Transcript what is quality

QUALITY, NABH &
INTERNAL AUDIT
Dr. Chandy Abraham
M.S., DNB, MRCS,
ADHA(Hosp.Adm.)
Quality Improvemint –

Quality
Improvemint –
unrealistically
expecting that
superficial changes
will fix a product
that leaves a bad
taste in your
mouth.
WHAT IS QUALITY ?
QUALITY
To the patients :
Quality means being treated with empathy, respect and
concern
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To the professionals :
Quality means delivering the most advanced knowledge and
medical scientific skills to help/save the patient
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To the medical audit :
Quality means having the best achievable outcome for each
patient
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To the Organisation :
Quality is “totality of characteristics of an entity that bear on
its ability to satisfy stated and implied needs
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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
What does the customer look for?
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“Fitness for purpose”
Some concepts
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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)
Quality Management System
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Vision
Mission
Quality Policies & Objectives
Processes
Procedures
Policies
Standards
Key Performance Indicators
An integrated approach
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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
Core Processes
Management Process
Market Research Process
Strategic Process
Registration & Admission Process
Registration 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
Support Processes
Purchase & Subcontracting Process
Provide & Manage
People Process
Monitor, Measure &
Improve Process
Manage Pharmacy
Process
Core Business
Process
Provide & Manage
Infrastructure Provision
Process
Provide & Manage
Information Process
Monitoring Methodology
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Purpose: Conformance and Continual
Improvement
Internal Audit every 3 months
External Audit every 6 months
Measurement of Quality:
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Satisfaction Survey (Internal & External)
Quality Control
Calibration & AMC Schedule
Results of Audits
Standards
"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."
NATIONAL
ACCREDITATION BOARD
FOR HOSPITAL &
HEALTH CARE
PROVIDERS
(NABH)
PROVIDERS CONCERNS

