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National SightFirst Conclave 2018
October 7, 2018, Siliguri
Dr. B.K. Rana
Founding CEO
Way to Quality: Accreditation Process
Introduction of QAI
 QAI- Quality & Accreditation Institute
Change Adapt Improve
2QAI
Introduction of QAI
 Vision: Nurturing the largest global pool of organisations
and people through quality improvement and
accreditation framework.
 Mission: To conceive and deliver education, training,
accreditation and related programs in partnership with
stakeholders using an approach of co-design and co-
creation.
3QAI
Introduction of QAI
Values:
 Listener: Seek continuous feedback from stakeholders
to address their concerns
 Competitive: Look for viable options to benefit users of
our services
 Transparency: Clearly defined policies made available
in public domain
 Innovation: Continuously evolve using co-design and
co-creation
4QAI
Organisation Structure of QAI
Board of Directors
Centre for
Education and
Training (CET)
Centre for
Laboratory
Accreditation
(CLA)
Centre for
Accreditation
of
Accreditation
(CAHSC)
Centre for
Accreditation of
Veterinary
Facilities (CAVF)
Advisory Board
Centre for
Proficiency
Testing (CPT)
CEO
5QAI
Structure of CAHSC
6QAI
Governing Board
Chairman
CEO
Heads of Programs Administration & Accounts
Appeals Committee
Technical Committees Accreditation Committee
Executive
Panel of Assessors/ Experts
Centre for Accreditation of
Health & Social Care (CAHSC)
 Board constituted- Prof M.C.Misra, Chair
 Accreditation of ART including IVF Centres
 Accreditation of Home Healthcare
 Accreditation of Dialysis centres
QAI 7
QAI
8
QAI is an institutional member of the
International Society for Quality in Health Care
(ISQua)
 Dr. B.K. Rana, Founding CEO is a member of the
Board of Directors (2017-2019)
Quality & Accreditation Institute
Accreditation Mark of Quality and Accreditation
Institute
Global Operations
 Global Associates:
 Ghana
 Nigeria
 Nepal
 Maldives
 Bangladesh
 Philippines
 UAE
 Bahrain
 Mexico
 UK QAI 10
QAI Journal of Healthcare Quality &
Patient Safety
www.qaij.org
Accreditation
Public recognition of the achievement of accreditation
standards by a healthcare organisation, demonstrated
through an independent external assessment of that
organisation’s level of performance in relation to the
standard.
(ISQua)
Quality & Accreditation Institute
Accreditation
 Accreditation relies on establishing technical competence
of a HCO in terms of standards in delivering services
with respect to its scope.
 It focuses on learning, self development, improved
performance and reducing risk.
 Accreditation is based on optimum standards,
professional accountability and encourages healthcare
organisation to pursue continual excellence.
Quality & Accreditation Institute
Why accreditation?
 One study found that only 20% of eligible patients
received β-blockers following a heart attack, despite the
fact that they have been proven to be an effective
intervention, reducing mortality by 43%.
 Another study found that antibiotics are frequently over-
prescribed; contributing to microbial resistance to these
drugs. Such resistance could cost as much as $7.5 billion
a year for more expensive healthcare interventions.
QAI-CAHSC/Home Care/Standards 14
Cataract-operated left eye
got infected, man lost eye
due to medical negligence gets
Rs 5 lakh relief (TOI)
Hospital
fined
for
botched
eye
surgery
after 12
years
(TOI)
Five lose sight after
surgery at X hospital
(The Telegraph)
Why accreditation??
 Improves care and enhances public confidence.
 Ensures transparency in the functioning.
 Provides the framework for an integrated and
focused management structure.
 Recognition by payers, government and
vendors.
Why accreditation?
 Financial Transparency
 Role model to other hospitals.
 Recognition of services.
 Helps in promoting Medical Tourism.
 Awakening of patients about their rights
 Reduced ALOS
 Increase in revenue?
Consumer’s Perspective
 Patient safety of prime importance.
 Increased patient involvement in care
 Open disclosure.
 Patient rights and responsibilities clearly
defined.
 Protocol based treatment.
