ACCREDITATION STANDARD FOR MEDICAL IMAGING SERVICESASHISH 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 organization’s level of performance in relation to the standard. (ISQua) QCI is an Autonomous body jointly set up by the Government of India and Indian industries to establish and operate National Accreditation Structure. . consumers. has full functional autonomy in its operations.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. The board while being supported by all stakeholders including industry. government. A constituent board of Quality Council of India (QCI) To provide accreditation services to hospitals and healthcare providers 4 . 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) 5 . 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 6 . 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. 8 . International Recognition ISQua Board Member Member of Accreditation Council ASQua Board Member 9 . International Recognition ISQua Accreditation of NABH Standards for Hospitals (April 2008 – March 2012) 10 . process and outcomes Focused on Patient Care and Safety .Basic Principles of Accreditation Statutory/ Regulatory/ Licensing – Compliance Must It is based on structure. Accreditation Standards 12 . 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. 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) .Methodology The hospitals were provided with questionnaire related to some service and clinical standards. analyzed and following observations were made .RESULTS The data from hospitals accredited under NABH accreditation program was collected. SERVICE STANDARDS INDICATORS . doctors booking & console as per work load Staff review meetings for discussion complaints & suggestions .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. radioactive& chemotherapeutic drugs. storing and dispensing sound alike. storage & dispensing policies/procedures for medications well defined Improved inventory practices as a result of training of staff Special care taken in handling. 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. .Procurement. 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 . code blue occurrence. pre operative anesthesia. capacity utilization. Protocols for preventive health checks. cardiac evaluation. angiography have been reinforced . doctor’s performance etc. More emphasis on preventive care through patient education.OPD Consultation Increased patient satisfaction Corrective steps taken to reduce OPD consultation waiting time Monthly review of statistics on mortality. implemented with standardized processes Wastages identified and corrective actions taken.DIAGNOSTI CS Procedures and policies for pathology & radiology depts. 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 . wrong patient &wrong surgery is defined and implemented Infection and environmental surveillance carried out .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. Patient’s rights are now recognized and respected. procedures and services improved considerably. . Turn around time reduced Pharmacy: Waiting time reduced Ready stock of emergency drugs at all times Improved inventory practices.CONCLUSIO N Staff Registration: awareness about various policies. Restricted control and access to patient’s data. IT and Billing: policy for the access of data and OPD Security records. Patient rights regarding privacy and confidentiality reinforced. . OPD Consultations: Mandatory nutritional assessment . Diagnostics: Equipment calibration/preventive maintenance schedule monitored regularly. Corrective actions identified & implemented. OT and Nursing: Fumigation policy and hands washing is continuously monitored in OT. . incidental teaching and supervision to ensure quality nursing service. Better Infection control Continuous training. Motivation to nursing staff to be a partner in delivery of healthcare. Quality assurance programme implemented.