The Union Ministry of Ayush has issued the draft 'Accreditation Standards for Ayurveda Hospitals' which will facilitate healthcare organisations to deliver safe and high quality care to the patients. Compliance with all chapters is equally important to establish compliance with the accreditation standard.
The accreditation standards are not expected to be prescriptive. They only lay down the requirements and it is up to the healthcare organisations to come out with the systems, processes and modes of measuring performance indicators, which can demonstrate compliance to the requirements as specified in the standard.
The requirements of the standards shall have to be identified; evidenced by data gathered, analysed and interpreted with the aim of improving the quality system of a hospital. Wherever the word shall/should is used, it is imperative that the organisation implement the same. Where the phrase can/could/preferable is used the organisation would use its discretion and implement it according to the practicability of the proposed guidance.
In general, the organisation will need to establish clear evidence backed by robust systems and data collection to prove that they are complying with the intent of the standards. These systems are as we say, defined, implemented, owned by the staff and finally provide objective evidence of compliance.
Some of the key issues include: Patient related issues like monitoring safety, treatment standards and quality of care. This would mean to effectively meet the expectation of patients and their families and associates; Employee related issues like monitoring competence, on-going training, awareness of patient requirements and monitoring employee satisfaction; Regulatory related issues like identifying, complying with and monitoring the effective implementation of legal, statutory and regulatory requirements which affect patient safety; and Organisation policies related issues like defining, promoting awareness of and ensuring implementation of the policies and procedures laid down by the organisation, amongst staffs, patients and interested parties including visiting medical consultants.
Another key area is NABH Standards related issues like 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 (for example, related to emergency, surgical procedures, laboratory services, radiological services, etc) in a particular organisation, 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 understood and applied.
The first edition of NABH standard has been in practice for last six years now (2009-15) and is revised and up-graded to 2nd edition. The guiding principles for revision of the standards have mainly been the experience of stakeholders including assessors, hospitals, members of accreditation and technical committees and industry experts. Secretariat of NABH did bulk of job by collating and assimilating the feedback information, linking with relevant chapters and presenting to the technical committee for deliberations. This was again discussed in detail by industry experts. It was finally and extensively reviewed by committee appointed by Ministry of Ayush, which went in to thought process and came out with the edition.