ACCREDITATION STANDARD FOR MEDICAL IMAGING SERVICES

ASHISH RANJAN
AASTHA SERVICE INTERNATIONAL F-17, IIND FLLOR , SUBASH CHOWK , LAXMI NAGAR, DELHI-110092

What is Accreditation?
Public recognition of the achievement of accreditation standards by a healthcare organization, demonstrated through an independent external assessment of that organizations level of performance in relation to the standard. (ISQua)

Hospital Accreditation in India

Started in India in the year 2005 by National Accreditation Board for Hospitals & Healthcare Providers (NABH) NABH is a constituent board of Quality Council of India (QCI) set up to establish and operate accreditation programme for healthcare organizations. QCI is an Autonomous body jointly set up by the Government of India and Indian industries to establish and operate National Accreditation Structure. The board while being supported by all stakeholders including industry, consumers, government, has full functional autonomy in its operations.

A constituent board of Quality Council of India (QCI)

To provide accreditation services to hospitals and healthcare providers
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Structure of QCI
Quality Council of India

National Accreditation Board for Certification Bodies (NABCB)

National Accreditation Board for Testing and Calibration Laboratories (NABL)

National Accreditation Board for Education and Training (NABET)

National Accreditation Board for Hospitals & Healthcare Providers (NABH)

National Board for Quality Promotion (NBQP)

Quality Information and Enquiry Service (QIES)

Structure of NABH
Quality Council of India

National Accreditation Board for Hospitals & Healthcare Providers

Appeals Committee Secretariat Technical Committee Panel of Assessor/Expert

Accreditation Committee

NABH Activities
Accreditation of Hospitals Accreditation of Blood Banks Accreditation of SHCO/ Nursing Homes Accreditation of OST Centers Accreditation of PHC/CHCs Accreditation of AYUSH hospitals Accreditation of Wellness Centers Accreditation of Medical Imaging Services (Ready for launch) Accreditation of Dental Centers (Ready for launch)

International Recognition NABH is an institutional member of the International Society for Quality in Health Care (ISQua) since 2006.

International Recognition
ISQua Board Member Member of Accreditation Council ASQua Board Member

International Recognition
ISQua Accreditation of NABH Standards for Hospitals (April 2008 March 2012)

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Basic Principles of Accreditation

Statutory/ Regulatory/ Licensing Compliance Must It is based on structure, process and outcomes Focused on Patient Care and Safety

Accreditation Standards

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Accreditation Standards for Medical Imaging Service

1) 2) 3) 4) 5) 6) 7) 8) 9)

Control of Service (CS) Control Of Imaging Processes And Procedures (CPP) Control Of Personnel(CP) Control Of Equipment (CE) Control Of Documents And Record (CDR) Risk Control and Safety (RCS) Control Of Services(CS) Control Of Imaging Process And Procedures (CPP) Human Resource Management (HRM)

10 chapters,100 standards,514 objective elements.

Objective of the study

To analyze the improvements in the quality of services rendered by different hospitals, accredited under the accreditation program of NABH, based on certain service and clinical standard indicators.

Methodology
The hospitals were provided with questionnaire related to some service and clinical standards. They were requested to provide information on benefits of accreditation in terms of improvement in performance under different standards provided. The standards selected are: Service standards: a) Registration desk b) Pharmacy c) IT and Billing Clinical Standards: a) OPD standards b) Diagnostic (Laboratory and c) OT and Nursing

Radiology)

RESULTS
The data from hospitals accredited under NABH accreditation program was collected, analyzed and following observations were made

SERVICE STANDARDS INDICATORS

REGISTRATION DESK
Scope of services well defined and understood by staff Patients rights and responsibilities are identified and respected Increased patient satisfaction and quality of care Admission process streamlined, admission counseling started Job responsibilities of staff clearly defined

Increase in staff strength in areas like enquiry, doctors booking & console as per work load

Staff review meetings for discussion complaints & suggestions

Procurement, storage & dispensing policies/procedures for medications well defined Improved inventory practices as a result of training of staff Special care taken in handling, storing and dispensing sound alike, look alike and high risk medicines Regular medical audits

PHARMAC Y

Lower incidents of medication related adverse events in care

Adverse drug reactions & medication error tracking & review has been reinforced Policies defined for handling of narcotic, radioactive& chemotherapeutic drugs.

IT & BILLING

Auto log& limitation on viewing privileges

New out patient and in patient billing counters to meet up additional workload.

Auto stoppage of medication which have serious side effects unless reordered by the physician

Safety of patient data & decrease in waiting time for billing

Introduction of billing counseling

IT generated discharge summary

Schedule of charges displayed through kiosk and handouts

CLINICAL STANDARDS INDICATORS

OPD Consultation
Increased patient satisfaction

Corrective steps taken to reduce OPD consultation waiting time

Monthly review of statistics on mortality, code blue occurrence, capacity utilization, doctors performance etc.

More emphasis on preventive care through patient education.

Protocols for preventive health checks, cardiac evaluation, pre operative anesthesia, angiography have been reinforced

DIAGNOSTI CS

Procedures and policies for pathology & radiology depts. implemented with standardized processes

Wastages identified and corrective actions taken. Biomedical waste practices improved

Regular training of staff in radiation safety

Continuous monitoring of clinical tests results

Staff with requisite qualifications and experience is employed

Increased patient safety and enhanced quality of services provided

OT & Nursing
Improved practices in OT and reduced chances of error

Rational use of blood and blood products in OT

Proper documentation of OT notes and sign offs by treating surgeons are in place

Sterilization and disinfection practices are monitored and are in place

Policy to prevent adverse events like wrong site, wrong patient &wrong surgery is defined and implemented

Infection and environmental surveillance carried out

CONCLUSIO N
Staff

Registration:

awareness about various policies, procedures and services improved considerably. Patients rights are now recognized and respected. Turn around time reduced
Pharmacy:
Waiting

time reduced Ready stock of emergency drugs at all times Improved inventory practices.

 IT

and Billing:
policy for the access of data and OPD

Security

records. Restricted control and access to patients data.

OPD

Consultations:

Mandatory

nutritional assessment . Patient rights regarding privacy and confidentiality reinforced.

 Diagnostics:
Equipment

calibration/preventive maintenance schedule monitored regularly. Quality assurance programme implemented. Corrective actions identified & implemented.
OT

and Nursing:

Fumigation

policy and hands washing is continuously monitored in OT. Better Infection control Continuous training, incidental teaching and supervision to ensure quality nursing service. Motivation to nursing staff to be a partner in delivery of healthcare.