MBA (Hospital Administration)

TOTAL QUALITY MANAGEMENT & HOSPITAL ACCREDITATION

Dr. V. Tulasi Das

Dept. of HRM

Center for Distance Education

AcharyaNagarjuna University
2022
 CONTENT
Page
UNIT - I Evolution of Quality Management
No
Introduction- concept, definition, origin &
Lesson - 1 growth of Quality Management, Prerequisites of
Quality Management in Hospitals
Importance and Significance of TQM for
Hospitals,
Lesson - 2
Quality Management in Hospitals, Role of
Medical Record in Quality Management
Lesson - 3 Quality Cirles; Quality Assurance.

UNIT - II Quality Management in Hospital

Front Office; OPD; Casualty; Labs; OT;

Lesson - 4
CSSD; IP
Nursing services; Emergency and Trauma care,
Lesson - 5
Dietary; House Keeping
ICU; CCU; MRD, Laundry; Canteen; Hospital
Lesson -6
stores.
UNIT -
Team work and Tools in TQM
III
TQM team work; Employee involvement; Key
Lesson - 7
result areas; Leadership; TQM Tools

Quality Function Deployment (QFD);

Concurrent engineering; FMEA; P-C-D-A
Cycle; JIT (Just in Time); Kaizan; ‘O’ defect
Lesson - 8
programme, Statistical Tools in TQM; Flow
diagram; Pareto Analysis; Cause and effect
diagram; Control Charts
Bench Marking; Business Process
Reengineering; Six Sigma; Assessing
Lesson -9
Quality, Patient satisfaction survey; TQM
practices in Indian Hospitals
UNIT -
Organisation and Roles in Quality
IV
Quality Policy; Commitment to Patients and
Lesson - 10
Staff
Code of Conduct for Health Professionals, Job
Lesson - 11
Description of Quality Manager
Quality Steering Committee , Obstacles to the
Lesson -12
practice of Quality in Hospitals.
UNIT - V Hospital Accreditation
Concept of Hospital Accreditation; ISO
Lesson - 13
2000 & 14000
NABL, NABH, JCI & JCAHO; Accreditations
Scenario in India and abroad;
Lesson - 14
Organizations and authorities for
accreditations in India
Accreditation process; Role of the
Lesson -15 government in developing an
accreditation system.
 Unit -I

Lesson – 1: Evolution of Quality Management

Learning objectives:After studying this lesson , the students are able to understand the
aspects of quality management, its importance, its origin, and its growth.

 Introduction of Quality Management

 Evolution of Quality Management
 Concept of Quality Management
 Definition of Quality Management
 Need & Principles of Quality Management

Structure

1.1 Introduction
1.2 Evolution of Quality management
1.3 Concept of Quality management
1.3 Need for Quality management
1.4 Definitions of Quality management
1.5 Principles of Quality Management
1.7 Components of quality management
1.8 Tools of Quality management
1.9 Summary
1.10 Key words
1.11 Self-assessment questions
1.12 Further readings
1.1 Introduction

Quality management has three main components: quality control, quality assurance, and
quality improvement. Quality management is focused not only on quality, but also on the
means to achieve quality and sustain total quality management, which is the organization-
wide management of quality. It consists of planning, organizing, directing, controlling, and
assuring quality.
In other words, quality management is the act of overseeing all activities and tasks that must
be accomplished to maintain a desired level of excellence. This includes the determination of
a quality policy, creating and implementing quality planning and assurance, and quality
control and quality improvement. It is also referred to as "total quality management" (TQM).
In general, quality management focuses on long-term goals through the implementation of
short-term initiatives.
Quality management practices primarily result in increased productivity, lower repair costs,
increased customer loyalty, and higher profits.
Quality is simply meeting the customers’ requirements and has been expressed in many
ways:
 “Fitness for purpose”. (Juran)
 “Quality should be aimed at the needs of the consumer, present and future”. (Deming)
 “Conformance to requirements”. (Crosby)
 “Degree to which a set of inherent characteristics fulfills requirements”. (ISO)

Dimensions of Quality:

 Performance.
 Aesthetics.
 Special features: ie; convenience, high tech.
 Safety.
 Reliability.
 Durability.
 Perceived Quality.
  Service after sale.

1.2 Evolution of quality management:

The concept of quality has existed for many years, though its meaning has changed and
evolved over time. In the early twentieth century, quality management meant inspecting
products to ensure that they met specifications. In the 1940s, during World War II, quality
became more statistical in nature.
Dr. Juran has a well-deserved reputation as the founder of a range of quality management
techniques. His quality management approach is based on three key principles: the Pareto
principle; quality management principles; and the Juran Trilogy – quality planning, quality
control, and quality improvement.
Until the early 19th century, manufacturing in the industrialized world tended to follow this
craftsmanship model. The factory system, with its emphasis on product inspection, started in
Great Britain in the mid-1750s and grew into the Industrial Revolution in the early 1800s.
American quality practices evolved in the 1800s as they were shaped by changes in
predominant production methods. After entering World War II, the United States enacted
legislation to help gear the civilian economy to military production. During this period,
quality became a critical component of the war effort and an important safety issue. Unsafe
military equipment was clearly unacceptable, and the U.S. armed forces inspected virtually
every unit produced to ensure that it was safe for operation.
The beginning of the 20th century marked the inclusion of "processes" in quality practices. A
"process" is defined as a group of activities that takes an input, adds value to it, and provides
an output. Walter Shewhart began to focus on controlling processes in the mid-1920s, making
quality relevant not only for the finished product but for the processes that created it.

The History of Quality

1.3 Concept of Quality Management:
“Quality is conformance to specifications.” - British Defense Industries Quality Assurance
Panel
“Quality is conformance to requirements.” - Philip Crosby
“Quality is fitness for purpose.” - Dr Juran
“Quality is synonymous with customer needs and expectations.” - R J Mortiboys
“Quality is a predictable degree of uniformity and dependability, at low cost and suited to
the market.” - Dr Edward Deming
Quality is a measure of the achievement of an organization in terms of customer satisfaction.
It means everything that an organization does, in the eyes of the customer. It is excellence
that is better than a minimum standard.
“Quality management” ensures superior quality products and services. Quality of a product
can be measured in terms of performance, reliability and durability. Quality management
tools ensure changes in the systems and processes which eventually result in superior quality
products and services.
Quality management is the act of overseeing all activities and tasks needed to maintain a
desired level of excellence. Quality management includes the determination of a quality
policy, creating and implementing quality planning and assurance, and quality control and
quality improvement.
Service quality in the hospitality industry has become one of the most important factors in
gaining a long-term competitive advantage and customer trust in a very competitive market.
This gives the hospitality industry a great chance to be different from other businesses in the
industry.
Quality management tools help an organization to design and create a product which the
customer actually wants and desires. Quality Management ensures increased revenues and
higher productivity for the organization.Quality management helps organizations to reduce
waste and inventory. It enables employees to work closely with suppliers and incorporate
“Just in Time” Philosophy.
Quality in the hospitality industry is defined as “the consistent delivery of products and guest
services according to expected standards”. Increasingly, guests are willing to pay more when
they visit hospitality properties offering service that meets or exceeds their service
expectations.
Quality management ensures high quality products and services by eliminating defects and
incorporating continuous changes and improvements in the system. High quality products in
turn lead to loyal and satisfied customers who bring ten new customers along with them.

1.4 Need Quality management:

Any organisation needs quality for:

a) Customer satisfaction and happiness

b) Goodwill (the image of the organisation) and high productivity
c) Capturing the market
d) Minimising the cost as well as losses.
e) Maximising the profit.
f) Recognising the role of everyone in the organisation
g) Fixing a common goal for the entire organisation
h) Emphasise teamwork among the staff.
i) Establishing performance measures for the employees
j) Betterment of employees.
k) Increased viability.

1.5 Definitions:
Quality is the totality of features and characteristics of a product that bears on its ability to
satisfy the stated or implied needs. Quality is doing the right things the right way and is
uniquely defined by each individual. Quality is the degree to which an object or entity (e.g., a
process, product, or service) satisfies a specified set of attributes or requirements. Quality is
the degree to which a set of inherent characteristics fulfils requirements.
Quality refers to the sum of the attributes or properties that describe a product. These are
generally expressed in terms of specific product characteristics such as length, width, colour,
specific gravity, and the like.
Quality means the totality of features and characteristics of a product or service that bear on
its ability to satisfy given needs.
JosephMJuransaid“Qualityisfitnessforuseorpurpose”.

ISO 9000:2000defines “Quality is the degree to which a set of inherent

characteristicsfulfillsrequirements”.
BillConwaydefinesqualityas“Development,manufacture,administrationanddistributionofcon
sistentlylowcostproductsandservicesthatcustomersneedandwant”.

W.EdwardsDemingdefinesitas“Apredictabledegreeofuniformityanddependabilityatlowcost
andsuitedtomarket”.
AccordingtoBroth“Qualityisthedegreeofexcellenceatanacceptablepriceandcontrolofvariabilit
yatanacceptablecost”
AccordingtoSarkar,“Qualityofaproductorserviceistheabilityoftheproductorservicetomeetthec
ustomers’requirements”
Based on the above definitions it becomes clear that quality is a multidimensional
conceptthatrelateshumanneedstohumanactionsaswellastoorganizationalgoals.Itisnotastaticpr
ocessorconceptbutasadynamicprocessitchangesaccordingtochangesintheneedsofthecustomer
s.Hencethequalityisdeeplyuser-oriented.

1.6 Principles of quality management:

1. Customer focus
2. Leadership
3. People involvement
4. Process approach
5. Systematic approach to management
6. Continual improvement
7. Factual Approach to Decision Making
8. Mutually Beneficial Supplier Relations

1.7 Components of quality management:

The components of quality in the hospitality industry that can be used to develop and
implement a quality service system are the following:
1. Consider the guests/patients being served
2. Determine what the guest’s/patients desire
3. Develop procedures to deliver what guests want
4. Train and empower staff
5. Implement revised systems
6. Evaluate and modify service delivery systems.
1.8 Quality Management Tools:

Quality Management tools help organization collect and analyze data for employees to easily
understand and interpret information. Quality Management models require extensive
planning and collecting relevant information about end-users. Customer feedbacks and
expectations need to be carefully monitored and evaluated to deliver superior quality
products.

Quality Management tools help employees identify the common problems which are
occurring repeatedly and also their root causes. Quality Management tools play a crucial role
in improving the quality of products and services. With the help of Quality Management tools
employees can easily collect the data as well as organize the collected data which would
further help in analyzing the same and eventually come to concrete solutions for better
quality products.

Quality Management tools make the data easy to understand and enable employees to
identify processes to rectify defects and find solutions to specific problems.

Following are the quality management tools:

Check List - Check lists are useful in collecting data and information easily .Check list also
helps employees to identify problems which prevent an organization to deliver quality
products which would meet and exceed customer expectations. Check lists are nothing but a
long list of identified problems which need to be addressed. Once you find a solution to a
particular problem, tick it immediately. Employees refer to check list to understand whether
the changes incorporated in the system have brought permanent improvement in the
organization or not?

Pareto Chart - The credit for Pareto Chart goes to Italian Economist - Wilfredo Pareto.
Pareto Chart helps employees to identify the problems, prioritize them and also determine
their frequency in the system. Pareto Chart often represented by both bars and a line graph
identifies the most common causes of problems and the most frequently occurring defects.
Pareto Chart records the reasons which lead to maximum customer complaints and eventually
enables employees to formulate relevant strategies to rectify the most common defects.

The Cause and Effect Diagram - Also referred to as “Fishbone Chart” (because of its shape
which resembles the side view of a fish skeleton)and Ishikawa diagrams after its creator
Kaoru Ishikawa, Cause and Effect Diagram records causes of a particular and specific
problem .The cause and effect diagram plays a crucial role in identifying the root cause of a
particular problem and also potential factors which give rise to a common problem at the
workplace.

Histogram - Histogram, introduced by Karl Pearson is nothing but a graphical representation

showing intensity of a particular problem. Histogram helps identify the cause of problems in
the system by the shape as well as width of the distribution.

Scatter Diagram - Scatter Diagram is a quality management tool which helps to analyze
relationship between two variables. In a scatter chart, data is represented as points, where
each point denotes a value on the horizontal axis and vertical axis.

Scatter Diagram shows many points which show a relation between two variables.

Graphs - Graphs are the simplest and most commonly used quality management tools.
Graphs help to identify whether processes and systems are as per the expected level or not
and if not also record the level of deviation from the standard specifications.

1.9 Summary:

A quality management strategy for an organisation that is seeking to or has already

implemented a continuous improvement programme must include respect for people, an open
culture and engaged leaders. When an organisation puts the highest value on people, then
quality efforts can focus on improving outcomes for people. There are more tangible and
measurable components and tools that accompany a lean quality management system such as
root cause analyses, improvement slips, checklists, and observations.

1.10 Key words:

Quality: the “degree to which a set of inherent characteristics (attributes) of the object
satisfies a set of requirements.”
Total Quality management: as a continuous effort by the management as well as
employees of a particular organization to ensure long term customer loyalty and customer
satisfaction.

Quality Policy: A brief statement that aligns with an organization's purpose, mission, and
strategic direction.

1.11Self-assessment questions:

1. Discuss about quality management in detail?

2. Discuss the management of origin and growth quality?

3. What are the dimensions of quality and the quality management tools?

4. Discuss the concept of quality management and its significance in service sector
organizations?

1.12Further readings:

 Best Quality management systems by written by James O. Westgard, PHD and

StenWestgard.
 Beyond Total Quality Management, Greg Bounds, McGraw Hill.

 Quality Management/KanishkaBedi/Oxford University Press/2011

 Total Quality Management (TQM),Principles, Methods, and Applications, By Sunil
Luthra, Dixit Garg, AshishAgarwal, Sachin K. Mangla, 2021
Lesson-2 Quality Management in Hospitals & Role of Medical Record

Learning objectives:
This lesson helps students familiarize themselves with the basic concept and framework of
Total Quality Management, its significance in the hospital industry and the role of medical
records in quality management.

 What is TQM?
 Why TQM in Hospitals?
 What are the prerequisites of Quality Management in Hospitals?
 Role of Medical Record in Quality Management?

2.1 Introduction
2.2 Origin of TQM
2.3 Definitions & Objectives of TQM.
2.4 Benefits of TQM
2.5 Significance of TQM for Hospitals
2.6 Prerequisites of Quality Management in Hospitals
2.7 Role of Medical Record in Quality Management
2.8 Summary
2.9 Key words
2.10 Self-Assessment Questions
2.11 Further Readings:
2.1 Introduction:
Total quality management (TQM):
Total Quality Management (TQM), a buzzword phrase of the 1980’s, has been killed and
resurrected on a number of occasions. The concept and principles, though simple seem to be
creeping back into existence by “bits and pieces” through the evolution of the ISO9001
Management Quality System standard. “Total Quality Control” was the key concept of
Armand Feigenbaum’s 1951 book, Quality Control: Principles, Practice, and Administration,
in a chapter titled “Total Quality Control”. Feigenbaum grabs on to an idea that sparked many
scholars interest in the following decades that would later be catapulted from Total Quality
Control to Total Quality Management. Total Quality Management (TQM) is a management
strategy aimed at embedding awareness of quality in all organizational processes. TQM has
been widely used in manufacturing, education, government, and service industries, as well as
NASA space and science programs.
Total Quality Management (TQM) is a management framework based on the belief that an
organization can build long-term success by having all its members, from low-level workers
to its highest ranking executives, focus on improving quality and, thus, delivering customer
satisfaction.
Total quality management (TQM) is the continual process of detecting and reducing or
eliminating errors in manufacturing, streamlining supply chain management, improving the
customer experience, and ensuring that employees are up to speed with training.
TQM, in the form of statistical quality control, was invented by Walter A. Shewhart. It was
initially implemented at Western Electric Company, in the form developed by Joseph Juran
who had worked there with the method.
Initially, some of the companies who have implemented TQM include Ford Motor Company,
Phillips Semiconductor, SGL Carbon, Motorola and Toyota Motor Company.
Over the last two decades, service organisations have embraced total quality management
(TQM) as an effective management tool to improve their service quality. They have begun to
show a keen interest in TQM by working on quality and related areas.

2.2 Origin of TQM:

The history of total quality management (TQM) began initially as a term coined by the Naval
Air Systems Command to describe its Japanese-style management approach to quality
improvement. An umbrella methodology for continually improving the quality of all
processes, it draws on knowledge of the principles and practices.

 The behavioral sciences

 The analysis of quantitative and non-quantitative data
 Economics theories
 Process analysis

1920s  Some of the first seeds of quality management were planted as the
principles of scientific management swept through U.S. industry.
 Businesses clearly separated the processes of planning and carrying
out the plan, and union opposition arose as workers were deprived
of a voice in the conditions and functions of their work.
 The Hawthorne experiments in the late 1920s showed how worker
productivity could be impacted by participation.

1930s Walter Shewhart developed the methods for statistical analysis and
control of quality.
1950s  W. Edwards Deming taught methods for statistical analysis and
control of quality to Japanese engineers and executives. This can be
considered the origin of TQM.
 Joseph M. Juran taught the concepts of controlling quality and
managerial breakthrough.
 Armand V. Feigenbaum’s book Total Quality Control, a forerunner
 for the present understanding of TQM, was published.
 Philip B. Crosby’s promotion of zero defects paved the way for
quality improvement in many companies.

1968  The Japanese named their approach to total quality "companywide

quality control." It is around this time that the term quality
management system arises.
 Kaoru Ishikawa’s synthesis of the philosophy contributed to Japan’s
ascendancy as a quality leader.

Today  TQM is the name for the philosophy of a broad and systemic
approach to managing organizational quality.
 Quality standards such as the ISO 9000 series and quality award
programs such as the Deming Prize and the Malcolm Baldrige
National Quality Award specify principles and processes that
comprise TQM.
 TQM as a term to describe an organization's quality policy and
procedure has fallen out of favour as international standards for
quality management have been developed. Please see our series of
pages on quality management systems for more information.

2.3 Definitions Objectives of TQM:

Total Quality Management (TQM) Total = Quality involves everyone and all activities in the
company. Quality = Conformance to Requirements (Meeting Customer Requirements).
Management = Quality can and must be managed. Total Quality Management is to obtain
total quality by involving everyone’s daily commitment.
Total Quality Management is defined as “a management philosophy concerned with people
and work processes that focuses on customer satisfaction and improves organizational
performance”

TQM can be explained as follows:

 If quality is to satisfy customer’s requirements continually.

