Deliverable - 15

Project Report

Report Submitted to

Project Director

European Union Support to Health and Nutrition

to the poor in Urban Bangladesh

Room No – 1413, 15th Floor, Nagar Bhaban, 5

iota Consulting BD
Phonix Road, Dhaka – 1000

House # 67, Road # 17, Block – C, Banani, Dhaka –

1213
iota Consulting BD
Multi-directional Support for Enterprise
 Contents

1 Context of this project ............................................................................................................. 3

2 Project at a glance.................................................................................................................... 4

2.1 Baseline study ................................................................................................................... 4

2.2 Study of International Standard ....................................................................................... 5

2.3 Framework for Accreditation............................................................................................ 6

2.4 Recommendation ............................................................................................................. 6

3 Project Implementation Status ................................................................................................ 8

3.1 Baseline study ................................................................................................................... 8

3.1.1 Baseline Study in Respect to BSB .............................................................................. 8

3.1.2 Baseline Study in Respect to DGHS and HEU .......................................................... 10

3.1.3 Practice of Individual Hospital ................................................................................. 11

3.2 Study of International standards .................................................................................... 18

3.2.1 JCI Accreditation Standard for Hospitals, 2017 ....................................................... 19

3.2.2 MSQH Hospital Accreditation Standard, 2017 ........................................................ 21

3.2.3 NABH Hospital Standards, 2015 .............................................................................. 28

3.2.4 Study on BS EN 15224:2016 (QMS)–ISO 9001:2015 for Healthcare ....................... 32

3.2.5 ISO 15189:2012 An Overview of the Standard ........................................................ 32

 3.3 1st Workshop .................................................................................................................. 33

3.4 Governance of Accreditation System ............................................................................. 34

3.5 Recognition Prospect ...................................................................................................... 36

3.5.1 Recognition from Umbrella Organization................................................................ 38

3.6 Assessor Competency and Assessment Protocol............................................................ 43

3.7 2nd Workshop and Outcome ......................................................................................... 46

3.8 Framework for Accreditation.......................................................................................... 47

3.8.1 Rationale for Relying on Existing Accreditation Standard ....................................... 48

3.9 Organizational Structure and Management of Accreditation Body................................ 49

3.10 Validation Workshop ...................................................................................................... 57

4 Project Output Summary ....................................................................................................... 59

5 Further use of this project outcome ...................................................................................... 60

1 Context of this project
Recently Bangladesh has been declared as the middle-income country. Bangladesh is going to

celebrate the 50 years of its independence and the year 2021 has been picked by the government

of Bangladesh as bench mark year for its journey to become a developed country. adequate and

good quality health services are of the important indicator of development for any country. In the

coming daces more and more people will be living in the urban area. It will be difficult to ensure

quality health care service to the increasing number of urban population without having a set

standard of healthcare facilities – specially for the non-government healthcare facilities i.e. clinics

or private hospitals.

To ensure quality healthcare services is very essential to have a set standard for every aspect of

the service. The line director hospitals and clinics services give license and monitors the healthcare

facilities across the country. The line director hospitals and clinics evaluates the facilities and gives

license if the facility ensures its compliance with the checklist and meet the minimum requirement

set by the LD DGHS. He checklist only look for the essential facilities, resources and equipment to

run a healthcare facility.

With the increasing per capita income demand for quality healthcare services is also in the raise.

To fill the gap many prominent healthcare service providers are coming forward with a promise of

quality services. Along with good doctors, stuffs and equipment they area also offering a good

environment for the patients. Even in the district level there are many good healthcare facilities in

private sector. Unfortunately, the patients or the care tacker cannot choose among the the

healthcare facilities on the basis of any widely acceptable rating or certification.

In many developed countries, as well as many countries of South Asia like India and Thailand have

their own accreditation system. In most countries the accreditation is voluntary. Some renowned

hospitals of South Asia also have accreditation from some internal accreditation body i.e., JCI. A

recognized Accreditation is a statement from the healthcare facilities about the standard of their

overall service quality. An accreditation also helps the patient or healthcare clients to understand

the service quality of the facility.

In this above context, this project titled “Strengthening Hospital Accreditation System” is a very

timely endeavor. With the help of this project Bangladesh will get the framework of the

governance system and framework of an accreditation standard for healthcare facilities.

2 Project at a glance
This project is consisting of four main components as

a. Baseline Study

b. Study of international Standards

c. Framework for Accreditation

d. Recommendation

All those main components have further sub-components.

2.1 Baseline study

This component of the project aims to draw a realistic picture of Bangladesh for the capability of

its institution and the present situation of accreditation. Sub-components of baseline study are
 I. Assessment of Bangladesh Board of Accreditation for its existing capacity, authority

and their interest regarding the accreditation of healthcare facilities.

II. Assess the capability of government agencies like Directorate General Health

Services (DGHS) and the Health Economic Units (HEU).

III. Assessing the interest, demand and the present situation of the healthcare facilities

is another objective f the baseline facility.

After completion all the survey, interview and data collection the iota Consulting BD and SSMF

will submit a baseline study report.

2.2 Study of International Standard

To recommend the framework of governance and standard for an accreditation system suitable

for Bangladesh it is important to know and analyze the other similar standards. Sub-components

of this study are

I. Collection of the standard which will be studies. The consulting organization is will

collect suitable standards – specially standards from South east Asian countries – for

the study.

II. After collecting the standard, consulting organizations will study the standards

III. A workshop will be conducted for the fine tuning of this study.

Consulting organizations will produce a study report on the internal standards which had been

studied.
2.3 Framework for Accreditation

This component addresses the issue of governance, authority, competency of the assessor and

the recognition prospect of the standard. Sub-components of this study are

I. The governance process of the accreditation system will be recommended with this

sub-component.

II. The consulting organization to evaluate the prospect of getting recognition of the

standard from internationally recognized bodies i.e., ASQ or IAF etc.

III. After the study a workshop will be arranged to inform and get recommendation

from the interested parties.

2.4 Recommendation

This is the final stage f this project. Sub-components of this phase are

I. Framework/Skeleton for accreditation Standard/Guideline will be proposed for the

further development of the original standard.

II. Recommendations will be made for a governance framework to maintain the

standard and for the accreditation system.

Consulting organization will outline a pilot project for the accreditation system.
3 Project Implementation Status
3.1 Baseline study

3.1.1 Baseline Study in Respect to BSB

General objective of the baseline study is to assess the current scenario of Bangladesh

regarding accreditation of hospitals and health care services. In the proposed study of

baseline, there are three major components:

▪ Study of the possibility of Bangladesh Accreditation Board (BAB) for its existing

capacity, authority and interest for providing accreditation in healthcare facilities.

▪ Study of the present practices of government agencies, like, Directorate General of

Health Services (DGHS) and the Health Economic Unit (HEU), in controlling the

quality of healthcare services available in Bangladesh.

▪ Assessing the present situation, interest and demand of the healthcare facilities to

obtain accreditation, is one of the objectives of the baseline study.

