NABH / NABL - Health and Family Welfare Department

12 th April 2012
Dr J L Meena
State Quality Assurance Officer
Department of Health & FW
Govt. of Gujarat

AS A PATIENT WHAT QUALITY
LEVELS WOULD YOU ACCEPT
FROM YOUR HEALTH SERVICES?
90%
95%
98%
96%
99%
99.9%

IF 99.9% IS ACCEPTABLE TO YOU, THEN…
•YOUR HEART FAILS
TO BEAT 32,000
TIMES EACH YEAR
* 500 SURGICAL
OPERATIONS ARE
PERFORMED
WRONGLY
EVERY WEEK
* 20,000 WRONG
DRUG
PRESCRIPTIONS
MADE EVERY YEAR
* 19,000 BABIES ARE
DROPPED BY
DOCTORS
AT BIRTH

WELL …..
“ THERE IS ONLY A 1 %
DIFFERENCE IN THE DNA
GENETIC CODE BETWEEN A
CHIMPANZEE AND A
HUMAN BEING”

•IN OUR PROFESSION THERE IS NO SCOPE
FOR ERROR. FOR ANY ERROR COMMITTED
IS ALL THE DIFFERENCE BETWEEN
LIFE AND DEATH, BETWEEN RELIEF AND
DISABILITY
•THERE IS NO SECOND CHANCE
Then …..

Is Quality necessary ?

SAFETY ?
‣67% do NOT have a safety policy
‣92% do NOT have a safety programme
‣71% do NOT have a safety officer
‣88% do NOT have a written waste disposal
procedure
‣83% have fire extinguishers but only 8%
have fire drills (Mock drills)
As per Lab Survey report

Are you thinking Quality costly ?
• Yes Quality is a Costly affair,
but the cost of poor quality &
the loss of life due to poor
quality services are much more
than adopting quality services.
8

Are you Aware ?
15% of patient’s test report in a study
receive either incorrect or delayed
reports or abnormal results.
Boone DJ, IQLM, 2005

HOW TO ACHIEVE
EXCELLENCE IN HEALTH
TQM…….

GOAL
• To develop a healthcare system based on total
quality management principles (NABH / NABL) and
application of information technology to achieve
efficiency in operations, faster & standard
communication across the state.
• To enhance the quality of healthcare services by
providing specialized treatment and preventive
healthcare at free / affordable cost.
MISSION
VISIO
N
• To develop a pool of healthcare professionals in
the public health sector trained in the
implementation of health care quality standards
and information technology to bring productivity
and effectiveness in health care delivery system.
• “To be the network of finest Public Healthcare
Institutions which providing quality medical care
services, preventive, promotive, curative &
rehabilitative health care services with the state of
art technology, easy accessibility, affordability and
equity to the people of Gujarat and beyond.

NABH Standards for Hospitals
10 Chapters
100 Standards
514 Objective Elements
NABH Standards for PHCs/CHCs
4 Sections
38 Standards
238 Objective Elements
ISO 15189:2007 for NABL Laboratories.
NABH Standards for AYUSH Hospitals
S No. AYUSH Branch No. of Chapters No. of Standards No. of Objective
Elements
1 Ayurveda 10 94 489
2 Unani 10 94 491
3 Siddha 10 92 475
4 Homeopathy 10 87 435
5 Yoga & Naturopathy 9 51 229
(PHCs & CHCs NABH Standards have been made by Govt. of Gujarat with the support of Quality Council of India)

Government of Gujarat is the first state in India
which initiated for actively pursuing quality
improvements in the public healthcare facilities
through the network of Primary Health Centers
(PHCs), Community Health Centers (CHCs), District
Hospitals & Medical Colleges.
In order to institutionalize Quality Assurance, Gujarat
is the only state which has been set up the District
Quality Assurance cell, Regional Quality
Assurance Cell & State Quality Assurance cell
with regular officer.