To
provide
care
as
per
established norms
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Adequate resources
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Self satisfaction with the final
outcome
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Should
enhancement
contribute
of
to
skills,
competence and experience
RECIPIENTS CONCERNS
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Accessibility
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Affordability
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Prompt attention
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Less waiting time
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Early diagnosis and cure
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Return to Productivity as early as
possible
Humane Treatment ie to be treated
ORGANISERS CONCERNS
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Responsible to the Society for the
funds spent on health care
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To
ensure
safety
of
public
and
prevent inappropriate or suboptimal
care
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To meet the requirements of the
recipient and provider of the health
WHAT IS ACCREDITATION
Accreditation is an external review of
quality with four principal
components:
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It is based on written and published
standards
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Reviews are conducted by professional
peers
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The
accreditation
process
administered by an independent body
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The aim of accreditation is to encourage
organizational development.
is
Focus of standards
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Patient Safety
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Staff and employee safety
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Environment and community safety
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Information
Communication
Education
and
NABH STANDARDS
NABH Standards
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10 Chapters
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100 Standards
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503 Objective Elements
Section I:
Patient-Centered Standards
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STD
Access, Assessment and Continuity of Care (AAC) 15
OE
78
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Patients Rights and Education (PRE)
05
29
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Care of Patients (COP)
18
105
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Management of Medications (MOM)
13
61
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Hospital Infection Control (HIC)
09
60
44
317
Section II:
Health Care Organization
Management Standards
STD
OE
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Continuous Quality Improvement (CQI)
6
37
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Responsibilities of Management (ROM)
5
20
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Facility Management & Safety (FMS)
9
41
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Human Resource Management (HRM)
13
47
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Information Management Systems (IMS)
7
40
41
186
Accreditation Process
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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
WHO CAN APPLY
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Any Health Care Organisation
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Requirements
• Currently in operation as a HCO
• Preferably registered or licensed
• Willing to assume responsibility
improving quality of care
for
• Should be able to meet the prescribed
standards
of
the
accrediting
organisation
HOW CAN ONE APPLY
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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
SCREENING OF APPLICATIONS
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Completeness
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Accuracy
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Clarifications sought if required
PREASSESSMENT SURVEY
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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
ACCREDITATION SURVEY
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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
METHODOLOGY OF SURVEY
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Initial presentation by the hospital
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Document Review
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Adherence to statutory obligations
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Visits to various areas
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Facility surveys and tours
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Random structured interviews
INITIAL PRESENTATION BY
THE HOSPITAL
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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
INITIAL PRESENTATION BY
THE HOSPITAL
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Key Monitoring Indicators
• Resource
• Volume
• Utilization
• Performance
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Control charts
Problems
faced
and
measures
undertaken/
undertaken
remedial
being
DOCUMENT REVIEW
• Quality Manual
• Various Policies and Procedures
• Minutes
of
committees
Meetings
• Medical Records
• Medical / Nursing Audit
• Adverse Events
• Action Taken Reports
• Personal Records of Staff
of
various
OBSERVATIONS
• Facility Safety
• Level
of
compliance
policies and procedures
• BMW Management
• Standard Precautions
• Patient care
• Fire Safety
• Equipment Management
with
laid
down
INTERVIEW
• Staff Interview
•
•
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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
SCORING PATTERN
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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
OUTCOMES OF
ACCREDITATION SURVEYS
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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
DURATION OF ACCREDITATION
AWARDS
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Generally three years with one Reassessment
survey to ensure continued compliance and to
assess the CQI programme
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If
during
accreditation
The
Accreditation
organisation receives inputs that the organisation
is substantially out of compliance with the current
standards
then
Resurvey
or
withdrawal
accredited decision may be resorted to
of
AUDIT
“systematic, independent and
documented process for obtaining
evidence and evaluating it
objectively to determine the extent
to which audit criteria are fulfilled”
Audit/Assessment---examines a
system
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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?
GENERAL PRINCIPLES OF
AUDIT:
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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
GENERAL PRINCIPLES--- Contd.
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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.
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)
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INTERNAL AUDIT– Contd.
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Predetermined schedule
Comply with standards laid down
Trained and qualified personnel.
(Where resources permitindependent)
Maintain records of audit findings
and corrective actions.
Accreditation Coordinator:
Hospital should have one person
designated
 Responsible for planning
records
Involvement of experts to complete
the audit
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Requirements for Internal Audits
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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.
AUDIT CYCLE
The audit comprises four phases
 Planning and preparation
 Conduct of the audit
 Recording and reporting audit finding
 Follow up and confirmation of
corrective action
The audit is complete when corrective
actions are taken and these are
verified by the auditor.
Conducting Audit
Personal attributes
 Knowledge of
standards
 Knowledge of
hospital function
 Audit and still be
friends
Don’t exhibit
supremacy
No Fault finding!
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How to Go About
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Create willingness
Initial
impetus
from
Top
management
Requires involvement of all staff
This requires repeated training and
briefing
Once consensus is there identify core
coordinating or Quality management
Team
How to Go About
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Focus on uniform training of all
employees in key areas
Encourage by financial and / or nonfinancial incentives
Initially prepare to provide extra
resources
Avoid
disappointments
if
initial
benefits do not accrue as expected
Be prepared for a longer gestation
period for benefits to accrue
How to Go About
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Examine what are you doing
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Find what you should be doing
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Document the gaps
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Compare with the standards
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Complete gap analysis
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Identify areas for improvement
These May Look
Difficult Initially, But
the First steps are
Never easy.
Quality Norms and Accreditation??
Response of Medical Fraternity
PROBLEMS AND
CHALLENGES
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HCOs are very enthusiastic
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Ill prepared
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Initial preparation is shoddy
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Resources required initially
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Benefits have a longer gestation
period
PROBLEMS AND
CHALLENGES
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Quality Consciousness at all
levels will take time
Sustenance and consistency of
efforts will be required
Commitment on a consistent
basis
High rates of attrition will
require repeated and continual
training
Public Sector will take a longer
time to get into the process
ACCREDITATION IS A
JOURNEY
AND
NOT A DESTINATION.
OPPORTUNITY
IS NOWHERE
OPPORTUNITY
IS NOW HERE
BON VOYAGE !!!!!