Importance of Accreditation for Lions Eye Hospitals

P. K. RoyChairman,

Lions Seva Eye Hospital

Importance of Accreditation for Lions Eye Hospitals• Lions Eye Hospitals mostly engaged in

Free cataract Surgery• Economy of the hospitals dependent on

Cataract Surgery re-imbursement grant by LCIF or DBCS

• LCIF stopped financing against cataract surgery and DBCS funding is uncertain

• Economy of the Lions Eye Hospitals are at stake.

ThreatsA good number of Private hospitals have started operation recently posing threats to Lions Eye Hospitals

Technical Infrastructure of the Pvt. Hospitals are better than Lions Eye Hospitals.

Pvt. Hospitals have provided better service.

ThreatsPriority of these Pvt. hospitals are patient satisfaction.

Professional approach and corporate style of functioning develop patient confidence.

But the cost of service of Pvt. Hospitals are much higher than Lions Eye Hospitals

Steps necessary for Lions Eye HospitalsLions Eye Hospitals has to find out avenues to overcome these imminent threats.

Measures need to be taken:i) Improve technical infrastructure

for attracting patientsii) Improve quality of service to

develop confidence of the patient

Steps necessary for Lions Eye Hospitals

iii. Attract patients(other than free) who are agree to pay the cost of service.

iv. Utilize the low overhead cost and comparatively cheap price of service in Lions Hospitals.

v. To compete with Pvt. Hospitals and for sustainable growth Lions Eye Hospitals has to go for Accreditation

What is Accreditation Accreditation means Certification of competence in a specified subject or areas of expertise by external agencies. Accreditation is an external review of quality .There are four principal component It is based on written and published standards Reviews are conducted by professional peers The accreditation process is administered by

an independent body The aim of accreditation is to encourage

organizational development.

Focus of standards

Patient Safety

Staff and employee safety

Environment and community safety

Information Education and

Communication

Patient Centered StandardsSection I

Access, Assessment and Continuity of Care

Patients Rights and Education

Care of Patients

Management of Medications Hospital Infection Control

Health Care Organization Management Standard, Section - II

Continuous Quality Improvement (CQI)

Responsibilities of Management (ROM)

Facility Management & Safety (FMS)

Human Resource Management (HRM)

Information Management Systems (IMS)

Accreditation - Procedure

First step : Self-evaluation by unit seeking accreditation

Second step : External evaluation / on-site visit by independent experts

Third step : Decision, based on assessment of predetermined quality standards

WHO CAN APPLYAny Health Care Organization

RequirementsCurrently in operation as a HCOPreferably registered or licensedWilling to assume responsibility for

improving quality of careShould be able to meet the prescribed

standards of the accrediting organization

HOW CAN ONE APPLYBasic Ingredients

Organizations apply on prescribed

format giving details as required

Submission of a self assessment form

indicating the outcomes of its own

survey and Internal Audits

Extent of adherence to the laid down

standards

WHERE TO APPLYSeveral quality accreditation agencies are available.These are :

i. Joint Commission International (JCI) is an International body working for maintaining standard in the HCO),

ii. National Accreditation Board for Hospitals (NABH), -a constituent board of Quality Council of India

iii. ISO 9001-2000- is an international quality management system

iv. Malcolm Baldridge, - Baldrige Program is dedicated to performance excellence.

The most common one being ISO and NABH.

DOCUMENT REVIEW• Quality Manual• Various Policies and Procedures• Minutes of Meetings of various

committees• Medical Records• Medical / Nursing Audit• Adverse Events• Action Taken Reports• Personal Records of Staff

Accreditation ProcessApplicationsScreening of the ApplicationsPre-assessment surveyAssessment SurveyReview of the recommendations of the

assessing body by the Accreditation Committee

Recommendations to the boardAccreditation decision

ACCREDITATION

These May Look Difficult ,

But Nothing Is Impossible

Impossible Means - I’ M Possible

ACCREDITATION IS A JOURNEY AND NOT A

DESTINATION.

T H A N K Y O UF o r y o u r

p a t i e n c e …