  Quality is “fitness for use” (Joseph Juran).
 Total Quality is to achieve quality at low cost. (Kanji)

Objectives of TQM:

• To develop a conceptual understanding of the basic principles and methods associated

with TQM.
• To develop an understanding of how these principles and methods have been put into
effect in a variety of organizations.
• To develop an understanding of the relationship between TQM principles and the
theories and models studied in traditional management;
• To do the right things, right the first time, every time.

Five broad attributes have been identified for understanding quality:

i. Reliability – Ability to perform the promised service dependably and accurately.

ii. Assurance – Knowledge and courtesy of employees.
iii. Tangibles – Physical facilities, equipment and appearance of personnel.
iv. Empathy – Caring, individualised attention provided to the customers.
v. Responsiveness – Willingness to help customers and provide prompt service.

Total quality management (TQM) is the continual process of detecting and reducing or
eliminating errors in manufacturing, streamlining supply chain management, improving the
customer experience, and ensuring that employees are up to speed with training.
Total Quality Management (TQM) is a participative, systematic approach to planning and
implementing a constant organizational improvement process. Its approach is focused on
exceeding customers' expectations, identifying problems, building commitment, and
promoting open decision-making among workers.
A core definition of total quality management (TQM) describes a management approach to
long-term success through customer satisfaction. In a TQM effort, all members of an
organization participate in improving processes, products, services, and the culture in which
they work.

Principles of TQM:
2.4 Benefits of TQM:
Various total quality management benefits are as follows:
 Reduction of defects because TQM promotes quality awareness and participation of all
members of the organization, not just the QA or QC department. It means quality at the
source.
 Total quality management system leads to ease of problem solving. Through
measurements
such as SPC and other techniques such as failure analysis, defects and failures (even potential
failures) can be identified and addressed.
 TQM also leads to continuous improvement of processes and products. TQM system
should
also improve the efficiency of people and machine.
 TQM leads to quality products which leads to customer satisfaction.
 Reducing defects and improving machine and personnel efficiency, TQM
should lead to cost savings and profitability improvement (bottom line).
 A philosophy that improves business from top to bottom.
 A focused, systematic and structured approach to enhancing customer’s satisfaction.
 Process improvement methods that reduce or eliminate problems i.e. non-conformance
costs.
 Tools and techniques for improvement – quality operating system.
 Delivering what the customer wants in terms of service, product and the whole
experience.
 Intrinsic motivation and improved attitudes throughout the workforce.
 Workforce is proactive – prevention-orientated.
 Enhanced communication.
 Reduction in waste and rework.
 Increase in process ownership – employee involvement and empowerment.
 Improved customer/supplier relationships (internally & externally).
 Market competitiveness.
 Quality based management system for ISO 9001:2000 certification.

2.5 Significance of TQM for Hospitals:

At TQM, systems are established to prevent clinical and administrative problems, increase
patient satisfaction, continuously improve the organization's processes, and provide
healthcare services as good as or better than those of its competitors.

Quality improvement is the framework used to systematically improve care. Quality

improvement seeks to standardise processes and structures to reduce variation, achieve
predictable results, and improve outcomes for patients, healthcare systems, and organizations.

Total Quality of performance that is directly related to healthcare safety, security, attitude
staff , role of doctors in terms of ‘time’ includes appointment, delay time , service time ,
timing with regards to medical treatment and surgery. It is mainly focuses on quality of
administration and management, quality of doctors and supporting staff & quality of hospital
care aspects etc.

Hospitals and other healthcare organization across the globe have been progressively
implementing TQM to reduce costs, improve efficiency and provide high quality patient
care.TQM, which places on improved customer satisfaction, offers the prospect of great
market share and profitability.TQM can be an important part of hospitals competitive strategy
in quality of healthcare system.

Total quality management (TQM) is an administration attitude of uninterruptedly refining the

quality of the goods/services/processes by concentrating on the customers' (patients')
requirements and anticipations to augment consumer (patient) contentment stable
performance. Successful TQM implementation leads to improved organizational performance
success.

2.6 Prerequisites of Quality Management in Hospitals

Healthcare could be an extremely competitive global business. Patients sometimes prefer to

visit personal hospitals, hoping to receive high-quality service.
There are numerous reasons why it is important to improve the quality of healthcare,
including enhancing the accountability of health practitioners and managers, resource
efficiency, identifying and minimizing medical errors while maximizing the use of effective
care and improving outcomes, and aligning care to what users expect.

The service quality aspects that are important for patient satisfaction in the context of quality
assurance prerequisites such as continuous process, systematic process, Plan-Do-Check–Act
cycle (PDCA-cycle), patient-centeredness, process improvement in health care, Cooperation
between professionals Quality assurance (a) structural level (b) indicators associated with
care processes (c) clinical outcomes. Dedicated top management leadership that is a
commitment to quality improvement, Five broad attributes such as reliability, assurance,
tangibles, empathy, responsiveness, transformation of organisational culture, employee
education and training, quality measurement and statistical analysis at all levels, bench
marking, employee empowerment, affordability and convenience, and TQM model Six
Sigma were identified as factors essential for quality assurance in any health care setting.

Quality health services should be effective; safe; people-centred; timely; equitable;

integrated; and efficient. Improving the quality of health services requires strong national
direction from governments, focused sub-national support, and action at the health facility
level.

2.6 Role of Medical Record in Quality Management:

Medical record documentation is often used to protect the legal rights of the patients and the
staff, providing information for medical research, training the health-care staff, and
qualitative reviews.
The primary purpose of a medical record is to provide a complete and accurate description of
the patient's medical history. This includes medical conditions, diagnoses, the care and
treatment provided and results of such treatments. It also ensure that patients get the care they
need by providing medical professionals the information necessary to make good care
decisions
The purpose of medical documentation goes beyond simply recording patient care so that
medical professionals can monitor and plan the patient's status and care. It reduces the risk of
treatment errors and improves the likelihood of a positive outcome. It also provides a
resource to review cases for opportunities to improve care and offers necessary information
for medical billers.

Major reasons to document medical records properly:

a. Communicates with other health care personnel. Documentation communicates the

what, why, and how of clinical care delivered to patients.
b. Reduces risk management exposure.
c. Records CMS (Centres for Medicare & Medicaid Services) Hospital Quality Indicators
and PQRS (Physician Quality Reporting System) Measures.
d. Ensures appropriate reimbursement.

2.7 Summary:

TQM can be an important part of hospitals' competitive strategy in the quality of their
healthcare system. TQM is considered an innovative approach to the management of
organizations and integrates quality orientation into all processes and procedures in health-
care delivery. In the long run, implementation can help healthcare professionals gain more
qualified behaviours with a total commitment to work toward handling the patients, which
will augment their performance. Hospitals in competitive markets are more likely to attempt
to differentiate themselves from their competitors on the basis of greater service quality.

2.8 Key words:

Continuous Improvement: It refers to the concept that continuous focus on improving an

Notes

Customer Focus: Perfection in service with zero defects and full satisfaction to the end-user
whether it’s internal or external.
Medical records: A document that explains all detail about the patient's history, clinical
findings, diagnostic test results, pre and postoperative care, patient's progress and medication.

Organization’s performance

TQM: an approach to organizational management that focuses on improving processes and

standards that translates to customer satisfaction.

2.9 Self-assessment questions:

1. Define TQM? Discuss its origin and objectives?

2. Discuss the significance of TQM in the hospital industry?

3. What are the pre-requisites of quality management in hospitals?

4. Discuss the benefits of TQM?

5. What is the role of medical records in maintaining quality management practises in

health care organizations?

2.10 Further readings:

 Dale, B. (2015). Total quality management. John Wiley & Sons, Ltd.
Ron Basu, “Implementing Quality: A Practical Guide to Tools and Techniques”, 2016,
 THOMPSON.
 Mujkherjee, PN, “Total Quality Management”, 2007, PHI.
 R. P. Mohanty& R. R. Lakhe, “TQM in the Service Sector”, Jaico Books.2016
 Lesson-3: Quality circles & Quality assurance
Learning objectives:
This lesson inculcates the knowledge and concepts of quality circles and quality assurance,
which help healthcare managers, perform their roles in effective decision-making.

What is Quality Circles, its objectives & advantage’s?

What is Quality Assurance, its implementation &functions?

Structure:
3.1 Introduction to Quality Circle
3.2 Historical Background of Quality Circle
3.3 Definitions, Objectives & Characteristics of Quality circles
3.4 Advantages of Quality circles
3.5 Basic Organizational Structure of Quality Circles
3.6 Factors to affect Quality Circles Effectiveness
3.7 Concept, Purpose & Principles of Quality Assurance
3.8 Implementation of Quality Assurance Process
3.9 Quality Assurance Functions

3.1 Introduction:
A quality circle or quality control circle is a group of workers who do the same or similar
work, who meet regularly to identify, analyze and solve work-related problems. It consists of
minimum three and maximum twelve members in number.
A quality circle is a participatory management technique that enlists the help of employees in
solving problems related to their own jobs.
The objective is to improve quality, productivity and the total performance of the
organisation and also to enrich the quality of work life of employees.QC initiatives are not
only improve the productivity efficiency of system but also improve the problem solving
skill, involvement and thought process of team member of QC and also motivate further for
involvement of others.

3.2 Historical Background of Quality Circle:

This concept of Quality Circle has introduced by Dr. K. Ishikawa started Quality Control
Circles (known as Quality Circles in India and in many nations) originally for the self and
mutual development of the workmen. They are also a very logical outcome of the Japanese
drive for training and accomplishment in quality control and quality improvement. From the
early 1950's, Japanese learnt from the seed courses of Dr. E. Deming's on statistical methods
for quality control and Dr. J. Juran's courses on Quality Management. With zeal for learning
and self- sufficiency, they vigorously promoted quality education by local experts across their
country. It began with massive education of engineers, and then top and middle managers,
supervisory levels.
Under their system of organising work, it became logical to extend training on quality to the
Gembacho', the 'leading hand' of the workers in a section. Dr. Kaoru Ishikawa and his
associates
realised the immense potential of front line employees. It is not only the best way to help
people to develop their own potential but also from the organisation point of view for
contribution through training, development and motivation for quality control and
improvement.
The training featured intra departmental groups of 10 or so workers seated around a table and
hence the name 'QC Circle'. This thought revolution has been of immense benefit to Japan as
a country, to the Japanese organisations that adopted it and to most of the ASEAN countries
who have been pursuing it.
Problem solving was no more the exclusive purview of supervisors and managers (with
workers only to do as told) but the people who are performing the tasks at work place are
trained and empowered to solve work related problems and recommend solutions. Persons
becoming members of Quality Circles realise and develop their potential, individually and in
groups, acquiring new skills and competencies. Such competencies only will help to improve
their performance and capabilities for their own betterment.
This technique was first started by Kaoru Ishikawa in Japan in early 1960s.The movement in
Japan was coordinated by the Japanese Union of Scientists and Engineers (JUSE).The first
circles were established at the Nippon Wireless and Telegraph Company but then spread to
more than 35 other companies in the first year.
A quality circle is a participatory management technique that enlists the help of employees in
solving problems related to their own jobs.
A quality circle or quality control circle is a group of workers who do the same or similar
work, who meet regularly to identify, analyse and solve work-related problems. It consists of
minimum three and maximum twelve members in number.
3.3 Definitions, Objectives & Characteristics of Quality circles:
Quality circle is defined as a small group of people engaged in similar work who meet
voluntarily on regular basis under the leadership of their supervisors to identity and discuss
their work problems, analyse the causes thereof and recommend the solutions to superiors
and to implement the solutions themselves.

A group of employees who perform similar duties and meet at periodic intervals, often with
management, to discuss work-related issues and to offer suggestions and ideas for
improvements, as in production methods or quality control, called quality circle.
Therefore quality circle is nothing but a small group of employees who come together to
discuss
with the management issues related to either quality control or improvement in production
methods form a Quality Control Circle (QCC). These employees usually work in the same
areas, and voluntarily meet on a regular basis to identify, analyze and solve their problems.

Philosophy of Quality Circle: QC’s is a people - building philosophy, which provides self-
motivation and improves work environment. It represents a philosophy of managing people
specially those at the grass root level.

Objectives of QC are:
 The objectives of Quality Circles are multi-faced– Change in attitude; self-
development; development of team spirit, improvement in organizational culture
 To improve quality and productivity.
 To reduce the cost of products or services by waste reduction, safety, effective
utilization of resources, avoiding unnecessary errors and defects.
 To identify and solve work-related problems and interfere with production as a team.
 To tap the creative intelligence of people working in the org. and make full use of
human resources.
 To improve communication within the organization.
 To improve employees loyalty and commitment to the organization and its goals.
(Promoting Morale of employees)
 To build a happy, bright, meaningful work environment.
 To satisfy the human needs of recognition, achievement and self-development.
Characteristics of quality circle:
a. A circle, usually consisting of 6-8 members, from the same section.
b. Membership of a Quality Circle is voluntary.
c. Circle members should meet regularly, ideally once a week, in particular place also
inparticular time.
d. Circle members select a name for their circle in the first meeting and elect a leader to
conduct themeetings.
e. Members are specially trained in problem solving and analysis techniques in order to play
their role effectively.
f. Circle works on a systematic basis to identify and solve work – related problems for
improvingquality and productivity not just discussing them.
g. The management must ensure that solutions are implemented quickly once they have
beenaccepted
h. The management must give appropriate and proper recognition to solution

3.4 Advantages of Quality circles:

(a) They focus on product quality in a planned way.
(b) They train employees to identify their problems, find solutions and implement them
without seeking the advice of technical experts.
(c) They satisfy members’ higher-order needs of recognition and self-actualization.
(d) They improve members’ participation in work-related problems and enhance their job
satisfaction.
(e) They promote productivity, efficiency, cost reduction, design, testing, safety etc. of the
products.
(f) Since teaching is done in an informal way, employees are not burdened with analyzing
and solving their problems. Rather, they feel motivated to offer suggestions to management.

3.5 Basic Organizational Structure of QC:

A quality circle should have an appropriate organizational structure for its effective and
efficientperformance. The structure may vary from one org. to another, but it is useful to have
basicframework as a model:
In a typical organization, the structure of a QC may consist of the following elements:
Steering committee: Gen. manager / works manager, rep. from top management, rep. of
human resource development and a rep. of employees’ union.
Coordinator: an administrative officer / personnel officer from middle level management.
Facilitator: senior supervisory officer / foreman. A facilitator may manage up to 10 circles.
A facilitator is usually from one of the three departments – quality control, production or
training.
Circle Leader: circle leaders may be from the lowest level of supervisors. A circle leader
organises and conducts circle activities.
Circle members: line and / or staff workers ( circle members should attend all meetings as
far as possible, offer suggestions and ideas, participate actively in group processes, and attain
training seriously.

3.6 Factors to affect Quality Circles Effectiveness:

Quality circles are effective in achieving the goals if they are framed with the following
factors in mind:
(a) They start with the analysis of small problems and gradually move to bigger problems.
(b) Members of the QCs are voluntary and not mandatory to get their maximum support.
(c) Members of the QC are taught the basic techniques of problem-solving in an informal
way.
(d) Before members’ proposal to solve the problem is put to implementation, it is checked by
the supervisors.
(e) Management supports QC activities rather than leave them totally to the employees.
(f) Members are recognized for their contribution to organizational problems.

Quality Assurance:
3.7 Concept of Quality Assurance: Quality Assurance (QA) is defined as an activity to
ensure that an organization is providing the best possible product or service to customers. QA
focuses on improving the processes to deliver Quality Products to the customer. An
organization has to ensure, that processes are efficient and effective as per the quality
standards defined for products/services. Quality Assurance is popularly known as QA
Testing.
QA is process oriented activity. It is a planned system of monitoring procedures of process
conducted by personnel not directly involved in the inventory compilation/development
process. A set of activities designed to ensure that the development and/or maintenance
process is adequate to ensure a system will meet its objectives.QA activities ensure that the
process is defined and appropriate. Methodology and standards development are examples of
QA activities. A QA review would focus on the process elements of a project - e.g., are
requirements being defined at the proper level of detail.QA is set of activities whose purpose
is to demonstrate that an entity meets all quality requirements. This is done by adopting a
standard set of process and usual QA techniques like review, training, facilitation etc. It can
be termed as defect prevention. Quality assurance is an audit function.
Quality assurance is a way of preventing mistakes and defects in manufactured products and
services to customers; which ‘ISO 9000’ defines as "part of quality management focused on
providing confidence that quality requirements will be fulfilled". QA= QC + Good
Manufacturing Practices (GMP) or Services provided are the practices required in order to
conform to the guidelines recommended by agencies that control the authorization and
licensing of production and delivery of goods and services.

Purpose of QA:
a) To meet the rising expectations of consumers of quality of services.
b) Help patients by improving quality of care.
c) Assess competence of medical staff, serve as an impetus to keep up to date and prevent
future mistakes.
d) Bring to notice of hospital administration, about the deficiencies and in correcting the
causative factors.
 e) Help exercise a regulatory function.
f) Restricting undesirable procedures.
g) Eliminating medical errors, Adverse Drug Events, and HAI.

Principles of Quality Assurance:

a) QA is a never ending process of continuous improvement, and continuous updating
with rapid advances in science and technology and medical knowledge.
b) The emphasis is on establishing professional excellence and patients’ satisfaction at
reasonable cost.
c) Quality is not proportionate to the use of sophisticated technology or to be expensive.
d) Technical imperative should not insist on prolonging life at any cost, with no
consideration to quality of life.
e) Decisions must be based on data.
f) Customers define the quality.

3.8 Implementation of Quality Assurance Process:

Quality assurance has a defined cycle called PDCA cycle or Deming cycle. PDCA (Plan-Do-
Check-Act or Plan-Do-Check-Adjust) is an iterative four-step management method for the
control and continual improvement of processes and products.
The phases of this cycle are:
a. Plan
b. Do
c. Check
d. Act

These above steps are repeated to ensure that processes followed in the organization are
evaluated and improved on a periodic basis. Let's look into the above steps in detail -
a. Plan - Organization should plan and establish the process related objectives and
determine the processes that are required to deliver a high-Quality end product.
b. Do - Development and testing of Processes and also "do" changes in the processes.
c. Check - Monitoring of processes, modify the processes, and check whether it meets the
predetermined objectives.
d. Act - Implement actions that are necessary to achieve improvements in the processes.
An organization must use Quality Assurance to ensure that the product is designed and
implemented with correct procedures. This helps reduce problems and errors, in the final
product.
QA can be evaluated by independent assessors from outside the hospitals. Internal QA: QA
can be evaluated by local assessors (Usually by senior persons) from the same hospitals.
Benchmark is something that serves as a standard by which others may be measured or
judged.
QA Committee involves Medical Administrator, Two Senior Clinicians, Pathologist,
Radiologist, Matron (Senior Nurse), Medical Record Officer (Secretary),
Additional Personnel: eg Super-Specialists, consultants.

