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 forimprovement based on extent of conformance to existing applicable accreditation standards.Method: A cross-sectional observational study was conducted in an apex public sector ophthalmichospital in India during March and April 2016. Opportunities for improvement identified based on extentof compliance to accreditation standards as per criteria laid in NABH self-assessment toolkit. Reviewsof hospital departments, services and functions were done through document review; visit to differentpatient care areas; staff and patient interviews were conducted. A sample of ten observations was takenfor each objective element from same or different areas based on applicability and scored as full, partial ornon-compliant (0, 5, 10 respectively).Gaps were identified based on score less than 50% of aggregate orindividual standard with more than two zeros.Results: Hospital was compliant to accreditation standards of NABH with an overall score of 74%. Allregulatory requirements met. Opportunities for improvement identified were related to quality assuranceof 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 andcontinuous quality improvement (an advanced stage of accreditation) amongst few others which arepredominantly specifically oriented to accreditation related activities. The study delineates how the identifiedopportunities can be met based on interpretation of the standards. The study is limited by the fact thatdocumentation in the form of circulars and a Residents’ Manual which are not as per the requirements ofNABH have been considered.