Hospital Accreditation Process

Practical advice and tips for successful audit outcome

Accreditation is a third party review for the benefit of organization for multiple purposes or stamping of quality standards which are practiced in day to day service to the patients. There are multiple agencies for accreditation and in India; we have NABH and NABL under the quality council of India. Other international accreditation agencies are JCI for hospitals and CAP for laboratories.

I belong to a tertiary care organization and we are accreditated for both NABH and NABL.

We have firsthand experience of passing through assessments and getting through the whole process.

Here is our take on some important assessment aspects which are reproducible provided you are ready to undergo for benefit of organization as well as it will challenge you to extremes where in you will shine out like a gem at the end of same with due polishes and glow. It will additionally be a feather in your cap as this will be a third party proof that you have followed and achieved standards of accreditation which is ultimately going to benefit patients who are seeking care .

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The organization prepares for accreditation process in a following manner.

1. Assemble all members who are key members for accreditation
2. Define organizational strategy - perform a SWOT analysis
3. Form and monitor performance of committees (there are PTC, Infection control, Transfusion and blood products, ethics and review, advisory, safety and accreditation committees in any organization depending upon scope of services offered). Committee must have: core members, an agenda, minutes of meeting are recorded and timelines are given to members.
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   It is the role of senior administration to ensure that everything is followed in stipulated timelines.

4. Train staff - training can be of multiple things as far as infection control as a discipline is concerned. Formulate training calendar as per requirement of organization.

Training in infection control has to encompass following areas.

a. Infection control committee, structure, functioning and compliance to standards of accreditation

b. Interaction and communication on day to day basis during rounds of hospitals

c. Biomedical waste

d. Hand hygiene

e. Standard precaution

f. Transmission based precautions

g. Isolation precautions

h. Safe injection and infusion practices

i. Bundle care and prevention of HAIs - CLABSI ,CAUTI, VAP and SSIs.

j. Disinfection and sterilization precautions

k. Occupational safety of healthcare workers

l. Immunization and accident reporting (e.g. needle stick injuries)

m. Surveillance of Hospital acquired infections

n. Microbiology laboratory and sample collection

o. Use of single use devices and policy for same

p. Cleaning protocol for critical, semi critical and non critical areas of hospital

q. Environmental surveillance

r. Other need based training in specific areas e.g. dialysis, radiation safety in radiology and nuclear medicine

s. Housekeeping training

t. Conducting audits in infection control

u. Kitchen and food safety

v. Laundry and linen safety

w. External visits and audits for training

5. Conduct baseline assessment or mock audit to know current gaps in system, procedures, manpower, material and any other resources.
6. Start documentation procedure and help relevant stake holders in preparation of the policy and procedures that comply with standards of accreditation.
7. Get all required approvals from higher authorities/ senior management.
8. Start implementation and conduct on site surveillance audit with difficulties with staff
9. Resolve their difficulties with available resources and adjustments in time and modify processes accordingly.
10. Once satisfactory, apply for accreditation process and get assessed.
11. During assessment, there will be certain non compliances which will be raised. Address them in stipulated time period given for completion and comply to standards.
12. Follow principles of organizational values at all times and do not stop or subsidize routine patient work.
13. Establish culture of quality in the organization with available resources and available literature of the subject.
14. Some of basic qualities which are essential for infection control officer or for quality are good visionary leadership, understanding and thorough knowledge of available guidelines, good communication skills at all levels of organization, understanding organizational structure and function, acceptability and ability to work in team, expert advice, availability and readiness to participate for larger benefit for patient care. Most importantly ability to adopt and practice essential components with available resources and upgrading the overall knowledge and understanding of staff. Another important aspect is patience and keeping a balance between different contradictory arguments and counter arguments which may occur based upon different temperaments of different people while dealing with various people at organization level.
15. Transparency in maintaining documents is one of critical success factor for infection control. It is a direct face of quality of care offered to patients.

Types of assessment to be faced by departments generally under NABH accreditation:

1. Pre assessment
2. Final assessment
3. Verification
4. Surveillance
5. Re-accreditation

Also updates in standards happen from time to time with additional clauses and sub clauses which are to be complied by organization for which staff and concerned people need to undergo training from providers.

Many times these assessments last for few days and then it is really stretching for the staff because they have to additionally do work in patient care areas and at same time face assessment.

Many times remarks given (non conformities) are not as per standard guidelines and are biased by personal experience or subjectivity. With time, the institutions undergoing accreditation realizes that two different assessors also do not have common joint consensus as far as some of areas related to infection control are concerned and their statements can be contradictory because there is deficiency for specialists who are expert in infection control field . There can be incidents where two guidelines are contradictory and in such cases, organization must be given freedom to follow what is best suitable for their scope. The differences of opinion should not hamper the autonomy of organization and multiple factors which govern the practices like resources and manpower, material must be taken in account before arriving at conclusion.

Resource material for establishing infection control:

There is a lot of literature and guidelines are available from national and international agencies. There are CDC, IDSA, HICPAC and NICE guidelines and recommendations. There are WHO guidelines on SSI prevention and also for the hand hygiene. AORN guidelines are available for nursing in operating theatres. There are WHO guidelines available for cleaning and disinfection.

Additionally some of certification in infection control are offered by international agencies and national level some of programs are conducted by various organizations like Shankar netralaya, Infection Control Academy of India (IFCAI), JIPMER, Tata memorial hospital, Mumbai; Care hospitals, Hyderabad and HIS India and other local associations. National guidelines on infection control and antibiotic policy for nation is available and downloadable from ICMR which can act as national document and help in forming institutional policy.

HAIS-ICMR-AIIMS program has been initiated by AIIMS, Delhi in collaboration with CDC and is helping to establish nationwide surveillance in India and currently limited but hopefully we will have a nationwide surveillance initiating in stepwise manner. NABH and other accreditation agencies are also collecting Indian data on Hospital acquired infections. Three have been other local surveillance networks like MAHASAR etc. Which work at regional level.

Accreditation if taken in appropriate manner can definitely change whole scenario of healthcare in any given area or for that matter for the whole country provided it is functional in a manner and with discipline and principles of standardization which it must adhere to.

Accreditation is as such a boring exercise for operational managers as it is involving multiple tasks and enormous documentation by the same people who are actually involved in doing ground work. For top management, it is a luxury or stamp of their ability and expertise and for the insurance agencies and other third party agencies it is assurance and for accreditation agencies it has become a sustainable business.

For infection control practices, accreditation is definitely helpful in establishing process and systems which are essential to prevent hospital acquired infections and also it has helped organization to divert resources towards prevention which is becoming very important arm of accreditation. However at same time duplication and wasteful expenditure must be prevented and all the process and procedures should be as per guidelines which are already published in literature.

At same time, government hospitals or public organization are far from practicing standards of infection control with just basic facilities in spite of so much advances in modern medicine. The infrastructure is insufficient and inappropriate, the staff sensitization is not enough and there is lot of inertia from senior administration as far as resources are concerned. There are few only organization which can be counted in this nation who are government and accreditated.

To conclude

Journey has been already started for quality standards as far as healthcare sector in India is concerned but there is long way ahead. With visionary leadership and committed leaders, it is definitely possible and with more investments from capital equities and international funding and medical tourism, there is a lot of scope as well as need to prioritize mechanisms to address unmet needs as far as infection control practices are concerned.

It is time to realise that complete documentation just for the sake of accreditation purpose is not a substitute for continuous quality of patient care and services offered by healthcare organizations.