Presented by LT COL DR PRATIMA SINGHQCI and

Presented by LT COL (DR) PRATIMA SINGHQCI and NABH CERTIFIED CONSULTANT

QCI/NABH CGHS STATE GOVT ECHS Insurance Company TPA Medical tourism Medicolegal Clinical est. act corporate

QCI NABH/NABL /NABET Institutional member of ISQua Appeals committee Accreditation committee Technical committee std for hco/shco/dental/m is/blood bank/phc Secretariat Panel of experts/assessors

� REGISTRATION HOSPITAL � POLLUTION CONTROL DEPT-WATER/AIR/SOUND � BMW MANAGEMENT � AERB –RADIOLOGY � USG REGISTRATION AND TRACKER SONOGRAPHY � PHARMACY LICENSE � LIFT LICENSE � NARCOTIC DRUG LICENSE � CANTEEN LICENSE � SPIRIT � DIESAL STORAGE � COMPRESSED GASES � FIRE SAFETY

Front office managment Emergency registration Documentation Transfer admission transfer opd mgt Codes Disaster trg Lab X ray/usg Sample collection • Legal mandatory • Records • Quality control • Radiation safety • Documentatio n /forms/report ing/ • Quality assurance • Equipment /inventory mgt Processing Reporting Outsourcing Urgent report Internal quality External quality Documentation /forms/records/ • Equipment and inventory mgt

Icu Equipment Staff Medicines Bmw SOP/Protocols Documentations Infection control OT Anesthesia Surgery Consent Surgical safety checklist PAC Post op care High risk cases mgt SOP/Protocol Equipment Staff Material mgt Bmw/infection control documentaion Emergency services Gynae/obs Paed Ambulance Blood transfusion

Pharmacy • License • Narcotic drugs • First in first out • Procurement • Storage • Dispensing • Documentation Opd/icu/ot/emergency Drugs doccumentaion 7 Rs of drug admin Reduce medication errors High risk drugs mgt Indent/store/dispense medicine safely

PATIENT RIGHTS PATIENTS RESP CONSENT INFORMED DECISION MAKING HIGH RISK COUNSELLING

Infection control manual Infection control commiitee • Staff/patient • Attendent • HAI • Infection control surveillance BMW/sterilization Disinfection Housekeeping Equipment disinfection CSSD OT/ICU/Emergency

Quality commitee • Other hospital commiitees Quality indicators Quality manual Procedures Sops records All dept Audit

Management commitee • Finance • Policy Management review meeting • All committees review Quality policy Ethics Safety pts and staff

Safety commitee • Safety of staff patients. attendents • visitors Disaster Fire Water Elect Gas Vaccum Radiation Equipment safety

Staff recruitment • Personnel file • Medical exam • documentation Training retention • Regular training • Assessments • competency Employee rights and resp • Grievance • Disciplinary

Med record Safety confidentiality completeness • Mrd commiitee • Med audit Medicolegal aspect Insurance companies/tpa Death cases LAMA cases Transfer cases Document check

MINIMUM LEVEL • PREACCREDITATION • ENTRY LEVEL CONTINUAL PROGRESSION • PREACCREDITATION • PROGRESSIVE LEVEL OPTIMUM LEVEL • FULL CERTIFICATION

1 • COPY OF STANDARDS FORM NABH SECT • GAP ANALYSIS WRT STANDARDS AND CLOSURE OF GAPS 2 • SELF ASSESSMENT WRT STANDARDS • QUALITY DOCUMENTATION COMPLETION 3 • APPLICATION TO NABH +FEES +DOCUMENTS • SELF ASSESSMENT TOOLKIT 4 • SCRUTINY APPLICATION BY NABH • CHECKING READINESS OF HCO AND DOCUMENT REVIEW 5 • ASSESSMENT BY NABH ASSESSORS • NON CONFORMANCE TO STANDARDS AND REVIEW 6 • CLOSURE OF NC RAISED BY ASSESSOR • ACCEPTANCE BY NABH ACCREDITATION COMMIITTEE • GRANT OF PREACCREDITATION STATUS ENTRY LEVEL 7

� Valid 2 years � 6 monthly report indicators to NABH � Renewal/progressive level/full accreditation

THINK , DREAM, BELIEVE IN BEST PRACTICES Lets move together !! THANK YOU