Implementation of
safety and quality
practices
Incorporation of
management tools
PROJECT
OBJECTIVES
Building
sustainability
Continuous Quality
Improvement
Benchmarking the
indicators

Patient satisfaction
survey
Employee
satisfaction survey
PRACTICES
IMPLEMENTED
Clinical protocols
Code alerts
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
Implementation of
Patient Rights &
Responsibilities
Facility
Management
Practices
Management of
Medication

Incidence Reporting
System
Hospital Safety
Programme
PRACTICES
IMPLEMENTE
D Cont…
Patient Information
Quality Control &
Safety in diagnostics
Inventory
Management

Outcomes…..

Journey of Quality Improvement (Cont)…
4 Years Back Today
Lack of standards
No Gap analysis report in standard
format.
Lack of Statutory requirements (e.g.
Licenses, Acts, Rules & Certificates).
Absence of written policies &
procedures.
Poor sanitation and cleanliness.
Staff shortage.
Lack of trained health care staff for
emergency (resuscitation) services.
No concept of internal audit
NABH Standards for Hospitals, Blood
bank & CHC / PHC) & ISO 15189:2007 for
lab in place
Gaps identified and addressed
Statutory requirements fulfilled
Written policies & procedures available.
Hygienic Hospital environment
Recruitment of staff as per workload
through RKS.
Staff trained in Basic Life Support and
Advanced Cardiac Life Support
Staff trained as internal auditors, audits
conducted to find out non conformances,
corrective & preventive measures taken to
rectify it

Journey of Quality Improvement (Cont)…
4 Years Back Today
Inadequate infrastructure for handling
biomedical waste and infection control
safety practices
Damaged and poor condition of building
No Calibration system of Instruments for
Quality check
All required practices in place
Repairing & renovation done
Calibration system of Instruments for
Quality check are available.
No blood bank / storage facility in some
hospitals.
Shortage of equipments and proper
ambulances .
Lack of accountability & planning.
Absence of quality standards.
No participation in EQAS/ inter laboratory
comparisons
Hospitals have blood bank / storage
facility in as per need
Sufficient equipments and ambulances.
Policy and processes for care of the
patients in place
Quality standards e.g. medical audit,
management of medication, care of
patients etc practiced
Participation in EQAS / inter laboratory
comparison and achieving good scores in
it.

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

“Achievements”
India’s 1 st NABH / NABL Accredited Govt. Facilities:-
•Dist. General Hospital Gandhinagar
•Primary Health Centre Gadboriad, Dist: Vadodara
•Medical College Hospital Labs Bhavanagar
•Blood Bank (BJMC Ahmadabad)
•Food & Drug laboratory Badodara
•Mental Hospital, Vadodara
India’s 2 nd NABH / NABL Accredited Govt. Facilities:-
•Primary Health Centre Mahuwas, Dist: Navsari
•Govt. Medical College lab (BJMC Ahmadabad)
•Civil Hospital Sola, Ahmedabad (Progressive)
•Blood Bank, Medical College Surat

“Achievements”
Other NABH / NABL Accredited Govt. Facilities:-
•Primary Health Centre Salun, Dist: Kheda
•Primary Health Centre Sokhada, Dist: Vadodara
•Primary Health Centre Jetalpur, Dist: Ahmedabad
•Blood Bank, Medical College Bhavnagar
•Blood Bank, Medical College Vadodara
•Primary Health Centre Dabhoda, Dist: Gandhinagar
•Food & Drug laboratory Kutch
•Blood Bank, Medical College Jamnagar
•Mental Hospital, Ahmedabad
•Medical College Laboratory Surat

Category wise Status of Accredited Institutes
Sr.
No
.
Type of Accreditation
(NABH / NABL)
Total No of
Accreditation
Remark
1 NABH District Hospital 2 NABH
2 NABH Blood Bank 5 NABH
3 NABH CHCs and PHCs 6 NABH
4 NABL Hospital Laboratory 3 NABL
5 NABL Food & Drug Laboratory 2 NABL
6 Hospital For Mental Health 2 NABH
Total 20