Characteristics of a Quality Healthcare
System
 It is safe
 It is effective
 It is efficient
 It is patient centered
 It is equitable
 It is timely
19
Institute of
Medicine
2001
Building a Culture of
Quality & Safety
What does it mean?
 Not just a certificate
 Not just preparation for an assessment/survey
 Not just someone else is responsible
 Intention to improve under every circumstances
What is needed?
• Engaging leaders
• Link quality with outcomes
• Adopt quality management tools
• Building capacity through training &
consulting organizations
• Promoting recognition system for healthcare
quality professionals
What is needed?
• Patient / People centered care
 Remember that Bad system
not bad people are responsible
for most errors.
What is needed?
Outcomes!
Change-Adapt-Improve
• Change Management
• Change culture
• Change attitude
• Adapt to these changes
• Practice
• Stabilize
• Improvement
• Move on……….
Adapt
Improve
Change
Specific Issues to Eye Care
Facilities
Adverse Events
 Wrong site
 Wrong patient
 Wrong procedure
 Medication errors
Care of vulnerable patients
 Infants
 Children
 Physically challenged/ Disabled individuals
 Mentally challenged
 Elderly
Accreditation/Certification
Standards
30
Chapters Std. OE
Access, Assessment and Continuity of
Care (AAC)
7 32
Care of Patients (COP) 11 52
Management of Medications (MOM) 6 32
Patients Rights and Education (PRE) 7 33
Hospital Infection Control (HIC) 6 28
QUALITY & ACCREDITATION INSTITUTE
Chapters Std. OE
Continuous Quality Improvement (CQI) 6 31
Responsibilities of Management (ROM) 3 17
Facility Management & Safety (FMS) 4 17
Human Resource Management (HRM) 10 26
Information Management Systems
(IMS)
6 34
Total 66 302
QUALITY & ACCREDITATION INSTITUTE
Feedback
To
Health care
Organization
And
Necessary
Corrective
Action
Taken
By
Health care
Organization
Submission of application (online)
Review
Pre/ Final assessment
Review of Assessment Report
(by Secretariat)
Accreditation committee
Approval for accreditation/ Certification
Issue of certificate
Process for accreditation/ Certification
Why all this?
……I want to
Build a culture of
Quality & Safety
Thank you
bkrana@qai.org.in
www.qai.org.in
QAI 36

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Way to quality (sight first conclave)

  • 1. National SightFirst Conclave 2018 October 7, 2018, Siliguri Dr. B.K. Rana Founding CEO Way to Quality: Accreditation Process
  • 2. Introduction of QAI  QAI- Quality & Accreditation Institute Change Adapt Improve 2QAI
  • 3. Introduction of QAI  Vision: Nurturing the largest global pool of organisations and people through quality improvement and accreditation framework.  Mission: To conceive and deliver education, training, accreditation and related programs in partnership with stakeholders using an approach of co-design and co- creation. 3QAI
  • 4. Introduction of QAI Values:  Listener: Seek continuous feedback from stakeholders to address their concerns  Competitive: Look for viable options to benefit users of our services  Transparency: Clearly defined policies made available in public domain  Innovation: Continuously evolve using co-design and co-creation 4QAI
  • 5. Organisation Structure of QAI Board of Directors Centre for Education and Training (CET) Centre for Laboratory Accreditation (CLA) Centre for Accreditation of Accreditation (CAHSC) Centre for Accreditation of Veterinary Facilities (CAVF) Advisory Board Centre for Proficiency Testing (CPT) CEO 5QAI
  • 6. Structure of CAHSC 6QAI Governing Board Chairman CEO Heads of Programs Administration & Accounts Appeals Committee Technical Committees Accreditation Committee Executive Panel of Assessors/ Experts
  • 7. Centre for Accreditation of Health & Social Care (CAHSC)  Board constituted- Prof M.C.Misra, Chair  Accreditation of ART including IVF Centres  Accreditation of Home Healthcare  Accreditation of Dialysis centres QAI 7
  • 8. QAI 8 QAI is an institutional member of the International Society for Quality in Health Care (ISQua)  Dr. B.K. Rana, Founding CEO is a member of the Board of Directors (2017-2019) Quality & Accreditation Institute
  • 9. Accreditation Mark of Quality and Accreditation Institute
  • 10. Global Operations  Global Associates:  Ghana  Nigeria  Nepal  Maldives  Bangladesh  Philippines  UAE  Bahrain  Mexico  UK QAI 10