3.9 Quality Assurance Functions:

There are 5 primary Quality Assurance Functions:
1. Technology transfer: This function involves getting a product design document as well
as trial and error data and its evaluation. The documents are distributed, checked and
approved
2. Validation: Here validation master plan for the entire system is prepared. Approval of
test criteria for validating product and process is set. Resource planning for execution of a
validation plan is done.
3. Documentation: This function controls the distribution and archiving of documents. Any
change in a document is made by adopting the proper change control procedure. Approval
of all types of documents.
4. Assuring Quality of products.
5. Quality improvement plans.
3.10 Summary:
A quality control circle programme is similar to an ISO 9000 quality standard with regard to
management structure and training. There should be a total quality management (TQM) plan
in place, so QCCs should be part of that plan. QA helps to establish and maintain a set of
requirements for providing reliable products and services. It is supposed to make customers
more trustful of a company and make work more efficient.

3.11 Key words:

Quality: The consistent delivery of products and guest services according to expected
standards.
Total Quality Management: TQM is a management approach that seeks to provide long-
term success by providing unparalleled customer satisfaction through the constant delivery of
quality services.
Quality Assurance (QA): An activity to ensure that an organization is providing the best
possible product or service to customers.
Quality circle: A group of employees who volunteer to meet regularly to discuss and
propose solutions to problems (as of quality or productivity) in the workplace.
Medical record: A chronological written account of a patient's examination and treatment
that includes the patient's medical history and complaints, the physician's physical findings,
the results of diagnostic tests and procedures, and medications and therapeutic procedures.

3.12 Self-assessment questions:

1. Discuss the concept of quality management and its significance in service sector
organizations?
2. How should TQM be defined? Discuss its objectives?
3. Discuss the prerequisites of quality management in hospitals?
4. Explain the role of medical record keeping in the quality management aspect?
5. Define quality circles? Discuss about factors contribute to quality circles
effectiveness?
6. Discuss quality assurance and the PDCA cycle?
3.13 Further readings:
 Sridharabhat: Total Quality Management Texts and Cases, Himalaya, 2015.
 KanishkaBedi: Quality Management, Oxford, 2015.
 Dale H.Besterfield et al, Total Quality Management, Third edition, Pearson Education
(First Indian Reprints 2004).
 Evans, J., Quality Management, Organization and Strategy, 6th Edition, Cengage
International, 2011.
 Unit-2
Lesson-4 Quality Management in Hospital

Learning objectives:After studying this lesson, students would be able to know the meaning
and scope of various aspects that help in hospital administration management practice.

 Quality Management in Hospital

 Front Office
 OPD
 Casualty
 Labs
 OT
 CSSD
 IP

Structure:
1.1 Introduction
1.2 Concept Quality Management in Hospital
1.3Front Office
1.4OPD
1.5Casualty
4.6Labs
4.7OT
4.8CSSD
4.9 IP
4.10 Summary
4.11 Key words
4.12 Self-assessment questions
4.13 Further readings
4.1 Introduction:

The ever-increasing demands of healthcare consumers is a great concern in the global

healthcare sector, and only by providing high-quality, advanced treatment options at
affordable rates, hospitals or other healthcare providers can establish sustainable and
successful business. To pursue this, the significant standards to be set for better ‘Hospital
Quality Management’. Any healthcare organization can attain this by streamlining the
process and workflows educating, monitoring and implementing quality improvement
programs.

Hospital quality management means the process of managing the entire entailed hospital
operation in a worthwhile fashion by applying the various hospital quality measures and
standards, so that the hospital functions in a desirable condition. The Indian hospital system
follows NABH Quality Standards, which provides guidelines to healthcare administrators and
also facilitates the overall hospital functions to remain exceptional and patient-friendly.
However, the hospital management has to control all the related activities prudently, by
applying the appropriate hospital quality measures, with special attention to the key areas of
organizational activities such as the process improvement, cost reduction, productivity &
performance improvement, and throughput time.

4.2 Concept of Quality Management in Hospital:

Overall improving the quality and performance in the healthcare environment can help
providers with reliable, cost-effective and sustained healthcare processes and enable them to
achieve their goal of improving care delivery and enhancing patient outcomes. Health care is
very complex sector and delivery of service is the fragmented care. Quality can be a common
paradigm to address the need of all groups in health care. Quality improvement is the process
approach to the organization’s operational challenges.
Quality Management Quality management is the act of management functions to maintain a
desired level of excellence. It is management activities and functions involved in
determination of quality policy and its implementation.
It has four main components:-
i. Quality planning
ii. Quality assurance
 iii. Quality control
iv. Quality improvement

Quality management is focused not only on product and service quality, but also on the
means to achieve it.The goal of an organization committed to quality care is a
comprehensive, systematic approach that prevents errors or identifies errors so that adverse
events are decreased and safety and quality outcomes are maximized.
The ever-increasing demands of healthcare consumers is a great concern in the global
healthcare sector, and only by providing high-quality, advanced treatment options at
affordable rates, hospitals or other healthcare providers can establish sustainable and
successful business. To pursue this, the significant standards to be set for better ‘Hospital
Quality Management’. Any healthcare organization can attain this by streamlining the
process and workflows educating, monitoring and implementing quality improvement
programs.In addition, applying statistical quality management solutions based on statistical
data will enable the hospital management to increase patient and physician satisfaction
considerably.
“Make use of our expertise in Quality Management in Healthcare and Create Your Own
Signature in Healthcare Industry.”
The goal of quality management in health care is to reduce costs and improve patient
outcomes-a win-win scenario for both health care organizations and patients.
“It is a holistic approach to the art of managing quality output considering together the
people, process and products rather than independent factors and driven towards the objective
with effective & efficient performance output”. DR. N.C DAS
The Health Resources and Services Administration (HRSA) define quality management as
“systematic and continuous actions that lead to measurable improvement in health care
services and the health status of targeted patient groups.” In health care, improved quality
management helps reduce waste, decrease mistakes, and improve patient care.
Quality Management: a philosophy that defines a healthcare culture emphasizing customer
satisfaction, innovation, and employee involvement.
Quality improvement is an on-going process used by organizations to adopt the quality
management philosophy.
In healthcare, quality management refers to the administration of systems design, policies,
and processes that minimize, if not eliminate, harm while optimizing patient care and
outcomes
Hospital quality management means the process of managing the entire entailed hospital
operation in a worthwhile fashion by applying the various hospital quality measures and
standards, so that the hospital functions in a desirable condition.

Principles of quality management:

i. Customer focus
ii. Leadership
iii. People involvement
iv. Process approach
v. Systematic approach to management
vi. Continual improvement
vii. Factual Approach to Decision Making
viii. Mutually beneficial supplier relations

Quality management requirements:

a. Customer participation in QM.
b. Leadership for the steering of quality.
c. Personnel as a prerequisite for high quality.
d. QM for preventive as well other activities.
e. Management of processes as a basis for QM.
f. Information as a basis for the continuous enhancement of quality.
g. Systematisation of QM.
h. Feedback and detailed recommendations.
i. Quality criteria support quality management.

Elements of quality management:

Errors in the hospital are invariably due to system failure in85% of cases (Edward Deming).
Only 15% are attributed to people’s performance. Therefore attention should be given on bad
system than bad people.

Improvement of systemic errors can be done by:-

a) Commitment of TOP Management,
b) Active support of Middle Management.
c) Education and training of staff.
d) Formation of quality management team.
e) Developing Quality culture in the work place.
f) Making aware all staff about the goal and objective of the organisation.
g) Developing quality policy and quality manual.
h) Developing Standard Operating Procedure for all areas (SOP).
i) Good Hospital Information System (HIS).
j) Formulation of criteria’s and Standards for measuring activities.
k) Constant monitoring and Supervision and feedback.
l) Introducing Medical Audit System.
m) Rectification of errors and Evaluation.
n) External quality control.

Benefits of Quality Management:

 Greater efficiency and proactive planning may overcome resource constraints.
 Successful malpractice suits could be reduced with quality care.
 Job satisfaction can be enhanced because QM involves everyone on the improvement
team and encourages everyone to contribute.

4.3 What is Front Office?

“Front office” personnel work with patient records, insurance billing, computerized
accounting, patient databases, transcription of dictated notes and applying standardized codes
to patient records, among other responsibilities.
The Front Office is a department of the hospital which directly interacts with the patients
when they first arrive. The staffs of this department are very visible to the patients or their
family members. It functions as a central point of contact across the organization. The
department keeps information and records of all the patients of the hospital. It also plays a
key role in forming overall impressions of the services provided by the organization.
The front desk position is often the first person that patients or their well-wishers interact
with when making contact with the hospital. So they are essentially the face and voice of the
hospital and for this reason, they play an important role in the representing of the
organisation. A Hospital Front Office Executive is a person who works in the hospital front
office and manages a variety of tasks.
Let us know in detail about the front desk executive.
Qualities of a Hospital Front Desk Executive
Here are some of the qualities that a front office executive of a hospital or any
healthcare institute must have:
1. Neat and professional appearance as it maintains professionalism
2. Being pleasant and approachable
3. Disciplined and Punctual
4. Speak multiple languages, especially in the regional language where the
hospital or healthcare institute is based
5. Strong interpersonal skills-working with the team and getting along with
a variety of different people
6. Multitasking capabilities and organisational abilities
7. Technical prowess
8. Ability to stay calm under pressure

Roles and responsibilities of a Hospital Front Office & Billing Executive:

There are various roles and responsibilities that a Front Office executive should perform at a
Hospital or any healthcare institute to make sure that the hospital runs smoothly.
Some of the important functions of a Hospital Front Office & Billing Executive are –
 A front office executive is responsible for attending the incoming calls, responding to
them and transferring the call to the appropriate department.
 Scheduling the appointments at the correct time and with the correct doctor
 Listening to clients and communicating in a positive and confident manner with those
over the phone or clients in the reception area.
 Handling billing and detailing client invoices
 Collecting payment to ensure the practice turns a profit so everyone gets paid
 Copying, faxing and emailing documents between clinics, hospitals, and patients
 There is a whole lot more that goes into making a hospital a great place to work, and
even better place for clients to visit, and ensuring things run smoothly and efficiently
from the moment the doors open.
4.4 OPD:

Outpatient Department (OPD) Treatment:

OPD is a treatment wherein certain treatment or diagnosis of a certain type of illness upon the
advice of a medical practitioner. This involves the patient visiting the clinic or any of the
doctors' consultation rooms.
OPD means an outpatient department, where patients come to the hospital to consult their
health issues with the doctor to start the treatment. Patients do not necessarily need to be
hospitalized but can visit any medical facility, such as a diagnostic centre, consultation room,
pharmacy, etc. in the hospital.
An OPD is a hospital department designed to be a first contact point between the patient and
the hospital staff. A Patient who goes first time to the hospital, he directly goes to OPD and
then the OPD decides to which department a patient should go.
The OPD is designed for diagnosis, Diagnostic tests, and minor surgical services for patients
that do not have to be admitted to the hospital. Generally an OPD is constructed on the
ground floor of any hospital and divided into several parts like Neurology department,
Orthopedics department, Gynaecology department, General medicine department etc. Here
the patient completes all the formalities and then go the respective department.
OPD is the basic care that is required to be treated. Clients are only required to visit the clinic
and doctors make the diagnosis after they pay the amount for treatment. It is a ward where
patients are diagnosed and treated by doctors.

Advantages of OPD:
 It is the first step in getting medically treated.
 It is a stepping stone for more proper treatment and prevention.
 It provides screening and investigations.
  One can easily access resources and information.
 It is an important step to prevent illness.

OPD is less expensive and it gives the care that is required for the patient. It is a highly
acclaimed step in the medical field because without OPD, patients will not be able to
understand their medical condition. By making regular visits to the OPD, patients can get
informed about various diseases and will also be prevented from illness. There is a lot of
guidance and control by the administration so it is easily controlled and the best service is
provided.

4.5 Casualty:

The original term (casualty) meant a seriously injured patient. It was predominantly a military
word, a general term for the accidents of service: after a battle the dead, the wounded, and the
sick lumped together as “casualties”. Casualty is the part of a hospital where people who have
severe injuries or sudden illnesses are taken for emergency treatment.
Casualty as defined “as a patient who comes to the hospital unannounced with accidental
injury and is seen and treated otherwise than at a consultative session.” -MoH, London.
“The first and foremost requirement of a Casualty is that it should do the patient no harm”
Florence Nightingale.
Medical emergency is defined as a situation where the patient requires urgent and high
quality medical care to prevent loss of life, limb or organ and initiate action for the
restoration of normal healthy life.
Also defined as a condition determined clinically or perceived by the patient or his/her
relatives as requiring immediate medical, dental or allied services failing which may result in
loss of life or limb”- WHO.
The Emergency department (ED) is a very critical and sensitive unit of any hospital and is
involved in the management of emergency cases. The emergency service brings about an
interface between the hospital and the community, which is emotionally sub charged.
An emergency department (ED), also known as an accident and emergency department
(A&E), emergency room (ER), emergency ward (EW) or casualty department, is a medical
treatment facility specializing in emergency medicine, the acute care of patients who present
without prior appointment; either by their own means or by that of an ambulance. The
emergency department is usually found in a hospital or other primary care centre.
Quick and competent care can save lives and also reduce the severity and duration of illness.
The emergency service provides immediate, emergency diagnostic and therapeutic care to the
patients with injuries by accidents, or sudden attacks of illness or exacerbation of
disease.These patients require immediate attention and treatment. Emergency patients receive
resuscitation and lifesaving treatment. If the patient is serious it can make all the difference
between life and death. High quality of outcome is expected by patients.

The ED is also referred as casualty wing for emergency cases • It should have a distinct entry
independent of OPD main entry. The patient expects high quality of outcome such as:

 Right time
 Right care
 Right expertise
 Right attitude
 Right cost

Characteristics of Causality:

 It should be an independent department working round the clock.

 It should be located in the complex of the OPD for reasons of easy accessibility and
sharing medical facilities with the OPD.
 It shall be on the ground floor of the hospital.
 Guidance to the route from main entrance to the doorways of reception hall shall be
provided.

4.6 Labs:
A medical laboratory or clinical laboratory is a laboratory where tests are carried out on
clinical specimens to obtain information about the health of a patient to aid in diagnosis,
treatment, and prevention of disease.
Laboratory Services include testing of materials, tissues or fluids obtained from a patient or
clinical studies to determine the cause and nature of disease.
Medical laboratories vary in size and complexity and so offer a variety of testing services.
More comprehensive services can be found in acute-care hospitals and medical centres,
where 70% of clinical decisions are based on laboratory testing.[2] Doctors offices and
clinics, as well as skilled nursing and long-term care facilities, may have laboratories that
provide more basic testing services.
Clinical laboratories are healthcare facilities providing a wide range of laboratory procedures
which aid the physicians in carrying out the diagnosis, treatment, and management of
patients. These laboratories are manned by medical technologists (clinical laboratory
scientists) who are trained to perform various tests to samples of biological specimens
collected from its patients. Most of the clinical laboratories are situated within or near
hospital facilities to provide access to both physicians and their patients.
Medical Laboratories includes Clinical Pathology, Microbiology,Biochemistry,Haematology,
Bacteriology, Biochemical analysis, Histopathology, Myco bacteriology, Hormonal
assays ,Cytology,Virology,Routine Pathology,Mycology,Parasitology,Immunology and
Serology etc.
Laboratory Services play a critical role in the detection, diagnosis and treatment of disease.
Samples are collected and examination and analysis of body fluids, tissue and cells are
carried out. Main services are:
 To perform diagnostic tests.
 To identify organisms, like E-coli bacteria.
 To count and classify blood cells to identify infection or disease.
 To operate complex diagnostic equipment.
 To perform immunological tests to check for antibodies.
 To type and cross-match blood samples for transfusions.
 To analyze DNA

Lab equipment’s and LIS (Lab information system):

It involves about planning for lab equipment’s & maintenance. Basic instruments and
equipment’s should be made available. All vital equipment should be in duplicate or have an
alternative arrangement. Selecting the best instrument for the laboratory is a very important
part of equipment management

Following element should be considered during management program in laboratory:

1) Selection and purchasing

2) Installation
3) Calibration and performance evaluation
4) Maintenance
5) Troubleshooting
6) Service and repair
7) Retiring and disposing of equipment
A lab information system ("LIS") is a class of software that receives processes, and stores
information generated by medical laboratory processes. These systems often must interface
with instruments and other information systems such as hospital information systems (HIS).
A LIS is a highly configurable application which is customized to facilitate a wide variety of
laboratory workflow models. It is a complete management system that handles all business
functions from patient management, results generating, to physician decision making.

Key Features of LIS:

The lab machines including the auto analysers are interfaced with the hospital information
system and their complete operations are automated without human intervention.HL7
standards incorporates the ability to receive data from other lab machines. Sample
management system creates barcodes and tracks the samples of blood, saliva, urine etc.
Assures that the technicians complete all the pending tests. Helps to generate automated
results from various laboratory machines and updates patient records. It enhances the ability
to handle large number of specimens without compromising on safety. Improves efficient
tracking of specimens by usage of bar codes for the specimens.

Benefits of Lab Information System Doctors:

 The lab results of critical patients would be notified instantaneously to the doctor.
 All the lab results would be submitted directly to the doctor Patients.
 No delay in the execution of doctors‟ orders.
 No need to make repeat visits to collect the results.
 Avoids no mix-up of samples of different patients at the lab by Lab Technician.
 Immediate receipt of the doctors‟ orders to perform a lab test.
 Easier reporting of lab results of the patients

4.7 OT:

Operation theatre (OT):

Operation Theatre (also known as an operating room (OR), operating suite, or operation
suite) is that unit of the hospital where all the major and minor surgical procedures are
performed. Operation theatre is a strictly prohibited area to maintain sterile aseptic
conditions.

A protective and clean atmosphere in the operation theatre can ensure in maintaining vital
functions, prevent dangerous secondary infections and thereby promote healing without any
complications.

