NABH accreditation for hospitals
has become popular to the extent that it is now almost a necessity for any hospitals
to have accreditation for competing in healthcare market. Hundreds of hospitals have applied and are making
effort to bring themselves up to the level expected by NABH. There are
different ways in which hospitals prepare themselves for accreditation. Some
put up their own team to understand and implement standards while others hire a
consultant to help them towards this. Chain hospitals replicate their
accreditation work of one of their other hospitals in other units. Irrespective of the method adopted,
preparation for accreditation requires, substantial resources, proper planning
and dedicated efforts on part of the organization. Preparing for accreditation
is like a journey with milestones to achieve and unless the path and approach
chosen is correct, reaching the milestones can become very difficult.
With my experience of over 10 years
with NABH accreditation, I have published a book ‘Accreditation of HealthcareOrganizations’ (Jaypee Publishers), which could be very helpful for those
hospitals preparing for accreditation. Till date, it is the only book on this subject
in the country.
For those who would like to have a
quick read, instead of reading the entire book, below I have written a brief on
‘Preparing for Accreditation’, which I have taken mostly from one of the
chapters of my book.
Before this, please also go through this post on 'How not to prepare for accreditation', as it is equally important to prevent yourself from wrong ways of preparing.
A Healthcare Organiaztion (HCO) preparing for accreditation must go through following steps
1. Taking a Decision:
The first and most careful step to be taken towards
accreditation preparation is to take a firm decision to go for it. Since the
time, money and efforts involved in accreditation preparation can be
substantially high for many HCO, the decision of going for accreditation should
be taken cautiously. Often HCO arbitrarily decides for preparing for
accreditation and later realize the true difficulty in completing the process
and as a result, their accreditation journey remains half-way. As organizations
fails to get accredited which causes lack in motivation, smaller developments
they made towards its preparation also starts receding and efforts and
resources spent for those development gets wasted. There are hundreds of HCO in
the country who has applied for accreditation years back but have not been able
to complete, as they are stuck at some level in the process. Common reasons for
not successfully completing the accreditation process are financial,
constratints, Infrastructural problems, unavailability of sufficient expertise,
lack of time and lack of motivation.
An HCO should be aware of reasons
of failure and prevent themselves from getting affected by one of them. A firm
decision for preparing for accreditation which is based upon a fairly good idea
of resource and effort requirement can help HCO overcoming most of the road
blocks mentioned above.
2. Baseline gap assessment
Once the decision is taken, the initial
steps in accreditation preparation is to do a comprehensive baseline gap
assessment of the HCO in comparison to accreditation requirements. This helps
in determining technical and financial feasibility of accreditation
preparation. Besides, the assessment also lays foundation for accreditation
preparation and serves with useful information to plan out entire preparation
exercise. In order to get a good idea about the present status and preparation
required for accreditation the baseline gap assessment should be focussed upon
those aspects that consumes more time, money and efforts for addressing. Following
sub-sections provide an understanding on how to conduct a useful baseline gap
assessment.
Team:
Accreditation
preparation is a team work and it starts right from the baseline gap
assessment. Since the exercise involves assessing different disciplines of the
HCO, a relevant working team should be formed for this. The team should consist
at-least one person who has significant knowledge and understanding of
accreditation requirements. He/she should be supported by members who are
knowledgeable in field of civil engineering, legal requirements, human
resources, bio-medical equipment and clinical care. List of standards and
objective elements can be used as a checklist to conduct the assessment. If
required help of an external consultant should be taken to get the gap
assessment done.
Physical facility gap assessment:
One of the important aspect to be assessed
is the physical facility including all its engineering installation. Since they
are difficult to modify and cost intensive assessment should carefully identify
if there is any deficiency with respect to accreditation requirements. One
should note that accreditation requirements may not be providing any
specification related to physical facility, but could be interpreted based upon
the process related requirements.
Human resources gap assessment:
Fulfilling HR requirements are also cost
intensive and time consuming. Hence the assessment should at the first place
identify gaps related to HR requirement. Similar to physical facility
accreditation standards may not give specifications of HR or numbers required
but will indicate about it. The team should refer other guidelines and work out
specific HR needed to fulfil accreditation requirements.
Regulatory requirements gap assessment:
Obtaining legal clearances, licenses,permits can be a time consuming task and at times be extremely difficult.
Through baseline gap assessment the team should assess if the HCO meets all
regulatory requirements and possess necessary documents for the same.
Bio-medical equipment gap assessment:
This is another area which is cost intensive
and hence should be included in the assessment. Few important biomedical
equipment related points that should be checked during the assessment is given
in the link above.
Baseline gap assessment report:
The assessment finding should be documented as
a report which should list out gaps in physical facility, legal requirements,
HR and bio-medical equipment. Each area of the HCO should be assessed and gaps
of each area should be separately documented in the report. Additionally, the
gaps can be highlighted as critical, semi-critical and non-critical from
accreditation point of view. This report can then become a checklist of major
things to be done for accreditation preparation.
Click here to see a sample checklist of important points
to be covered in baseline assessment
3. Assigning Responsibilities
After baseline gap assessment is done and a decision continues
to go for accreditation preparation, it’s time to assign responsibility for
this work. While it requires every body’s involvement in accreditation,
somebody who is responsible for driving the effort is an essential thing to do.
Also, considering the amount and level of work involved in accreditation the
responsibility should be taken by some one senior in the organization who has
necessary authority.
Designating accreditation co-ordinator:
Accreditation coordinator is overall
responsible for planning and preparation of accreditation requirement across
the organization. A senior person from the organization with requisite
knowledge of accreditation and quality should be designated as accreditation
co-ordinator. He/she is also responsible for communicating with accreditation
agency and handling external assessments.
