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PDCAApproach to Accreditation


  • Kunal Jawahar Thakkar
  • Agency : Health Care Delivery, NABH Standards, PDCA
  • Objective : This study done at super specialty hospital provides organizations with an opportunity to strategize accreditation processes with a time tested approach. The hospital was going towards achieving NABH accreditation, as a first step towards it, with the question that “does the hospital fully compliant to NABH standards?” and with the objective of bringing a basic quality approach towards accreditation, this study on PDCA approach to accreditation was done.
  • Background : In every organization, there is an opportunity to improve the quality and performance of the healthcare delivery. The problem frequently faced by organizations today is to know which quality approaches – complemented by and integrated with existent quality improvement systems – would have the greatest impact on the outcomes delivered by their healthcare providing systems.
  • Methodology : With scoring the hospital in comparison with standards as 0/5/10 and checking them as in which step of PDCA are the objective elements; it was found that the current status of operations at the hospital is about 70 percent compliant to NABH standards and out of 479 applicable objective elements, only 293 have completed their PDCA cycle of improvement. Percentage compliance and requisites for compliance to standards were found out for all the objective elements. Chapter HIC – hospital infection control among the patient centric standards and chapter CQI – continuous quality control among the organization centric standards were with the lowest scores.
  • Findings : With scoring the hospital in comparison with standards as 0/5/10 and checking them as in which step of PDCA are the objective elements; it was found that the current status of operations at the hospital is about 70 percent compliant to NABH standards and out of 479 applicable objective elements, only 293 have completed their PDCA cycle of improvement. Percentage compliance and requisites for compliance to standards were found out for all the objective elements. Chapter HIC – hospital infection control among the patient centric standards and chapter CQI – continuous quality control among the organization centric standards were with the lowest scores.
  • Recommendations : The study revealed areas that need special focus and all the requisites to achieve NABH accreditation. It was emphasized and proved that accreditation is not mere buzzword but an extraordinary tool for health care institutions to improve their services. Application of PDCA approach to Accreditation is the right way for hospitals to trudge the path of quality healthcare provisioning.
study done at super specialty hospital provides organizations with an opportunity to strategize accreditation processes with a time tested approach