Operation theatres should ideally have equipment like defibrillators, oxygen concentrators,
sterilizer machine, suction machine, anaesthesia machine, operation table, and light at their
disposal to ensure that all surgical procedures are conducted safely in the hospital.

OT rooms are supplied with wall suction, oxygen, and possibly other anesthetic gases. Key
equipment consists of the operating table and the anesthesia cart. In addition, there are tables
to set up instruments. There is storage space for common surgical supplies.

Features of the Operation theatre module:

i. Accurate scheduling of the operations, with flexibility in managing surgeries.

ii. Comprehensive checklists for monitoring patients
iii. Detailed pre-operative assessment
iv. Multilingual consent forms
v. Inventory and stock management of the OT
vi. Sterilization schedules, checks, and audits
vii. Anaesthesia details monitoring devices.
viii. Interface with monitoring devices is provided.
ix. Alerts on abnormal readings

4.8 CSSD:

The development of concept of sepsis was coined by Lister and Koch as a result of discovery
of microorganism. With this discovery, the need for aseptic technique in handling and
sterilizing the equipment used in surgery and medicine was felt for the care of patient. The
modern concept of CSSD was derived during Second World War.
1928: American College of Surgeon first started CSSD in their Hospital.
1955: Cambridge Military Hospital.
1958: Belfast Actual development took when Nuffield Provincial Hospital Trust (UK), a
central Health council began to take interest.
Now (21th century): CSSD is an integral part of every hospital
The Central Sterile Supply Department (CSSD) is the service responsible for receiving,
storing, processing, distributing and controlling the professional supplies and
equipment’s(both sterile and non-sterile) for all user unit of hospital for the care and safety of
patient under strict quality control.
It is an important facility of hospital that supplies sterile instruments and materials for
dressing and procedures carried out in ward and other departments of hospital. CSSD has a
great role in reducing Hospital Acquired Infection (HAI)
Normally the following types of articles are entertained by CSSD:
 Diagnostic sets like L.P set, Sternal Puncture set etc.
 Treatment sets like Cut down sets, aspiration set etc.
 Dressing materials -OT linen & instruments -Rubber Gloves, Catheters
 IV sets & infusion sets

Aims & objectives:

To provide the safe and sterile supplies to all the user unit of hospital.
Objectives:
 To provide efficient, economic and uniform source of sterile supply for the care and
treatment of sick.
 To assist purchase department for decision making and selection of goods.
 To assist management of hospital in standardization of good Cleaning, Packaging,
labelling and dating of material.
 To supply equipment’s to highly specialized units.
 To educate students, Nurse and ancillary persons.
 To save nursing time at nursing station.
 To participate effectively in Hospital infection control committee.
 Applied research for improvement techniques.
Sterilization is the process of freeing any articles from living microorganisms including
bacteria, Fungi, Virus etc. This process is carried out through sterilizers. 1. Heat Sterilization
Dry Heat Sterilization Steam Sterilization 2.ETO (Ethylene Oxide Sterilization) 3.Chemical
Sterilization 4.Radiation Sterilization (Gamma)

4.9 In-Patient(IP):

The term ‘inpatient’ (IP) refers to someone who is admitted to the hospital for medical
treatment and health care services. Most patients enter the inpatient hospitalisation through a
pre-planned surgery or treatment or during emergencies. Inpatient care requires an overnight
stay, whether briefly or for extended periods of time. In most cases, patients require in-depth
observation and monitoring.
Most of the hospitalisation falls under this and it is the most basic coverage of health policies.
To categorise you as an inpatient and to receive the benefits of the insurance policy, you need
to be admitted to the hospital, either planned or unplanned, for 24 hours.Patients are assigned
a ward or a room based on the type of care they need and the availability of the bed.
Typically, each general ward Consist of 30 beds and each ward provides hospital bed with all
facilities for in-patients services.
Various In patient department services are as like Medicine Ward, Cardiac ward, Surgery
Ward, Chest Medicine Ward, Obstetric Ward, Gynaecology Ward, Dermatology Ward,ENT
Ward, Eye Ward,Pre Op Ward, Post-Op Ward, Emergency Room, Dental Ward, Neurology
Ward, Nephrology Ward, Rheumatology Ward,Isolation,Infection Ward,Pediatric Ward,
BurnWard, Special ,Disable Ward, DiarrhoeaWard, Communicable Ward etc.
Critical care area In-Patients wards are like ICU, NICU, PICU, SICU, CCU, CTVS, LR,
Causality, Operation theatre and HDU etc.

Examples:

 Traumatic injury
 Serious illnesses such as stroke, flu, etc.
 Severe burns
 Chronic diseases, such as cancer that require specialised treatment
 Childbirth (normal and caesarean section) - typically has a waiting period etc.

Types of inpatient care

Following are the different types of inpatient care.

a) Serious health issues: Patients with serious health illnesses need in-depth monitoring and
observation from healthcare professionals. Some severe health illnesses include seizures
due to brain damage, respiratory problems, and being in a state of coma.

b) Complex surgeries: From bypass surgeries to organ transplantation of the heart, or other
vital organs, complicated surgeries require long-term observation under the care of
medical care professionals.

Here are the differences between inpatient and outpatient hospitalisation.

Factors Inpatient Outpatient

 When the patient does not
When the patient has been require formal
formally admitted to a hospital, hospitalisation, the patient
Definition either more than a day (at least requires treatments
24 hours) or an extended period, performed outside the
the patient is called an inpatient. hospital setting; then, the
patient is called an outpatient.

Short-term: Annual blood

Long-term: Complex surgeries, check-ups, minor surgeries,
Type of medical care traumatic injuries, severe medical screenings,
illnesses. treatments, etc. that do not
require hospitalisation.

Considerably higher than Substantially less than

Cost
outpatient care. inpatient care.

Specialists and a larger group of

Primary care physicians and
caretakers (physicians,
specialists (physician
Healthcare professionals surgeons, nurse practitioners,
assistants, physical therapists,
pharmacists, physical therapists,
etc.)
etc.

4.10 Summary:
Coupled with growing awareness and demand from various stakeholders towards quality
to meet the patient safety standards and better patient outcomes, quality in healthcare is
becoming a mandate. Hence healthcare sector is becoming increasingly competitive and
are rapidly opting for quality management and adopting relevant accreditation standards
and thus gaining competitive advantage.
Quality management in health care ensures that patients receive an excellent provision of
care. Health care organizations such as medical clinics and hospitals are responsible for
performing this function to show their due diligence to taking optimal care of their
patients. By employing quality management applications to a health care business,
doctors and administrators can benefit from identifying ways to improve internal
processes that will ream more “quality” outcomes for their patients.

4.11 Key words:

Front Office: It represents the customer-facing division of a firm.

LIS: A laboratory information system (LIS) is computer software that processes, stores and
manages data from all stages of medical processes and tests.

Quality management: Quality management is the act of overseeing all activities and tasks that
must be accomplished to maintain a desired level of excellence. This includes the
determination of a quality policy, creating and implementing quality planning and assurance,
and quality control and quality improvement.

OPD: An OPD is structured to be the primary point of communication among the patient and
the medical professionals in a medical department.

Casualty: Casualty is the part of a hospital where people who have severe injuries or sudden
illnesses are taken for emergency treatment.

CSSD:An integrated place in hospitals and health care facilities that performs sterilization
and other actions on medical devices, equipment and consumable.

Inpatient:a patient who stays in a hospital while receiving medical care or treatment.

4.12 Self-assessment questions:

1. Discuss quality management aspects in detail in the health care industry?

2. What is the meaning of the term "front office"?Explain the roles and responsibilities of
the hospital front office.
3. Discuss the outpatient department in detail?
4. Make brief notes on: a) casualty, b) laboratory information system.
5. Discuss Operation Theatre & its features.
6. Explain the significance of CSSD in hospitals?
7. Discuss in-patient care and its various types?

4.13 Further readings:

 Quality Management in Hospitals, S. K. Joshi, 2008.

 Introduction to Healthcare Quality Management, By Patrice L. Spath, 2009.
 Applying Quality Management in Healthcare: A Systems Approach, Fourth Edition,
Aupha/Hap Book, 2017.
 Lesson - 5 Nursing services; Emergency and Trauma care

Learning objectives:

It helps the students to understand the significance of their role in providing the best services
to hospitals.

Structure:

5.1 Introduction
5.2 Concept of Nursing services
5.3 Objectives& Factors to be considered in Planning Hospital Nursing Services
5.4 Emergency
5.5 Trauma care
5.6
5.7 Summary
5.8 Key words
5.9 Self-assessment questions
5.10 Further readings

Nursing services:

5.1 Introduction

Nursing service is the part of the total health organization which aims at satisfying the
nursing needs of the patients/community. In nursing services, the nurse works with the
members of allied disciples such as dietetics, medical social service, pharmacy etc.
Nursing profession is considered a caring profession to begin with; it was an art and a
vocation. Now it is considered a scientific profession nursing care is defined as the care of the
patient with regard to nursing needs, with he ever increasing dimension of medical sciences
quantitatively and qualitatively nursing care is becoming more and more complex with its
management services.
The nurse role is the hub of all activities in a hospital centredaround the patient. Nursing is a
dynamic, therapeutic and educative process in meeting the health care needs of the patient. It
ensures timely and continuous care for the sick. Ensures qualitative, quantitative, efficient
and effective nursing care.Nursing services play an essential role in society today by being
advocates for health promotion, educating the public and patients on preventing injury and
illnesses, participating in rehabilitation, and providing care and support.

Concept of Nursing Services:-

Nursing service is the part of the total health organization which aims at satisfying the
nursing needs of the patients/community. In nursing services, the nurse works with the
members of allied disciples such as dietetics, medical social service, pharmacy etc. in
supplying a comprehensive program of patient care in the hospital.
Definition of Nursing Services:-
WHO expert committee on nursing defines the nursing services as the part of the total health
organization which aims to satisfy major objective of the nursing services is to provide
prevention of disease and promotion of health.

Organization of Nursing Services:-

CHIEF NURSING OFFICER
|
NURSING SUPDT
|
DY. NURSING SUPDT.
|
ASSTT.NURSING SUPDT.
|
WARD SISTER-CLINICAL SUPERVISOR
|
STAFF NUIRSE ---- STUDENT NURSE

Objective of Nursing in Ward:-

 Maximum comfort and happiness by way of pleasant surroundings.
 Qualitative/comprehensive care to the patient.
 Care based on the patient’s needs.
 Accurate assessment of illness.
 Adequate material resources at all times.
 Health education to the patient and attendants.
 Managerial skills as and when required.
 Privacy at all levels.

Factors to be considered in Planning Hospital Nursing Services:-

 Number and type of patient.
 Number of beds and type of ward.
 The services required.
 Procedures/techniques necessary for care.
 Number and type of personal needed to perform care effectively.
 Physical facilities.
  Provisional of equipment and supplies

5.4 Emergency care:

Medical emergencies are increasing at an exponential rate every day. Every Indian hospital
encounters an increasing number of acute cases in the form of Trauma, Medical, Surgical,
Gynaecological and Paediatric emergencies.
Emergency medical care can cut down fatality rate, improve treatment outcomes, reduce
rehabilitation time, and optimize treatment costs for many patients.
Emergency & Trauma Care Technician provides immediate care to the injured and efficient
care in accidental cases. These technicians are imparted knowledge of disease processes,
bedside procedures and technical skills to handle critical/ emergency/ traumatic cases.
Emergency medicine doctors or EMDs treat patients who need immediate medical care. They
are professionals specializing in trauma care, advanced cardiac life support, and management
of other life-threatening conditions.
The hospitals should be well-equipped with the most advanced technologies and equipment.
The staff, nurses and physicians work round the clock to deal with all levels of medical
emergencies. With highly advanced emergency room, highly experienced doctors,
paramedics and staff nurse who are versatile in dealing with all sorts of medical emergencies.
An emergency medical condition is a sudden and unexpected onset of a health condition that
needs to be promptly treated or managed. In the absence of timely treatment, the condition
could worsen and lead to debilitated bodily functions, serious and lasting damage to organs
and other body parts, or even death.
During an emergency, it isn’t practically possible to diagnose the condition before admitting
the patient for treatment. However, if doctors presume that the patient is experiencing a
condition that is secured by PMBs or prescribed minimum benefits, the medical scheme has
to approve the treatment. The schemes may also require that the diagnosis is confirmed along
with evidence that supports it within a certain period of time.
Hospitals need to provide the high quality and technologically advanced emergency medical
care services such as
a) Ambulance Services: Ambulances with an inbuilt ICU service with a transport
ventilator, multipara monitoring, emergency drugs, oxygen facility, and necessary
equipment. It is being managed by ACLS providers / trained paramedics.
 b) Triage: The triage is an area where the patients are segregated based on the severity
of the emergency and thereafter directed to appropriate areas of care. A triage is
staffed by a resident in the emergency medicine along with a paramedic and a staff
nurse who are trained adequately.
c) Emergency / ICU services: Emergency cases/treatments need to be, managed by MD
(Emergency Medicine) physicians who are capable of managing all kinds of
emergencies.
d) Critical Care: Emergency care does not begin and end in the emergency room, as
emergencies may arise anywhere. Hence the need for coverage from pre-hospital care
till the patient’s transfer to definitive care is the ICU. The 24/ 7 critical care area is
managed by consultants who have completed DM / Fellowship in Critical Care.
e) Special Services: Emergency care hospitals need to maintain an in-house residents in
all the departments Cardiology, Cardiothoracic Surgery, Medicine, Pulmonology,
Nephrology, Urology, Neurology, Neurosurgery, Oncology, Vascular Surgery,
Obstetrics & Gynaecology, Paediatrics, ENT, Head and Neck Surgery, Maxillofacial
Surgery, Gastroenterology - Medical and Surgical covered by consultants who stay in
the vicinity of the hospitals.
f) Facilities: Emergency room comprises separate resuscitation bays, which are
prioritized, and each emergency room has a decontamination room for managing
critical cases. Also need to have an isolation room to limit the spread of contagious
diseases, an emergency ward and emergency OT’s. The emergency is managed by
specialists in emergency medicine (who have completed MD in emergency) along
with trained residents in emergency with a backup by critical care physicians which
include all services.

5.5Trauma Care:
A trauma centre is a hospital equipped and staffed to provide care for patients suffering from
major traumatic injuries such as falls, motor vehicle collisions, or gunshot wounds.
A trauma patient is a person who has suffered a physical injury which may be minor, serious,
life-threatening or potentially life-threatening. Trauma injuries are usually categorised as a
blunt or penetrating wound.
Trauma care begins before the patient arrives at the hospital. Typically, rescue personnel
respond to a call and provide pre-hospital care

Trauma care system" means a subsystem within the emergency medical services system,
consisting of an organized arrangement of personnel, equipment and facilities, designed to
manage the treatment of the trauma patient.

Objectives:

 Describe the elements of the primary survey and how they are utilized during trauma
cases.
 Review the elements of the secondary survey and how they are utilized during trauma
cases.
 Outline the necessary actions and interventions of nursing staff in a trauma setting.
 Identify areas of concern that members of an interprofessional treatment team
commonly encounter during trauma cases and outline methods that health team
members can follow to decrease the incidence of these issues.

5.6 Dietary:

Diet plays a vital role in the treatment of patients. Proper diet is the key to good health and
vigour. Inadequate and improper diets are not only responsible for under nutrition but also
contribute to several chronic degenerative diseases such as cardiovascular diseases, diabetes
and cancer.
Hospital food service is essential to provide inpatients with nutritious meals which shall help
them to recover from their illness. Meals should be carefully planned and served as per
patient’s requirement. The objective of a dietary service is to make provision for clean,
hygienic and nutritious diet for the patients as per their nutritional requirement.
A dietician in Food Service Management of the Hospital Kitchen and food service area plays
a key role in hospitals.
Dietary department perform two major activities that is
i. Nutritional care of patients
 Out-patient diet clinic
 In-patient Nutritional Care
 Food service management

ii. Food Service Management Activities

 Receiving of raw materials.
  Storage of raw materials in proper storage area like the walk in cooler for
perishable goods and dry storage area for non-perishable goods.
 Production of food where various meals are prepared according to prescribed diet
plan.
 Serving of food according to the portion prescribed in the diet plan with the help
of standardize cups and serving the diet tray at the patient’s bed side.
 Medical Check-up and health of Food handlers.
 Maintenance of Cleanliness in the Kitchen

Dietary services include various activities such as:

a) Selection, procurement and storage of food ingredients.
b) Inventory control of the food items.
c) Menu planning of different kinds of food.
d) Development of recipes as per the nutritional requirement of patients.
e) Preparation and cooking and presentation of food.
f) Distribution of food and serving of food.
g) Planned preventive maintenance programs for the equipment.
h) Training and development of the staff.

5.7 House Keeping:

“Housekeeping is a support service department in a hospital, which is responsible for

cleanliness, maintenance & aesthetic upkeep of patient care areas, public areas and staff
areas”. It is also known as sanitation department/ sanitation section/ sanitation services etc.

Definition of Housekeeping:

Housekeeping is the provision of a clean, comfortable, safe and aesthetically appealing

environment. (Raghubalan.G&Raghubalan.S)

Housekeeping is the maintenance of a clean, pleasant and orderly environment which has
always formed an essential part of civilized living.

Housekeeping is defined as the provision of a clean, comfortable and safe environment for
thepatients and public in a hospital setup.