Core team:
Depending
upon the size of the hospital and baseline assessment a team of working
executives should be formed to work towards accreditation.
Quality improvement committee:
This committee should be formed to play the advisory and
monitoring role towards accreditation preparation.
(Check this post for all hospital committees and teams that needs to be formed for NABH)
(Check this post for all hospital committees and teams that needs to be formed for NABH)
Department coordinator:
For each department one staff can be designated as
co-ordinator or facilitator to undertake accreditation related activities in
their department
4. Accreditation Training:
Before the preparation of accreditation work started
the core team should assess their need of obtaining necessary training with
respect to accreditation. There are several training programmes conducted by
accreditation agencies which can be attended by core team including
accreditation coordinator. If possible, HCO may invite an expert to conduct an
in-house training workshop on accreditation, which can be attended by larger
number of staff, including department coordinators.
If there is an in-house availability of a person who
has expertise in accreditation he/she can be involved in core team or in
training or as an advisor.
5. Planning and Timeframe:
Baseline gap
assessment identifies major time consuming work required to be done. In
addition a process gap assessment should be done at initial stage of
preparation to identify the processes and systems that needs to be developed or
modified. This should be done thoroughly as it will lead to formation of plan
of preparation. The process gap assessment can be done by core team in
consultation with department coordinators. The accreditation standards and
objective elements should be used as a checklist.
Based upon process gap assessment a plan with
timeframe should be developed by the core team. The plan should list out the
preparatory activities required and start and end time for the same. The plan
should be carefully developed to be comprehensive and realistic. If required
the plan should be shared with quality committee to seek multiple inputs.
You can check this sample plan with timelines for
accreditation preparation. The plan
should be used as a tool to check if required progress is being made within
time line for accreditation. The
development in preparation should be reviewed periodically to match it with
plan and wherever required appropriate steps should be taken. Plan can be
modified if required with justifiable reasons.
6. Preparation and Approaches:
There are two basic approaches to carry out the
activities in the accreditation preparation plan. Centralized and
de-centralized approach. They are discussed in below sub-sections.
Centralized
approach: Primary responsibility of undertaking and completing
activities in plan is with core team and is done centrally, while department
coordinator and other staff are minimally involved. The policy, process,
documentation and specific details related to an activity are majorly done by
the core team for all departments with help of inputs and information collected
from departments. This approach better ensures compliance to plan and its
timelines and also provides uniformity in systems and processes across the HCO.
However, since the involvement of department staff and coordinators are
minimal, and also sometimes the centrally developed policy may not be conducive
to practical requirements in department, implementation can become difficult
Decentralized
approach: In this responsibility of undertaking and completing specific
tasks are given to departments with core team only playing the role of support
and coordination. The approach builds better involvement of all staff and
practically useful systems and processes can be created. The disadvantage
however is difficulty in maintaining uniformity and sticking to timelines.
While both approaches have its own advantage and
disadvantage, an HCO can decide upon a mix of both. Activities that require
high level of uniformity and critical to accreditation can be handled
centrally, while activities that are technical-operational can be
decentralized. For example documentation can be done centrally after collecting
relevant information from departments while responsibility for things like
meeting regulatory requirements can be given to department primarily.
7. Phasing of Accreditation:
While achieving accreditation is the final milestone
of preparation, some milestones can be created in between the journey to get a
sense of progress and achievement. This can be done by phasing out the
preparation plan with each phase representing a milestone to be achieved.
Documentation:
In this phase major focus of accreditation preparation is on creating
relevant documents. Documentation prepares the systems and processes to be
implemented in the HCO to meet accreditation requirements. Refer chapter 16 for
documentation requirements of accreditation.
Training:
Training
phase is directed towards implementing the documented systems and procedures
across the organization. A training plan that contains list of trainings, names
of trainers, trainees and evaluation of training should be developed. Although
documentation and trainings are continuous activity, a completion of stage
should be defined.
Internal audits:
This phase is directed to check whether or not the documented
systems have been effectively implemented. Each departments should be audited
based upon a relevant checklist. The exercise may be repeated if required. This
is an important phase as its successful completion enable HCO to go for
administrative process of accreditation
Accreditation phase:
In this phase activities related to external assessments and addressing
the non-conformities are majorly handled. This is a final phase as after its
successful completion accreditation is granted to the HCO
Other activities:
A range of other activities should be done parallel to the
phases described above. These activities are determined out of baseline gap
assessment and process gap assessment and are not included in any of the phases
above.
8. Key to successful preparation:
Success of accreditation preparation is majorly
determined by whether or not the HCO gets accredited. Some key points that
helps in making the preparatory activities a success are given below
Dedicated and
motivated core team: Core team plays the major and important role in
accreditation preparation and hence having a dedicated team for this purpose is
key to success. Motivation of the team is equally important. While working
towards a tangible result in itself is a motivation, appreciation and
recognition of their work benefits a lot.
Involvement of
staff: Implementation of accreditation requirements is the ultimate check,
which cannot happen without sufficient involvement of most of the staff. Closer
connect with staff on the job and with their in-charges and supervisor is
essential in implementation
Continuity of
effort: Most of the time HCO starts with full force but gradually the level
of effort declines. Sustaining the effort till the end is what can result in
success
Expertise:
Correct understanding of accreditation requirements and how to address them is
another key to successful preparation. Thus having an expert of the subject in
core team or as advisor makes it more likely to result in success
Management
support: Keeping accreditation as a priority and having necessary
cooperation from management is essential in preparing.
