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Business Accent
Common Deficiencies Identified During Accreditation Assessment Surveys
The aim of the study was to focus on common non-compliances
and partial compliances in hospitals against the NABH standards during the accreditation
surveys
Col (Dr) S K M Rao |
National accreditation initiative in this country is a recent
phenomenon and was natural fallout of increased demand for quality medical care
in the emerging economic boom in the country in general and healthcare industry
in particular. The National Accreditation Board for Hospitals and Healthcare
Providers (NABH) was set up under the aegis of Quality Council of India (QCI)
in the year 2006. As the national initiative was started quite recently, a limited
number of hospitals have undergone pre-assessment surveys. Notwithstanding the
limitation of sample size, a preliminary analysis of pre-assessment summaries
of 10 hospitals across the country was carried out.
Aim of the Study
The aim of this study was to focus on common non-compliances and partial compliances
observed by assessors in the hospitals against the NABH standards during the
accreditation surveys with a view to suggest the areas of improvement for the
hospitals. This study could also help us identify future areas of training for
healthcare workers.
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Name of chapter
|
No of observations
|
Percentage
|
(n = 392) |
| Access, assessment and continuity of
care |
52 |
13.26% |
| Patient rights and education |
18 |
4.59% |
| Care of patient |
-80 |
20.40% |
| Management of medication |
-32 |
8.16% |
| Hospital infection control |
-58 |
14.79% |
| Continuous quality improvement |
-23 |
5.86% |
| Responsibilities of management |
-9 |
2.29% |
| Facility management and safety |
-79 |
20.15% |
| Human resource management |
-30 |
7.65% |
| Information management system |
-11 |
2.80% |
| Further distribution of these observations
was carried out standard wise and the major findings have been tabulated
in Table 2 |
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Table 1
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Methodology
Pre-assessment report for 10 randomly selected hospitals that have started the
journey of accreditation were obtained from NABH and analysed. Data has been
anonimised as per norms of confidentiality of NABH. Results were further analysed
for top scores of non-compliance/ partial compliance chapter wise, standard
wise and objective element wise. Results were also compared with other national
and international studies available on the subject.
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Standard
|
No of observations
|
Percentage
|
HIC - 2 (21) 35%
(n = 392) |
| FMS - 9 |
-23 |
5.86% |
| HIC - 8 |
-17 |
4.33% |
| FMS- 2 |
-15 |
3.82% |
| FMS- 5, COP - 12 |
-14 |
3.57% |
| COP- 1, FMS - 3 |
-12 |
3.06% |
| AAC- 12, HRM-9, COP-6 |
-10 |
2.55% |
Actual description of each standard,
which scored eight and above on non/partial compliance chart, is as follows:
AAC-12 (10): There is an established radiation safety programme.
COP-1 (12): Uniform care of patients is guided by the applicable
laws and regulations.
COP-4 (8): Policies and procedures guide the care of patients requiring
CPR.
COP-6 (10): Policies and procedures guide the care of patients in
the ICU.
COP-7 (9): Policies and procedures guide the care of vulnerable patients.
COP-12 (14): Policies and procedures guide the care of patients undergoing
surgical procedures.
HIC-2 (21): The organisation has an infection control manual which
is periodically updated.
HIC-8 (17): Statutory provisions with regard to bio-medical waste
management are complied with.
CQI-5 (8): There is an established system of audit of patient care
services.
MOM- 3(8): Policies and procedures exist for storage of medication.
FMS-2 (15): The organisations and facilities operate to ensure safety
of patients, their families, staff and visitors.
FMS-3 (12): The organisation has a programme for clinical and support
services equipment management.
FMS-4 (8): The organisation has provision for safe water, electricity,
medical gases and vacuum.
FMS-5(14): The organisation has plan for fire and non fire emergencies
within the facilities.
FMS-9 (23): The organisation has system in place to provide a safe
and secure environment.
HRM-9 (10): There is documented personal record for each staff member. |
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Table 3
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Results
As brought out in methodology after analysing survey reports for selected 10
hospitals, it was observed that in total the assessors had raised 392 observations
of non-compliances or partial compliances. The distribution of these observations
chapter wise is given below in the Table 1. Maximum observations were pertaining
to the chapter 'Care of Patients' followed by 'Facility Management and Safety'.
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(Objective Elements)
FMS-9(b): Safety
committee coordinates monitoring of the safety plan and policies.
FMS-3(e): Equipment are periodically inspected and calibrated.
CQI-5(b): The parameters to be audited are defined by the organisation.
HIC-8(b): Segregation and collection of bio-medical waste.
COP-1(c): The care and treatment orders are signed, named, timed
and dated by the concerned doctor.
FMS-5(a) Fire and non-fire emergenci:es.
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Table 2
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Comparison
Our results on standard-wise distribution were compared with similar international
studies carried out by ANAES of France and JCAHO of USA. Maximum observations
in our study were pertaining to safety aspects of facility and environment followed
by infection control issues, which are comparable to JCAHO reports on safety
in design of environment, and infection control did figure in top non-compliances
in ANAES as well as JCAHO. Analysis of observations was carried out for objective
elements and results have been tabulated in Table 3
Comparison
Our results on objective element-wise distribution were compared with similar
international study carried out by ANAES of France. Maximum observations in
our study were pertaining to safety aspects of facility and equipment maintenance,
which did not figure in ANAES list. However, dating, timing of medical records
by the doctors was common findings in both the studies.
Recommendations
Based on analysis carried out and comparisons made with various studies, the
following areas of priority have been recommended for hospitals that are preparing
for accreditation. It is advisable that hospitals focus on all the standards,
objective elements given in NABH standards. However, more attention could be
paid towards following areas:
- Safe and secure environment for patients, staff and
visitors.
- Fire safety.
- Equipment calibration and maintenance.
- Infection control programme.
- Infection control data and analysis.
- Policies for surgical procedures and ICU.
- Care and treatment orders are signed, timed, dated
by treating doctor.
- Radiation safety programme.
- Maintenance of personal HR records.
- Clinical audit.
- Storage of medicines/ inventory control.
- Issues of patient consent.
- Complying with statutory and legal provisions.
- Vulnerable patients safety.
- CPR evaluation.
- Emergency protocols.
The writer is Director Hospital Projects Army HQ New Delhi
Email: tcolskmrao@hotmail.com
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