Housekeeping is often perceived as a tedious job but one feels comfortable only in the
environment which is clean and well ordered, so cleanliness is important for the health of
persons. Cleaning is carried out for the following reasons: Aesthetic appeal, Hygiene
Maintenance & Safety etc.
 i. Aesthetic Appeal:
Leave every surface clean. Ceilings, floors, furniture, walls, windows, fixtures, fittings etc.
Leave the area tidy and place every item in the right place. Maintain order on table tops,
arrange books, pens and other items, keeping symmetry in mind. Take care of indoor plants.
Water natural plants, get rid of dead plants, and clean the pots, vases and leaves. Keep
artificial flowers and other artefacts free of dust. Use feather dusters on paintings and fragile
decorative items.
The process of cleaning is a hygienic practice because it gets rid of dust, dirt and germs. A
Housekeeper must be well kempt(Change under garments regularly, brush the teeth and keep
the breath fresh, wear clean and ironed uniforms, Shave regularly, use anti-per spirants, Keep
the hair clean and tidy).Avoid cross contamination by using disinfectants. The use of colour
coded equipment helps to avoid cross contamination as well. The universal colour code is
RED- for toilets i.e. Red dust cloths, Mop buckets, Mop sticks etc. YELLOW- for sinks,
BLUE- for furniture and GREEN for the kitchen. Special attention should be paid to sensitive
areas such as the toilets, bathrooms, all the areas in the hospitals etc. The housekeeper needs
a lot of order and presence of mind to be thorough, fast, effective and efficient and at the
same time being cautious and sensitive to the health of others and to his or her health as well.
Changing hand gloves, dust cloths, washing the hands regularly, disinfecting cleaning
equipment and keeping them clean ensures personal and environmental hygiene.

ii. Maintenance:
The very act of cleaning is a routine maintenance for that area being cleaned as such; the
housekeeper needs to be vigilant in observing items, equipment, and appliances etc. that are
out place and need repairs. Observing is one step, the next step is to report to the
relevant/appropriate personnel and the third step is to follow up the repairs. The housekeeper
needs to acquire skills of simple maintenance procedures such as driving in nails, changing
bulbs, tightening screws etc. Maintenance of the cleaning agents and equipment is also very
important. This entails storing them properly in a cleaning store that is airy. Other tips will be
given subsequently.

iii. Safety:
The safety of housekeepers is important as well as the safety of those who benefit from their
services. The use personal protective equipment is essential. Examples of PPE are nose
masks, hand gloves, covered shoes, uniforms, goggles, ear plugs etc. The housekeeper needs
to get rid of all hazards while cleaning.Safety hazards can be categorized as micro-organisms.
They are gotten rid of mainly through disinfecting and sterilizing. Physical-hair human/ pet,
insects and pests, nuts and bolts, drawing pins, soil etc. They can be gotten rid of by cleaning
with chemical cleaning agents. They should be labelled, tightly closed, stored in the right
place and used according to the manufacturer’s instructions.

Responsibilities of Housekeeping Department:

 Daily cleaning
 Periodic cleaning
 Trash and garbage removal including proper
 hospital waste disposal
 Discharge cleaning
 Exterminating bugs and pests
 Preventing spread of infection
 Safety and security of the hospital
 Creating healing environment
 Gardening
 Interior decoration
Organization chart of housekeeping consists of administrator, housekeeping manager,
housekeeper, sanitary worker &gardener etc.
Organizing Housekeeping Department is concerned about various aspects such as location,
Facility space requirement, Storage areas (e.g. under staircase),Cupboards with locks, Notice
boards, Management information system, Registers (attendance, asset,...),Forms (Indent,
requisitions,),Asset list (equipment, materials..), and Checklist (Quality, Maintenance..) etc.

5.8 Summary:

It is important for nurses to treat a patient's physical ailments as well as his or her emotional
needs. When nurses show empathy, they foster a collaborative relationship with patients. In
any emergency, time is crucial, and care providers should know the value of time. The
hospital's trauma department is staffed with trauma physicians, emergency room physicians,
surgical residents, and nurses.

5.9 Key words:

Dietary services: Providing food and drink to a patient according to an order.

Housekeeping: It is a support service department in a hospital, which is responsible for
cleanliness, maintenance & aesthetic upkeep of patient care areas, public areas and staff
areas”. It is also known as sanitation department/ sanitation section/ sanitation services etc.
Medical emergency: A medical emergency is an acute injury or illness that poses an
immediate risk to a person's life or long-term health, sometimes referred to as a situation
risking "life or limb".
Nursing: It includes the promotion of health, prevention of illness, and the care of ill, disabled
and dying people.
Trauma care: Trauma care means medical services and nursing services provided to a patient
suffering from a sudden physical injury.

5.10 Self-assessment questions:

1. Discuss about nursing services & its objectives?
2. Explain about emergency care services?
3. Define Trauma Car? Explain Objectives of trauma care?
4. Discuss about Dietary services?
5. Define Housekeeping? Explain Responsibilities of Housekeeping Department?

5.11 Further readings:

• Hospital-Based Emergency Care: At the Breaking Point. National Academies of

Sciences, Engineering, and Medicine. (2007). Washington, DC: The National Academies
Press.

• TQM in Health Care-Huch. CH Koch.

• Hospital Administration – G. D. Kunders

Lesson -6 ICU; CCU; MRD, Laundry; Canteen; Hospital stores.

Learning objectives: It enables health care/ hospital manager to understandthe additional

services apart of core medical services which reflect the patient’s service expectations.
What is ICU&CCU?
Significance of MRD
Laundry services
Canteen facility
Hospital stores

Structure:
6.1 ICU
6.2 CCU
6.3 Medical Records Department (MRD)
6.4 Laundry
6.5 Canteen
6.6 Hospital stores
6.7 Summary
6.8 Key words
6.9 Self-assessment question
6.10 Further readings

6.1 ICU:
An intensive care unit (ICU), also known as an intensive therapy unit or intensive treatment
unit (ITU) or critical care unit (CCU), is a special department of a hospital or health care
facility that provides intensive care medicine.ICU is highly specified and sophisticated area
of a hospital which is specifically designed, staffed, located, furnished and equipped,
dedicated to management of critically sick patient, injuries or complications. It is a
department with dedicated medical, nursing and allied staff.It is emerging as a separate
specialty and can no longer be regarded purely as part of anaesthesia, Medicine, surgery or
any other speciality. It has to have its own separate team in terms of doctors, nursing
personnel and other staff who are tuned to the requirement of the speciality.
The ICU is a specialized department in the hospital, staffed by highly skilled physicians,
nurses and more to provide care for the sickest patients
Dr.Zakieh said. “These patients have a life-threatening disease or injury that requires constant
monitoring and treatment.”
Intensive care units were grouped into four types: medical, including coronary care; surgical,
including trauma and cardiovascular; neonatal and paediatric; and medical-surgical.
Types of Intensive Care Units, Neonatal Intensive care unit (NICU), Paediatric Intensive care
unit (PICU),Psychiatric Intensive care unit (PICU),Coronary care unit (CCU), Neurological
Intensive care unit (Neuro ICU) ,Post- anaesthesia care unit (PACU).

The Intensive care team consists of doctors, nurses, therapists, nutritionists, chaplains and
other support staff, builds an environment for healing or dying.

6.2 CCU:
The first description of the coronary care unit (CCU) was presented to the British Thoracic
Society in July 1961.A coronary care unit (CCU) or cardiac intensive care unit (CICU) is a
hospital ward specialized in the care of patients with heart attacks, unstable angina, cardiac
dysrhythmia and (in practice) various other cardiac conditions that require continuous
monitoring and treatment.
Critical care Nursing is a specialty within nursing that deals specifically with human
responses to life threatening problems. The care of seriously ill clients from point of injury or
illness until discharge from intensive care. Critical care deals with human responses to life
threatening problems trauma /major surgery.

Critical care is a term used to describe as the care of patients who are extremely ill and whose
clinical conditions is unstable or potentially unstable.
Critical care unit is defined as the unit in which comprehensive care of a critically ill patient
which is deemed to recoverable. It is a specially designed and equipped with skilled staff and
personnel to provide effective and safe care for patients with life threatening problem that is
potentially reversible.
ICU is defined as” Motorization of vital parameters ( blood pressure, respiration, pulse rate,
temperature, hydration, electrolyte, blood gas, etc.) and systemic organ functions (heart,
brain, lungs, kidneys, liver) in a multi-disciplinary approach, AND maintaining those
parameters in normal (physiological – healthy) limits”.

6.3 MRD:
Medical Records Department or the MRD is an essential part of a hospital or a healthcare
setup which primarily stores records of the patients who have been either treated in the OPD
(Out Patient Department), IPD (Inpatient Patient Department) or Emergency Unit of the
hospital.
A medical record is a systematic documentation of a patient’s medical history and care. It
usually contains the patient’s health information (PHI) which includes identification
information, health history, medical examination findings and billing information.Medical
Record of the patient stores the knowledge concerning the patient and care given. It contains
sufficient data written in sequence of occurrence of events to justify the diagnosis, treatment
and outcome. In the modern age, Medical Record has its utility and usefulness and is a very
broad based indicator of patients care.
The Medical Records Department (MRD) prime objective is the provision of patient Medical
Records in a timely manner to different hospital units in order to assist clinicians, allied
health professionals and other hospital staff in the provision of quality care to patients.
A medical records department is the whole soul of any information of the patient who is
discharged from the hospital after treatment. A medical records department mainly functions
to store the medical records or treatment files of patients who are either treated in the
inpatient department or in the emergency unit.
The outpatient department records can be stored in the medical records department or can be
stored separately.
The medical records department also send data to the government about the number of births
and deaths in the hospital for their registrations in the census. These medical records also
serve useful in legal proceedings as proof of treatment.
Components of medical record include Front Sheet or identification Summary Sheet Consent
for Treatment Legal Documents like referral letter, request for Information etc. Discharge
Summary, referral slip Admission notes, clinical progress notes, Nurses progress note
Operation report if operation has been performed Investigation reports like, X-ray, pathology
etc. Orders for treatment and medication forms listing daily medications ordered and given
with signatures of the doctor prescribing the treatment and the nurse administering it
Medical record department collects following information as a part of medical record
information to maintain an effective case sheet of an In-patient.The medical record is a legal
document providing a chronicle of a patient's medical history and care. Physicians, nurse
practitioners, nurses and other members of the health care team may make entries in the
medical record. The medical record includes a variety of types of "notes" entered over time
by health care professionals, recording observations and administration of drugs and
therapies, orders for the administration of drugs and therapies, test results, x-rays, reports, etc.
  Patient Demographics
 Financial Information
 Consent and Authorization Forms
 Release of information
 Treatment History
 Progress Notes
 Physician’s Orders and Prescriptions
 Radiology Reports
 Nursing Notes
 Medication List
 Notice of Privacy Practices
 Patient Confidentiality

Use of medical records:

 To document the course of patient’s illness & treatment.
 Communicate between attending doctors and other health Care professional providing
care to the patient.
 Collection of health Statistics.
 Legal Matters & Court Cases
 Insurances Cases

6.4 Laundry:
Laundry processes include washing (usually with water containing detergents or other
chemicals), agitation, rinsing, drying, pressing (ironing), and folding.
The aim of Hospital Laundry is to provide adequate supply of clean Linen for the comfort
and safety of the patient and personal appearance of the personnel. The goal of Linen and
laundry is to provide regular and timely supply of clean Linen to the satisfaction of
patients and staff.
Laundry is defined as a place where the washing and finishing of cloths and other articles
are carried out. (Or) It is the area or part of housekeeping where the linen is washed and
pressed.
 There are two types of laundry services 1) Commercial/off-site/contracted laundry 2) on-
premises/on-site/in-house laundry.

Laundry Department provides the following services:

a) Collecting soiled linen from various places.
b) Sorting the linen and processing them.
c) Inspecting and repairing or replacing damaged materials.
d) Distributing clean linen to the respective user departments.
e) Maintaining different types of registers.

6.5 Canteen:
The Hospital are required to maintain a well-equipped canteen (or) catering facility for
patients, their relatives, doctors, staff and even for any visitors who walk into hospital.
The primary aspect of canteen is to provide quality and hygienically safe food to all who
come in.
Hospital catering services are an essential part of patient care to provide good-quality,
nutritious meals play a vital part in patients’ rehabilitation & recovery, & limit the
unnecessary use of nutritional supplements. Hospital catering services should be cost
effective & flexible enough to provide a good choice of nutritious meals that can
accommodate patients’ specific dietary requirements & preferences.

Objectives of Canteen/Catering Department:

1. Control catering budget & contract: food, beverages & snacks.
2. Choose & order ingredients.
3. Develop Recipes, menu’s taking into consideration dietetic advice, patients age, culture,
religion & medical condition.
4. Prepare food to Quality approved standards.
5. Deliver food to wards, patients & staff restaurants.
6. Serve food to patients at ward level (Nurses/ Hostesses).
7. Provide snacks.
8. Maintain & supervise food hygiene at all times.
9. Consider development of patient restaurants or other novel food delivery / outlets.
10. Control cost & monitor waste.
11. Audit &develop service delivery
6.6 Hospital stores:
Hospitals Store is a medical equipment and surgical supply store that works with hospitals,
clinics, pharmacies and patients.
The stores function is a vital part of all industrial undertakings, whether in the public or the
private sector. The store is the centre of activities of materials in motion. Conditions of
operation in different undertakings differ widely and, therefore, the practices followed also
vary widely.

Purpose and objectives:

The main objectives of the stores function is to provide efficient service to all operating
functions- production, construction, repairs and maintenance, etc.
Make available a balance and timely flow of all materials- raw materials, spare parts and
components, tools and equipment and all general stores.
Receive, inspect and issue the above stores to work in progress.
Accept, store and arrange disposal of scrap and unwanted stores.

Responsibilities and Functions:

The main responsibility of the store function is to provide stores service most economically.
To discharge the responsibilities effectively the following functions will have to be
performed-
1. Identification is the process of codifying and describing all items required to be stocked.
2. Receipt is the process of accepting after inspection all materials required for use in the
organization.
3. Inspection is checking of all incoming materials for quality.
4. Storage is the process of storing the materials in warehouse, stockyards, etc.
5. Stock control is the process of provisioning which means continuously arranging
recoupment, receipts and issues of stocks so as to ensure required service consistent with
economy.
6. Issues and dispatch is the process of receiving demand from consumers and issuing the
demanded materials without loss of time.
7. Stock records have to be maintained showing day to day position of receipt issues and
stock balances.
 8. Stores accounting is charging each issuer voucher in a manner so that the money spent
is properly allocated.
9. Stock taking is the process of verifying physically the quantities of materials and their
condition in the stock at specified intervals to see if they agree with quantities shown in
stock records.

Types of Hospital Stores:

The hospital stores can be divided into two broad categories:
a) Non Consumable Stores: These stores may be utilized repeatedly.
b) Consumable Stores: These stores are utilized only once.

6.11 Summary:
The critical care unit of a hospital is responsible for providing emergency support to patients
who need immediate care for sudden and critical health problems. In order to achieve this,
hospitals must provide the highest quality linens to their patients and require healthy and
hygienic food for visitors.

6.12 Key words:

CCU: It refers to a cardiac care unit, which is a specialized unit for patients with heart-related
problems.
ICU: A special department of a hospital or health care facility that provides intensive care
medicine.
Laundry:Laundry processes include washing (usually with water containing detergents or
other chemicals), agitation, rinsing, drying, pressing (ironing), and folding.
Medical record : A chronological written account of a patient's examination and treatment
that includes the patient's medical history and complaints, the physician's physical findings,
the results of diagnostic tests and procedures, and medications and therapeutic procedures.

6.13 Self-assessment questions:

 1. Discuss ICU and CCU in detail?
2. Explain the significance and role of the medical record department in a hospital?
3. Discuss the services provided by the laundry department in hospitals?
4. Discuss the objectives of the canteen?
5. What exactly is the definition of a hospital store? Discuss the responsibilities and
functions of hospital stores?

6.14 Further readings:

 Sharma, Madhuri(2003)-Essentials for Hospital Supportive Services, Jaypee Brothers,
New Delhi.
 Sakharkar,B M (1998)-Principles of Hospital Administration & Planning-jaypee
Publishers New Delhi.
 Kunders, G.D.(2004)-Facilities Planning and Arrangement in Healthcare, Prism Books
Pvt Ltd. Bangalore.
 Davies Llewellyn R &macaulay H M C(1995)- Hospital Planning and Administration,
Jaypee Brothers, New Delhi.
 Hospital-Based Emergency Care: At the Breaking Point. National Academies of Sciences,
Engineering, and Medicine. (2007). Washington, DC: The National Academies Press.

UNIT - III Team work and Tools in TQM

Lesson - 7
Learning objectives:
It provides insights into various tools that are used for assessing product and service quality,
and how the selection of these tools can help in the pursuit of excellence. These concepts are
designed to provide a valuable perspective for future healthcare managers. To provide
fundamental knowledge of TQM teamwork concepts and tools for the continuous
improvement of quality patient care.

 TQM team work

 Employee involvement
 Key result areas
 Leadership
 TQM Tools

Structure:
7.1 Concept of TQM team work
7.2 Significance of TQM team work
7.3 Tools in TQM
7.4 Employee involvement in TQM implementation
7.5 Key result area
7.6Summary
7.7 Key words
7.8 Self-assessment questions
7.9 Further readings

7.1 Concept of TQM team work:

The teamwork principle of TQM involves collaboration between managers and non-
managers, and between functions therefore leading to improvement in the social
relationships.Teamwork TQM organizations discover the benefits of having effective teams
at all levels.With the use of teams, the business will receive quicker and better solutions to
problems. Teams also provide more permanent improvements in processes and operations.
Total Quality Management (TQM) is a management framework based on the belief that an
organization can build long-term success by having all its members, from low-level workers
to its highest ranking executives, focus on improving quality and, thus, delivering customer
satisfaction.Total Quality Management is extremely important when customer wants full
satisfaction. In implementing TQM it is very important every employee should be part of
process.
Teamwork is a key element of TQM.With the use of teams; the business will receive quicker
and better solutions to problems. Teams also provide more permanent improvements in
processes and operations. In teams, people feel more comfortable bringing up problems that
may occur, and can get help from other workers to find a solution and put into place.
Team Management involves integration of teams with effective recognition & reward,
communication and performance appraisal of teams for successful implementation of TQM
practices.

7.2 Significance of TQM team work:

Team members contribute their individual thoughts and expertise to the team and bear
different responsibilities in the fulfilment of the team's objectives. of everyone and takes
advantage of the experience and knowledge possessed by its members, therefore allowing
everyone to “own” a part of the product or service.
Quality Improvement Team (QIT) is a team taking lead to implement quality improvement
activities. Group of multi skilled employee charged with responsibilities of improving
processes or services. The team include top and middle management members to coordinate
initial planning and implementation.A Process Improvement Team is a group of individuals
who work well together and bring specific skills to the table to solve a problem. A Team
should always include a customer or end user.
The quality management principles commonly stated in the standards are customer focus,
leadership, staff participation, process-based approach, system approach to management,
continuous improvement, fact-based approach to decision making, and supplier relationships.
7.3 Tools in TQM:
Total quality management (TQM) tools help organizations to identify, analyze and assess
qualitative and quantitative data that is relevant to their business. These tools can identify
procedures, ideas, statistics, cause and effect concerns and other issues relevant to their
organizations. Implementation TQM tools help assisting creative thinking and problem
solving and give continuous improvement in performance and customer satisfaction must be
adopted.
These tools can identify procedures, ideas, statistics, cause and effect concerns and other
issues relevant to their organizations. Each of which can be examined and used to enhance
the effectiveness, efficiency, standardization and overall quality of procedures, products or
work environment, in accordance with ISO 9000 standards (SQ, 2004).According to Quality
America, Inc. there are number of TQM tools such as brainstorming, focus groups, check
lists, charts and graphs, diagrams and other analysis tools.
 Pareto Principle
 Scatter Plots
 Control Charts
 Flow Charts
 Cause and Effect , Fishbone, Ishikawa Diagram
 Histogram or Bar Graph
 Check Lists
 Check Sheets
The following are some of the most common TQM tools in use today. Each is used for, and
identifies, specific information in a specific manner. It should be noted that tools should be
used in conjunction with other tools to understand the full scope of the issue being analyzed
or illustrated. Simply using one tool may inhibit your understanding of the data provided, or
may close you off to further possibilities.

