Programs: MBA

K SANDHYA RANI 225012301368

Subject Code: MMBA22E64
Name of the Subject : Hospitl Operations Management

1. Case study – 10 Marks

One of the renowned Corporate Hospital of the city “Fit & Healthy” planned to
standardize and improve the quality of care of their services provided to the patient.
They made some renovation of the hospital campus. They even planned to procure
some of the new biomedical equipment necessary for the diagnostic and therapeutic
services of the patient. In order to improve the quality of services for the patient,
they decided to apply for NABH Accreditation. The hospital administrator and all
the other clinical and non- clinical faculties were divided into various committees
for the purpose of obtaining NABH accreditation. All the people working in that
hospital were also provided various training for the purpose of NABH
Accreditation. With all their joint efforts they applied for Entry level NABH
Accreditation and also succeeded in passing through the initial level of NABH Pre-
Accreditation. Subsequently, they proceeded working towards obtaining the next
level of accreditation.
Questions:

i) What do you mean by NABH Accreditation and what are the benefits of
obtaining NABH accreditation?

National Accreditation Board for Hospitals & Healthcare Providers (NABH) is a

constituent board of Quality Council of India (QCI), set up to establish and operate
accreditation programme for healthcare organizations.

Hospital Accreditation Programme

Hospital Accreditation:

The hospital accreditation program was started in the year 2005. It is the flagship
program for NABH. This program was started with an intent to improve healthcare
quality and patient safety at public and private hospitals, has subsequently grown to
greater heights, with the standards being recognized internationally at par with
other global healthcare accreditation standards and accredited by ISQua
(International Society for Quality Assurance in Healthcare). The accreditation
standards for hospitals focuses on patient safety and quality of the delivery of
services by the hospitals in a changing healthcare environment.
Programs: MBA
K SANDHYA RANI 225012301368
Subject Code: MMBA22E64
Name of the Subject : Hospitl Operations Management

Ten chapters of Hospital Standards are:

a) Access, Assessment and Continuity of Care (AAC)

b) Care of Patients (COP)

c) Management of Medication (MOM)

d) Patient Rights and Education (PRE)

e) Hospital Infection Control (HIC)

f) Patient Safety and Quality Improvement (PSQ)

g) Responsibilities of Management (ROM)

h) Facilities Management and Safety (FMS)

i) Human Resource Management (HRM)

j) Information Management System (IMS)

Benefits of Accreditation

Benefits for Patients

• Patients are the biggest beneficiary among all the stakeholders.

• Accreditation results in high quality of care and patient safety.

• The patients are serviced by credentialed medical staff.

• Rights of patients are respected and protected. Patient’s satisfaction is regularly

evaluated.

Benefits for Organization

• Accreditation to a health care organization stimulates continuous improvement.

• It enables the organization in demonstrating commitment to quality care and patient

safety thereby ensures best clinical outcomes.

• It raises community confidence in the services provided by the health care

organization as services provided by credentialed medical staff.
Programs: MBA
K SANDHYA RANI 225012301368
Subject Code: MMBA22E64
Name of the Subject : Hospitl Operations Management

• It also provides opportunity to healthcare unit to benchmark with the best.

• An accreditation status also provides marketing advantage in a competitive health

care.

• The HCO standards having been certified by ISQua gives an international recognition
which will also help to promote medical tourism.

• Finally, accreditation provides an objective system of empanelment by insurance and

other third parties.

Benefits for Staff

• The staff in an accredited Hospital is satisfied lot as it provides for continuous

learning, good working environment and leadership.

• Efficiencies and competencies of staff also gets improved in an accredited Hospital.

• It improves overall professional development, knowledge and competencies in

systematic ways with defined ownership and accountability of all the staff
including Medical and Para Medical Staff.

Benefits to paying and regulatory bodies

Finally, accreditation provides an objective system of empanelment by insurance

and other third parties. Accreditation provides access to reliable and certified
information on facilities, infrastructure and level of care.

ii) What is the difference between NABH Full accreditation & Entry level
Accreditation?