▪ Study on BAB

Bangladesh Accreditation Board (BAB) is formed by the Bangladesh Accreditation Act,

2006. As per this act, BAB acts as an accreditation body for organizations providing

certification, testing and inspection services. BAB does not have any mandate to engage

in activities related to accreditation of hospitals and providers of medical care. The BAB

Act precludes BAB from engaging in such services. BAB may take part in accreditation of

the certification body(s) which might certify healthcare facilities in future. It is to recognize
that BAB is an established accreditation body in Bangladesh, which has recognition by

international forum, i.e., IAF (International Accreditation Forum), APLAC (Asia Pacific

Laboratory Accreditation Cooperation), etc. It has gained substantial capability to adopt

and implement international standards related to the accreditation services, i.e., ISO

17020, ISO 17021, ISO 15189, ISO 17025 etc.

Needless to say, there is always a possibility of expanding the scope of BAB through revision

of the act and thereby making use of BAB’s extensive experience in the area of

accreditation.

iota Consulting BD and SSMF has communicated with BAB and had a meeting on 04

February 2018 to initiate the discussion on this issue. When asked if BAB would be

interested to have the Act revised to enable BAB to engage in the aforementioned

accreditation services, the Director General informed that he would discuss this in proper

forum.

The first meeting was held on 04 February 2018 with the Director Generation of
Bangladesh Accreditation Board.

The participants, time & date of the meeting are:

On behalf of Bangladesh Accreditation Board: The Director General, Mr. Monowar Hossain
along with Mr. Md. Mahbubur Rahman, Deputy Director and Mr. Mohammad Abbas Alam,
Assistant Director

On behalf of iota Consulting BD: Mr. Mohammad Golam Kibria, CEO; Mr. Arafat Kabir, COO
and Md. Rajib Ul Haque, Senior Consultant
 Time: 10:30 am

Date: 04-02-2018

The salient points of the discussion were,

01. BAB does not have any mandate to engage in activities related to accreditation of
hospitals and providers of medical care. The BAB Act precludes BAB from engaging in
such services.
02. When asked if BAB would be interested to have the Act revised to enable BAB to engage
in the aforementioned accreditation services, the Director General informed that he
would discuss this in proper forum.

3.1.2 Baseline Study in Respect to DGHS and HEU

Study on Directorate General of Health Services (DGHS)

In collaboration with WHO (World Health Organization), a project on the objective of

establishing an accreditation board for health services is running on. 2 exclusive personnel
have been provided to the Directorate to work for 5 years on this project. Professor Dr.
Jahangir (Director of Hospital management) also apprised that the process of
institutionalization of an accreditation system requires a new legislation. This specific
legislation process is being undertaken in the last few years. He suggested that an
Accreditation System should evolve with participation from al the stakeholders. The
operation of the board should include organizations like BMRC (Bangladesh Medical
Research Council) and BMDC (Bangladesh Medical & Dental Council). He also informed
that two professionals, Dr. Khalilur Rahman, Program Manager and a deputy Program
Manager had already been solely appointed for the same agenda. He advised our team to
work closely with the designated team for hospital accreditation.
 It appears that the Directorate General of Hospital Services is substantially aligned towards
introducing accreditation services for hospitals and healthcare providers through new
legislation in Bangladesh.

It is also obvious that any new recommendation contrary to the current advancement of
the matter of formulation legislation for accreditation of hospitals and healthcare services
will be ineffective without the involvement of DGHS.

Study of Health Economics Unit (HEU)

A meeting was held with the Director General of Health Economics Unit (Health Services
Division), Ministry of Health & Family Welfare. He informed that HEU is actively involved
with the process formulating legislation for introducing accreditation services for hospitals
and healthcare providers.

The role of Health Economics Unit (HEU) for facilitating accreditation of hospitals and
healthcare providers is substantial and its capability can be harnessed for achieving
positive impact.

Moreover, the HEU has prepared a monitoring tool to evaluate the performance of the
health care facilities. It is a good initiative towards the accreditation standard.

3.1.3 Practice of Individual Hospital

This project has interviewed four hospitals and those are

A. Anwer Khan Modern Hospital, Dhaka (Private hospital)

B. Shahid Asadullah Ideal Hospital, Dinajpur (Private hospital)
C. Dhaka Medical College, Dhaka (Public Hospital)
D. HI TEC Multicare Hospital Ltd (private hospital)

Hospital are usually conservative to provide any kind of information and many hospitals
has given information us informally.
Progress summary from the survey is as follows

Anwer Khan Modern Hospital Limited (private hospital)

The Anwer Khan Hospital wants accreditation for the whole hospital or a certification from

an international renowned body, as it will increase the hospital’s brand image and

reliability. It will also give advantage to get corporate clients especially the multinational

ones. The hospital authority understands the difference between licensing and

accreditation. But it has no knowledge about International Organization for

Standardization (ISO) or Bangladesh Accreditation Board (BAB). The hospital is related to

LD, Hospitals and Clinics, Directorate General of Health Services (DGHS) for regulation and

inspection purposes. Licensing by DGHS was followed by in house training (actually

workshop almost in every quarter of the hospital).

The hospital authority things that Government can go for public private partnership to

improve the service quality and lower the cost of treatment.

The hospital authority informed that 20+ government and autonomous bodies (e.g. DGHS,

Health Ministry, Department of Narcotics, Department of Environment, BMDC etc.) are

monitoring the hospital from taxation to waste management.

Shahid Asadullah Ideal Hospital, Dinajpur (private hospital)

The hospital has no accreditation and the authority does not want accreditation, as it will

increase the cost, and in a district town patients will not bear the extra cost.

The authority does not know about the pre-requisite for accreditation. But they are aware

of the difference between licensing and accreditation and know about the management

system certification. They have no knowledge about BAB and their services regarding

accreditation. They are not aware of any quality improvement activities of HEU.

The management has relationship with LD, Hospitals and Clinics, DGHS. The LD’s office

inspects the hospital as per the licensing conditions. The management opined that the LD’s

office may provide them training on the hospital management and good practices.

The hospital has no quality assurance team. However, owners visit daily several times all

the floors or areas of the hospital to ensure that everything is going on well. There is no

quality indicator. The monitors mainly look for cleanliness and presence of the right person

in the right place. Observation is made to see if the toilets are clean and if running water

is available in these toilets. But no record is kept for that monitoring. There is no follow-up

meeting, but they follow-up actions if there is any inconsistency. Departments do not

report on any indicator. No such system exists.

Dhaka Medical College Hospital

On behalf of Dhaka Medical College Brigadier AKM Nasiruddin, Director, Dhaka Medical

College Hospital (DMCH) provided the information on current scenario and prospect of

hospital accreditation in DMCH. The gist of collected information is given below:

Presently Dhaka Medical College Hospital is not accredited by an accreditation body. The

hospital management team is aware of pre-requisites for accreditation which are,

1. Self-assessment and external peer assessment team

2. Standard Setting

3. Well organized hospital record system

The hospital appreciates accreditation, because it will ensure the following standards,

1. Maintenance of patient and staff safety

2. Improvement of quality of patient care

3. Client Satisfaction

4. Reducing Professional (medical) errors

5. Judicial use of scarce resource

The hospital would prefer accreditation initially to few departments like ICT, OT,

Emergency department then gradually to management system and finally to all other

departments. The hospital would like to acquire accreditation based on standards like
those of NABH (it is derived from our neighboring country which is culturally, economically

alike) initially, and then from Joint Commission International (JCI) afterwards (because it is

the latest body in the whole world). The hospital management team understands

difference between licensing and accreditation and also is familiar with management

system certification. Dhaka Medical College doesn’t have any ISO certification. Hospital

team is unaware of BAB and its services.

