National Accreditation Board for Hospital and Health care

National Accreditation Board for Hospital and Health care (NABH) in Gujarat Quality Improvement Programme in Public Health Sector Department of Health & FW Govt. of Gujarat , Gandhinagar Email: sqipgujarat@yahoo. com

VISION STATEMENT To be the network of finest public healthcare institutions in the state of Gujarat, providing quality medical care services with the state of art technology with easy accessibility, affordability & equity to the people of Gujarat & beyond.

INTRODUCTION NABH Accreditation for public healthcare Institutes of Gujarat Mo. U between QCI, New Delhi & Govt. of Gujarat on 7 th July, 07 A joint effort to improve the quality and safety of healthcare services Scope includes all functions of the Hospitals, CHCs, PHCs, Medical College Labs, FDCA lab, and Blood Banks Aims at achieving the status of accredited public healthcare Institutes

Implementation of safety and quality practices Incorporation of management tools PROJECT OBJECTIVES Building sustainability Set hospital on the path of Continuous Quality Improvement Benchmark the indicators

PROJECT STRATEGY Sensitization of the top level Management on Quality Aspect and finalized the Quality Improvement Programme at State level. Selection of the hospital for quality Improvement Programme (NABH / NABL) MOU sign between QCI, New Delhi & Govt. of Gujarat (7 th July 2007) Sensitization of the programme officers for NABH

PROJECT STRATEGY Cont… Appointment of the QCI Consultant, Assistant Hospital Administrator, NABH / NABL Coordinator at facility level and District Quality Assurance officers at District level On-site study to analyze the prevalent status and practices and to identify gaps (Infrastructure, Equipment, Documentation, Processes and Practices) Addressing to Human resource, Instruments, Equipments, Infrastructure and legal (Acts /Licenses) Gaps. Formulation of committees with specific role and responsibility (Quality Assurance Committee, Hospital Infection Control Committee/Team, Medical Audit Committee, Emergency preparedness/Disaster Committee, Formulary Committee, Hospital Safety Committee, Hospital Ethics Committee, Diet Committee, Hospital Grievance Committee etc)

PROJECT STRATEGY (Cont…. ) Involvement of staff (Skill development & Motivation ) Development, Review and Implementation of policies and procedures for departmental functioning Development of Quality Management System (e. g. Patient / Employee Satisfaction, Clinical Record Indicators and quality indicators etc ) Conduction of continuous trainings Process Monitoring Internal Assessment (By Internal team) and Closures of Gaps Pre & Final Assessment (By NABH, New Delhi)

Strategies Adopted for sustainability Appointment of Asst. Hospital Administrators at facility level & Quality Assurance officers at District & Hospital level, Identified NABH Coordinators & NABL Directors at Facility level. NABL Internal audit training of 25 members (e. g. Head of the departments of medical college laboratories). A team of 40 persons trained of which 19 certified as NABH Assessors PG certificate training course of 50 candidates (e. g. Additional Directors, Superintendents, CDMOs, and Quality assurance officers) in Quality Management & Accreditation of Healthcare Organization.

Patient satisfaction survey PRACTICES IMPLEMENTED Employee satisfaction survey Clinical protocols Codes alert RED for FIRE, YELLOW for EXTERNAL CALAMITIES, BLUE for CARDIAC ARREST, BLACK for BOMB THREAT, PINK for CHILD ABDUCTION Quality Indicators

Disaster preparedness plan Basic infection control practices PRACTICES IMPLEMENTED Cont… Implementation of patient rights & Responsibilities Facility management practices Management of Medication

Process Case Study of Gandhinagar cont. . Period Activities July -August 2007 v. Gap Assessment of all clinical and non clinical areas September. November 2007 v. Distribution of Gujarati and English version of NABH standard book v. Sensitization of staff towards NABH December 2007 April 2008 v. Constitution of Various Hospital Committees v. Initiation of Documentation v. Initiation of Medical Audits v. Beginning of Indicator Monitoring System as a pilot study v. Applied for Pre-Assessment v. Self assessment with NABH Standards v. Identification of Pioneers and Internal Assessors v. Identification of training needs and Initiation of Training May - July 2008 v. Pre assessment done ( on 31 st May 2008) v. Pre-assessment gap closure activities initiated v. Infrastructure renovation started in following areas - OT, CSSD, Labour ward & Laboratory 11