1) Pie Charts and Bar Graphs: Used to identify and compare data units as they relate to
one issue or the whole, such as budgets, vault space available, extent of funds, etc.

2) Histograms: To illustrate and examine various data element in order to make decisions
regarding them Effective when comparing statistical, survey, or questionnaire results.
3) Run Chart: Follows a process over a specific period of time, such as accrual rates, to
track high and low points in its run, and ultimately identify trends, shifts and patterns.

4) Pareto Charts / Analysis: A Pareto chart is one of the key tools used in total quality
management and six sigma methodologies. It is basically a bar chart showing how much each
cause contributes to an outcome or effect. It is a simple tool that helps organizations identify
the most frequent defects, complaints, or any other factor that can be counted and
categorized.It is a visual tool widely used by professionals to analyse data sets related to a
specific problem or an issue.A Pareto chart is a special example of a bar chart. For a Pareto
chart, the bars are ordered by frequency counts from highest to lowest. These charts are often
used to identify areas to focus on first in process improvement.

5) Force Field Analysis: Force field analysis is a basic tool for root cause analysis that can
help you take action once the root cause has been identified. Force Field Analysis helps you
to think about the pressures for and against a decision or a change. It was developed by Kurt
Lewin. The technique is based on the assumption that any situation is the result of forces for
and against the current state being in equilibrium.

How to Conduct a Force Field Analysis

i. Define the objective of your change project.
ii. Identify and list all driving forces for the change.
iii. Identify and list forces pushing against the change.
iv. Assign each force an impact score.
v. Propose solutions to positive influence the forces.
vi. Create a Change Management Plan.

5) Focus Groups: Useful for marketing or advertising organizations to test products on the
general public. Consist of various people from the general public who use and discuss your
product, providing impartial feedback to help you determine whether your product needs
improvement or if it should be introduced onto the market.

6) Brainstorming and Affinity Diagrams:Brainstorming is the systematic and structured

process of generating all possible ideas, on the basis of the creative thinking of a group of
people. Teams using creative thinking to identify various aspects surrounding an issue.
The affinity diagram organizes a large number of ideas into their natural relationships. It is
the organized output from a brainstorming session. Use it to generate, organize, and
consolidate information related to a product, process, complex issue, or problem.
A group decision-making technique designed to sort a large number of ideas, process
variables, concepts, and opinions into naturally related groups. These groups are connected
by a simple concept. Purpose: To sort a list of ideas into groups.

2) Tree Diagram:A Tree Diagram is a way of visually representing hierarchy in a tree-like

structure. Typically the structure of a Tree Diagram consists of elements such as a root
node, a member that has no superior/parent.A tree diagram is a new management
planning tool that depicts the hierarchy of tasks and subtasks needed to complete and
objective.
a) To identify the various tasks involved in, and the full scope of, a project.
b) To identify hierarchies, whether of personnel, business structure, or priorities.
c) To identify inputs and outputs of a project, procedure, process, etc

8) Flowcharts and Modelling Diagrams: A flowchart is a picture of the separate steps of a

process in sequential order. It is a generic tool that can be adapted for a wide variety of
purposes, and can be used to describe various processes, such as a manufacturing process, an
administrative or service process, or a project plan. Assist in the definition and analysis of
each step in a process by illustrating it in a clear and comprehensive manner.
a) Identify areas where workflow may be blocked, or diverted, and where workflow is
fluid.
b) Identify where steps need to be added or removed to improve efficiency and create
standardized workflow

3) Scatter Diagram:A scatter diagram visualizes the relationship between two variables. A
scatter diagram is one of the best tools to show a non-linear pattern.
It is used in “Control Quality” process as a corrective action approach to understand
causes of poor performance of dependent variable due to independent variable effect. A
scatter plot is a mechanism to understand the influence of independent variable over
dependent variable.
 a) To illustrate and validate hunches
b) To discover cause and effect relationships, as well as bonds and correlations, between
two variables
c) To chart the positive and negative direction of relationships

4) Relations Diagram: An interrelationship diagram is defined as a new management

planning tool that depicts the relationship among factors in a complex situation. The
interrelationship diagram shows cause-and-effect relationships. Its main purpose is to
help identify relationships that are not easily recognizable. To understand the
relationships between various factors, issues, events, etc. so as to understand their
importance in the overall organizational view.
A relations diagram is used for identifying cause-and-effect relationships when evaluating
problems that are especially confusing or complicated. When a network of these
relationships is present in a problem, the relations diagram becomes especially useful
because it allows one to visualize the relationships.

5) PDCA:PDCA (plan-do-check-act, sometimes seen as plan-do-check-adjust) is a

repetitive four-stage model for continuous improvement (CI) in business process
management. The PDCA model is also known as the Deming circle/cycle/wheel,
Shewhart cycle, control circle/cycle, or plan–do–study–act (PDSA). The PDCA/PDSA
cycle is a continuous loop of planning, doing, checking (or studying), and acting. It
provides a simple and effective approach for solving problems and managing change. The
model is useful for testing improvement measures on a small scale before updating
procedures and working practices.
The Plan-Do-Check-Act style of management where each project or procedure is planned
according to needs and outcome, it is then tested, examined for efficiency and effectiveness,
and then acted upon if anything in the process needs to be altered.
This is a cyclical style to be iterated until the process is perfected. All of these TQM tools can
be easily created and examined by using various types of computer software or by simply
mapping them out on paper. They can also be easily integrated into team meetings,
organizational newsletters, marketing reports, and for various other data analysis needs.
Proper integration and use of these tools will ultimately assist in processing data such as
identifying collecting policies, enhancing work flow such as mapping acquisition procedures,
ensuring client satisfaction by surveying their needs and analysing them accordingly, and
creating an overall high level of quality in all areas of your organization.

7.4 Employee involvement in TQM implementation:

Total employee involvement is an organization methodology and set of management
principles that encourages individual contributors, team members, and employees to
participate much more in the problem solving, decision making and planning processes that
affect their organization.
Total Employee Involvement (TEI) Total employee involvement is a system for direct
participation of employees to organizational success, by letting them take responsibilities. It
enables everyone deeply involved, using own brain power, in problem solving, learning,
continuous improvement activities, & systematic search for opportunities.

Employee involvement improves quality and increases productivity, because:

 Employees make better decisions using their expert knowledge of the process.
 Employees are more likely to implement and support decisions they had a part in
making.
 Employees are better able to spot and pinpoint areas of for improvement.
 Employees are better able to take immediate corrective actions.
 Employee involvement reduces labor/management friction by encouraging more
effective communication and cooperation.
 Employee involvement increases morale by creating feeling of belonging to the
organization.
 Employees are better able to accept change because they control the work
environment.
 Employees have an increased commitment to unit goals because they are involved.

Employee Involvement process:

a) Motivating the work force
b) Team building
c) Training
d) Suggestion system
e) Reward an recognition
 f) Gain sharing
g) Performance appraisal

7.5 Key result areas:

Key Result Areas (KRAs) refers to a short list of overall goals that guide how an individual
does their job, or general achievement and progress goals for an organization or one of its
divisions.
TQM has been coined to describe a philosophy that makes quality the driving force behind
leadership, design, planning, and improvement initiatives.To be successful implementing
TQM, an organization must concentrate on the eight key elements:
i. Ethics.
ii. Integrity.
iii. Trust.
iv. Training.
v. Teamwork.
vi. Leadership.
vii. Recognition.
viii. Communication.
7.6Summary:
Managers play an important role in total quality management (TQM) by providing frequent
reports to staff members highlighting the scope of improvement. Implement TQM tools to
assist with creative thinking and problem solving and give continuous improvement in
performance and customer satisfaction. These tools are methods and frameworks that help
employees communicate more effectively in formulating business problems and their
solutions.

7.7 Key words:

Affinity diagram: A technique which is used to organizes a large number of ideas into their
natural relationships.

Brainstorming: A group creativity technique by which efforts are made to find a conclusion
for a specific problem by gathering a list of ideas spontaneously contributed by its members.

Focus group: A focus group is a group interview involving a small number of

demographically similar people or participants who have other common traits/experiences.

Scatter diagram: A scatter diagram is used to examine the relationship between both the axes
(X and Y) with one variable.

Teamwork: It is the collaborative effort of a group to achieve a common goal or to complete a

task in the most effective and efficient way.

Tree diagram: It is a new management planning tool that depicts the hierarchy of tasks and
subtasks needed to complete and objective.

7.8 Self-assessment questions:

1. Discuss the concept of TQM teamwork and its significance?

2. Explain the tools of TQM in detail?

3. Make a brief note about: a) the Pareto chart; and b) the scatter diagram.

4. Discuss the PDCA model?

5. Discuss employee involvement in TQM implementation?

6. Write short notes on key result areas?

7.9 Further readings:

 SundaraRaju, S.M., Total Quality Management: A Primer, Tata McGraw Hill, 1995.
 Srinivasan, N.S. and V. Narayana, Managing Quality- concepts and Tasks, New Age
International, 1996.
 Sridhar Bhat, Total Quality Management, Himalaya House publications, Mumbai,
2002
 Total Quality Management (TQM) by Besterfield Dale H.5e by Pearson, 2018.
 Total quality management implementation in the healthcare industry, by Mohammed
R Twati -2019.
 The Textbook of Total Quality in Healthcare Edited By A. F. Al-Assaf, June Schmele
 Lesson - 8 Quality Function Deployment & TQM Tools

Learning objectives: There are many tools and methods that can be used for assessing
product or service quality, and the selection of these tools can help in the pursuit of
excellence. It helps the students choose appropriate statistical techniques for improving
processes. The total quality management tools will help the students understand the
procedures for measuring the quality of the organization/process and will also enable him/her
to identify the parameters that are improving or depriving the quality.

8.1 Quality Function Deployment (QFD)

8.2 Concurrent engineering
8.3 FMEA
8.4 P-C-D-A Cycle
8.5 JIT (Just in Time)
8.6 Kaizan
8.7 ‘O’ defect programme
8.8 Statistical Tools in TQM
 Flow diagram
 Pareto Analysis
 Cause and effect diagram
 Control Charts
8.9 Summary
8.10 Key words
8.11 Self-assessment
8.12 Further readings
8.1 Quality Function Deployment (QFD):
QFD was originally developed by Dr.YojiAkao and Shigeru Mizuno in the early 1960s.The
House of Quality made it first appearance on 1972 in the design of an oil tanker by
Mitsubishi Heavy Industries. Quality function deployment is a systematic approach of
specifying the customer needs and desires, rating them in terms of priority and designing the
quality products and process to serve these requirements, through proper planning.
"QFD" is a flexible and comprehensive Decision making technique used in product or service
development, brand marketing, and product management.Quality Function Deployment
(QFD) is a structured approach defining to customer needs or requirements and translating
them into specific plans to produce products to meet those needs.
Quality Function Deployment (QFD) is a process and set of tools used to effectively define
customer requirements and convert them into detailed engineering specifications and plans to
produce the products that fulfill those requirements.

Advantages of QFD:
a) Promotes better understanding of customer needs
b) Improves customer satisfaction.
c) Promote team work.
d) Better understanding of design interactions.
e) Breaks barriers between functions and departments.
f) Minimizes number of later engineering changes.
g) Introduces the new design in to the market faster.
h) Better documentation of design and development process.
 i) Reduces overall cost of design and manufacture.

8.2 Concurrent engineering:

Concurrent engineering, also known as simultaneous engineering, is a method of designing
and developing products, in which the different stages run simultaneously, rather than
consecutively. It decreases product development time and also the time to market, leading to
improved productivity and reduced costs.
Concurrent engineering can be defined as a systematic approach to integrated product
development that emphasizes response to customer expectations and embodies team values of
cooperation, trust, and sharing of information and knowledge. Therefore, generally,
concurrent engineering can be viewed as the earliest possible integration of the overall
company's knowledge, resources, and experience in design, development, marketing,
manufacturing, and sales into creating successful new products, with high quality and low
cost.
Concurrent engineering, also known as simultaneous engineering, is a method of designing
and developing products, in which the different stages run simultaneously, rather than
consecutively. It decreases product development time and also the time to market, leading to
improved productivity and reduced costs.
Concurrent Engineering is a long term business strategy, with long term benefits to business.
Though initial implementation can be challenging, the competitive advantage means it is
beneficial in the long term. It removes the need to have multiple design reworks, by creating
an environment for designing a product right the first time round.

8.3 FMEA:
A Failure Mode and Effects Analysis (FMEA) is a generally valid analytical method in
quality management and is considered standard in many companies today. It is used to find
potential errors in products before they occur. Appropriate actions are then implemented to
prevent these potential errors from occurring.FMEA is an analytical technique that combines
the technology and experience of people in identifying foreseeable failure modes of a product
or process and planning for its elimination .
FMEA is an engineering technique used to define, identify and eliminate known and / or
potential failures, problems, errors which occur in the system, design, process and service
‘before they reach the customer’. Failure modes and effects analysis (FMEA) is a step-by-
step approach to identify all possible failures in a design, a manufacturing or assembly
process, or a finished product or a final service. “Failure modes” means the ways or modes,
in which something may fail. “Failures” are errors or defects which affect the customer and
can be potential or actual failures. “Effect analysis” refers to the study of the consequences or
effects of those failures. Failure modes and effects analysis (FMEA) is also called as
“Potential failure modes and effects analysis”, or “failure mode, effects and critically
analysis” (FMECA)
FMEA is one of the tools of total quality management which helps in finding out the possible
failure modes of a design, product, process or service and setting up ways of preventing their
recurrences. It is a methodology to assess and reduce risk in systems, products or services. It
aims to define, identify, prioritise and eliminate known or potential failures at an early stage
as possible.FMEA is a preventive approach for systematically mapping the causes, effects
and possible actions regarding the observed problems or failures.FMEA is pro-active tool
which is used to foresee the probable failures which can occur at a later stage. It involves
critical analysis of each and every process with the aim of identifying problems which may
emerge in the future.

Benefits of FMEA:
a) Improves the quality, reliability, and safety of products / services / machinery and
processes
b) Improves company image and competitiveness
c) Increases customer satisfaction
d) Reduces product development timing and cost / support integrated product
development
e) Documents and tracks action taken to reduce risk
f) Reduces potential for Warranty concerns
g) Integrates with Design for Manufacturing & Assembly techniques

8.4 P-C-D-A Cycle:

Walter A. Shewhart, the renowned physicist and statistician from Western Electric and Bell
Labs, developed the original concept during the 1920s. The PDCA/PDSA cycle is a
continuous loop of planning, doing, checking (or studying), and acting. It provides a simple
and effective approach for solving problems and managing change. The model is useful for
testing improvement measures on a small scale before updating procedures and working
practices.The PDCA Cycle is a four-step technique that is used to solve business problems.
Many managers unknowingly use the PDCA Cycle as it encompasses much of the same
framework as strategic management.
PDCA is an iterative design and management method used in business for the control and
continuous improvement of processes and products. It is also known as the Deming
circle/cycle/wheel, the Shewhart cycle, the control circle/cycle, or plan–do–study–act.
Another version of this PDCA cycle is OPDCA.
It consists of four-stage problem-solving model used for improving a process or carrying out
change. When using the PDSA cycle, it's important to include internal and external
customers; they can provide feedback about what works and what doesn't.It stimulates
continuous improvement of people and processes. It lets your team test possible solutions on
a small scale and in a controlled environment. It prevents the work process from recurring
mistakes.

8.5 JIT (Just in Time):

Just-in-time, or JIT, is an inventory management method in which goods are received from
suppliers only as they are needed. The main objective of this method is to reduce inventory
holding costs and increase inventory turnover.JIT can enhance value for customers and at the
same time can ensure higher profits for firm.Just-In-time or JIT, is a management philosophy
aimed at eliminating manufacturing wastes by producing only the right amount and
combination of parts at the right place at the right time. It is also that ‘Just in Time (JIT)’
enforces ‘Continuous Improvement’ by continual reduction of non-value- added inventory
stocks to lower and then further lower levels. This is based on the fact that wastes result from
any activity that adds cost without adding value to the product, such as transferring of
inventories from one place to another or even the mere act of storing them. The goal of JIT,
therefore, is to minimize the presence of non-value-adding operations and non- moving
inventories in the production line. This will result in shorter through put times, better on-time
Total Quality Management & Just In Time.
The JIT system consists of defining the production flow and setting up the production floor
such that the flow of materials as they get manufactured through the line is smooth and
unimpeded, thereby reduce material waiting time. This requires that the capacities of the
various workstations that the materials pass through are evenly matched and balanced, such
that bottlenecks in the production line are eliminated. This set-up ensures that the materials
will undergo manufacturing without queuing or stoppage. JIT is most applicable to operations
or production flows that do not change, i.e., those that are simply repeated over and over
again.
Just-in-time manufacturing is also known as the Toyota Production System (TPS) because the
car manufacturer Toyota adopted the system in the 1970s.Kanban is a scheduling system
often used in conjunction with JIT to avoid overcapacity of work in process. The success of
the JIT production process relies on steady production, high-quality workmanship, no
machine breakdowns, and reliable suppliers. The terms short-cycle manufacturing, used by
Motorola, and continuous-flow manufacturing, used by IBM, are synonymous with the JIT
system.

Advantages and Disadvantages of JIT:

JIT inventory systems have several advantages over traditional models. Production runs are
short, which means that manufacturers can quickly move from one product to another. Also,
this method reduces costs by minimizing warehouse needs. Companies also spend less money
on raw materials because they buy just enough resources to make the ordered products and no
more.
The disadvantages of JIT inventory systems involve potential disruptions in the supply chain.
If a raw-materials supplier has a breakdown and cannot deliver the goods promptly, this
could conceivably stall the entire production line. A sudden unexpected order for goods may
delay the delivery of finished products to end clients.