S.N
Name of the Facility
Total Facility
Under
NABH
/NABL
Total
Accredited
facilities
Final
Assessment
done
Pre Assessment
done
Facilities under
Process for
NABH/ NABL
1 District Hospitals 23 2 3 4 14
2
3
4
Medical college
Hospitals
Medical college,
Blood Banks
Medical college,
Laboratories
6 0 0 0 6
6 5 0 0 1
6 3 0 0 3
5 Mental Hospitals 2 2 0 0 0
6 Dental Hospitals 2 0 0 0 2
7
8
9
10
Category wise Status of Accredited Institutes
Paraplegia Hospital,
Ahmedabad
Primary Health
Centers (PHCs)
Community Health
Centers (CHCs)
NABL Food & Drug
Laboratories
1 0 0 1 0
29 6 2 4 17
26 0 0 0 26
2 2 0 2 0
Total 103 20 5 11 69

Patient-Centered Standards
Health Care Organization
Management Standards
100
90
80
70
60
50
40
30
20
10
0
57
90
Access, Assessment and Continuity of
Care (AAC)
44
Care of Patients (COP)
97
50
Management of Medications (MOM)
94
69
Patients Rights and Education (PRE)
91
17
Hospital Infection Control (HIC)
87
100
90
80
70
60
50
40
30
20
10
0
0
80
Continuous Quality Improvement
(CQI)
95
50 47.6
Responsibilities of Management
(ROM)
85
Facility Management & Safety
(FMS)
55.3
91
Human Resource Management
(HRM)
46.3
95
Information Management Systems
(IMS)
Average Scoring in % (Aug 07)
Average Scoring in % (Aug. 09)
Average Scoring in % (Aug 07)
Average Scoring in % (Aug. 09)
District Hospital Gandhinagar

PHC GADBORIAD NABH ASSESSMENT SCORE
10.00
10.00
9.30 9.33 9.17
9.45
9.00
8.00
7.00
6.00
5.00
4.00
4.47
4.75 4.72
3.92
4.46
3.00
2.00
1.00
0.00
Before
After

‣High quality of care
‣Dedicated and sincere medical staff
‣Access to a quality focused organization
‣Rights respected and protected
‣Patient Satisfaction evaluated
‣Involvement in care process
‣Patient safety
‣Pain management
‣Safe transport
‣Continuity of care

High Quality of Care cont…

Staff shall attend to any emergency at all times
beyond the normal OPD or working hours.

staff member should be available to provide
guidance or basic information to the patients and
their families.
Exchange a few words with the clients

High Quality of Care cont…

High Quality of Care cont…
ABC-VED Classification for
Management of Medicine

Provided baby
kits to new born to
prevent hypothermia

Crush Card trolley
contained:-
Comb, Toothpaste, Oil, Glas
s etc for save the pt. ?
Crush Card trolley
contained:- all life
saving drugs for save
the pt.

Proper Maintenance of
Medical Records
Implementation of Initial
Clinical Assessment

800
749
719
Deliveries
700
632
620
January to December
600
585
576
500
501
513
400
300
282
200
216
199
190
128
127
191
180
176
159
119
100
0
78
26
62
53
47
40
36
53
24
53
42
14
13
10
25
12
Gadboriad Mahuwas salun Jetalpur Sokhda Hadiyol Dabhoda
2007 2008 2009 2010 2011

January to December

January to December

BJMC Blood Bank Turn Around Time (Hours)
Turn Around Time (Hours)
3
3
January to December
2.5
2.3
2
1.5
1
1
0.5
0.45 0.45
0
2007 2008 2009 2010 2011

BJMC Blood Bank No. of Blood transfusion reactions
No. of Blood transfusion reactions
25
25
January to December
20
20
18
15
10
5
5 5
0
2007 2008 2009 2010 2011

January to December
BJMC, Blood Bank
100
90
80
70
60
70
60
80
80
85
85
90
90
92
99 98 98 99 98 98
50
40
30
20
10
0
2007 2008 2009 2010 2011
% of Blood donor satisfaction
% of Clinician Satisfaction
% of Blood product quality as per clinical Improvement of Patient