The hospital doesn’t have any linkage with Health Economics Unit and its activities.

Hospital has quality assurance team which comprises of Director as President of the board

and all department heads, nursing superintendent, ward masters and meet once in every

03 months. The following quality indicators are monitored (occasionally) by the quality

assurance team,

1. Death review

2. Average of length of stay

3. Bed occupancy rate

4. Admission rate

5. Discharge rate

6. Death rate

7. Hospital infection rate

8. Work place injury

9. Drug and food safety

10. Ethical and legal issue

11. Performance appraisal

12. Record review

The record of the meeting is kept for future reference. Occasionally decisions taken in the

meetings are implemented. Not every department reports on those indicators.

Instructions are generated from the outcomes of these meetings.

HI TEC Multicare Hospital Ltd (private hospital)

On behalf of HI Tec Multicare Hospital Ltd., Managing Director and Prof Dr. Md. Saiful

Islam, provided the information on current scenario and prospect of hospital accreditation

in HI Tec Multicare Hospital Ltd. The summary of collected information is as below:

Presently the hospital is not accredited by any accreditation body. The hospital

management team explained the following points as pre-requisite for accreditation,

1. Self and peer assessment teams

2. Performance standards

3. Trained staff

4. Hospital reporting and record system

The hospital would like to acquire accreditation. Because it would assure them the

followings:

1. Patient safety

2. Staff safety
 3. Improved patient care

4. Reduced medical errors

5. Reduced expenditure

6. Efficient use of resource

The hospital would like to earn accreditation for their important departments like ICU,

CCU, HDU, OT and Post Operation ward first and then gradually rest of the departments.

The hospital management team prefers NABH and JCI boards set criteria for their

accreditation.

The management team knows the difference between licensing and accreditation. The

hospital has no linkage with HEU (Health Economics Unit). Hospital management team

does not have any quality assurance team. There is a written protocol for handover of

patients to next duty staff. Existing staffs are numerically sufficient but inadequate in terms

of training. The staff from all departments require skill development (particularly on

nursing, ICU, CCU, HDU and post operation care).

One of the major findings of the baseline study is that, after the accreditation act for

healthcare organizations is passed, there will arise an acute need for an accreditation

standard that is sufficiently comprehensive, easy to implement, and that facilitates

accreditation of organizations which can achieve recognition of local and global

stakeholders.
 Therefore, the current project maintains a lot of focus on studying various available

accreditation standards for hospitals and healthcare service providers and to cull most

appropriate requirements relevant to prevailing scenario of Bangladesh.

3.2 Study of International standards

As per the contract iota Consulting BD along with its partner SSMF has conducted the first

workshop and captured the recommendation from the key stakeholder to establish a

Hospital accreditation System in Bangladesh. This is the second report form iota Consulting

BD and it is about the proposed framework of accreditation standard.

In course of journey both of the organizations has evaluated healthcare accreditation

standards from some developing and developed countries, mainly form Southeast Asia,

South Africa and USA.

Studied standards are:

A. JCI (Joint Commission International) Accreditation Standard for Hospitals, 6th Edition
B. NABH (National Accreditation board for Hospital and Healthcare) Hospital Standards, 4th
Edition
C. MSQH (Malaysian Society for Quality in Health) Hospital Accreditation Standard 2017, 5th
version
D. BS EN 15224:2016 (Quality Management Systems) – EN ISO 9001:2015 for Healthcare

We have studied all the five standards from four different countries – USA, India, Malaysia

and South Africa – and one international organization – International Organization for

Standardization. Result of our study are elucidated in this report.

 We have included the proceedings of the first workshop with this report in the substituent

chapters.

3.2.1 JCI Accreditation Standard for Hospitals, 2017

3.2.1.1 Overview of the Standard

Joint Commission International Accreditation Standards for Hospitals, 6th Edition, provides

the basis for accreditation of hospitals throughout the world. Joint Commission

International (JCI) standards define the performance expectations, structures, and

functions that must be in place for a hospital to be accredited by JCI.

The standards are divided into two main sections: 1) patient-centered care and 2) health

care organization management. In addition, two chapters are included for hospitals that

meet eligibility criteria for academic medical center accreditation—these standards

address additional requirements for human subjects research and medical professional

education.

Within each section, standards are separated into chapters. Each standard includes an

intent statement, which describes the rationale for the standard, and measurable

elements, which are the specific requirements of the standard. In addition to the standards

chapters, the Accreditation Participation Requirements, an introduction, the eligibility

requirements, a summary of key accreditation policies, a glossary, and an index are

included.
3.2.1.2 Structure of the Standard
As discussed previously the standard is divided in to two main parts. Here we will discuss

those two parts particularly i.e., Patient centered standard and Healthcare organization

Management Standard.

Section I: Accreditation Participation Requirements

Accreditation Participation Requirements (APR)
Section II: Patient-Centered Standards
International Patient Safety Goals (IPSG)
Access to Care and Continuity of Care (ACC)
Patient and Family Rights (PFR)
Assessment of Patients (AOP)
Care of Patients (COP)
Anesthesia and Surgical Care (ASC)
Medication Management and Use (MMU)
Patient and Family Education (PFE)
Section III: Health Care Organization Management Standards
Quality Improvement and Patient Safety (QPS)
Prevention and Control of Infections (PCI)
Governance, Leadership, and Direction (GLD)
Facility Management and Safety (FMS)
Staff Qualifications and Education (SQE)
Management of Information (MOI)
Section IV: Academic Medical Center Hospital Standards
Medical Professional Education (MPE)
Human Subjects Research Programs (HRP)

ccreditation is a long-term process that demands commitment. There is a great deal of preparatory

work leading up to a survey and then subsequent performance and improvement work is done to
ensure those accreditation standards are maintained. Organizations that achieve and maintain JCI

accreditation are dedicated to providing their patients the best level of care possible.

JCI standards and evaluation methods stand alone in the world as unique tools designed to drive

positive change. Its standards and evaluation methods are:

▪ Designed to stimulate and support sustained quality improvement

▪ Created to reduce risk

▪ Focused on building a culture of patient safety

▪ Developed by health care experts from around the world—and tested in every world

region

▪ Developed by health professionals specifically for the health care sector

▪ Applicable to individual health care organizations and national health care systems

Our study result is that the JCI standard is will not be fully adoptable for the present situation of

Bangladesh.

3.2.2 MSQH Hospital Accreditation Standard, 2017

3.2.2.1 Overview of the Standard

MSQH was formed in 1997 and started implementation of the Hospital Accreditation Program in

late 1999. The latest edition of the standards reaffirms MSQH’s commitment to continuously

improve the quality and safety of patient care in the country through the implementation of a

national set of standards for healthcare facilities and services.

The new set of standards (5th Edition) have addressed the following:
 1. Reflects the dynamic changes occurring in health care in terms of new technologies and
advancement of best practices in medical knowledge.
2. Focus has moved further from structure, process, generic outcomes to specific
outcomes. Performance measurement and evidence of quality and safe services is now
an essential requirement for certification.
3. Adoption of World Health Organization (WHO) Patient Safety Initiatives and Malaysian
Patient Safety Goals.
4. Introduction of Organization-wide Standards that include standards on Patient and
Family Rights, Prevention and Control of Infection and Health Information Management
System, etc.
5. Specific requirements of clinical services e.g.: Medical, Surgical, Obstetrics &
Gynaecology, Paediatrics, Cardiology Services, Oncology Services, etc.
6. Inclusion of Core Criteria and evidence of compliance.
7. Quantitative rating scale for measurement of compliance to standards as well as
maintaining the peer review decision making process.
8. Introduction of Risk Assessment.
9. Adoption and compliance with International principles and standards 4th Edition 2014
developed by ISQua Accreditation Federation Council – for ISQua International Standards
certification.
10. MSQH is not just a standard it is also a self-assessment and third-party audit tool.
11. It has different layers of standard, evidence of compliance, KPIs etc.

