Hospital Accreditation Documentation Process

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Hospital Accreditation Documentation Process
Standard Requirements
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What is Hospital Accreditation?

• Accreditation is a voluntary process. Its
  standards are usually regarded as optimal and
  achievable.
• It provides a visible commitment by an
  organization to improve the quality of patient
  care, to ensure a safe environment and to
  continually work to reduce risks to patients and
  staff.
• Accreditation has gained worldwide attention as
  an effective quality evaluation and management
  tool.
• The focus of accreditation is on continuous
  improvement in the organizational and clinical
  performance of health services, not just the
  achievement of a certificate or award or merely
  assuring compliance with minimum acceptable
  standards.
• Accreditation focuses on learning, self
  development, improved performance and reducing
  risk.

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Why Hospital Accreditation?

• Ensures a Quality Index for Health Consumers. A
  growing number of hospitals in India are turning
  to accreditation agencies worldwide to both
  standardize their protocols and project their
  international quality of health care delivery. 
• It is a Public Recognition of the achievement of
  accreditation standards by a healthcare
  organization, demonstrated through an independent
  external peer assessment of that organization's
  level of performance in relation to the
  standards.
• Attract foreign patients.
• The process of accreditation is envisaged to
  result in a process of fundamental change in the
  technical procedures of service delivery, in the
  appropriate use of available technologies, in the
  integration of relevant knowledge, in the way the
  resources are used, and in the efforts to ensure
  social participation.
• Quality Assurance helps improve effectiveness,
  efficiency and in cost containment, and
  accountability and the need to reduce errors and
  increase safety in the system.

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Requirements of NABH Accreditation

• The general and technical NABH accreditation
  requirements that any organization must follow
  while implementation of NABH system to achieve
  best results and quick NABH certification.
• Access, Assessment and continuity of care.
• Patient Right and Education.
• Care of Patients.
• Management of Medication.
• Hospital Infection Control.
• Continuous Quality Improvement.
• Responsibility of Management.
• Facility Management and Safety.
• Human Resource Management
• Information Management System.

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Advantages of Hospital Accreditation

• Key advantages that organization can achieve with
  implementation of accreditation system in any
  hospitals and healthcare units.
• Patients are benefited with Accreditation most.
• Accreditation results in high quality of care
  and patient safety. The patients get services by
  credential medical staff
• Rights of patients are respected and protected
• Patient satisfaction can be evaluated.
• The staff are satisfied lot as it provides for
  continuous learning
• Accreditation to a health care organization
  stimulates continuous improvement.
• It enables the organization in demonstrating
  commitment to quality care.
• It also provides opportunity to healthcare unit
  to benchmark with the best.
• Accreditation provides access to reliable and
  certified information on facilities,
  infrastructure and level of care.

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Documents Requirements for Hospital Accreditation

• The key sections of Hospital Accreditation set
  out a range of documents requirements for
  developing, implementing and maintaining a
  hospital and medical laboratory in Quality
  management system tailored to the design and
  production of hospital devices.
• Sample hospital Manual
• Hospital Mandatory Procedures
• Exhibits and Standard Operating Procedures
• System Sample Forms
• Audit Checklists

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Total Hospital Accreditation Documents by
Global Certification Consultancy
The Hospital Accreditation documents by
Certificationconsultancy.com are very useful for
hospitals in designing quick documentation for
hospital NABH accreditation. This document
includes hospital manual, procedures, exhibits,
formats and audit checklist are very helpful of
upgraded and implements QMS System and easy way
of NABH certification. This document are written
in English and easily editable, which saves much
time.
Click to Download Free Sample Documents
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Hospital Manual
The Hospital manual is a mandatory documents for
NABH accreditation certification, which maintain
quality system in hospital and medical lab and
research center. This manual documents describes
scope of services, hospital policy and mission,
applicable law and regulation, quality policy and
organization structure. The hospital manual
shall outline the structure of the documentation
used in the quality management system your
organization.
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Hospital System Procedures
The Hospital system procedures are designed to
help the organization in developing effective
system procedures for make the best system and
quick process improvements. All required system
procedures list below

• Procedure for hazards identification and risk
  assessment
• Procedure for identification of legal and other
  requirements
• Procedure for objectives and targets
• Procedure for OHSMP
• Procedure for consultation and communication
• Procedure for operational control
• Procedure for emergency preparedness and response
• Procedure for performance monitoring and
  measurement
• Procedure for incident investigation,
  nonconformity, corrective action and preventive
  action

• Procedure for control of nonconforming services
• Procedure for management review
• Procedure for document and data control
• Procedure for corrective and preventive action
• Procedure for control of quality records
• Procedure for internal audit
• Procedure for control of monitoring and measuring
  equipments
• Procedure for Training

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Hospital Exhibits
The exhibits and SOPs are very helpful tool to
teach all employees and staff about how to
implements and improvements of Quality management
system in Hospital that helps organization to
continues improvements and get number of
benefits. Following list of Exhibits will be
given along with documents.

• Billing Section Activity
• CATH Laboratory
• Patient Service
• ECHO, ECG And Trade mill testing(TMT) Laboratory
• Maintenance
• Training
• Linen Activity
• Marketing

• Medical Shop
• Microbiology Laboratory
• Nursing Station
• Pathology Laboratory
• Purchase
• Stores Process Flow
• Utility
• X Ray And Sonography Laboratory

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Hospital Accreditation Sample Forms
The sample formats documents are not compulsory
to follow organization, but this documents very
helpful of maintain records as well as establish
control and make quality system in the
organization. List of sample formats below

• Sanitation audit report
• Pest control report
• Fumigation report
• Operation theatre readiness form
• Toilet Cleaning record
• Daily Equipment Cleaning record
• Suggestion Card
• Patient Complaint Report
• Inquiry Monitoring record
• Near Miss Report and more

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Hospital Accreditation SOPs
The Hospital SOPs are given to help to any
significant aspects issues and used as a training
guide as well as to establish control and make
system in the organization. Following list of
Sample Hospital SOPs below

• Access assessment and continuity of care
• Care of Patient
• Continuous Quality Improvement
• General
• Management of Medicine
• Patient rights and Education

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Hospital System Audit Checklist
The hospital system checklist is a good tool for
the auditor to make audit question to make
effective hospital accreditation internal audit
for their organization. There are audit
questions based on NABH accreditation clause wise
and department wise requirements are included in
the total documentation kit for Hospital
Accreditation System.
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Benefits of Using Hospital Accreditation Documents

• By using these documents, you can save a lot of
  your precious time while preparing your hospital
  to the NABH accreditation.
• Take care for all the section and sub sections
  of NABH guidelines and helps you in establishing
  better system
• Document kit enables you to change the contents
  and print as many copies as you need. The user
  can modify the documents as per their industry
  and create own NABH documents for their
  organization
• Readymade templates and sample documents are
  available which can reduce your time in document
  preparation
• Save much time and cost in document preparation
• The audit questions helps in making perfect
  audit checklist
• You will get better control in your system due
  to our proven formats and templates
• This document kit is very much useful to the
  users to make the world class hospital and
  establish good system and discipline with work
  force from the beginning

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Thank You for Attending Presentation on Hospital
Accreditation Documentation Process
For More information write us at
sales_at_certificationconsultancy.com
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