January to December
BJMC, Blood Bank
Total Blood Collection Issue of Components
60000
54316
50000
45100
40000
32151
32451
30000
20000
20572
20832
10000
0
2009 2010 2011

Adverse Donors Reaction B J Medical College Blood Bank
Ahmedabad
20
19
18
17
17
16
16
16
15
16
14
14
12
12
11
12
10
9
9
9
8
8
7
8
7
7
6
6
5
6
6
4
2
2
0
2009 2010

Average waiting time for discharge (hrs)
“District Hospital Himmatnagar”
January to December
3 2.8
2.5
2.3
2
1.9
2.1
1.7 1.7
2
1.5
1.5
1
0.5
0
2010 2011

Average Number of patient complaints per Month
“District Hospital Navsari”
200
180
January to December
185
177
160
140
139
152
128
136
122
120
100
92
80
60
40
20
0
1st Quarter 2nd Quarter 3rd Quarter 4th Quarter
2010 2011

Average Number of patient compliments per Month
“District Hospital Navsari”
January to December
250
219
200
158
168
157
180
159
150
129
132
100
50
0
1st Quarter 2nd Quarter 3rd Quarter 4th Quarter
2010 2011

DELIVERY SERVICES, PHC, SALUN (JAN-DEC)
600
513
585
500
400
MoU sign with QCI
on 7 th July 2007
300
282
200
100
37 45
70 73
86
0
2003 2004 2005 2006 2007 2008 2009 2010
No.of Delivaries

Sir T Bhavnagar Medical College Lab (Total test)
500000
455119
450000
400000
350000
300000
250000
200000
203883
278072
177407
209849
257022
341711
150000
108527
100000
50000
2071
9224
23099
29871
0
Biochemistry Microbiology Histopathology
2007 2008 2009 2010

B J Medical College Lab (Total test)
1800000
1600000
1529858
1703964
1708998
1400000
1200000
985966
1000000
800000
577636
675601
600000
400000
200000
156624
180213
189055
0
Biochemistry Histopathology Microbiology
2008 2009 2010

B J Medical College Lab (Jan – Dec)
% of Rejected Samples
3.5
3.0
3.0
2.9
2.5
2.0
2.2
2.1
1.9
1.5
1.5
1.3 1.3
1.2 1.2
1.1 1.1
1.0
0.5
0.0
Sample Rejection Rate 2010

1 st time Joint replacement surgery in Dist. Hospital Gandhinagar

surgery
Expect. Cost Rs. in
Thousand
Private
Our hospital
Knee
replacement
165 55
Hip replacement 215 65
arthroscopy 35 5
laparoscopy 45 3
Infertility
surgeries
30 1.5

Benefits to Staff
‣Professional staff development
‣Provides education on laid down
standards
‣Provides leadership for quality
improvement within medicine and nursing
‣Increases satisfaction with continuous
learning, good working
environment, leadership and ownership

Continuous Learning

NABH ACCREDITATION AWARD FUNCTION BY
GOVT. OF GUJARAT & QCI, NEW DELHI

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

Changing

Changing

After

All the Services provided by PHC Gadboriad are
displayed in all the villages & roadside

Food Trolley

CSSD With Proper
Zoning

End of Life
care ?
Well Maintain
PM Room

Before
After
After
Laboratory
After

After
After

Maternity Ward

Admin block

After
Before

Before
After

After
Before

After
Before

Before
After

Before
After

After

After

After

After

After

After

After

After

After

After

After

After

After

After

After

After

After

After

After

After

After

After

After

After

After

After

After

After

After

After

After

After

After

After

After

Pharmacy

Documentation & MRD

Sinages

IEC

Utilization Rates & Key
Indicators Monitoring

NABH ACCREDITATION AWARD FUNCTION BY
GOVT. OF GUJARAT & QCI, NEW DELHI

NABH ACCREDITATION AWARD FUNCTION BY
GOVT. OF GUJARAT & QCI, NEW DELHI

Niziriya Team Visit
Visit by Rajasthan Govt.
MLAs with Speaker
WHO Team Visit

It has been a quality revolution which is a “rewarding experience”.
The National delegates (Teams from Rajasthan, Bihar, Delhi,
Madhya Pradesh, Kerala, Maharashtra, Chhattishghadh, Andhra Pradesh,
Orissa, Karnataka etc) and International delegates
(Nigeria, WHO, Ireland etc ) visited the organizations, observed
tremendous changes and have commendable remarks “which were
thought to be unattainable in public sector. thus setting up an
example for Health Care Organizations to deliver best health care
services to masses”.