3.2.2.2 Structure of the Standard

MSQH has two different parts in the standard, but it is unlike the JCI or NABH standard. Heading

of the part is “Hospital Wide Service Standard” which describe the management part of the

hospital i.e., fire safety, environmental safety, waste management, infection control etc.
On the other hand, the second part is titled as “Service Standard”. It is more specific on the

different departments and services of the hospital like surgical, pediatric, ICU/CCU, cardiology,

oncology etc.

Chapters of this standard are

A. Hospital Wide Service Standard

1. Governance, Leadership & Direction
2. Environmental and Safety Services
3. Facility And Biomedical Equipment Management And Safety
4. Nursing Services
5. Prevention And Control Of Infection
6. Patient and Family Rights
7. Health Information Management System

B. Service Standards

8 Emergency Services

9 Clinical Services - Non-Specialist Facility (For District Hospitals)

9A Clinical Services - Medical Related Services

9B Clinical Services - Surgical Related Services

9C Clinical Services - Obstetrics And Gynaecology Services

9D Clinical Services - Paediatric Services

9E Clinical Services - Cardiology Services

9F Clinical Services - Oncology Services

10 Anaesthetic Services

11 Operating Suite Services

12 Ambulatory Care Services

13 Critical Care Services - Icu/Ccu/Cicu/Crw/Hdu/Burns Care Unit

13A Critical Care Services - Scn/Nicu/Picu/Phdw

13B Critical Care Services - Labour/Delivery Services

13C Chronic Dialysis Treatment

14 Radiology/Diagnostic Imaging Services

15 Pathology Services

16 Blood Transfusion Services

17 Rehabilitation Medicine Services

17A Allied Health Professional Services - Physiotherapy Services

17B Allied Health Professional Services - Occupational Therapy Services

17C Allied Health Professional Services - Dietetic Services

17D Allied Health Professional Services - Speech-Language Therapy Services

17E Allied Health Professional Services - Audiology Services

17F Allied Health Professional Services - Optometry Services

17G Allied Health Professional Services - Health Education Services

17H Allied Health Professional Services - Medical Social Services

17I Allied Health Professional Services - Psychology Counselling Services

17J Allied Health Professional Services - Clinical Psychology Services

18 Pharmacy Services

19 Central Sterilizing Supply Services (Csss)

20 Housekeeping Services

21 Linen Services

22 Food Services

23 Forensic Medicine Services

23A Mortuary Services

24 Standards for General Application - Generic

24A Standards for Clinical Research Centre

 Structure of MSQH Standard

Main Standards Standard for Services Parts of Each Service Standard Parts of Sub-Standards

▪ Criteria for Compliance

Hospital Wide Service Standard

▪ Evidence of
Compliance
8 Service ▪ Self-Rating
Standards ▪ Areas of Improvement
and Risks
▪ Surveyor Rating
▪ Organization and Management
▪ Human Resource Development
and Management
▪ Policies and Procedures
▪ Facilities and Equipment
▪ Safety and Performance
Improvement Activities
▪ Special Requirements Performance
Service Standard

Indicator

24 Service
Standards
This is a robust standard for hospital accreditation. Malaysia have started this initiative at 1997

and they release their first edition of the standard in 2011. The first edition was only 22 pages

and now it is more than 1300 pages standard.

What Bangladesh can learn from the standard is the evidence of compliance for each criteria of

compliance and the performance indicator for each service standard. Clause 5.1.4 of every

service standard have some performance indicator and MQSH have a separate guideline for

measurement of performance indicator identified for each service standard.

3.2.3 NABH Hospital Standards, 2015

3.2.3.1 Overview of the Standard

NABH Standards for hospitals prepared by technical committee contains complete set of

standards for evaluation of hospitals for grant of accreditation. The standards provide

framework for quality of care for patients and quality improvement for hospitals. The

standards help to build a quality culture at all level and across all the function of hospital.

NABH Standards has ten chapters incorporating 102 standards and 636 objective

elements.

The attention of users of this guideline is drawn to those points identified as 'mandatory'.

These shall be identified; data gathered, analyzed and interpreted with the aim of

improving the quality system of a hospital.

In general, the organization need to identify, meet requirements of and provide objective

evidence of compliance with the following Issues

1. Patient related monitoring safety, treatment standards and quality of care. This would

include effectively meeting the expectation of patients and their attendants, families and

visitors.

2. Employee related monitoring competence, on-going training, awareness of patient

requirements and employee satisfaction.

3. Regulatory related: identifying, complying with and monitoring the effective

implementation of meeting legal, statutory and regulatory requirements.

4. Organization policies related defining, promoting awareness of and ensuring

implementation of, the policies and procedures laid down by the organization, amongst

staffs, patients and interested parties including visiting medical consultants.

5. NABH standards related identification of how the organization meets the NABH

standards and the objective elements. Where a part of an element, an element or a

standard cannot be applied in a particular organization, adequate explanation and

justification must be provided to NABH and its team of assessors to enable exclusion of

applicability. In particular, it must be ensured that the intent of each chapter of standards

is applied.

As discussed earlier the accreditation standard is divided into 10 chapters, which have

been further divided into 102 standards and these standards have been further divided

into 636objective elements.

Objective elements are measurable components. Objective elements are required to be

met in order to meet the requirement of a particular standard. Similarly, standards are

required to be met in order to meet the requirement of a particular chapter. Finally, all

chapters are deciding factor to determine whether a hospital is meeting the requirements

of the Accreditation Standard. The intent statement provides a brief explanation of a

chapter’s rationale, meaning, and significance. Intent statements contain detailed

expectations of the chapter that are evaluated in the on-site assessment process. For most

of the objective elements, interpretation is provided just after each one of these. Also, a

remark is given to further elaborate on how that objective element can be met. These
 standards are equally applicable to government and private hospitals, and are applicable

to whole organization.

3.2.3.2 Structure of the Standard

This standard has 10 chapters and the 102 standards for the NABH standard.

AAC.1. The organisation defines and displays the healthcare services that it provides.

AAC.2. The organisation has a well-defined registration and admission process.

AAC.3. There is an appropriate mechanism for transfer (in and out) or referral of
patients.

AAC.4. Patients cared for by the organisation undergo an established initial

assessment.

AAC.5. Patients cared for by the organisation undergo a regular reassessment.

AAC.6. Laboratory services are provided as per the scope of services of the
organisation.

AAC.7. There is an established laboratory quality assurance programme.

AAC.8. There is an established laboratory safety programme.

AAC.9. Imaging services are provided as per the scope of services of the
organisation.

AAC.10. There is an established quality assurance programme for imaging services.

AAC.11. There is an established safety programme in the imaging services.

AAC.12. Patient care is continuous and multidisciplinary in nature.

AAC.13. The organisation has a documented discharge process.

