A NABH Accredited Hospital

Dr L H Hiranandani Hospital
Your family hospital TM

To be the preferred choice for healing and good health

A NABH Accredited Hospital

Making accreditation a tool for continuous quality improvement May 27, 2011

A NABH Accredited Hospital

Structure of Presentation

Introduction Accreditation & Quality The Impact Th I t Conclusion

A NABH Accredited Hospital

Introduction
Dr L H Hiranandani Hospital The challenge was service and quality Service S i = including soft skills training t i i

Quality To render this more elaborate arrangements necessary Processes Training on the process g p Testing

A NABH Accredited Hospital

Introduction

Our Quality policy We are committed to rendering the best available medical treatment to our patients. Therapy patients. will be evidence based and will emulate global standards in every sphere. We will strive to improve the quality of sphere. care at every given time, thus ensuring patient satisfaction Accreditation Authorization

A NABH Accredited Hospital

Accreditation & Quality Q y

Training without testing did not yield results
Testing need to be phase implemented

ISO certification Practice what you preach certification

Helped clean up our act Gave the organization processes to follow Staff were now getting used to processes In 12 months we were ready for the next step

A NABH Accredited Hospital

Accreditation & Quality

Testing time had come g NABH v/s JCI NABH Was the unanimous choice (Indiaaa .. India). India).

Accreditation important to have the organization willing to measure itself against national standards

A NABH Accredited Hospital

Impact - Milestones
ISO Certification and NABCB Accreditation November 29, 2006 29,

A NABH Accredited Hospital

Impact - Mil t I t Milestones

NABH Accreditation September 17, 2007

A NABH Accredited Hospital

Impact - Milestones
NABL January 05, 2011

A NABH Accredited Hospital

Impact - Milestones
NABH Reaccreditation September 14, 2010

NABH reaccreditation Date picture of both

A NABH Accredited Hospital

Impact - Overall
Repetitive t R titi nature of complaints d f l i t decreased d Accountability increased Many processes in the hospital got updated yp p g p Nursing Critical care Training sessions increased Hospital occupancy increased

A NABH Accredited Hospital

Impact - Clinical
Clinical Cli i l parameters were established t t bli h d Nurse assessment protocols were established. Errors focused established. upon Nutrition assessment protocols were established Drug safety focus increased manifold Infection control protocols were redefined ere

Impact - Clinical

A NABH Accredited Hospital

The patient safety protocols re written

were

Hospital infection control protocols were reevaluated l t d Antibiotic policy was accepted by all even the Icons who had for years had eminence based practice Overall patient care was more streamlined Patient safety increased and satisfaction

A NABH Accredited Hospital

Impact - Management
The team is organization aware that processes drive the

It triggers the need for a mind set change To understand and follow the process It ensures that a mechanism is in place that can help p pick up mistakes and help take corrective action p p A reporting mechanism gets set and the escalation of issues is defined

A NABH Accredited Hospital

Impact - Management
Role and responsibilities of the management team are fine tuned The concept of internal audit is very acceptable not only by the administration but all Good documentation stands in good stead especially in litigation related issues g The organization is also sensitized to functional appraisals

A NABH Accredited Hospital

Impact - Support Services InIn house services I -h i

Preventive maintenance schedules are adhered to that helps in h l i equipment efficiency i t ffi i Optimal supply chain Good inventory control Improved safety through operational readiness and constant checks (Fire fighting equipment, DG sets water quality from supply source) The need for constant training

A NABH Accredited Hospital

Impact - Support Services

Out sourced services Enhanced knowledge base (customized training) Sense of ownership Enhanced pride especially in house keeping and related services Creation of a specialized task force e.g Security Audit of agency facility to ensure they maintain standards as prescribed Systems and processes have helped systemized work culture even with the outsourced agencies

A NABH Accredited Hospital

Impact - 2008

A NABH Accredited Hospital

Impact - 2009

A NABH Accredited Hospital

Impact - 2010

A NABH Accredited Hospital

Conclusion
By applying for and receiving the National Accreditation for Hospital and Healthcare Providers (NABH) and being the first hospital in Mumbai to do so, D L H Hiranandani H it l h demonstrated a Dr Hi d i Hospital has d t t d commitment to quality health care. Quality health care. care is crucial to our people's welfare and it is important to have organizations that are willing to measure themselves against national standards

Dr Sujit Chatterjee MD Chief Executive