8.6 Kaizen:
Kaizen is a Japanese business philosophy that focuses on gradually improving productivity
by involving all employees and by making the work environment more efficient. Kaizen
translates to "change for the better" or "continuous improvement."Kaizen focuses on
eliminating waste, improving productivity, and achieving sustained continual improvement in
targeted activities and processes of an organization.The three pillars of kaizen,
standardization, 5S, and elimination of waste, are critical to achieving the goals.
Kaizen is a problem solving process with existing resources. Kaizen can help a hospital to
create “continuous quality improvement culture” to meet in/external clients’ satisfaction and
expectation.
Kaizen approach consists of five elements:
i. Teamwork
ii. Personal discipline
iii. Improved morale
iv. Quality circles
v. Suggestions for improvement

8.7 ‘O’ defect programme:

Zero Defects, a term coined by Philip Crosby in his book “Absolutes of Quality
Management,” has emerged as a popular and highly-regarded concept in quality
management.Zero Defects is a management tool aimed at the reduction of defects through
prevention.
Zero defects are a management tool aimed at the reduction of defects through prevention. It is
directed at motivating people to prevent mistakes by developing a constant, conscious desire
to do their job right the first time. Zero defect management is a revolutionary idea which
managed to completely redesign the production philosophies of era.
The approach of zero defects is such that workers willingly join in quality control. Therefore
they are made to think and believe that responsibility of controlling the quality is of workers.
The approach of this system is to motivate for gaining of zero defect.
The theory of zero defects has been based upon four elements that are as followed:
Performance: The performance is judged by the quality standards and zero defects seek
perfection as close as possible.
Requirement: Quality should meet the requirement and introducing zero defects in this
means providing quality requirements at a particular time.

Step-by-step procedure: In zero defects procedure, the quality is looked after from the
beginning to the end.

Measurement in financial terms: Later, at the end of the procedure, one needs to judge
production, waste as well as revenue regarding budget impact.

Four important principles of zero defects in quality management:

i. Quality is important to assure that all the important factors of production are taken
care of making way for good processes and procedures.
ii. Quality must be given equal importance and must be set right. It doesn’t make sense
that the company starts with its production and then tries to figure out the quality
standards. The number of defects detected must be minimal. If not, it will cost a huge
amount to the business to set everything right.
iii. Quality is money. The business has to ascertain its waste, production, and profits in
monetary terms to compare the data.
 iv. The company must keep zero defects as its target and must try to reach a state of
perfection though it is practically impossible to attain such a state.

Advantages of Zero defect:

It benefits the organization in many ways.
 Aligns process: One of the most significant advantages of this concept is that it tries to
precisely align all the required processes. So, it ensures that the firm does not suffer any
significant damage or loss and thus saves costs. It also leads to waste reduction as it is
constantly monitored and controlled.

 Enhances workers’ morale: Usually, workers think that some minor mistakes will
happen while working. But the zero-defect concept changes this mind-set of the workers
and encourages them to work without any defect. That increases workers’ morale.

 Improves customer relationship: Better quality means delighted customers and repeat
customers. This end of the day translates to long-term customer relationships and more
profits for the company. But the business must be careful that the strict environment
created to ensure zero defects does not lead to reduced morale of its employees.

8.8 Statistical Tools in TQM:

Statistical Tools in TQM:
Statistical methods in quality improvement are defined as the use of collected data and
quality standards to find new ways to improve products and services.
Statistical Tools of Quality:
 Flow chart- For depicting the essential steps of a process by using standard symbols.It is
used for depicting the steps of a process in an easily understandable form, by using
standard symbols. It is used to document and analyse the connection and sequence of
events in a process with symbols.

 Check sheet- For systematic data gathering, by tabulating the frequency of occurrence.A
structured, prepared form for collecting and analysing data; a generic tool that can be
adapted for a wide variety of purposes.Check sheets are nothing but forms that can be
used to systematically collect data.
 Histogram- For graphically displaying the frequency distribution of the numerical
data.The most commonly used graph for showing frequency distributions, or how often
eachdifferent value in a set of data occurs.Histograms help in understanding the variation
in the process. It also helps in estimating the process capability.

 Pareto diagram- For identifying the vital few causes that account for a dominant share
of a quality loss. A bar graph that shows which factors are more significant. A Pareto
chart is one of the key tools used in total quality management and six sigma
methodologies. It is basically a bar chart showing how much each cause contributes to
an outcome or effect. It is a simple tool that helps organizations identify the most
frequent defects, complaints, or any other factor that can be counted and categorized.It is
a visual tool widely used by professionals to analyse data sets related to a specific
problem or an issue.A Pareto chart is a special example of a bar chart. For a Pareto chart,
the bars are ordered by frequency counts from highest to lowest. These charts are often
used to identify areas to focus on first in process improvement.

 Cause and effect diagram- For identifying and analysing the potential causes of a given
problem. (Also called Ishikawa or fishbone diagrams): Identifies many possible causes
for an effect or problem and sorts ideas into useful categories.
Developed by Dr Kaoru Ishikawa in It is also known by the name of Ishikawa diagram
or Fishbone diagram. This diagram is helpful in representing the relationship between an
effect and the potential or possible causes that influences it.This is very much helpful
when one want to find out the solution to a particular problem that could have a number
of causes for it and when we are interested in finding out the root cause for it.
There is a systematic arrangement of all possible causes which give rise to the effect in
Ishikawa diagram. Before taking up problem for a detailed study, it is necessary to list
down all possible causes through a brainstorming session so that no important cause is
missed. The causes are then divided into major sources or variables.
Example:

 Scatter diagram-For depicting the relationship between two variables.Graphs pairs of

numerical data, one variable on each axis, to look for a relationship.It is a graph of points
plotted; this graph is helpful in comparing two variables. The distribution of the points
helps in identifying the cause and effect relationship Between two variables.

 Control chart- For identifying process variations and signalling corrective action to be
taken.Graph used to study how a process changes over time. Comparing current data to
historical control limits leads to conclusions about whether the process variation is
consistent (in control) or is unpredictable (out of control, affected by special causes of
variation).A control chart is nothing but a run chart with limits. This is helpful in finding
the amount and nature of variation in a process.

 Flow diagram: A flowchart is a type of diagram that represents a workflow or process. A

flowchart can also be defined as a diagrammatic representation of an algorithm, a step-by-
step approach to solving a task.Flow diagram is a collective term for a diagram
representing a flow or set of dynamic relationships in a system.A flow diagram, or
flowchart, is a specific type of activity diagram that communicates a sequence of actions
or movements within a complex system. A flow diagram is a powerful tool for optimizing
the paths of people, objects, or information.It is a graphical representation of a process.
It's a diagram that illustrates the workflow required to complete a task or a set of tasks
with the help of symbols, lines and shapes. Flowcharts are used to study, improve and
 communicate processes in various fields.It gives in detail the sequence involved in the
material, machine and operation that are involved in the completion of the process.

A flowchart is a picture of the separate steps of a process in sequential order. It is a

generic tool that can be adapted for a wide variety of purposes, and can be used to
describe various processes, such as a manufacturing process, an administrative or
service process, or a project plan.

 Cause and effect diagram:

A cause and effect diagram, otherwise called an Ishikawa or "fishbone" diagram, is a graphic
instrument used to investigate and show the potential causes of a specific effect. Use the
exemplary fishbone diagram medical when causes bunch normally under the classifications
of Materials, Methods, Equipment, Environment, and People. This diagram can show or
analyse the causes of problems at each progression in the process.
A cause and effect diagram has an assortment of benefits:
 It assists groups with the understanding that numerous causes add to an effect;
 It graphically shows the relationship between the causes of the effect and to one
another;
 It assists in identifying zones for improvement.
Example:
 Control Charts:
A quality control chart is a graphical representation of whether a firm's products or processes
are meeting their intended specifications.The control chart is a graph used to study how a
process changes over time. Data are plotted in time order. A control chart always has a
central line for the average, an upper line for the upper control limit, and a lower line for the
lower control limit.
Quality control charts depict measures of quality for processes or for products. They show the
deviation, if any, from the set, ideal standards, or specifications. The charts are useful for
ensuring smooth operational processes and uniform quality product/services levels.

Types of Control Charts:

There are various types of control charts which are broadly similar and have been developed
to suit particular characteristics of the quality attribute being analyzed. Two broad categories
of chart exist, which are based on if the data being monitored is “variable” or “attribute” in
nature.

Variable Control Charts:

a) X bar control chart:
This type of chart graphs the means (or averages) of a set of samples, plotted in order to
monitor the mean of a variable, for example the length of steel rods, the weight of bags of
compound, the intensity of laser beams, etc.. In constructing this chart, samples of process
outputs are taken at regular intervals; the means of each set of samples are calculated and
graphed onto the X bar control chart. This chart can then be utilized to determine the actual
process mean, versus a nominal process mean and will demonstrate if the mean output of the
process is changing over time.

b) Range “R” control chart.

This type of chart demonstrates the variability within a process. It is suited to processes
where the sample sizes are relatively small, for example <10. Sets of sample data are
recorded from a process for the particular quality characteristic being monitored. For each
set of date the difference between the smallest and largest readings are recorded. This is the
range “R” of the set of data. The ranges are now recorded onto a control chart. The center line
is the averages of all the ranges

c) Standard Deviation “S” control chart.

The “S” chart can be applied when monitoring variable data. It is suited to situations where
there are large numbers of samples being recorded. The “S” relates to the standard deviation
within the sample sets and is a better indication of variation within a large set versus the
range calculation. An advantage of using the standard deviation is that all data within a set
are utilized to determine the variation, rather than just the minimum and maximum values.
Attribute Control Charts:
Attribute control charts are utilized when monitoring count data. There are two categories of
count data, namely data which arises from “pass/fail” type measurements, and data which
arises where a count in the form of 1, 2,3,4,…. arises. Depending on which form of data is
being recorded, differing forms of control charts should be applied.

a) “u” and “c” control charts:

The “u” and “c” control charts are applied when monitoring and controlling count data in the
form of 1,2,3, …. i.e. specific numbers. An example of such data is the number of defects in a
batch of raw material, or the number of defects identified within a finished product.
The c chart is used where there can be a number of defects per sample unit and the number of
samples per sampling period remains constant.
In the u chart, again similar to the c chart, the number of defects per sample unit can be
recorded, however, with the u chart; the number of samples per sampling period may vary.

b) “p” and “np” control charts:

P charts are utilized where there is a pass / fail determination on a unit inspected. The p chart
will show if the proportion defective within a process changes over the sampling period (the
p indicates the portion of successes). In the p chart the sample size can vary over time. A
similar chart to the p chart is the np chart. However, with the np chart the sample size needs
to stay constant over the sampling period. An advantage of the np chart is that the number
non-conforming is recorded onto the control rather than the fraction non-conforming. Some
process operators are more comfortable plotting the number rather than the fraction of non-
conformances.

c) Pre-control Charts:
Where a process is confirmed as being within statistical control, a pre-control chart can be
utilized to check individual measurements against allowable specifications. Pre-control charts
are simpler to use than standard control charts, are more visual and provide immediate “call
to actions” for process operators. If however a process is not statistically “capable” i.e.
having at least 1, pre-control can result in excessive process stoppages.

8.9 Summary:
The House of Quality is the primary chart in quality planning and is a prerequisite for a
successful Quality Management (QM) programme. TQM emphasises improvement of every
process by searching for all the problems in the company with the selection of effective tools
to obtain appropriate solutions. Techniques can be included in the "house of quality" for this
purpose.

8.10 Key words:

Control chart: A graph used to study how a process changes over time.

Histogram: A Quality Control Tool that graphically displays a data set.

JIT: A just-in-time (JIT) is system of manufacturing is based on preventing waste by

producing only the amount of goods needed at a particular time, and not paying to produce
and store more goods than are needed.
Quality Function Deployment (QFD): A structured approach to defining customer needs or
requirements and translating them into specific plans to produce products to meet those
needs.

Zero Defects: Zero defects are a quality philosophy based on the idea that a level of perfect
quality, as in zero defects, is achievable and should be a company-wide goal.
8.11 Self-assessment:

1. Discuss quality function deployment and its advantages?

2. Write short notes to a) Concurrent engineering b) Just-in-Time

3. What does "zero defect" mean? Explain its principles?

4. Discuss Attribute Control Charts in detail?

5. Explain Kaizen and its approaches?

6. Discuss FMEA & its benefits?

7. Discuss variable control charts?

8. Explain the cause and effect diagram with an example?

8.12 Further readings:

 AmctaMitra “Fundamentals of Quality Control and improvement” Pearson Education,
2002
 Charantimath M. Poornima (2009), Total Quality Management. Pearson Education,
 India
 ManoharMahajan, “Statistical Quality Control”, DhanpalRai& Sons, 2001.
 Mukherjee, N.P. (2006), Total Quality Management, PHI Learning Pvt. Ltd.
 Sharma S.C., “Inspection Quality Control and Reliability”, Khanna Publications, 2004.
 Lesson -9 Bench Marking, Business Process Reengineering, Six Sigma, Assessing
Quality&Patient satisfaction survey

Learning objectives: It helps the students to learn the contemporary techniques application
in industries to improve quality effectively & efficiently.

What is Bench Marking?

What is Business Process Reengineering?
Six Sigma
Need for Assessing Quality
Patient satisfaction survey
TQM practices in Indian Hospitals

Structure:
9.1 Concept of Bench Marking
9.2 Process of Benchmarking & its types
9.3 Advantages of Benchmarking
9.4 Business Process Reengineering
9.5 Six Sigma
9.6 Need for Assessing Quality&Patient satisfaction survey
9.7 TQM practices in Indian Hospitals
9.8 Summary
9.9 Key words
9.10 Self-assessment
9.11 Further readings
9.1 Concept of Bench Marking:
Benchmarking is defined as the process of measuring products, services, and processes
against those of organizations known to be leaders in one or more aspects of their operations.
Benchmarking provides necessary insights to help you understand how your organization
compares with similar organizations, even if they are in a different business or have a
different group of customers.Benchmarking is the practice of comparing business processes
and performance metrics to industry bests and best practices from other companies.
Dimensions typically measured are quality, time and cost.The concept will help organisations
to measure current performance levels and identify opportunities for improvement. It explains
how to identify strengths, weaknesses and success factors in benchmarking.
Benchmarking is the process of continually improving the business or the organization by
evaluating the scope for improvement, comparing the current position with that of the
previous one or with the business practices of the relevant competitors, thereby establishing
standards to be achieved.
Benchmarking can also help organizations identify areas, systems, or processes for
improvement either incremental (continuous) improvements or dramatic (business process re-
engineering) improvements.

Process of Benchmarking:
Benchmarking is not an immediate solution to a problem. It is a step by step treatment of the
problem area. These steps are explained in detail below:

Types of Benchmarking:
Benchmarking is a strategic activity. It requires a lot of research and analysis. To make it
efficient, the company must be clear about the type of related strategy it must adapt to treat a
specific problem area.
It is classified into the following two categories each of which holds some strategies:

9.3 Advantages of Benchmarking:

Benchmarking is essential for organizations to sustain high-level competition and to keep up
with the customer’s requirement and needs.
The various benefits of setting benchmarks in the organization:

a) Improves Learning Methodology

b) Initiates Technological Up gradation
c) Improve Company’s Standards
d) Enhances Work Quality
e) Cope Up with Competition
f) Improves Efficiency
g) Increases Customer Satisfactions
h) Help Overcome Weaknesses

9.4 Business Process Reengineering:

Business Process Reengineering involves the radical redesign of core business processes to
achieve dramatic improvements in productivity, cycle times and quality.A major aim of BPR
is to analyse workflows within and between business functions in order to optimize the end-
to-end business process and eliminate tasks that do not improve performance or provide the
customer with value. The primary aim of BPR is to cut down process redundancies and
enterprise costs. BPR is also known as process innovation as it attempts to remodel processes
to eliminate unproductive layers.
Business process reengineering is also known as business process redesign, business
transformation, or business process change management.
Business process reengineering (BPR) is the practice of rethinking and redesigning the way
work is done to better support an organization's mission and reduce costs.
BPR is influenced by technological innovations as industry players replace old methods of
business operations with cost-saving innovative technologies such as automation that can
radically transform business operations.
BPR helps in building a strategic view of operational procedures by making radical inquiries
about how processes are improved and how things could be done. It eliminates unnecessary
activities and thereby helps in reducing organizational complexity. It coordinates and
integrates several functions immediately.

Steps in BPR:

9.5 Six Sigma:

Six sigma is a quality management methodology used to help businesses improve current
processes, products or services by discovering and eliminating defects.The Six sigma was
founded by Motorola in the 1970s.
The primary objective of Six Sigma is customer satisfaction, and to achieve the objective,
various methods are followed to improve the performance of a product or business process.
DMAIC and DMADV are the main methodologies of Six Sigma that apply to different
business environments.
It is a business strategy to achieve excellence by applying different statistical, TQM and
Project Management tools. Six Sigma originated from the field of statistics as a set of
practices designed to improve manufacturing processes and limited defects, but its
application was subsequently extended to other types of business processes as well. In Six
Sigma, a defect is defined as any process output that does not meet customer specifications,
or that could lead to creating an output that does not meet customer specifications. The term
‘Six Sigma’ referred to the ability of manufacturing processes to produce a very high
proportion of output within specification. Processes that operate with ‘six sigma quality’ over
the short term are assumed to produce long-term defect levels below 3.4 defects per million
opportunities (DPMO).
Six Sigma is a business methodology and a data-driven process whose goal is to produce
nearly perfect products for consumers, reducing product defects down to 3.4 defective parts
per million, or 99.99966% defect-free products over the long term. It is an essential part of
any business process improvement as it significantly improves the efficiency of your business
by identifying flaws and weaknesses in your processes. In order to bring improvement to
eliminate defects and waste, a set of tools and methods are developed over the years by Six
Sigma practitioners that address control and problem-solving.

Benefits of Using Six Sigma:

It induces a change in the management style and produces a culture of error/defect-free
production, cost control, and a customer satisfaction environment with employees.
 It reduces defects.
 It also reduces production costs.
 Keep control of competitive pricing.
 It is a customer-focused approach.
 Gains high productivity.
  High returns on investments are gained.

List of Six Sigma Tools:

 DMAIC: DMAIC is a 5-step process, and it is the first and most used method/tool in Six
Sigma.
The 5 steps are:
 Define
 Measure
 Analyse
 Improve
 Control
The DMAIC process helps in creating continuous improvement in your manufacturing
methods by using data and measured objectives. Also, there is a process known as DMADV,
which is used to develop a new process, product, or service, whereas DMAIC which is useful
for improving current processes.