AAC.14. Organisation defines the content of the discharge summary.

We have studied standards used in the mature economy, ie, JCI and we have also studied MSQH,

that belongs to an Asian Country (Malaysia). Our study shows that for Bangladesh, a standard

that is easy to implement but not too brief or incomplete, is most suitable.

That way, we have selected the NABH standard of India as the basis of our recommendation. In

NABH itself, there are requirements that are too heavy for the healthcare industry of Bangladesh

and hence those are recommended to be addressed during the continual improvement cycle of

the service provider.

Whatever is the standard, following items are the minimum that need to be dealt with in the

standard:

01. Access, Assessment and Continuity of Care

02. Care of Patients (COP)

03. Management of Medication (MOM)

04. Patient Rights and Education (PRE)

05. Hospital Infection Control (HIC)

06. Continuous Quality Improvement (CQI)

07. Responsibilities of Management (ROM)

08. Facility and Safety (FMS)

09. Human Resource Management (HRM)

10. Information Management System (IMS)

3.2.4 Study on BS EN 15224:2016 (QMS)–ISO 9001:2015 for Healthcare

BS EN 15224:2016 is a quality management system for the healthcare organization

adopted from ISO 9001:2015. In Bangladesh perspective, the hospital can use it for the pre

accreditation approach. Otherwise, the organization can be certified in ISO 9001:2015 for

their quality management system.

Risk base thinking and process approach is the main future of those standard which could

be incorporated I the future hospital accreditation standard for Bangladesh.

3.2.5 ISO 15189:2012 An Overview of the Standard

The value of implementing and sustaining an ISO 15189 QMS is not easy to quantify. The literature

is sparse. Firstly, variability in the medical laboratory industry is high. Secondly, it would be difficult

to show statistically significant differences in outcome measures because of this complexity.

Furthermore, what constitutes appropriate outcome measures is controversial in itself. Over the

last nine years in which we have been involved with laboratories that implemented ISO 15189

quality management systems, we have found the following elements to be of value to laboratories.

Engaging in ISO 15189 is a journey that requires many years of commitment. We often hear that

“things” become easier the longer the laboratory pursues this course. The culture of the laboratory

changes gradually to enable a mindset of “seeing” problems as, or before, they occur, therefore

evolving to a culture of prevention. Staff engagement improves and morale improves, as there is
no blame and staff members are part of the solution. Reductions in LAP inspection deficiencies

have been demonstrated as a result of investing in ISO 15189.

Financial reward is a desirable and most-often-sought argument in favor of ISO 15189. Although

the literature of money-savings in an ISO 15189 system is sparse, cost-of-quality models have

demonstrated potential cost savings . Such models consider the cost of trying to be the best you

can be (cost of pathologists' continuing medical education or money spent on process design), the

cost of maintaining a quality operation (eg, accreditation program expenses or enrollment of

pathologists in PT programs), the cost of correcting process failures before the result is reported

(eg, cost of histology having to recut skin biopsies to obtain a full face), and the cost of resolving

problems after reporting results (eg, cost of pathologist's time to amend a report because

operating room staff indicated the wrong site on a requisition form). Using ISO 15189 methods to

reduce the cost allows laboratories to estimate expected cost savings and financial benefits to gain

high-level management support and stakeholder buy-in.

ISO 15189 requires the right attitude and mindset -- those who practice it like to think of it as a

“lifestyle choice,” rather than just another accreditation.

3.3 1st Workshop

Due to the baseline condition of the state of quality management of the healthcare providers of

Bangladesh, a stringent accreditation standard will not be effective. The proposed standard should

be flexible, more focused on the basics of quality management, practicable without massive re-
organization and investment in the existing infrastructure, and it should be result orientated

having capability of continual improvement at accelerated rate.

He provided examples from both Indian and Malaysian standards and explained that a standard

must have achievable indicators which should be SMART and should render intended results.

3.4 Governance of Accreditation System

Governance of an accreditation system is crucial in the sense that it defines the

impartiality, conflict management and success of the accreditation body in delivering its

services. Governance includes independence of decision making process, access to

resources, ability to maintain impartiality, adherence to well-laid out and transparent

method of operation. These are imperative conditions for developing a prestigious and

respectable accreditation system, that the relevant health care providing facilities will be

interested to buy in.

This project would hold dialogues/discussions on the governance of hospital accreditation

system with the different government and private agencies and stakeholders; and would

propose a structure for governance and management.

It is important for a health care organization to make a definite plan of action for obtaining

accreditation and nominate a responsible person to co-ordinate all activities related to

seeking accreditation. The person nominated should be familiar with a health care

organization’s services, functions and existing quality system.

A request can be made to Accreditation boars/council Secretariat for procurement

of relevant standards against the payment, if any. Clarifications on the document to be

procured may be obtained from the Secretariat in person, by post, on telephone or

through e-mail. The health care organization should get fully acquainted with all

accreditation documents and understand the assessment procedure & methodology of

making an application.

Health care organization needs to conduct self-assessment to ascertain whether they are

fulfilling the accreditation criteria or whether health care organization complied with the

Standards, If find the gap during self-assessment take corrective action to fill the gap.

Relevant requirements for the accreditation should be discussed amongst

concerned staff of the health care organization. This will enable them to understand their

weaknesses and strengths. The health care organization must ensure that the policy and

procedures for various departments and services provided by health care organization

and other documents are available and implemented.

The health care organization looking for accreditation should understand the

accreditation assessment procedure and prepare for facilitated the assessment procedure.
 Application for the
Accreditation from Hospital

Deposition of fees for the

Accreditation

Pre-assessment report with

Pre-assessment visit
observation, if any

Whether
Allow Hospital a certain No Hospital qualify for
time for improvement the final
Assessment? Yes

Allow Hospital to resolve

the observation

Final-assessment report
Final Assessment visit
with observation, if any

Hospital to close all the

observation

No
Whether
Hospital resolved all
the observation?

Yes

Hospital to be Accredited Surveillance regime

3.5 Recognition Prospect

Accreditation is usually a voluntary program, sponsored by a non-governmental or private

agency, in which trained external peer reviewers evaluate a health care organization’s

compliance with pre-established performance standards. Quality standards for hospitals

and other medical facilities were first introduced in the United States in the ‘Minimum
Standard for Hospitals” developed by the American College of Surgeons in 1917. After

World War II, increased world trade in manufactured goods led to the creation of the

International Standards Organization (ISO) in 1947.2 Accreditation formally started in the

United States with the formulation of Joint Commission on Accreditation of Healthcare

Organizations (JCAHO) in 1951. This model was exported to Canada and Australia in the

1960s and 1970s and reached Europe in the 1980s. Accreditation programs interest is

growing rapidly among developing countries. There are other forms of systems used

worldwide to regulate, improve and market health care providers and organizations

including Certification and Licensure. Certification involve formal recognition of

compliance with set standards (e.g. ISO 9000 standards) validated by external evaluation

by an authorized auditor. Licensure involves a process by which a government authority

grants permission, usually following inspection against minimal standards, to an individual

practitioner or healthcare organization to operate in an occupation or profession. Although

the terms accreditation and certification are often used interchangeably, accreditation

usually applies only to organizations, while certification may apply to individuals, as well as

to organizations.

