1. The presentation is solely meant for
Academic purpose

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11. Regulation Vs. Accreditation
 Regulation is mandatory
 Accreditation is voluntary
 Accreditation is promoted by way of
incentives and market forces
 In order to achieve best of both worlds,
regulation in time to come can simply
rely on accreditation

12. Standards
Auditing
Quality System

13. Accreditation
Management
Logistics
Nursing / Technician
Physician
Patient Safety
Surgeon
Paramedical

14. Benefits to HCO
Stimulates continuous improvement
Enables the HCO in demonstrating commitment to quality of care.
Raises community confidence in the services provided.
Provides opportunity to benchmark.
International recognition of services.
Better efficiency and Increase in revenue
Transparency in the overall operations
Provides the framework for an integrated and focused
management structure.
Recognition by payers, government and vendors

15. PATIENTS / ASSOCIATES
PATIENT DAY TO DAY OPD OPD DISCHARGE FEE
REGISTRATIO
REGISTRATION MONITORING ADMISSION CONSULTATION CERTIFICATE COLLECTION
N
FRONT LINE STAFF
REGISTRATION ,PARAMEDICAL, NURSES, REDSIDENT
CONSULTANT / DOCTORS
EMPOWERMENT
CEO/HODs

16. Benefits to Clinicians
Accredited hospital provides for effective
governance including structured support
services needed by Clinicians.
It provides for continuous learning
through monitoring of clinical indicators
including opportunity to benchmark.
Improves overall professional
development and provides opportunity
for leadership role in quality

17. Percentage of medication errors
Percentage of transfusion reactions
Urinary tract infection rate
Respiratory infection rate
Intra-vascular device infection rate
Surgical site infection rate
Incidence of falls
Incidence of bed sores after admission
Bed occupancy rate and average length of stay
Incidence of needle stick injuries

18.  Systems are checked
 Actual practice is not
 Safety is given top priority
 Measure what you do

19. Temp PACU Temp PACU
arrival exit
All 34.5 (32.8 – 35.7 (34 –
36.8) 37.2)
Patients with 34.8 (34 - 36 (35- 37.2)
bear hugger 36.8)
Without bear 34.4 (32.8 – 35.7(34 – 36.8)
hugger 36.4)
19

20.  Cover preoperative patients
 Minimize heat loss before surgery
 Monitor temperature/s
 Warmer / warm fluids/ early closure/ cover
plastic sheet
 Cover during transfer
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21.  One of the top priority areas
 HAIs
 Hand hygiene compliance
 Antibiotic use
 Antibiogram
 Abuse
 Prophylactic antibiotic
 Resistance pattern

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25. 2005 2010
1 Anesthesia Spinal/epidur Nerve blocks
al
2 High risk pts No Yes
3 Mobilization 24- 48 hrs 2-4 hrs
4 Pain relief OK excellent
5 Post op pts Slightly Alert, no vomiting
drowsy
5 Discharge 7 to 10 days 5 days
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26. 2000 2010
1 Ventilator 24 hrs 2 to 3 hrs
2 ICU stay 2- 3 days 18 hours
3 Pain relief (0 to 10) 2 to 4 0 to 2
4 Postop status Slightly drowsy Alert awake
5 Mobilization 3 days Day 0
6 Climbing steps 4 to 5 days 2 to 3 days
7 Blood transfusion 4 to 5 units 0 to 1 unit
8 Infection <5 % <1%
9 Discharge from hospital 12 to 15 days 5 to 6 days
10 Return to work 2 months 2 to 4 weeks
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