Pre Accreditation Entry Level - Hospitals. Hospital Accreditation is a public recognition by

a National Healthcare. Accreditation Body, of the achievement of accreditation standards by
a. Healthcare Organization, demonstrated through an independent external peer.
Introduction. National Accreditation Board for Hospitals & Healthcare Providers
(NABH) is a constituent board of Quality Council of India, set up to establish and operate
accreditation programme for healthcare organisations.
Programs: MBA
Subject Code: MMBA22E64
Name of the Subject : Hospitl Operations Management K SANDHYA RANI 225012301368

iii) What are the requirements of Hospital Preparedness for NABH Accreditation?

An organization planning to go for NABH accreditation may obtain a copy of NABH

accreditation standards and carry out a self assessment on the status of compliance with the
standards to ensure that the standards are implemented and integrated with the hospital
functioning. Note: For further details, please go through the various documents including
“General Information Brochure” available on our website.

iv) What is the role of Quality Manager in a hospital for NABH Accreditation?

Present-day hospitals work like corporates. For smooth day to day functioning, hospital
operations have to be handled very carefully with quality execution. Being a quality assurance
manager in healthcare assures programs and services are implemented at the highest standards
and patients receive the highest level of care. Quality managers are responsible for monitoring
and updating policies and procedures to include regulatory changes.

They also typically manage through subordinate managers and professionals in larger groups of
moderate complexity.

Quality managers intend to guarantee that the product or service an organization provides is fit
for purpose, is consistent, and meets both external and internal requirements. This comprises
legal compliance and customer expectations.

The role is concerned with monitoring and advising on the performance of the quality
management system, producing data and reporting on performance, measuring against set
standards.

The quality Manager needs to liaise with other managers and staff throughout the organization to
ensure that the quality management system is functioning properly. The role needs to focus on
changes and how to implement them and provide training, tools, and techniques to enable others
to achieve quality standards.

Responsibilities

Quality managers use a variety of measures and management systems, such as total quality
management, to carry out your role. However, a quality manager typically needs to:

 Devise and establish a hospital’s quality procedures, standards, and specifications

 Programs: MBA
Subject Code: MMBA22E64
Name of the Subject : Hospitl Operations Management K SANDHYA RANI 225012301368

 Review patient requirements and make sure they are met.

 Set standards for quality as well as health and safety

 Make sure that services meet international and national standards

 Look at ways to reduce waste and increase efficiency

 Define quality procedures in conjunction with operating staff

 Set up and maintain controls and documentation procedures

 Monitor performance by gathering relevant data and produce statistical reports

 Review existing policies and make suggestions for changes and improvements and how
to implement them

 Measure performance and identify any areas of weakness, recommending and

implementing improvements

 Assess the effectiveness of changes made

 Use relevant quality tools and make sure managers and other staff understand how to
improve the business.

Qualifications

Although a career as a quality manager is open to all graduates, a degree in a relevant area, such
as Hospital Administration (BHA). However, a Master’s degree (MHA) along with knowledge
about NABH and JCI are commonly quite preferred by employers. Experience is more important
in this role. To be a quality manager healthcare typically requires more than three years of
managerial experience.

Skills

Quality Manager needs to have:

Communication and interpersonal skills

Analytical and problem-solving ability

Planning and project management skills

 Programs: MBA
Subject Code: MMBA22E64
Name of the Subject : Hospitl Operations Management K SANDHYA RANI 225012301368

Persistence and the ability to influence others

The ability to lead and motivate a team

A strategic approach to work

The ability to facilitate change

Skills in numerical and statistical analysis

Attention to detail

An understanding and appreciation of other people’s work disciplines, such as Engineering and
science.

v) What is the benefits of ISO 9001:2015 healthcare certification?

