Accreditation: A Tool to Improve Quality

Dr. Rashi Agarwal, Director, Praxis HealthcarePraxis Healthcare is one the world’s largest healthcare solution providers offering services like Denial Management, Aged Claims & Safety Net, A/R Management, and Liability Claims Management.

Accreditation can be viewed as a great tool to improve quality in a hospital setup. Be it quality in patient care, quality in process flow, quality in workflow, all aspects are reviewed by this third eye. Hospital accreditation has been defined as,‘A self-assessment and external peer assessment process used by healthcare organizations to accurately assess their level of performance in relation to established standards and to implement ways to continuously improve’. Hospital quality assurance systems are operational control systems intended to fulfill specific expectations for treating patients.

Clinicians have customarily enjoyed a great deal of autonomy in their practices. The mechanisms for monitoring and assuring quality of the care provided have tended to be based on internal peer review. Time,however, has torn away much of the curtain of professional mystique. The changing healthcare environment with revised hospital accreditation guidelines have sharpened the clinical and administrative hospital staff’s concern for evaluating the quality of care they provide. Clinicians now see accreditation standards as a framework by which organizational processes will be improved and their patients are better cared for. Physicians and administrators now must face the challenge of establishing comprehensive and vigorous systems of quality assurance and learn to avoid the traps that impede implementation of such systems. Quality assurance is a very simple process that deals with finding problems and fixing them.

A comprehensive definition of quality healthcare would be,'The optimal achievable result for each patient,the avoidance of physician-induced(iatrogenic) complications, and attention to patient and family needs in a manner that is both cost-effective and reasonably documented'.

Importance of Accreditation in Hospitals
Accredited hospitals offer higher quality of care to their patients. Accreditation also provides a competitive advantage in the healthcare industry and strengthens community confidence in the quality and safety of care, treatment and services. Overall, it improves risk management and risk reduction and helps organize and strengthen patient safety efforts and creates a culture of patient safety. Not only does it enhance recruitment, staff education and development,but it also assesses all aspects of management and provides education on good practices to improve business operations. International accreditation like JCI creates a mark on the world map and increases business through medical tourism.

Few Quality Accreditation Programs for Hospitals
There are several quality accreditation standards. However, few that are common to hospitals are Joint Commission International
(JCI), National Accreditation Board for Hospitals(NABH),ISO 9001-2000, Malcolm Baldridge and many more. The most common ones being ISO& NABH. Other ones being departmental specific like NABL and others.

Difference between the Accreditation Standards
ISO is more process driven and is better for back-end departments like Accounts, HRD and others, while NABH & JCI are clinically oriented standards to directly impact patient care.

Accreditation Standards(NABH):NABH has 10 chapters incorporating 102 standards and 636 objective elements

Outlineof NABH Standards: Patient-Centered Standards(functions related to providing patient care)
•Access,Assessment and Continuity of Care(AAC)
•Care of Patient(COP)
•Management of Medication(MOM)
•Patient Right & Education(PRE)
•Hospital Infection Control(HIC)

Healthcare Organization& Management Standards:Functions related to providing a safe, effective and well-managed organization
•Continuous Quality Improvement(CQI)
•Responsibility of Management(ROM)
•Facility Management and Safety(FMS)
•Human Resource Management(HRM)
•Information Management System(IMS)

The Accreditation Process
•Begin with Accreditation Process by Education: Educate the leaders and the managers and explain the benefits,advantages, process, timeline, and the rest of the accreditation.

• Baseline Assessment:Use knowledgeable and credible evaluators(either internal or external consultants)(PRAXIS takes on consulting assignments for accreditation process) who will critically and objectively assess each area and conduct a detailed baseline assessment of the organization’s current adherence to the standards and each measurable element. Score as Met, Partially Met, or Not Met and cite-specific findings and recommendations. Also collect and analyze baseline quality data as required by the quality monitoring standards, for example, medication errors, hospital-associated infection rates, antibiotic usage, surgical complications, and establish an ongoing monitoring system for data collection (e.g., monthly, with quarterly data analysis) to identify problem areas and track progress in improvement

• Action Planning: Using the findings of the baseline assessment, develop a detailed project plan starting first with priority areas of the core standards. Responsibilities, deliverables, and time frames should be assigned. For example, Revise informed consent policy, develop a new informed consent statement, educate staff - in the next two month time period

• Chapter Assignment:Look for good people skills, time management skills, and consensus building skills and assign oversight of each chapter of standards to such a respected champion/leader who will identify team members from throughout the hospital and carry-out the process.

• Policies & Procedures: In addition to overall project plan,it is often helpful to compile a list of all required policies and procedures that will need development and revision.

• Continue to monitor your progress in meeting the standards,such as through a mini-evaluation of each chapterat regular intervals (e.g.,quarterly)

• Final Mock Survey:Plan for a final ‘mock survey’at least 4-6 months in advance of the target date of the actual accreditation survey. Use evaluators(internal or external consultants)who were not involved in the baseline assessment and preparation, who will look at the organization with a fresh and objective eye. Need to plan final revisions and corrections based on the findings of the final mock survey.

The success of any quality assurance program depends almost entirely on the commitment and interest of the administrators, nurses, paramedical staff and physicians. Leaders of quality assurance programs must be able to generate interest and commitment without burdening clinical and administrative staff with an activity they neither understand nor believe in. This will help move quality assurance out of its current paralysis in some hospitals. Quality assurance is to succeed in its goal to identify and correct problems and to improve the quality of patient care.