Confidence in the market place and in our public services is essential. Trust is placed in the

products and services on offer often without a second thought by the customer, such are

the regulations and standards against which products are manufactured and services

provided. Usually the accreditation bodies accredit all the health care organization to

evaluate their compliance with the pre-determined standard. Accreditation bodies

develop set standard to accreditation health care organizations. Organization which

 accredit certification body (CB) for the management system standard as the standards

developed by international standardization organization (ISO) follow ISO 17011:2018 -

Conformity assessment -- Requirements for accreditation bodies accrediting conformity

assessment bodies. This standard governs the accreditation bodies to maintain certain

quality as per the international standard for accreditation followed by evaluation.

Adherence to this kind of standards gives international recognition to the accreditation

process and the clients have more confidence on the evaluation process.

For the accreditation bodies of healthcare organization gaining national and international

recognition is crucial for maintaining the confidence and quality. There are some

international umbrella bodies to conduct peer review of the national health care

accreditation. Recognition may come under various from

▪ National Recognition

▪ International Recognition through Multi-Lateral Agreement (MLA)

▪ Recognition from umbrella organization

▪ Regional Recognition

3.5.1 Recognition from Umbrella Organization

In 1985, the International Society for Quality in Health Care (ISQua) emerged from

a meeting that had been convened by EURO in Udine, Italy, to discuss the implications

of quality assurance for the training of health care professionals. The society now has
members in over 60 countries; it set up a permanent secretariat in Melbourne,

Australia, in 1995, which is largely supported by Australian State and Commonwealth

governments.

In health accreditation a standard is “a desired and achievable level of performance against

which actual performance is measured”. Standards enable “health service organisations,

large and small, to embed practical and effective quality improvement and patient safety

initiatives into their daily operations”. External organisational and clinical accreditation

standards are considered necessary to promote high quality, reliable and safe products

and services . There are over 70 national healthcare accreditation agencies worldwide that

develop or apply standards, or both, specifically for health services and organisations.

The International Society for Quality in Health Care (ISQua) seeks to guide and standardise

the development of these agencies and the standards they implement. ISQua advocates

that accreditation standards themselves need to meet exacting standards, and has

standards for how to develop, write and apply them. ISQua conducts the International

Accreditation Program (IAP) for the accreditation of standards against their standards. The

International Standards Organisation (ISO), a network of the national standards institutes

of 162 countries, is the largest developer and publisher of international standards.

Standards from ISO are also applied in international health jurisdictions.

In short, healthcare standards, and standards for standards, are ubiquitous. They are

advocated to be an important means of improving clinical practice and organisational

performance. ISQua, and many national bodies, espouse, and have documented

methodologies to promote open, transparent, inclusive development processes where

standards are developed by members . They assert that their methodologies are effective

and efficient at producing standards appropriate for the health industry. However, the

evidence to support these claims requires scrutiny.

ISQua’s key activities include:

▪ organization of an annual conference on a global and a regional basis;

▪ publication of the International Journal for Quality in Health Care;

▪ coordination of a network of corporate and individual members with a common

international interest in quality improvement;

▪ development of special interest groups, such as in health care indicators and

accreditation (the ALPHA programme).

The Agenda for Leadership in Programs for Health- care Accreditation (ALPHA) was

launched in 1999 as the result of a series of annual meetings that started in 1994 in

Treviso, Italy. Representatives of long-standing national accreditation organizations first

came together at that time with people from countries where accreditation was only

in its infancy. A group that had first met in Wellington, New Zealand, to evaluate the

activities that became Quality Health New Zealand went on to develop interactions

through a series of reciprocal visits between Australia, Canada and New Zealand. These

visits provided peer group assessment and support, and the group began to standardize

the recognition of health care provision between countries.

Three programmes of work are being developed under the ALPHA umbrella.

▪ Standards. An approved framework of principles provides the basis for review

and assessment of the standards used by individual accrediting bodies for assess-

ment of health care facilities. An accreditation organization can apply for assess-

ment of its standards to determine whether they meet international

requirements.

▪ Accreditation survey. Through a series of pilot assessments, ISQua developed an

approved set of international standards for the organization and operation of

national programmes. These are freely available for self-development and can lead

to formal external recognition of the accreditors.

▪ Support. Most accreditation programmes need support and help with develop-

ment, rather than formal approval from the international community. This can be

provided through the network of ALPHA members.

The International Society for Quality in Health Care External Evaluation Association (IEEA)

was established by the International Society for Quality in Health Care in 2018 to deliver

its external evaluation services. The IEEA commenced operations in 2019 and provides

third-party external evaluation services to health and social care external evaluation

organisations and standards developing bodies around the globe. The IEEA is a separate
legal entity which is based in Geneva, Switzerland. Please note that any existing

accreditation awarded by the ISQua IAP has been transferred to IEEA and are now formally

recognised by the IEEA.

The International Accreditation Programme (IAP) delivers a unique global accreditation

service to health and social care external evaluation organisations and standards

developing bodies. Since 1999, the IAP has provided these organisations with an

independent third-party assessment process to validate existing systems and drive

continuous quality improvement. The IAP enables these organisations to demonstrate

their credibility and benchmark their performance on an international level. Operating in

over 60 countries, the IAP offers three separate peer review assessment options:

Accreditation of Health and Social Care Standards

▪ Accreditation of External Evaluation Organisations

▪ Accreditation of Surveyor Training Programmes

IEEA’s activity does not constitute an accreditation within the meaning of Article 2 (10) of

Regulation (EC) NO. 765 / 2008 of the European Parliament and of the Council of 9 July

2008. IEEA bases its evaluation of bodies and standards exclusively on privately developed

standards, and they do not comprise an assessment or accreditation by public authorities.

3.6 Assessor Competency and Assessment Protocol

For an accreditation system, it is essential to have an assessment protocol to be followed

and to have some competent assessors who can assess the hospitals, based on the

protocol. Formulation of an assessment protocol is a very critical work and for this to be

achieved, the project would need to formulate a competent and highly skilled technical

committee, comprising of different experts for different components i.e. clinical service,

diagnostic services, quality management, health safety of staffs, training, assessment etc.

After establishing an assessment protocol, it will be necessary to have some trained

assessors, who would be able to use the protocol to assessment the facility as per the

methodology contained in it. Assessor could also be certified by a designated organization-

BAB, DGHS or HEU. Assessors may have to renew their certificate after every three years.

This project would propose a framework on how to formulate the assessment protocol and

how to develop competent assessors who can conduct assessment on the basis of the

standard and the protocol.

The methods used to select, train and evaluate the performance of assessors is very

important to an accreditation body. The experience of the accrediting organizations across

the world has also been provided along with the options that could be applied in

Bangladesh. The surveyor is a professional who is trained and skilled in surveying

techniques and gathers the relevant information to enable hospital’s compliance against a

set of standards to be assessed. The assessment team there should be one doctor.

Surveyors could be health professionals with basic training in medicine, nursing,

administration and other related healthcare professions. Surveyors are practicing or have

practiced in health services management. Surveyors around the world share many

common features in terms of careers, training, profile and expectations. Surveyors are

trained and retrained by the accreditors in the knowledge of the standards and in

evaluation techniques. Surveyors see surveying as a role of helping health care institutions

to improve their quality performance. These similarities probably arise from the objectives

of the accreditors who try to make the survey process educational as well as a rigorous

evaluation. The management of surveyors is a critical activity for an accrediting

organization. A great deal of the credibility and validity of the programme depends on this

important function.

