What Are Challenges That Organizations Often Face When Preparing For Accreditation?

For any healthcare organization, getting accreditation means getting recognition for its performance standards, by a national accreditation body (NABH) or international accreditation organization (JCI).

It means that the organization has managed to meet the stringent standards at various levels set by the body, which is an independent external peer.

Accreditation is a testimony to a healthcare organization’s commitment to improve the safety and quality of patient care, ensure a safe care environment for patients, and continually work towards reducing risks to patients and staff.

The following are the challenges needed to be successfully overcome by the team to achieve accreditation.

  1. The dearth of Core Team

The core team must include the representatives of Clinicians, the Nursing team, Quality, HR and training, Engineering, microbiologists, Housekeeping, Front Office, F&B, MRD & Pharmacy, etc. The detailed gap analysis across various departments concerning the objective factors of accreditation standards is to be carried out by the core team, in tandem with functional heads. The core team shall get the full support of the higher management to accomplish the tasks & achieve desired standards for the organization.

  1. Procrastination and Inconsistent Processes

Most departments do not have written and practiced SOPs. Before beginning on the journey to accreditation, the core accreditation team needs to overcome the major challenge to break the inertia and ensure that the SOPs must be prepared on time by each department. There must also be a Cross-functional team for audits of each department to check the compliance with the SOPs. Implementation of the SOPs at the ground level is the key to the success of getting accredited which is achieved by intradepartmental training.

The audit observations, gap analysis, and gap closure are linked to the key result areas of a department & to ensure minimum non-compliance. 

  1. Unsafe Environment

The organization must work on improving the hospital infrastructure to ensure a safe environment for patients and staff.

  • The adherence to national building codes on fire norms.
  • The bilingual signages should be reworked.
  • The air condition, laminar flow in OT shall be reworked; HEPA filtration & OT direct excess should be controlled.
  • The air-conditioning design shall be for negative pressure in the isolation room.
  • Patient safety devices like nurse call units, care of vulnerable patients need to be tested for their functionality before submitting an accreditation application.
  • Patient Safety Goals should be achieved.
  • The organization must host proper meetings of all the relevant committees with precise documentation.
  1. Improper Documentation

The major issue to be worked on is the mistakes in documentation, like unsigned treatment orders, incomplete discharge sheets, and medication orders. The top administration needs to understand the sensitivity of the problem and address the issue. The resident medical officers play a critical role to reduce these errors. The checklist must be created to check patient files and a team of medical officers must facilitate the activity both at the ward and medical records office. 

Also, the fortnightly/monthly CMEs for clinicians can be conducted to emphasize documentation and capturing of conflicting events, near misses, and sentinel events.

  1. Untrained Staff for Emergency Preparedness

The training department must identify both, hospital-wide (FIRE, BLS, Patients Rights & Responsibilities, etc) and department–wide (e.g Nursing –BMW, Hand Hygiene, NSI, Spill management, etc) training needs. The trainers for each activity need to be identified and mapped in the training calendar. Classroom training and hands–on training for emergencies shall be conducted, and feedback of the same must be critically evaluated and presented to the core team. 

The biggest hurdle is to get employees to attend training sessions during duty hours. The challenge becomes intense when occupancy increases in the hospital. The constant motivation from departmental heads and the HR team can help overcome this challenge.

The mock drills on fire, community disaster, code blue, and spillage of bio-medical waste involve a team effort. The cohesiveness in the team shall be achieved after repeated mock tests.

  1. Lack of acceptance of Data-Driven Approach

Accreditation pushes a healthcare organization towards a data–driven approach as quality indicators/metrics like surgical site infection and patient satisfaction index are captured and analyzed by committees. The challenge is to capture correct information regularly, undiluted by human interference. 

As in many cases, the acceptance of data and arrangement to work towards the betterment of metrics by functional heads is a challenge. The top management initiative in quality improvement activities can help the hospital to move towards the journey of perpetual improvement.

  1. Partial implementations of Laws and Regulations

The list of regulatory compliances includes obtaining and renewing pharmacy, lift, and blood bank licenses before accreditation. Also, before filing for accreditation, the hospital needs centralized tracking of all these.     

The legal department should take initiative to put systems in a position to track all regulatory compliances. The departmental heads shall start sharing all documents with the legal department and management on priority.

  1. Inconsistent Work

The timeline is very essential to attain accreditation. There is a fixed duration to correct the non-compliances after the pre & final evaluation by the accreditation body. There must be a hunger and enthusiasm to do the perfect quality work on time in all the employees of the healthcare organization. The core team shall continuously support the employees to move ahead in this process.

  1. Having Misconceptions regarding Accreditation

 All stakeholders must know that Accreditation benefits them all.

  1. Patients get benefited because–
  • Having a high quality of care and safety.
  •  Services are given by credential medical staff only.
  •  The rights of patients are respected and protected.
  •  Patient satisfaction is regularly evaluated.
  1. Staff is benefited due to continuous learning, good working environment, leadership, and above all ownership of clinical processes.
  2. Health care organizations get benefited due to stimulated continuous improvement.

Accreditation also demonstrates a commitment to quality care. It raises community confidence in the HCO services. It provides the opportunity to the healthcare unit to attain the benchmarks and an objective system of empanelment by insurance and other third parties.

Accreditation also provides access to reliable and certified information on facilities, infrastructure, and level of care.

10. Inadequate Inventory Control Measures

Considering the large number of stores across the healthcare organizations, and drugs and consumables kept in each sub-store and patient areas, it is a major challenge to identify expired and near expiry drugs. The joint audit from the central store and user department on regular basis must help reduce the error. 

Overcoming these major challenges besides others like sustenance of facility/equipment, medication management, and nursing care, is essential & may help the hospital secure accreditation.

This is possible with the commitment of all stakeholders – the management, the team members, and the out-sourced employees. They must understand and know what the accrediting body is looking for, how to read and interpret the accreditation standards, and know what are the benefits of getting accredited.

This will help them to work towards it with better focus and enthusiasm. If you prepare well and have adequate project management you should be able to avoid these challenges and secure your accreditation.

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