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Hospital Accreditation

Hospital accreditation is a process by which healthcare organizations are assessed by an independent accrediting body to ensure that they meet specific standards of quality and safety. Accreditation is voluntary, but many hospitals seek accreditation to demonstrate their commitment to providing high-quality care and to gain recognition in the healthcare industry.

There are several accrediting bodies in India operating accreditation programs for hospitals and healthcare providers. These are ‘Quality & Accreditation Institute (QAI), National Accreditation Board for Hospitals and Healthcare Providers (NABH), Joint Commission International (JCI) and American Accreditation Commission International (AACI). Each organization has its own set of standards that hospitals must meet to achieve accreditation.

The accreditation process typically involves a comprehensive evaluation of the hospital's policies, procedures, and processes to ensure that they meet the accrediting body's standards. This can include an on-site survey, interviews with staff and patients, and a review of medical records and other documentation.

Achieving accreditation can be a rigorous and time-consuming process, but it can provide many benefits to hospitals. Accreditation can help hospitals improve the quality of care they provide, enhance patient safety, and reduce healthcare costs. Accreditation can also help hospitals attract and retain patients, increase staff satisfaction, and gain recognition in the healthcare industry.

AeonMed helps hospitals in developing their Quality management System, processes and people for achieving accreditation. We help by

  • Conducting a thorough Gap assessment, providing a Gap Assessment Report and providing recommendations for closing the gaps. The inclusions in the Gap analysis are - infrastructure, human resource, biomedical equipment, quality system processes, documentation, staff training pertaining to accreditation standards. Our recommendations help in developing the hospital plan for accreditation, training and assistance for developing structures, processes and measurements for quality system.
  • Helping in designing, creating and implementing various committees, teams and other staff sub-systems.
  • Develop Quality Assurance Programs for hospital labs, surgical services, intensive care units, emergency departments.
  • Help in creating and implementing Quality System Documentation, policies, procedures and processes (SOPs, Manuals, work-instructions etc) in close collaboration with of the hospital leadership and frontline staff.
  • Help in creating quality measurement system that includes data collection, and validation for various key-performance-indicators and metrices.
  • Help in developing a program for various audits – Clinical, Prescription, safety, quality, infection control to name a few.
  • We can conduct training program and events not only to upskill the hospital staff but to also meet requirements of accreditation standards. We deploy instructors and trainers of repute and experience.
  • We prepare Quality Team of the hospital for sustaining the quality system.
  • We conduct mock assessments, surveys, drills and internal assessments to prepare the staff to face the survey. Staff thus prepared is better positioned to face the survey, learns the nuances of quality system and is able to sustain the processes in future.
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Lab Accreditation

AeonMed provides valuable assistance in implementing a medical lab quality system. Here are some ways we help:

  • Quality Management System Development: AeonMed helps laboratories develop a comprehensive Quality Management System (QMS) that includes all the necessary policies, procedures, and documentation. We also provide training to laboratory personnel on the QMS and its implementation.
  • Standard Operating Procedures (SOPs) Development: AeonMed helps laboratories develop SOPs for all critical laboratory processes, including specimen collection, processing, and testing. They can ensure that the SOPs are comprehensive, accurate, and comply with regulatory requirements.
  • Quality Control Program Development: AeonMed helps laboratories develop and implement a quality control program that monitors and verifies the accuracy of laboratory results. AeonMed develops procedures for calibrating and maintaining equipment, monitoring the performance of laboratory personnel, and monitoring the quality of reagents and supplies.
  • Quality Assurance Program Development: AeonMed helps laboratories develop and implement a quality assurance program that ensures that the laboratory's quality control program is functioning as intended. We develop procedures for reviewing and evaluating laboratory results, identifying and resolving problems, and implementing corrective actions when necessary.
  • Training and Education: AeonMed can provide training and education to laboratory personnel on the laboratory's quality policies and procedures, as well as any regulatory requirements that apply. We tailor the training to the specific needs of the personnel and can ensure that it is documented.
  • Internal Audits and External Proficiency Testing Programs: AeonMed can conduct internal audits of the laboratory's QMS to ensure that it is functioning as intended. We also help laboratories participate in external proficiency testing programs to monitor the accuracy and reliability of laboratory results.
  • Regulatory Compliance: We help laboratories understand and comply with the regulatory requirements that apply to their location and type of laboratory. We also provide guidance on the steps required to meet regulatory standards and can help laboratories develop and implement the necessary policies, procedures, and documentation.
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Audits & KPIs

  • AeonMed designs and conducts specific audits as per hospitals own specific requirements.
  • When a hospital has an established and running quality management system and accreditation is already in place, audits by an independent agency can reveal significant gaps in quality of care and patient safety requirements.
  • Many hospitals who have already achieved accreditation, maintaining and regularly conducting audits and measuring KPIs can be difficult. AeonMed can become your trusted partner in providing services of conducting audits and KPI measurements.
  • We help the hospitals in meeting the requirements of sustaining accreditation program requirements.
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Quality-as-a-Service

Quality-as-a-Service in hospital settings is a unique offering from AeonMed. The focus is on sustaining quality systems and processes that have been developed with great efforts while obtaining accreditation.

Typically after the accreditation assessment is over and the award is received, the hospital goes back to business-as-usual mode. This dissipates all the gains achieved during the preparation and learning for accreditation. All that hard work goes awry!

So, once the coveted accreditation has been achieved its time to call us! We operate, sustain, improve and grow your quality system thereby sustaining accreditation and improving care outcomes, patient’s experience and easing work of hospital staff.

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Gap Audits

  • Gap Audits are a mandatory part of a decision to achieve accreditation. Often, the awareness about the existing system and processes gaps may not be there with the hospital leadership. This results in difficulties during implementation as gaps unfold progressively.
  • A thorough gap analysis is thus mandatory so that a good plan can be made for creating, implementing and sustaining quality system.
  • We at AeonMed offer this expertise to all kinds of healthcare facilities and for most accreditation standards of accreditation bodies be it QAI, NABH or JCI.
  • Our Gap Analysis reports invariably cover infrastructure,, system & process, HR gaps that are likely to come in the way of accreditation. The report also consists of recommendations and probable timelines that could be used for covering the gaps.

Training-as-a-Service – iTeSH

A specialized training solution helps address all these challenges. We at AeonMed have created a Training Solution for hospitals, called iTeSH, that offers effective training in online mode. Special features are

  • Flexible learning. Always-on, 24 x 7 availability, repeat as many times as required
  • Cost efficient solution, Multi-platform access – PC, android, IOS etc
  • One solution for all learning needs. No need to search trainers for every subject/topic
  • Updated, synthesized content based on current best practices. Content can also be co-created with us
  • Faculty – only those from reputed institutions, NABH / JCI / NQAS / NABL Assessors
  • Certification available for each course completed. Tests can be repeated
  • Full documentation of attendance, progress, completion, and multi-format evaluation
  • Exhaustive list of over 100 topics – related to accreditation requirements, quality systems, safety, and infection control.
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Patient Reported Outcomes

  • With global shift from volume based care delivery to Value based care, there is now a need to implement measurements that measure the value received by the patients. This is invariably done by implementing Patient Reported Measures – common ones being “Patient Reported Outcome Measures” and “Patient Reported Experience Measures”.
  • We help developing and implementing Patient Reported Measures as mandated by accreditation standards.

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AeonMed Health & Hospitals Pvt Ltd # 205, Samrat Ashoka Enclave Plot No. 6, Sector 18A, Dwarka New Delhi – 110078 INDIA

rv@aeonmed.in

+91 9906354666

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