Question

FOR APOLLO HOSPITAL IN INDIA

analysis of licensing and accreditation governing the organization to assess the impact in the organization's function and operations. Include the following:

Accreditation

Identify two types of accreditation governing the organization, or a branch of the organization.

Identify whether or not the accreditation is mandatory. Explain the purpose for the accreditation and how it supports the organization.
Discuss why this accreditation is important to the patient, to the organization, to the community, and to health care.
Identify accreditation requirements for the organization, and resources needed to maintain accreditation.
Describe the consequences for the organization if they were to lose the accreditation.
Evaluate which type of accreditation and licensures your health care organization requires.

Licensure

Identify two types of licensing the organization has received.

Identify whether or not the licensure is mandatory. Explain the purpose for the licensure.
Discuss why this licensure is important to the patient, to the organization, to the community, and to health care.
Identify licensure requirements for the organization, and resources needed to maintain licensure.
Describe the consequences for the organization if they were to lose the licensure.
Evaluate the consequences associated with both the accreditation process and licensing.

Answer 1

Hospital accreditation has been defined as “A self-assessment and external peer assessment process used by health care organizations to accurately assess their level of performance in relation to established standards and to implement ways to continuously improve”. Critically, accreditation is not just about standard-setting: there are analytical, counseling and self-improvement dimensions to the process.

Hospitals and healthcare services are vital components of any well-ordered and humane society, and will indisputably be the recipients of societal resources. That hospitals should be places of safety, not only for patients but also for the staff and for the general public, is of the greatest importance. Quality of hospitals and healthcare services is also of great interest to many other bodies, including governments, NGOs targeting healthcare and social welfare, professional organisations representing doctors, patient organisations, shareholders of companies providing healthcare services, etc. However, accreditation schemes are not the same thing as government-controlled initiatives set up to assess healthcare providers with only governmental objectives in mind - ideally, the functioning and finance of hospital accreditation schemes should be independent of governmental control.

Hospital Accredation Organizations

1. National Accreditation Board for Hospitals & Healthcare Providers (NABH)
2. The Joint Commission on Accreditation of Healthcare Organizations. JCAHO. Joint Commission on Accreditation of Hospital Organizations. (JCAHO)
3. National Committee for Quality Assurance (NCQA)
4. Healthcare Facilities Accreditation Program (HFAP)
5. Centers for Medicare and Medicaid Services (CMS)

Accreditation is a process of review that allows healthcare organizations to demonstrate their ability to meet regulatory requirements and standards established by a recognized accreditation organization. Accreditation is important because it helps determine if an institution meets or exceeds minimum standards of quality. Hospital accreditation is a process that assesses a hospital’s performance against a set of standards. This process is done differently across provinces and countries. In the recent times demand for quality in healthcare services has risen due to various market forces such as medical tourism, insurance, corporate growth and competition. As a result of these the expectations of the consumer for best in quality has also risen, which has indeed lead to the introduction of national and international accreditation bodies to act as a quality assurance mechanism, thus enhancing customers access to better healthcare services. National Accreditation Board for Hospitals and Healthcare Providers (NABH) defines Hospital Accreditation as a public recognition by a national or international healthcare accreditation body, of the achievement of accreditation standards by a healthcare organization, demonstrated through an independent external peer assessment of that organizations level of performance in relation to the standards. Health System in India is very dynamic and operates in an environment with rapid social, economical and technical changes. In the past there have been numerous instances of poor patient care, negligence, inadequate resources with inefficient facilities, lack of information and unwanted medical interventions. To further define, it is a “self-assessment and external peer assessment process used by health care organizations to accurately assess their level of performance in relation to established standards and to implement ways to continuously improve”. The various standards of accreditation are based on the principles of quality assurance, evidence based practice, medical ethics and prevention of medical error. On the other hand it consists of different types of healthcare organizations and institutions delivering different levels of care not only to the local population but also to foreigners who visit India for medical treatment (Medical Tourism). Such being the case, assuring quality in healthcare services becomes a mandate and receiving an accreditation is the only answer to it. It is the single most approach for improving the current standards of the hospitals. It is quite evident that many regulations made by the government are not followed in most states and hence the quality of healthcare remains poor and unattended. Since accreditation is voluntary, it challenges the medical regulations laid down by the government both at state and central level. The level of confidence and faith of the people in hospitals can be increased through accreditation since it ensures that the accredited healthcare organization practices and delivers continuous quality services and also functions in the best interests of all patient’s. The primary goal of the accreditation is to ensure that the hospitals not only perform evidence based practices but also give importance to access, affordability, efficiency, quality and effectiveness of healthcare. Accreditation fills the gaps or removes the areas of deficiency and ultimately establishes optimum standards, professional accountability and clinical excellence. Even the Government has acknowledged that accreditation should be performed by a way of independent assessment programmes and with incentives both for secondary and tertiary level of hospitals to ensure patient safety and quality of care.

In India NABH was set up to establish and operate accreditation programme for healthcare organizations with the objective of enhancing healthcare delivery system and promoting continuous quality improvement and patient safety. Regardless of ownership, legal status, size and degree of independence it provides accreditation to hospitals in a non-discriminatory manner. The standards laid by NABH are accredited by International Society for Quality in Healthcare (ISQua). This shows that the accredited hospital will also get international recognition.

In the USA, Joint Commission International (JCI) in the best known accrediting body whose standards of quality assurance and rigorous quality evaluation process is well known all over the world. As this concept is not new to the healthcare industry, other countries like Australia, Canada and UK also have their own models of hospital accreditation.

Variety of benefits can be availed by the healthcare organization on being certified by NABH. The biggest beneficiaries are the patients, since they are serviced by the credential medical staff. It also provides opportunity to the hospital to benchmark with the best in the industry. Since accreditation ensures continuous learning, leadership, good working environment and ownership of clinical process, the hospital staff feels more satisfied and contented at work. It provides an opportunity to get empanelled by various insurance companies and other third parties. Lastly, it provides access to reliable and certified information on facilities, infrastructure and level of care.

To conclude, accreditation is a transparent system of control over the accredited hospital which assures that the hospital will constantly fulfill the accreditation criteria. The on-site survey of the hospital and staff by the experienced accreditation assessment team encourages them to establish educational and performance improvement goals. The best part is that it gives the opportunity to the patients to give a feedback on the services they availed during their stay in the hospital and also to complain if they were dissatisfied. Finally it ensures that hospitals, whether public or private, national or expatriate, play there expected roles in national health system.