Accreditation ProcessJuly 8, 2020 2020-08-18 7:24
Hospital (JCI/ NABH/NABL) Accreditation Consultancy & Mock Services
PHASE 01- GAP ANALYSIS
Our consultants work with hospital staff for gap assessment, Review of existing documentations and Organization’s current practices. The gaps will be raised as per NABH 5thedn& JCI hospital accreditation standards 7th Edition.
The survey takes places via a combination of on-site visit, information gathering, and elaborate interviews. This survey will help /support our consultants to prepare the project plan & prepare timelines and responsibilities.
PHASE 02- PROJECT PLANNING
On the basis of Gap assessment our consultants & trainers will design project plan detailing documentation requirements, timelines and responsibilities.
This project plan will help us in Designing, Development & Modification of all the procedures, SOPs, work instruction (WI), Formats, Checklists, Manuals and other related documents as per standard requirements.
PHASE 03- REVIEW, MODIFICATION & DEVELOPMENT
Adequate Designing, Development & Modification of all the Procedures, SOPs, Work Instructions (WI), Formats, Checklists, Manuals and other related documents as per standard requirements. Designing of documentation as per requirement and training of the employees
PHASE 04- TRAINING ALL EMPLOYEES
Hospital Infection Control Prevention & Control, Disaster management & Adverse events capture, RCA & CAPA, Services - Registration, Admission, Care of patients, Critical Value alerts & Early warning signs monitoring, Management of Medications in hospital, Laboratory management, Radiology quality assurance, ICU & O T Services, Hospital infection control & prevention, Facility Management & Service, Human Resources Management, Medical Records & Information Management system
PHASE 05- IMPLEMENTATION
The implementation process will include training of health care workers on what is documented as per the organization’s policy. The record keeping and running of what is written in the Procedures and related formats throughout the organization.
PHASE 06- CLINICAL AUDITS
Throughout the project period, a quality link team is selected from different departments and a comprehensive training is given by Qualified trainers & Auditors from Medicuality. Training will consist of exercises, group workshops & tracers. The hospital personnel are practically trained on the survey concepts and methodologies.
PHASE 07- MOCK SURVEY
Once the requirements have been fully implemented, our auditors will conduct a mock survey to determine whether organization is ready for the formal audit. Below is very visible benefit of such exercise at this stage survey team consist of 3 surveyors representing same combination of official surveyors (Physician, Nurse & Admin) Hospital staff get a hands-on experience with sessions and tracers as survey simulation.
PHASE 08- FINE TUNING & TRACER PRACTICE
Consultants will work with facility staff to close the gaps identified from mock survey, key staff members will undergo repeated tracer methodology practise.
PHASE 09- PREPARATION FOR FINAL SURVEY
This phase involves preparation of survey logistics, document folders, last minute updates etc, and consultants will be available to assist staff members.