Process Case Study of Gandhinagar Period Activities August 2008 v. Continuation of Training & Monitoring v. Development of Quality Indicators (Patient Satisfaction and Clinical Record Indicators) September – October 2008 v. Continuation of Training & Monitoring November – December 2008 v. Development of privileges & credentials for medical and nursing staff v. Completion of OT, labour ward renovation v. Committee meetings Jan- July 2009 v. Finalization of departmental manual & training to all the respective department staff v. Conducting different mock drills v. Review of statutory compliances v. Renovation of Laboratory , radiology department v. Closures of Non-Compliances identified during Pre-assessment v. Different codes identification v. Filing the application for Final Assessment August 2009 v. Second Internal Assessment v. Development and training based on our non compliance v. Final assessment completed and compliance submitted to QCI 12

Outcome

Journey of Quality Improvement (Cont)… 2 Years Back Today Lack of standards in public health services. Standards in public health services (for Hospitals, Labs, Blood bank & CHC / PHC) in place There was no any Gap analysis report in standards format. Gaps identified and addressed Lack of Statutory requirements (e. g. Licenses, Acts, Rules & Certificates). All Statutory requirements are fulfilled (e. g. Licenses, Acts, Rules& Certificates). Absence of written policies & procedures for healthcare delivery. Written policies & procedures for healthcare delivery in place. Poor sanitation and cleanliness in hospitals due. Hygienic Hospital environment Staff shortage in every category leading to patient dissatisfaction Recruitment of staff as per workload through RKS. Need for trained health care staff for emergency (resuscitation) services. All critical staff trained in Basic Life Support and Advanced Cardiac Life Support

Journey of Quality Improvement (Cont)… 2 Years Back Today Inadequate infrastructure for handling biomedical waste and infection control safety practices All required practices in place Damaged and poor condition of the building and campus Repairing & renovation done No Calibration system of Instruments for Quality check are available. No blood bank / storage facility in some hospitals. All hospitals have blood bank / storage facility in as per need Shortage of equipments and proper ambulances to meet the scope of our hospital Sufficient equipments and ambulances are now available Lack of accountability & planning in delivery of care to patients. Policy and processes for care of the patients in place Absence of quality standards such as medical audit, management of medication, care of patient, facility management and safety, information management system & infection control. Quality standards e. g. medical audit, management of medication, care of patients etc practiced

Journey of Quality Improvement 2 Years Back Today Poor signage system in public hospitals. Well developed signage and displays for patient information Absence of Patient & Employees’ satisfaction monitoring system. Established No measurable parameter for patient safety. Measurable parameters for patient safety are available. No realization of our problems and weaknesses A clear understanding of what is lacking and what needs to be done No monitoring or reporting of adverse events, needle stick injury, Sentinel events etc. These are being reported and are monitored on an ongoing basis Practically non-existing security arrangement Availability of well trained security guards No Implementation of Different Codes in the facilities. RED for FIRE, YELLOW for EXTERNAL CALAMITIES, BLUE for CARDIAC ARREST, BLACK for BOMB THREAT, PINK for CHILD ABDUCTION

90 40 20 20 50 0 0 Information Management Systems (IMS) Facility Management & Safety (FMS) Responsibilities of Management (ROM) Continuous Quality Improvement (CQI) Hospital Infection Control (HIC) Patients Rights and Education (PRE) Care of Patients (COP) Access, Assessment and Continuity of Care (AAC) District Hospital Gandhinagar Human Resource Management (HRM) Average Scoring in % (Aug. 09) Average Scoring in % (Aug 07) Average Scoring in % (Aug. 09) Management of Medications (MOM) Average Scoring in % (Aug 07) 0 10 10 50 60 44 30 17 30 46. 3 47. 6 50 40 55. 3 70 50 57 60 85 80 80 69 70 97 90 100 90 80 95 91 95 100 87 91 94 Health Care Organization Management Standards Patient-Centered Standards

PHC GADBORIAD NABH ASSESSMENT SCORE 10. 00 9. 33 9. 30 9. 45 9. 17 9. 00 8. 00 7. 00 6. 00 5. 00 4. 47 4. 75 4. 72 4. 46 3. 92 4. 00 3. 00 2. 00 1. 00 0. 00 INFRASTRUCTURE TOTAL SCORE: PROCESS TOTAL SCORE GOVERNANCE TOTAL OUTCOME TOTAL SCORE: Before SCORE: After GRAND TOTAL