The assessment protocol will be completed after the accreditation standard is finalized.

After finalization the specific requirement will govern the protocol.

3.7 2nd Workshop and Outcome

Main discussion point of the second workshop was the framework of the accreditation standard

from chapter – 1 to Chapter – 5. All the participants and stakeholders participated into the

workshop to determine which issues are needed to be addressed and which one might be revised

or excluded as per the circumstance of Bangladesh. All the distinguished guest self-introduced

themselves.

Many donor organizations i.e., EU, USAID, UNICEF, WB etc. has extended support to for

establishing quality health care services through an appropriate accreditation system. He

discussed on how to formulate the standard, train assessors and conduct assessment. He also

informed that the drafting of low for the accreditation council is on full pace. He also expressed

DGHS’s support for this project and DGHS will assist this project. Mr. Aminul recognized the work

done by the iota and SSMF on this project and they will try to accommodate recommendation and

suggestion made by this project into the standard formulation and administration of the

accreditation body.
3.8 Framework for Accreditation

As per the contract iota Consulting BD along with its partner SSMF has conducted the first

workshop and captured the recommendation from the key stakeholder to establish a

Hospital accreditation System in Bangladesh. This is the second report form iota Consulting

BD and it is about the proposed framework of accreditation standard.

In course of journey both of the organizations has evaluated healthcare accreditation

standards from some developing and developed countries, mainly form Southeast Asia,

South Africa and USA.

Studied standards are:

E. JCI (Joint Commission International) Accreditation Standard for Hospitals, 6th Edition
F. NABH (National Accreditation board for Hospital and Healthcare) Hospital Standards, 4th
Edition
G. MSQH (Malaysian Society for Quality in Health) Hospital Accreditation Standard 2017, 5th
version
H. BS EN 15224:2016 (Quality Management Systems) – EN ISO 9001:2015 for Healthcare

We have studied all the five standards from four different countries – USA, India, Malaysia and

South Africa – and one international organization – International Organization for Standardization.

Result of our study are elucidated in this report.

We have included the proceedings of the first workshop with this report in the substituent

chapters.
3.8.1 Rationale for Relying on Existing Accreditation Standard
The project deliverable is a set of accreditation standard that should have following

properties:

▪ They should be appropriate to the ground realities of the existing situation of the
Quality Management of the Health Care Industry
▪ They should be such that they would add discernible, quantifiable values to the
industry
▪ They should be challenging in nature but achievable as well
▪ They should be easily comprehensible and deployable

In this regard, it was useful to start from the most stringent standard and study the more liberal

ones and then highlight a set of requirements that meets above criteria.

Needless to say, that the healthcare providers of Bangladesh are struggling demonstrate a good

level of Quality and recommending a standard that is suitable for a mature industry will not be

appropriate for it.

Hence, we have made a compromise between high level of quality expectation and the maximum

level of quality achievement possible.

In this report we have summarized the key points from the four standards.
3.9 Organizational Structure and Management of Accreditation Body

The organisation of the accreditation system for Bangladesh would be at the national level

only, as we are not a very big country. Recognizing the need for and working towards the

realization of the mission and vision of the organization and its accompanying policies and

plans require the building of appropriate infrastructure at the national level. The roles and

responsibilities should be identified initially to facilitate the structuring of the organization.

The purpose of this section is to expand in detail on the organization, structure and

management of the organization necessary for effective organization. As mentioned

accreditation body would be entrusted with overall policymaking at the national level,

support state level accreditation bodies. Develop and evolve in establishing training

institutions and modules for the accreditation process and liaison with other accrediting

bodies. It could develop national level standards, guidelines & protocols. It could conduct

research, documentation, information dissemination and evaluating the state level

accreditation bodies. It could function in a supportive role and as a federation of the

accreditation body. The accountability and audit of the accreditation bodies in terms of its

functioning, relevance needs to be incorporated within the existing system. It is envisaged

that there would be a Governing Board (GB) that would have representation from various

associations and organizations as well as the government and other stakeholders. In its

composition, care should be taken to allow each of the stakeholders to be equally

represented. This would prevent the GB from being monopolized and overtaken by

dominant stakeholders. The composition of the GB could be changed periodically. The

main function of the accreditation body would be to assess whether hospitals comply with

set standards, to assist them to upgrade their standards and to play an educative and

informative role. To carry out these functions such as assessment, educational,

administration and so on staff would be employed. The staff could work either full time or

part time depending on the resources available. The staff at various levels would

responsible and report to the governing board.

ISO 17011 - Conformity Assessment – Requirements for Accreditation Bodies Accrediting

Conformity Assessment Body would be a good reference for the governance of the

accreditation bodies except finance.

 Government

Board Members along with

chairman, vice chairman Supervision
and CEO/DG

Board Secretariat Support

CEO or Director General

Training and Assessor Committees

Administration Finance and Accounts Accreditation
Certification
Department Department Department
Department Technical Committee for
Standard and Guideline
Officer - 1 Officer - 1 Development and Revision
Assessment Section Appeal Section Lead Tutors

Research and
Officer - 2 Officer - 2 Associate Tutors Development Committee
Lead Assessors

Officer - n Officer - n Tutors Other Committees

Associate Assessors

Figure -Proposed Organogram of Hospital Accreditation Board or Council

The final session of the training program on accreditation of hospital services in Bangladesh was

organized by the Iota Consulting and the Social Sector Management Foundation (SSMF) on 10

November 2020 in the conference room of the Anwar Khan Modern Medical College. It was

attended by twenty four participants (attendance sheet attached).

The meeting was chaired by Prof. Dr. Ekhlasur Rahman, Principal of the College. Prominent among

the participants were the vice-principal of the college, the director of the hospital, head of the

department of medicine, four senior professors of other departments, head of the outdoor section

of the hospital, customer care officers, head of the nursing division etc.

Picture 1: Inauguration of the Pilot Phase

The Principal welcomed all and requested the participants to make self-introduction. After the

round of self-introduction the Principal narrated a brief history of the Iota and SSMF efforts on
training the relevant officials of the medical college. He also mentioned about the inaugural

function and orientation held in the beginning on the piloting of accreditation standard, which was

attended by Dr. Aminul Hasan, the then Director of Hospitals & Clinics of the Directorate General

of Health Services. He also mentioned about the two components that the consultants (Iota and

SSMF) will take up for training, i.e. Access to Care and Continuity of Care. Although Dr. Hasan

wished that as many of the ten components should be taken as possible for training, to which Dr.

Abu Muhammad Zakir Hussain at that time, the Senior Management Expert of the European Union

Technical Assistance for the Project European Union Support to Health & Nutrition to the Poor in

Urban Bangladesh, informed the director Hasan and the audience that time and the budget may

not support this, but Iota & SSMF should try to comply the director’s request. Principal Rahman

then requested Dr. Hussain, now an honorary chief executive officer of SSMF, to talk on the

objectives of the training programme.

Dr. Hussain gave a brief on the European Union’s project and on its components, e.g. role

delineation, capacity building for municipality and city corporation officials through national and

regional training programmes, technical support, accreditation system development,

strengthening of regulatory functions for hospital care, health and nutritional care provision in

selected urban areas by non-government organizations selected by European Union itself. Dr.