  • 11. QAI Journal of Healthcare Quality & Patient Safety www.qaij.org
  • 12. Accreditation Public recognition of the achievement of accreditation standards by a healthcare organisation, demonstrated through an independent external assessment of that organisation’s level of performance in relation to the standard. (ISQua) Quality & Accreditation Institute
  • 13. Accreditation  Accreditation relies on establishing technical competence of a HCO in terms of standards in delivering services with respect to its scope.  It focuses on learning, self development, improved performance and reducing risk.  Accreditation is based on optimum standards, professional accountability and encourages healthcare organisation to pursue continual excellence. Quality & Accreditation Institute
  • 14. Why accreditation?  One study found that only 20% of eligible patients received β-blockers following a heart attack, despite the fact that they have been proven to be an effective intervention, reducing mortality by 43%.  Another study found that antibiotics are frequently over- prescribed; contributing to microbial resistance to these drugs. Such resistance could cost as much as $7.5 billion a year for more expensive healthcare interventions. QAI-CAHSC/Home Care/Standards 14
  • 15. Cataract-operated left eye got infected, man lost eye due to medical negligence gets Rs 5 lakh relief (TOI) Hospital fined for botched eye surgery after 12 years (TOI) Five lose sight after surgery at X hospital (The Telegraph)
  • 16. Why accreditation??  Improves care and enhances public confidence.  Ensures transparency in the functioning.  Provides the framework for an integrated and focused management structure.  Recognition by payers, government and vendors.
  • 17. Why accreditation?  Financial Transparency  Role model to other hospitals.  Recognition of services.  Helps in promoting Medical Tourism.  Awakening of patients about their rights  Reduced ALOS  Increase in revenue?
  • 18. Consumer’s Perspective  Patient safety of prime importance.  Increased patient involvement in care  Open disclosure.  Patient rights and responsibilities clearly defined.  Protocol based treatment.
  • 19. Characteristics of a Quality Healthcare System  It is safe  It is effective  It is efficient  It is patient centered  It is equitable  It is timely 19 Institute of Medicine 2001
  • 20. Building a Culture of Quality & Safety
  • 21. What does it mean?  Not just a certificate  Not just preparation for an assessment/survey  Not just someone else is responsible  Intention to improve under every circumstances
  • 22. What is needed? • Engaging leaders • Link quality with outcomes • Adopt quality management tools • Building capacity through training & consulting organizations • Promoting recognition system for healthcare quality professionals
  • 23. What is needed? • Patient / People centered care
  • 24.  Remember that Bad system not bad people are responsible for most errors.
  • 26. Change-Adapt-Improve • Change Management • Change culture • Change attitude • Adapt to these changes • Practice • Stabilize • Improvement • Move on………. Adapt Improve Change
  • 27. Specific Issues to Eye Care Facilities
  • 28. Adverse Events  Wrong site  Wrong patient  Wrong procedure  Medication errors
  • 29. Care of vulnerable patients  Infants  Children  Physically challenged/ Disabled individuals  Mentally challenged  Elderly
  • 31. Chapters Std. OE Access, Assessment and Continuity of Care (AAC) 7 32 Care of Patients (COP) 11 52 Management of Medications (MOM) 6 32 Patients Rights and Education (PRE) 7 33 Hospital Infection Control (HIC) 6 28 QUALITY & ACCREDITATION INSTITUTE
  • 32. Chapters Std. OE Continuous Quality Improvement (CQI) 6 31 Responsibilities of Management (ROM) 3 17 Facility Management & Safety (FMS) 4 17 Human Resource Management (HRM) 10 26 Information Management Systems (IMS) 6 34 Total 66 302 QUALITY & ACCREDITATION INSTITUTE
  • 33. Feedback To Health care Organization And Necessary Corrective Action Taken By Health care Organization Submission of application (online) Review Pre/ Final assessment Review of Assessment Report (by Secretariat) Accreditation committee Approval for accreditation/ Certification Issue of certificate Process for accreditation/ Certification
  • 35. ……I want to Build a culture of Quality & Safety