Hospital Accreditation Documentation Process

1. Hospital Accreditation Documentation Process & Standard Requirements www.certificationconsultancy.com

2. What is Hospital Accreditation? • Accreditation is a voluntary process. Its standards are usually regarded as optimal and achievable. • It provides a visible commitment by an organization to improve the quality of patient care, to ensure a safe environment and to continually work to reduce risks to patients and staff. • Accreditation has gained worldwide attention as an effective quality evaluation and management tool. • The focus of accreditation is on continuous improvement in the organizational and clinical performance of health services, not just the achievement of a certificate or award or merely assuring compliance with minimum acceptable standards. • Accreditation focuses on learning, self development, improved performance and reducing risk. www.certificationconsultancy.com

3. Why Hospital Accreditation? • Ensures a Quality Index for Health Consumers. A growing number of hospitals in India are turning to accreditation agencies worldwide to both standardize their protocols and project their international quality of health care delivery.  • It is a Public Recognition of the achievement of accreditation standards by a healthcare organization, demonstrated through an independent external peer assessment of that organization's level of performance in relation to the standards. • Attract foreign patients. • The process of accreditation is envisaged to result in a process of fundamental change in the technical procedures of service delivery, in the appropriate use of available technologies, in the integration of relevant knowledge, in the way the resources are used, and in the efforts to ensure social participation. • Quality Assurance helps improve effectiveness, efficiency and in cost containment, and accountability and the need to reduce errors and increase safety in the system. www.certificationconsultancy.com

4. Requirements of NABH Accreditation • The general and technical NABH accreditation requirements that any organization must follow while implementation of NABH system to achieve best results and quick NABH certification. • Access, Assessment and continuity of care. • Patient Right and Education. • Care of Patients. • Management of Medication. • Hospital Infection Control. • Continuous Quality Improvement. • Responsibility of Management. • Facility Management and Safety. • Human Resource Management • Information Management System. www.certificationconsultancy.com

5. Advantages of Hospital Accreditation • Key advantages that organization can achieve with implementation of accreditation system in any hospitals and healthcare units. • Patients are benefited with Accreditation most. • Accreditation results in high quality of care and patient safety. The patients get services by credential medical staff • Rights of patients are respected and protected • Patient satisfaction can be evaluated. • The staff are satisfied lot as it provides for continuous learning • Accreditation to a health care organization stimulates continuous improvement. • It enables the organization in demonstrating commitment to quality care. • It also provides opportunity to healthcare unit to benchmark with the best. • Accreditation provides access to reliable and certified information on facilities, infrastructure and level of care. www.certificationconsultancy.com

6. Documents Requirements for Hospital Accreditation • The key sections of Hospital Accreditation set out a range of documents requirements for developing, implementing and maintaining a hospital and medical laboratory in Quality management system tailored to the design and production of hospital devices. • Sample hospital Manual • Hospital Mandatory Procedures • Exhibits and Standard Operating Procedures • System Sample Forms • Audit Checklists www.certificationconsultancy.com

7. Total Hospital Accreditation Documents by Global Certification Consultancy The Hospital Accreditation documents by Certificationconsultancy.comare very useful for hospitals in designing quick documentation for hospital NABH accreditation. This document includes hospital manual, procedures, exhibits, formats and audit checklist are very helpful of upgraded and implements QMS System and easy way of NABH certification. This document are written in English and easily editable, which saves much time. Click to Download Free Sample Documents www.certificationconsultancy.com

8. Hospital Manual The Hospital manual is a mandatory documents for NABH accreditation certification, which maintain quality system in hospital and medical lab and research center. This manual documents describes scope of services, hospital policy and mission, applicable law and regulation, quality policy and organization structure. The hospital manual shall outline the structure of the documentation used in the quality management system your organization. www.certificationconsultancy.com

9. Hospital System Procedures The Hospital system procedures are designed to help the organization in developing effective system procedures for make the best system and quick process improvements. All required system procedures list below: Procedure for hazards identification and risk assessment Procedure for identification of legal and other requirements Procedure for objectives and targets Procedure for OHSMP Procedure for consultation and communication Procedure for operational control Procedure for emergency preparedness and response Procedure for performance monitoring and measurement Procedure for incident investigation, non–conformity, corrective action and preventive action • Procedure for control of non–conforming services • Procedure for management review • Procedure for document and data control • Procedure for corrective and preventive action • Procedure for control of quality records • Procedure for internal audit • Procedure for control of monitoring and measuring equipments • Procedure for Training www.certificationconsultancy.com

10. Hospital Exhibits The exhibits and SOPs are very helpful tool to teach all employees and staff about how to implements and improvements of Quality management system in Hospital that helps organization to continues improvements and get number of benefits. Following list of Exhibits will be given along with documents. • Billing Section Activity • CATH Laboratory • Patient Service • ECHO, ECG And Trade mill testing(TMT) Laboratory • Maintenance • Training • Linen Activity • Marketing • Medical Shop • Microbiology Laboratory • Nursing Station • Pathology Laboratory • Purchase • Stores Process Flow • Utility • X Ray And Sonography Laboratory www.certificationconsultancy.com

11. Hospital Accreditation Sample Forms The sample formats documents are not compulsory to follow organization, but this documents very helpful of maintain records as well as establish control and make quality system in the organization. List of sample formats below: • Sanitation audit report • Pest control report • Fumigation report • Operation theatre readiness form • Toilet Cleaning record • Daily Equipment Cleaning record • Suggestion Card • Patient Complaint Report • Inquiry Monitoring record • Near Miss Report and more… www.certificationconsultancy.com

12. Hospital Accreditation SOPs The Hospital SOPs are given to help to any significant aspects issues and used as a training guide as well as to establish control and make system in the organization. Following list of Sample Hospital SOPs below: • Access assessment and continuity of care • Care of Patient • Continuous Quality Improvement • General • Management of Medicine • Patient rights and Education www.certificationconsultancy.com

13. Hospital System Audit Checklist The hospital system checklist is a good tool for the auditor to make audit question to make effective hospital accreditation internal audit for their organization. There are audit questions based on NABH accreditation clause wise and department wise requirements are included in the total documentation kit for Hospital Accreditation System. www.certificationconsultancy.com

14. Benefits of Using Hospital Accreditation Documents • By using these documents, you can save a lot of your precious time while preparing your hospital to the NABH accreditation. • Take care for all the section and sub sections of NABH guidelines and helps you in establishing better system • Document kit enables you to change the contents and print as many copies as you need. The user can modify the documents as per their industry and create own NABH documents for their organization • Readymade templates and sample documents are available which can reduce your time in document preparation • Save much time and cost in document preparation • The audit questions helps in making perfect audit checklist • You will get better control in your system due to our proven formats and templates • This document kit is very much useful to the users to make the world class hospital and establish good system and discipline with work force from the beginning www.certificationconsultancy.com

15. Thank You for Attending Presentation on Hospital Accreditation Documentation Process For More information write us at : sales@certificationconsultancy.com www.certificationconsultancy.com