Hussain said that the fundamental aim of accreditation is to improve quality based on certain

quality indicators and key performance indicators, covering as diverse areas as hospital

information communication and recording system; outdoor and indoor services; diagnostic

services; hospital safety measures; infrastructural issues such as building structure, electric and

plumbing systems; water, sanitation and hygienic conditions; food and food safety; logistics
management including medicine and other requisites; ambulance system; human resources

development; waste management etc. He then gave some past efforts taken since 2007 on

developing an accreditation system for hospital care in Bangladesh. He also informed the audience

that the Ministry of Health & Family Welfare is also proceeding forward for accreditation of the

medical, nursing and paramedical educational courses separately, outside the confine of the EU

project. He mentioned about the Bangladesh Accreditation Board, under the Ministry of

Commerce. He clarified that the Board looks after the import interest of the country and as such

only the diagnostic services in medical care are accredited by the Board. This the Board does in

collaboration of the ISO authority. The Board also arranges training for improving the quality of

care. Dr. Hussain mentioned about the independent accreditation system managed by the

Ministry of Education. He informed the audience about the accreditation certificates obtained by

zhe

Picture 2: Training on the Piloting

Evercare Hospital from JCI and by the Labaid from the Indian accreditation authority. He said that
these certificates improve the respect and prestige to the obtaining health care facilities. These

certificates tell the people about the high standards of quality that these health facilities maintain

and sustain. These certificates therefore make these hospitals more sought after and also ensure

a good price for their services based on client confidence.

Dr. Hussain stated that the Anwar Khan Modern Medical College & Hospital will have an assurance

that it was the first hospital where training was given on accreditation on a pilot basis. This will

help the college & the hospital to curve a special space in the annals of a concrete effort to develop

hospital accreditation in Bangladesh. He thanked the college & the hospital authority to allow the

consultants to conduct the training programme in the college & the hospital.

The chair, Prof. Ekhlas then invited Mr. Rajib ul Haque, consultant, Iota Consulting to present the

two components of accreditation to the participants (the presentation has been attached with this

report for the kind perusal of the Project authority). Mr. Haque elaborated on the procedures of

the first two chapter of the accreditation standard. Procedures are attached in the Annex – II

A very lively discussion followed the presentation. Questions, suggestions and clarifications raised

were noted and addressed. A short description of this has been scripted below.

One participant raised the topic of documentation and referral. It was clarified by Mr. Rajib that

these are incorporated in the ten components of the accreditation system that we are trying to

develop taking cue from the Indian, Malaysian, Australian accreditation systems and JCI and ISO

procedures.

Next point raised was on documentation and recording of patient’s history taking. These are parts

of the medical/ surgical procedures followed while giving service to a patient and are the first
procedural steps for his/her diagnoses and provision of treatment. As such these qualities are

measured through some indicators and are included in the accreditation system.

The issue of drug toxicity was brought up by one of the participants. The response given from Iota

and SSMF was that the issue of drug toxicity is also a quality issue. According to the treatment

protocol toxic drugs are the last resorts of prescription and when such a drug is prescribed, finding

no other alternative, the patient is made aware of the toxicity and the side-effects of the given

drugs and is requested to keep an eye on the development of these to take remedial measures in

time, i.e. stopping the drug or treating the toxicity and the side effects.

One participant asked about the prevention, control and management of infectious diseases and

whether these topics are included in the accreditation system. It was clarified that if a patient is

admitted in a hospital with infectious disease then it will come under the purview of accreditation

system through provision of quality care to the patient. But when it is community or population

based matter then it is not within the realm of a hospital accreditation system.

The issue of treatment came up during the discussion session. It was explained that bedside

treatment, treatment at outdoor clinics and treatment in the emergency room may be medical or

surgical interventions. Purely surgical interventions are provided in the operation theaters,

followed by post-operative care. There are clinically correct procedures which are to be followed

in all these service sites. The accreditation system narrates the procedures of these systems by

service type including correct identification procedures of a patient at every step of treatment.

Suitability of a treatment procedure for a given patient also falls within the domain of accreditation

steps. It was also clarified that detail and sufficient management procedures are included in the

accreditation system for emergency, surgical and diagnostic procedures.

Question was raised on the price of a clinical or diagnostic service in a hospital, given as per the

accreditation standard. It was elaborated by Dr. Zakir that the higher the rating of a hospital, which

means a higher and higher quality of care offered by the hospital, will automatically have demand

in the health care domain and will help the hospital to sell a higher quality service at a relatively

higher price, inasmuch as there is demand for service from that hospital. It is actually a market

force that comes into play economically.

A few participants wanted to learn more about the other components of the accreditation system.

It was decided that Iota will send the full range of the soft copies of the accreditation system and

components to the principal of the college and the director of the hospital, so that they may

distribute it among those who are interested to learn more about the accreditation system in full.

3.10 Validation Workshop

Outcomes of validation workshop are as follows

• Accreditation for health system; questioned why there is no standard system in

Bangladesh?

o Apollo/ Evercare Hospital has standard system (JCI)

o Lab Aid too (NABH)

• Mentioned Spot Survey questionnaire

• Presentation of a picture examplifying Nurses using PPE made from (Garbage Bag) in a New

York Hospital in Covid-19 Pandemic

• Medical Tourism=> $2 B Dollar per year towards India from Bangladesh

• Comparison of hospital qualities

o Bangladesh

o Private & Public (Services vary in quality from institution to institution)

• Need of improving hospital quality

• Accreditation: it is voluntary + requires Law

• This ensures happiness of patients (Accreditation)

• Looks after happiness of authorities (Laws)

• Visualization of Process Model (proposed Accreditation)

• Bangladesh Medical Accreditation Council (Proposition)

• Process of Standardization for Accreditation (similarity with ISO certification)

• Major Challenges:

o Non-existing accreditation system

• Sample model: NABH with 10 clauses

o A similar book of standard is also needed for Bangladesh

o Proposition of Standards => Bangladesh (Covid-19 is also a take home lesson;

highlighted mismanagements)
4 Project Output Summary
▪ Bangladesh Accreditation Board is not mandated for Hospital accreditation and a separate

authority is required

▪ There could an individual authority under Ministry or under DGHS, which would be

responsible for the accreditation activity

▪ Quality management practice in existing hospital is far from acceptable limit

▪ There are number of good accreditation standard available even in regional level.

▪ Hospital accreditation standard of Bangladesh can be prepared by consulting those

standards

▪ Hospital accreditation standard should include performance indicator

▪ This project has proposed governance structure for the accreditation body along with audit

process, certification process and auditor qualification process.

▪ This project also evaluated the possibility of external recognition for the Bangladesh’s

accreditation authority and accreditation standard. Both the organization and the standard

can get international recognition from ISQua.

▪ Piloting of first two chapter showed that we should not make the standard difficult to be

followed by the hospital right now. Standard can be made strict over time with subsequent

revisions.

▪ This project has proposed audit protocol and criteria for assessor competency
5 Further use of this project outcome
▪ Proposed accreditation framework could serve as a baseline material for developing the

hospital accreditation standard of Bangladesh, in future

▪ Future hospital accreditation standard of Bangladesh might adopt the proposed structures

or processes on

▪ Governance

▪ Standard development, review and revision

▪ Accreditation of hospital and appeal

▪ Criteria for qualified auditors and their endorsement

▪ International recognition from ISQua

Annex: Proposed Hospital Accreditation

Standard Framework