Identifying Opportunities for Improvement Using Accreditation Standards in a Public Sector Ophthalmichospital in India
Background: Quality of healthcare services, patient safety and staff satisfaction the essence of accreditation,
are indispensable to favourable patient outcomes. This study aimed at identifying opportunities for
improvement based on extent of conformance to existing applicable accreditation standards.
Method: A cross-sectional observational study was conducted in an apex public sector ophthalmic
hospital in India during March and April 2016. Opportunities for improvement identified based on extent
of compliance to accreditation standards as per criteria laid in NABH self-assessment toolkit. Reviews
of hospital departments, services and functions were done through document review; visit to different
patient care areas; staff and patient interviews were conducted. A sample of ten observations was taken
for each objective element from same or different areas based on applicability and scored as full, partial or
non-compliant (0, 5, 10 respectively).Gaps were identified based on score less than 50% of aggregate or
individual standard with more than two zeros.
Results: Hospital was compliant to accreditation standards of NABH with an overall score of 74%. All
regulatory requirements met. Opportunities for improvement identified were related to quality assurance
of labs, cardio-pulmonary resuscitation, pain assessment, awareness and reporting of medication errors,
redressal mechanism, effective implementation of patient safety and quality improvement programmes.
Continuous quality improvement chapter had lowest compliance (39%).
Conclusion: The hospital met accreditation requirements except those related to documentation and
continuous quality improvement (an advanced stage of accreditation) amongst few others which are
predominantly specifically oriented to accreditation related activities. The study delineates how the identified
opportunities can be met based on interpretation of the standards. The study is limited by the fact that
documentation in the form of circulars and a Residents’ Manual which are not as per the requirements of
NABH have been considered.