Background: Quality of healthcare services, patient safety and staff satisfaction the essence of accreditation, are indispensable to favourable patient outcomes. This study aimed at identifying opportunities for improvement based on extent of conformance to existing applicable accreditation standards.
Method:A cross-sectional observational study was conducted in an apex public sector ophthalmic hospital in India during March and April 2016. Opportunities for improvement identified based on extent of compliance to accreditation standards as per criteria laid in NABH self-assessment toolkit. Reviews of hospital departments, services and functions were done through document review; visit to different patient care areas; staff and patient interviews were conducted. A sample of ten observations was taken for each objective element from same or different areas based on applicability and scored as full, partial or non-compliant (0, 5, 10 respectively).Gaps were identified based on score less than 50% of aggregate or individual standard with more than two zeros.Results: Hospital was compliant to accreditation standards of NABH with an overall score of 74%. All regulatory requirements met. Opportunities for improvement identified were related to quality assurance of labs, cardio-pulmonary resuscitation, pain assessment, awareness and reporting of medication errors, redressal mechanism, effective implementation of patient safety and quality improvement programmes. Continuous quality improvement chapter had lowest compliance (39%).
Conclusion:The hospital met accreditation requirements except those related to documentation and continuous quality improvement (an advanced stage of accreditation) amongst few others which are predominantly specifically oriented to accreditation related activities. The study delineates how the identified opportunities can be met based on interpretation of the standards. The study is limited by the fact that documentation in the form of circulars and a Residents' Manual which are not as per the requirements of NABH have been considered.