1. HOSPITAL ACCREDITATION & RETAINING QUALITY
Dr. Bidhan Das

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

3. 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.

4. 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)

5. 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

6. 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)

7. 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

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

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

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

11. 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

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

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

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

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

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

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

18. INDICATOR
Clinical Indicator
Managerial Indicator

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

20. Clinical indicators Continuous monitoring of clinical activity
Improve care

21. 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

22. 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

23. 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

24. 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

25. 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

26. 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

27. 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

28. 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

29. 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

30. Patient Satisfaction Out patient satisfaction index-
For Hospitals with < 20 patients/day: 100%
For Hospitals with patients/day: 50%
For Hospitals with patients/day: 20%
For Hospitals with patients/day: 10%
For Hospitals with patients/day: 5%
For Hospitals with > 400 patients/day: 2%

31. 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

32. 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