Journey for NABH & NABL , Govt. of Gujarat, India 1 st Phase (2007 -2008) 2 nd Phase (2008 -2009) 3 rd Phase (2009 -2010) District Hospital Rajpipla. District Hospital Godhara District Hospital Valsad District Hospital Kutchch District Hospital Sola District Hospital Gandhinagar District Hospital Mehsana District Hospital Junagadh. Medical College Hospital Rajkot District Hospital Surendranagar District Hospital Porbander District Hospital Petlad District Hospital Nadiad District Hospital Navsari District Hospital Amreli District Hospital Himatnagar Jamana Bai Hospital Baroda Medical College Hospital Surat Medical College Hospital Jamnagar Medical College Hospital Bhavnagar Medical College Hospital Ahmedabad District Hospital Dahod District Hospital Kheda District Hospital Patan District Hospital Morvi District Hospital Limdi District Hospital Ahwa –Dang District Hospital Bharuch District Hospital Jhambhaliya Old Civil Hospital Surat ( All Phase-1 Hospitals: Pre assessment Completed, District Hospital Junagadh, Rajpipla & Gandhinagar -Final assessment Completed & Medical College Rajkot-Pre assessment due) (Base line study in process) (Documentation is complete. Implementation and Training as per Base line study in process) Note: FDCL Laboratory is accredited All Six Medical College Laboratories are taken for NABL e. g. Surat, Jamnagar, Bhavnagar, Rajkot, Baroda & Ahmedabad in 1 st Phase (year 2007 -2008). (Bhavnagar Final Assessment completed 18 -19 July 2009) All Mental Hospitals e. g. Ahmedabad, Jamnagar are taken in 2 nd phase year 2008 -2009. All Dental Hospitals e. g. Ahmedabad and Jamnagar in 2 nd phase year 2008 -2009. Paraplegia Hospital Ahmedabad in 2 nd phase year 2008 -2009. 47 CHCs & 170 PHCs in (2009 -2010) (PHC Gadboriad Final assessment Completed on 10 th Aug. 2009)

Benefits to Patients: ØHigh quality of care ØCredentialed and privileged medical staff ØAccess to a quality focused organization ØRights are respected and protected ØUnderstandable education and communication ØPatient Satisfaction is evaluated ØInvolvement in care decisions and care process ØFocus on patient safety ØPain management ØVulnerable patient ØSafe transport ØContinuity of care

Benefits to Staff Ø Improves professional staff development Ø Provides education on consensus standards Ø Provides leadership for quality improvement within medicine and nursing Ø Increases satisfaction with continuous learning, good working environment, leadership and ownership

Employees Satisfaction 100 90 100 You know your duties & responsibilities 90 83 80 80 70 70 60 60 50 50 40 40 30 30 76 21 18 20 You are assigned the job as per your knowledge and capability. 20 10 10 3 0 0 0 Highly Satisfied Average Dissatisfied Note: This Indicator was not monitored before NABH

Benefits to Hospital Ø Improves care Ø Brings in Corporate Governance Ø Stimulates continuous improvement Ø Demonstrates commitment to quality care Ø Raises community confidence Ø Opportunity to benchmark with the best

Road Ahead Ø To get all the Medical Colleges, District Hospitals, Blood Banks, Laboratories, PHCs & CHCs across the state accredited by NABH/ NABL.

Challenges Ø Financial Management. (Average Additional Expenditure for NABH about Rs. 3 to 4 Crores per District Hospital) Ø Human resource Management. (e. g. in Gandhinagar requirement of staff nurses as per workload (120) against sanction post (only 57). ) Acceptance specially in Doctors e. g. Medical Audit, Clinical audit etc. Ø Old and heritage building of the hospitals. Ø Up gradation of the hospitals from small facility to large facility. Ø Increase workload so that increase bed occupancy rate (150). Ø

Challenges Cont… Ø Ø Ø Reluctance to understand the NABH Standards and its implementation Staff orientation to Policies and Procedures at Departmental level. Repeated Training to contractual staff (Due to Highly Attrition Rate) L 1 policy of Government High consumption of power after central A/C. (5 -10 times) Lack of proper monitoring system and team building. 27

Connecting Further…. Health & Family Welfare Department, Govt. of Gujarat http: //www. gujhealth. gov. in Mukesh Puri IAS – Mission Director, purimukesh@hotmail. com National Rural Health, Govt. of Gujarat , Gandhinagar Mob: +919978408088 Quality is a journey, not a destination….