A Guideline for Quality Accreditation in Hospitals

Leaders of quality assurance programs must be able to generate interest and commitment without burdening clinical and administrative staff with an activity they neither understand nor believe in.

Hospital accreditation has been defined as “A self-assessment and external peer assessment process used by health care organizations to accurately assess their level of performance in relation to established standards and to implement ways to continuously improve.” Hospital quality assurance systems are operational control systems intended to fulfill specific expectations for treating patients.

Clinicians have customarily enjoyed a great deal of autonomy in their practices. The mechanisms for monitoring and assuring quality of the care provided have tended to be based on internal peer review. Time, however, has torn away much of the curtain of professional mystique. The changing health care environment with revised hospital accreditation guidelines have sharpened the clinical and administrative hospital staff’s concern for evaluating the quality of care they provide. Clinicians now see accreditation standards as a framework by which organizational processes will be improved and their patients will receive better care. Physicians and administrators now must face the challenge of establishing comprehensive and vigorous systems of quality assurance and learn to avoid the traps that impede implementation of such systems. Quality assurance is a very simple process that deals with finding problems and fixing them.

A comprehensive definition of quality health care would be, “The optimal achievable result for each patient, the avoidance of physician-induced (iatrogenic) complications, and attention to patient and family needs in a manner that is both cost effective and reasonably documented.”

Importance of accreditation in hospitals

Accredited hospitals offer higher quality of care to their patients. Accreditation also provides a competitive advantage in the health care industry and strengthens community confidence in the quality and safety of care, treatment, and services. Overall it improves risk management and risk reduction and helps organize and strengthen patient safety efforts and creates a culture of patient safety. Not only does it enhance recruitment and staff education and development, it also assesses all aspects of management and provides education on good practices to improve business operations. International accreditation such as that from the Joint Commission International (JCI), a nonprofit organization that is part of The Joint Commission on Accreditation of Healthcare Organizations—aka JCAHO or The Joint Commission—and founded in the late 1990s to survey hospitals outside of the United States, creates a mark on the world map and increases business through medical tourism.

Few quality accreditation programs for hospitals

There are several quality standards, however, there are few to which hospitals are commonly accredited. There is accreditation by the JCI, and accreditation to the standard from the National Accreditation Board for Hospitals and Healthcare providers (NABH)—part of the Quality Council of India. There is also compliance to the Baldrige Criteria for Performance Excellence and registration to ISO 9001—“Quality management systems—Requirements,” from the International Organization for Standardization (ISO). Also, there is more departmental-specific accreditation such as from the National Accreditation Board for Testing and Calibration Laboratories (NABL).

Difference between the accreditation standards

The ISO 9001 standard is more process driven and is better for back-end departments, such as accounting, human resources, etc., while NABH and JCI are clinically-oriented standards that directly affect patient care.

Accreditation standards (NABH and JCI): Patient-centered standards—functions related to providing patient care

• Access to care and continuity of care—access, assessment, and continuity of care
• Patient and family rights—patient rights and education
• Patient and family education
• Assessment of patients—management of medication
• Care of patients

Health care organization and management standards: Functions related to providing a safe, effective, and well-managed organization

• Quality improvement and patient safety—continuous quality improvement
• Prevention and control of infection—hospital infection control
• Governance, leadership, and direction—responsibilities of management
• Facility management and safety
• Staff qualifications and education—human resource management
• Management of information—information management system

The accreditation process

Begin with accreditation process by education: Educate the leaders and the managers and explain the benefits, advantages, process, timeline, etc., of the accreditation

Baseline assessment: Use knowledgeable and credible evaluators (either internal or external consultants) who will critically and objectively assess each area and conduct a detailed baseline assessment of the organization’s current adherence to the standards and each measurable element. Score as “Met,” “Partially Met,” or “Not Met” and cite specific findings and recommendations. Also collect and analyze baseline quality data as required by the quality monitoring standards (e.g., medication errors, hospital-associated infection rates, antibiotic usage, surgical complications, etc.) Establish an ongoing monitoring system for data collection (e.g., monthly, with quarterly data analysis) to identify problem areas and track progress in improvement.

Action planning: Using the findings of the baseline assessment, develop a detailed project plan starting first with priority areas of the core standards. Responsibilities, deliverables, and time frames should be assigned (e.g., revise informed consent policy, develop a new informed consent statement, educate staff in the next two-month time period.)

Chapter assignment: Look for good people skills, time-management skills, and consensus-building skills, and assign oversight of each chapter of standards to a respected champion or leader who will identify team members from throughout the hospital and carry out the process.

Policies and procedures: In addition to an overall project plan, it is often helpful to compile a list of all required policies and procedures that will need development and revision. Continue to monitor your progress in meeting the standards, such as through a mini-evaluation of each chapter at regular intervals (e.g., quarterly).

Final mock survey: Plan for a final “mock survey ” at least four to six months in advance of the target date of the actual accreditation survey. Use evaluators (internal or external consultants) who were not involved in the baseline assessment and preparation, who will look at the organization with a fresh and objective eye. Plan final revisions and corrections based on the findings of the final mock survey.

Final survey

The success of any quality assurance program depends almost entirely on the commitment and interest of the administrators, nurses, paramedical staff, and physicians. Leaders of quality assurance programs must be able to generate interest and commitment without burdening clinical and administrative staff with an activity they neither understand nor believe in. This will help move quality assurance out of its current paralysis in some hospitals. Quality assurance is to succeed in its goal to identify and correct problems and to improve the quality of patient care.

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