and Practises Training Evaluation

Training topics Policies and Processes Advanced Care of Life Supports / Basic Care of Life Supports Disaster management Safe practices in laboratory Handling of vulnerable patients Restraint techniques Hand washing End of life care Quality assurance Handling of hazardous materials Fire and non-fire emergencies Handling patient in ambulance Biomedical waste disposal Universal precautions Infection control surveillance and monitoring system Managing patient during non-availability of beds Radiation safety measures

Self Assessments Intra-departmental Inter-departmental Core team assessment Assessment by ASTRON

Continuous Effort Analyzing assessment results Re-assessment Identifying weak areas Retraining and/or reformation of policy/process Improving weak areas

Time Frame Activities Months Constitution and initial training of   1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 Constitution and initial training of teams Preliminary assessment Understanding standards Documentation Implementation and training Self assessments Retraining, re-modification Final self assessments NABH assessments and Accreditation

CHALLENGES Lack of commitment Lack of time Lack of clarity on roles of team, team members Difference of opinion on policy, procedures and standards Unavailability of adequate information Improper/Incomplete documentation

Improper/Incomplete records Inadequate training CHALLENGES Improper/Incomplete records Inadequate training In-experienced trainers Poor attendance Lack of time and resources Communication barriers Biased assessments Individual preferences Improper assessment methodology Improper assessment framework

Plan for Personal Excellence -Dianna Boober Define success in your own terms Assess your strengths Set goals with deadlines Develop discipline and be willing to pay the price Use time wisely Ask for advice Be receptive to feed back

Plan for Personal Excellence -Dianna Boober Stay informed Learn to communicate well Do Quality work Take risks Be dependable Be ethical Nurture relationships ABOVE ALL “HAVE A POSITIVE ATTITUDE”

ENVISIONING ASTRONOMICAL HEIGHTS FOR HEALTHCARE

BUILDING RELATIONSHIPS THANK YOU BUILDING RELATIONSHIPS