Express Healthcare

Benefits to Community
‣Quality revolution
‣Disaster preparedness
- Epidemics
- Physical
‣Access to comparative database

Disaster Preparedness
Fire Safety Training

Benefits to the Government
‣Efficiency of Government hospitals as key
contributors for building trust and confidence for the
hospitals in the hearts of the citizens of the State
through actively pursuing quality improvement
programme in various facilities.
‣Given a sense of pride to the government for
ensuring quality services to the poorest of the poor.
Confidence has been restored of the community in
Govt hospitals

Award Ceremony
•Certificate of Appreciation awarded to Ministry of Health
and Family Welfare Government of Gujarat for
establishing Quality Assurance framework in providing
quality healthcare to the people of Gujarat in 5 th National
Quality Conclave, New Delhi
•Appreciation awarded to Department of Health and
Family Welfare Government of Gujarat for their
pioneering effort to spearhead the Quality and
Accreditation Programme in health care organization.
In 3 rd International Health Care Quality Conclave.
•FICCI Health care Excellence Award to
Dist Hospital Gandhinagar & PHC
Gadboriad, Govt of Gujarat

AWARD FOR
QIP

Strategies Adopted for sustainability:
‣Appointment of Quality Assurance officers at State level, District
level, Assistant Hospital Administrator (AHA) at facility level. We are designated
NABH Coordinators & NABL Directors at Facility level.
‣NABH lead assessor training (Total trained persons 290 for hospitals & PHC /
CHC) & NABL Internal audit training (Total trained persons231) to
administrators, clinicians, paramedical & staff nurses etc.
‣Quality Improvement Programme (NABH, BMW, Kaizen, HOPE, fire & Non fire
emergency, Radiation Safety, Cleanliness) Training Total 114 to
administrators, clinicians & staff nurses etc.
‣Distance learning Post Graduation Certificate Course in Quality Management
and Accreditation of Health care Organization (PGQM & AHO) to the Additional
Directors, Superintendents, Chief District Medical Officers, Clinicians and
District Quality Assurance Officers (Total trained persons186) etc.
‣New posts of clinicians, paramedical and other are sanction by Government
of Gujarat as per requirement.
‣Extra budget as per requirement of NABH / NABL are sanction from 13 th
finance commission, Government of Gujarat and NRHM.
‣Other training as per requirement of NABH / NABL standards and mock drills
are being conducted on regular basis.
‣Formation of the state level review committee under the Chairmanship of
Commissioner of Health, Medical Service & Medical Education and Member
secretary is State Quality Assurance Officer.

Road Ahead
‣To get the Medical Colleges, District
Hospitals, Blood Banks, Laboratories, PHCs
& CHCs across the State accredited by
NABH/ NABL in a phased manner.

Challenges
•Acceptance (not for speak but for implementation of the quality) e.g. Hospital infection,
Sentinel event, Medical Audit & Clinical audit etc.
•Human resource Management.
•Financial Management (Adequate & on time).
•Old and heritage building of the hospitals.
•Up gradation of the hospitals from small facility to large facility.
•Increase workload so that increase bed occupancy rate (150).
•L 1 policy of Government
•High consumption of light after central A/C. (5-10 times)
•Lack of proper monitoring system and team building.
•Measurement of the quality in quantity.
•Chalta hain, Jugad etc.
•Depend on the person rather then system.
•Short term achievement.
•Take New initiative (New leader always think new but poor focused on previous
programme)