1. Hospital accreditation assistance

Hospitals wanting to introduce a program of Continuous Quality Improvement [CQI] usually need to employ expert specialist staff. However, appropriately trained and experienced personnel in this field are difficult to find and expensive to recruit. A cost-effective alternative is to out-source the hospital CQI program to consultants.

In this event, our small team of experts will assess the status of the hospital in relation to the quality of healthcare, and a written report will advise Management regarding an appropriate CQI program to move the hospital forward to a higher level. If this is accepted, our team will visit the hospital for training, at intervals to be agreed with Management. After thorough evaluation of the Hospital’s services in terms of quality, we assist our client’s in getting the certifications such as JCAHO, CIHQ and similar accreditations.

We provide the following in relation to accreditation:

  • Gap assessment and analysis
  • Assistance in developing and reviewing the hospital plan for Accreditation at various stages
  • Assisting the organization and formulation of committees and teams
  • Guiding on the development of Quality Assurance Program
  • Assisting in the development of Documents (SOPs, Manuals, Policies, instructions for the hospital, departments and infection control)
  • Assistance in the development of Record Keeping Program of the healthcare facility
  • Organization of Training programs throughout the accreditation preparation process
  • Training of pre-identified Hospital staff on NABH methodology for accreditation
  • Facilitation on the development of a facility assessment program
  • Monitoring of accreditation program activities, documentation, effectiveness of training programs and organizing refresher training programs as per need identified

Outline of Standards

Patient Centered Standards

  • Access, Assessment and Continuity of Care (AAC)
  • Care of Patient (COP)
  • Management of Medication (MOM)
  • Patient Right and Education (PRE)
  • Hospital Infection Control (HIC)

Organization Centered Standards

  • Continuous Quality Improvement (CQI)
  • Responsibility of Management (ROM)
  • Facility Management and Safety (FMS)
  • Human Resource Management (HRM)
  • Information Management System(IMS)