ISO 9001 is a universally used quality management standard, adopted by organizations all over
the world to standardize and improve the service given to customers. The standard is used across
all sectors of business, but is more prevalent in some than others. In my time working in both the
electronics and document conversion and storage business, ISO 9001 was a critical customer
requirement for different reasons. The electronics industry, which you can read about in this
previous blog article: Tips for ISO 9001 in the electronics industry, has an unwritten rule that if
you wanted to do business overseas, then ISO 9001 accreditation is required to display your
commitment to customer quality. In the scanning and data conversion business, contracts with
banks and government bodies mean that ISO 9001 is a vital requirement where the end user
demands standardization of processes, on-time delivery, and the knowledge that a formal
corrective action procedure is present to deal with any outages or process escapes that may
occur. So, during a recent discussion with an organization that provided a service to a hospital, it
struck me as very odd that this level of quality management is not an industry standard in our
hospitals – after all, what is more important to the general healthcare of the population than the
way that critical healthcare is managed? This got me thinking: Would hospitals benefit from ISO
9001 accredited quality management systems?
Programs: MBA
Subject Code: MMBA22E64
Name of the Subject : Hospitl Operations Management K SANDHYA RANI 225012301368

Uniformity of objectives and methodologies: This would allow all hospitals to use the same
processes to pursue goals.

Costs: Shared processes and methods allow staff to transfer and work at other sites seamlessly
with a minimum of training.

Staff costs: It could be strongly argued that if a standardized quality management process
existed within hospitals, that considerable administrative and expensive management costs
could be eliminated, given that standard processes, training, objectives, and goals would exist.

Morale: Shared and well-communicated objectives with a defined corrective action process,
supported by sturdy customer feedback, risk management, internal audit, and corrective action
procedures, ensure that staff have a defined goal and improves morale.

Information sharing: Standardized processes across multiple hospitals would allow data and
knowledge to be shared, ensuring greater efficiency and lower costs in pursuit of objectives.

Improved customer satisfaction: The absolute goal of any ISO implementation process.
Measuring, review, and action versus the respective clauses of the standard should ensure the
continual improvement cycle and provide better service and effective lessons learned for the
benefit of the end user, the patient.
Programs: MBA
Subject Code: MMBA22E64
Name of the Subject : Hospitl Operations Management K SANDHYA RANI 225012301368
So, it can be seen that although most hospitals surely use processes like internal audit and risk
management, there could be real benefits from the standardization of processes across multiple sites
within the ISO 9001 accreditation process. Improving customer satisfaction is the best reason to
implement ISO 9001, which you can read more about in this previous article: Handling customer
satisfaction with code of conduct and complaints procedure, and if you can improve service in a key area
where better processes and continual improvement can mean saving lives, the benefits are even greater.
The project size and costs may be great, but as with most organizations that have pursued ISO 9001, it
will soon be apparent that the benefits and savings would be greater.

ISO 9001 for hospitals:

Hospital performance statistics and articles about services falling short of expectations are rarely out of
the news these days, and it’s normally the negative statistics and stories that catch the attention of the
media. While all hospitals are measured by national and regional governments in terms of certain key
performance indicators, it seems that internal performance, and therefore quality management can vary
massively from hospital to hospital. So, given that hospitals are asked to perform versus the same KPIs, is
it not strange that each individual hospital will try and attain these objectives using different internal
methods? Let us examine what a standardized ISO 9001 process would bring to hospitals, and the
components of the standards that could bring value across a national hospital network:

Periodic management reviews: All organizations using the same formats and sharing targets and
objectives.
Internal audits: All hospitals would have to perform these as standard practice.
Measurement and control of suppliers: This would allow consistency and assurance that taxpayer money
was utilized efficiently.
Customer feedback: The ISO 9001 requirement to solicit customer feedback would help to ensure that
preventive measures would be more prominent than corrective actions.
Corrective action: A standardized and formal corrective action process that could be shared across
different sites could be a huge advantage to hospital managers.
Risk assessment: Again, this is obviously performed within most work environments, but a standardized
and regular format that is recognized across multiple sites could bring improved synergy and reduced
costs to the service provided.
Continual improvement: As the recurring theme of the 9001 standard, the above processes, when
undertaken correctly, can drive real improvement within a hospital environment similarly to any business.
So, these processes, along with the other core principles and clauses of ISO 9001, could help to bring
Programs: MBA
Subject Code: MMBA22E64
Name of the Subject : Hospitl Operations Management K SANDHYA RANI 225012301368
uniformity and continuity to a network of hospitals.