 DMADV Stands for:

 Define
 Measure
 Analyse
 Design
 Verify
The DMADV process helps in developing a high-quality product or service by creating an
efficient process doing thorough analyses and using data.

 The 5S System:
For quicker access and better management, workplace materials are organized following a
tool known as the 5S System. The waste that is produced by poor conditions and poor
workstations are eliminated with the help of this system.

The 5S are:
 i. Seiri (Sort) – Leaving only necessary items, all extra items are removed from current
production.
ii. Seiton (Set in order) – Organize all items and label them according to being clutter-
free.
iii. Seiso (Shine) – Keep your work area clean, and inspect everything in it regularly.
iv. Seiketsu (Standardize) – Write the standards that you have set, sort them, set them in
order, and shine steps above.
v. Shitsuke (Sustain) – Apply and execute the standards that you have set for your
company and make everyone follow it as a habit regularly.

9.6 Assessing Quality and Patient satisfaction survey:

A quality assessment (QA) measures the difference between expected and actual performance
to identify opportunities for improvement.QA in primary care is a process of planned
activities whose ultimate goal is to achieve a continuous improvement of medical care
through the evaluation of structure, process, and outcome measures
Patient satisfaction is one performance measure of health care quality. The purpose of the
Assessing Quality and Patient Satisfaction survey is to determine whether patients are
receiving the best possible services in the modern healthcare industry.
A patient satisfaction survey is a set of questions used to collect feedback from patients to
measure their satisfaction with the quality and care of the healthcare service provider. The
patient satisfaction survey questionnaire helps adjudge basic metrics across patient care that
aid medical institutions in understanding the level of care provided and pitfalls in service.
Patient satisfaction is the extent to which patients are happy with their healthcare, both inside
and outside of the doctor's office. A measure of care quality, patient satisfaction gives
providers insights into various aspects of medicine, including the effectiveness of their care
and their level of empathy.

Objective of patient satisfaction:

 Health Care Institutions are primarily patient centric.
 Patient Satisfaction is the strongest determinant of hospital functioning.
 Ultimate goal of the hospital is satisfaction of its customers.
 Not only to satisfy and cared-for patients and families, but also a positive outcome for
your staff, your community and your organization’s health
  Patient Satisfaction depends on workers motivation, dedication and duty towards the
patients.

Six underlying metrics which patient satisfaction should be measured on are:

 Quality of medical care
 Interpersonal skills displayed by medical professionals
 Transparency and communication between care provider and patient
 Financial aspects of care
 Access to doctors and other medical professional
 Accessibility of care

9.7 TQM practices in Indian Hospitals:

TQM: a focus on customers, continuous improvement and learning, and participation and
teamwork by all employees.
Total Quality of performance that is directly related to healthcare safety, security, attitude
staff , role of doctors in terms of ‘time’ includes appointment, delay time , service time ,
timing with regards to medical treatment and surgery.
TQM implementation can lead to a higher business performance of the healthcare industry as
well as a higher employee, customer, and personnel satisfaction
Hospitals and other healthcare organization across the globe have been progressively
implementing TQM to reduce costs, improve efficiency and provide high quality patient
care.TQM can be an important part of hospitals competitive strategy in quality of healthcare
system.
Quality management has become an important issue in healthcare organizations (hospitals)
during the last couple of decades. The increased attention to quality is due to governmental
regulations, influence of customers, and hospital management initiatives. Apparently, there
are many difficulties in managing healthcare organizations in a competitive marketplace with
a little support from official bodies especially in a developing country like India.The
SERVQUAL model and its application can help the healthcare facility in achieving
satisfaction on both ends - employees’ satisfaction and customer satisfaction. In healthcare
organizations, the traditional Indian culture, leadership style, and the mentality of the medical
professionals are somehow the barriers to the adoption of the TQM.
Quality practices at Apollo Hospitals:
At Apollo Hospitals, High-quality, evidence-based care (care that is proven) leads to saving
more lives and less time in the hospital. Quality care also means safer care for patients. This
involves constantly and proactively looking at processes to improve safety and, in turn,
quality. Quality is measured in many ways. There are Process Indicators (those that measure
parameters such as timeliness and baseline practices) and Outcome Indicators (such as
mortality rates, infection rates and complication rates). Apollo Hospitals, pursue clinical
quality through many initiatives such as
 Measures of quality for a hospital are the outcomes that matter to patients.
 Accreditation is another way to judge quality.
 Patient safety is at the heart of our ability to offer consistent, reliable quality care.
They have committed to taking every possible step to assure your safety.
 Infection Control program.
 India Covid guidelines.
 Apollo Quality Program (AQP)has implemented patient safety processes across
Apollo hospitals and broadly covers four areas, i.e. safety during clinical handovers,
surgical safety, medication safety and the six International Patient Safety Goals of
JCI.
 Apollo Clinical Excellence is a clinical balanced scorecard focusing on clinical
excellence.
 It incorporates 25 clinical quality parameters involving complication rates, mortality
rates, one-year survival rates and average length of stay after major procedures like
liver and renal transplant, CABG, TKR, THR, TURP, PTCA, endoscopy, large bowel
resection and MRM covering all major specialties.

9.8Summary:

TQM has become important in healthcare organisations since its eight main principles help
them to compete and improve services. The productivity and performance of the workforce
are two vital areas where the management has to focus for introducing quality management in
healthcare.

9.9 Key words

Benchmarking: The process of measuring products, services, and processes against those of
organizations known to be leaders in one or more aspects of their operations.

Business process reengineering: BPR is a management practice in which the related tasks
required to obtain a specific business outcome are radically redesigned.

Just-in-time: JIT is an inventory management method in which goods are received from
suppliers only as they are needed.

Key Result Areas: KRAs refers to a short list of overall goals that guide how an individual
does their job, or general achievement and progress goals for an organization or one of its
divisions.

Quality Function Deployment (QFD): It is a process and set of tools used to effectively
define customer requirements and convert them into detailed engineering specifications and
plans to produce the products that fulfil those requirements.

9.10 Self-assessment

1. Discuss the significance of patient satisfaction surveys in the hospital industry?

2. Explain the concept of benchmarking and its advantages?

3. Discuss business process reengineering?

4. Explain the role of TQM practises in the Indian hospital industry?

9.11 Further readings

 Besterfield-Sacre, “Total Quality Management”, 2006, 3rd Ed.PHI.
 Ron Basu, “Implementing Quality: A Practical Guide to Tools and Techniques”,
2006, THOMPSON.
 Greg Brue, “Six Sigma for Managers”, 2002, TMH.
 R. P. Mohanty& R. R. Lakhe, “TQM in the Service Sector”, Jaico Books
 Dr SyedaAmtulMahaboob TQM Practices of Hospitals in Hyderabad,2021
UNIT - IV Organisation and Roles in Quality

Lesson - 10
 Quality Policy; Commitment to Patients and Staff

Learning objectives:

It helps students to understand the aspects of quality policy, issues to be considered towards
fulfilling the commitment of patients & staff for rendering effective service to meet their
expectations.

Structure:

10.1 Organization and Roles in Quality

10.2 Quality Policy

10.3Commitment to Patients and Staff

10.4 Summary

10.5 Key words

10.6 Self-assessment equations

10.7Further readings

10.1 Organization and Roles in Quality:

Quality is a crucial parameter which differentiates an organization from its competitors.

Quality management tools ensure changes in the systems and processes which eventually

result in superior quality products and services.

Quality is critical to satisfying customers and retaining their loyalty so they continue to buy

or render services from an organization in the future. Quality products/services make an

important contribution to long-term revenue and profitability. The role of the quality

department within an organization is to promote and build quality within all departments of

the organization.

Quality is one of the most important management principles. Maintaining quality in all

aspects of the business allows the company to acquire loyal consumers, keep cash flows

consistent, and surpass the competitors in the market.

Quality management is critical to the growth and performance of any firm. It is also a

valuable resource in the struggle for client connections since it strives to provide a better

customer service experience. Quality must be maintained at all levels for business to prosper.

The aim is to increase customer happiness while driving corporate growth.

Overall improving the quality and performance in the healthcare environment can help

providers with reliable, cost-effective and sustained healthcare processes and enable them to

achieve their goal of improving care delivery and enhancing patient outcomes.

10.2 Quality Policy:

A Quality Policy is typically a brief statement that aligns with an organization's purpose,

mission, and strategic direction. It provides a framework for quality objectives and includes a

commitment to meet applicable requirements (ISO 9001, customer, statutory, or regulatory)

as well as to continually improve.

A quality management system (QMS) is a set of policies, processes and procedures required

for planning and execution (production/development/service) in the core business area of an

organization (i.e., areas that can impact the organization's ability to meet customer

requirements).

Don Berwick as proposed six dimensions of quality in health care: safety, effectiveness,

patient-centeredness, timeliness, efficiency, and equity which are to be considered while

formulating quality policy in health care industry.

In short, a quality policy describes about organization, what it offers and it commitment

towards delivering the highest quality product. Customer requirements are accounted for in

the quality policy. Quality objectives are the goals linked to meeting customer requirements.

What is hospital quality policy?

 Treat all patients equally, with empathy and dignity.

 Ensure safety of patients and staffs.

  To form and adapt stringent infection policies.

 To effectively and transparently communicate the course of the treatment to patient

and patient's family.

 To maintain highest level of professional competence.

10.3Commitment to Patients and Staff:

Professional commitment is defined as loyalty, the desire to stay in a profession, and a sense

of responsibility toward the profession's particular problems and challenges. Commitment to

nursing implies commitment to provide an optimal patient care and promote the nursing

profession.

Patients and their care should be the priority. Being highly committed towards patients will

helps to improve their quality of care and experience as well as that of other patients.

Commitment also means being committed to the job role. Patient relationships begin and end

with a commitment to patient-centred care.

Commitment to work or work commitment is defined as the level of enthusiasm an employee

has towards his/her tasks assigned at a workplace. It is the feeling of responsibility that a

person has towards the goals, mission, and vision of the organization he/she is associated

with. The roles and responsibilities of medical staff contribute towards improving quality.

Doctors assess and manage your medical treatment. Nurses provide on-going care. Allied

health professionals provide services to help with diagnosis and treatment, and help you

during the recovery process. Support and administrative staff work to support the day-to-day

running of the hospital

6 Cs for Commitment to patients and staff:

i. Care: ‘Care is our core business and that of our organizations and the care we deliver

helps the individual person and improves the health of the whole community. Caring
 defines us and our work. People receiving care expect it to be right for them,

consistently throughout every stage of their life. ‘In practice, this means putting high

quality care at the centre of all work and practices. It means consistently delivering

care that is focussed on the individual and promotes their health and wellbeing.

Additionally, it means delivering care that is right for each individual, at the right

time, at every stage of their life.

ii. Compassion: Compassion means delivering care with empathy, respect, and dignity,

recognizing people’s emotions, and forming relationships with patients based on

empathy. It can also be thought of as ‘intelligent kindness’ – recognizing emotions

and responding with kindness and is an important part of how people perceive their

care.

iii. Competence: Competence means that all those in caring roles must have the ability

to understand the health and social needs of each individual. It also means having the

expertise, clinical knowledge, and technical knowledge to deliver care treatments that

are effective and based on research and evidence.

iv. Communication: Communication is an essential part of any caring relationship and

effective team. Compassion in Practice establishes the quote ‘no decision about me

without me’, and communicating well is an important way of ensuring that this is

always the case. Communication is about recognizing that listening is just as

important as what we say and do. It’s about ensuring that you tell the patient what you

are doing: keep them informed at all times about their care. It’s also about ensuring to

always listen to the patient’s wishes and act upon them when you can.

v. Courage: Courage means doing the right thing, speaking up when there are concerns

and having the strength and vision to innovate and work in new, different ways.

Courage is important to ensure that everyone gets the quality of care that they
 deserve. It means putting the patient first and being brave enough to call out when

something is wrong.

vi. Commitment: The final one of the 6Cs refers to having a commitment to patients and

the community and putting this at the centre of work. Patients and their care should be

your priority. Being highly committed to them helps to improve their quality of care

and experience as well as that of other patients.

10.4 Summary:

Quality plays a major role in satisfying consumers and preserving their loyalty, ensuring that
they continue to purchase products or offer services from an organisation in the future.
Quality management tools ensure that improvements are made to systems and processes,
resulting in higher-quality goods and services. A quality department's mission inside a
company is to promote and develop quality across the organisation.

10.5 Key words:

Competence: the ability to do something successfully or efficiently.

Quality policy: It states the organization's purpose and strategic direction, framework for
quality objectives, and commitment to requirements.

10.6 Self-assessment questions:

1. Discuss quality roles in organizations, with a focus on the hospital industry?

2. What exactly is a quality policy? Explain its significance?

3. Discuss how commitment to patients and staff can be enhanced in hospitals?

4. Discuss the concept of six Cs for commitment to patients and staff?

10.7Further readings:

 Step By Step Quality Hospital Care, ByFarooq Jan, 2013.

 Quality Management,ByR.Panneerselvam,P.Sivasankaran,PHI Learning.
  Nigam, Shailendra (2009), Total Quality Management, Excel Books, India.
• Mukherjee, N.P. (2006), Total Quality Management, PHI Learning Pvt. Ltd.

Lesson - 11 Code of Conduct for Health Professionals, Job Description of Quality

Manager

Learning objectives:It provides an understanding about code of conduct for future quality
managers which help them to lead their job role effectively.
Structure:

11.1 Code of Conduct for Health Professionals

11.2 Job Description of Quality Manager

11.3 Basic Job Responsibilities of a Quality Improvement Manager

11.4Quality Manager Requirements

11.5Summary:

11.6Key words

11.7 Self-assessment equations

11.8Further readings

11.1 Code of Conduct for Health Professionals:

A code of ethics clarifies roles and responsibilities within a profession and provides guidance

to the professional for addressing common ethical questions. The Code of Conduct sets the

standard of conduct expected of healthcare support workers and adult social care workers. It

outlines the behaviour and attitudes that you should expect to experience from those workers

signed up to the code. It helps them to provide safe, guaranteed care and support.

The Code is the cornerstone of any healthcare organization's compliance program and is an

essential and integral component of the institution's culture.

A Code of Conduct encourages each employee, physician, contractor, vendor, or other

stakeholder to think about their actions and the consequences of behavior in the workplace. It

provides broad organizational guidance with ethical and compliance principles that will guide

the entity's operations and decision-making. Senior leadership, along with the Board of

Directors, has committed to it, and all staff members probably signed a statement of

understanding, promising to abide by it when they were hired and then doing so annually

thereafter.
While they can vary widely, the typical values outlined in healthcare providers' Codes of

Conduct are:

 To provide quality, cost-efficient, and medically necessary patient care.

 Conduct organizational business with integrity and transparency.

 Be of service to the organization’s community.

 For its employees and affiliates, to exemplify ethical behavior by doing what is right

and reporting what is wrong.

Hospital code of conduct is all about how the does health care organizations practice the

highest ethical and moral and professional standards which are required for providing patient

care. To adhere to all rules and regulations which are laid down by the governing bodies,

which include the Medical Council of India and other governing medical bodies.

11.2 Job Description of Quality Manager:

Being a quality assurance manager in healthcare assures programs and services are

implemented at the highest standards and patients receive the highest level of care. Quality

managers are responsible for monitoring and updating policies and procedures to include

regulatory changes.

Quality improvement managers in health care organizations run programs that focus on

operational efficiency and consistency. Quality improvement managers may be employed by

clinics, hospitals and health care companies. They may work in the field with hospital staff or

they may work in offices handling programs, documentation and administrative duties.

11.3 Basic Job Responsibilities of a Quality Improvement Manager:

Quality improvement managers review and revise existing policies and procedures. They must

successfully implement process improvement or quality management programs. They establish

work plan metrics and pursue data collection methods for accurate trending reports. They may

analyze performance metrics related to top diagnoses, clinical procedures and operational

performance in order to recommend valid solutions. They may focus on clinical prioritization,

service quality, and provides feedback and improvement initiatives.

Quality improvement managers may work with quality directors, committees and work groups

to drive desired outcomes. These could be based on service contracts, staff education and

accreditation requirements. Quality improvement managers may act as knowledge experts for

continuous improvement activities in all clinical, functional and administrative areas. They

monitor various department processes, such as care complaints and medical record assessments,

in order to recommend actions to address any risks or vulnerabilities. Every month, they review

clinical quality studies, trended industry data, national benchmark assessments and best practice

interventions.

Quality managers are responsible for monitoring and evaluating internal production processes,

examining products to determine their quality, and engaging with customers, and gathering

product feedback, among other duties.

Quality managers occupy important positions and will need to be highly conscientious and

responsible workers, as defective products could cost a company significant losses.

Quality Manager Responsibilities:

1. Understanding customer expectations of and needs from a product.

2. Developing quality control processes.

3. Designing product specifications.

4. Ensuring products are designed with adherence to legal and safety standards.

5. Supervising staff and monitoring production standards.

 6. Examining the quality of raw materials that are used in production.

7. Monitoring and evaluating internal production processes.

8. Evaluating the final output of products to determine their quality.

9. Rejecting products that fail quality standards.

10. Engaging with customers and gathering product feedback.

11. Producing statistical reports on quality standards.

12. Reporting to upper management on quality standard issues.

13. Evaluating product recalls.

14. Improving production efficiency and managing waste.

11.4 Quality Manager Requirements:

1. Degree in business administration or relevant field.

2. Quality control certification advantageous.

3. Excellent attention to detail.

4. Excellent verbal and written communication.

5. Data analysis and statistical aptitude.

6. Good interpersonal skills.

7. Highly conscientious and diligent.

11.3Summary:It outlines the expectations that employees who have signed up to the code
should exhibit. Employees are expected to give secure, dependable, assistive, care.A quality
manager is responsible for monitoring and reviewing internal production processes, inspectin
g goods for quality, interacting with consumers, and collecting product feedback, among othe
r responsibilities.

11.4 Key words:

Quality management: An executive is assigned to act as the point of overseeing all activities
and tasks that must be accomplished to maintain a desired level of excellence.

Job description: A written statement of what the job holder does how it is done, under what
conditions it is done and why it is done. It is a written document that identifies and describes
a job in terms of its duties, responsibilities, working conditions and specifications.

Code of Conduct:A statement setting out guidelines regarding the ethical principles and
standards of behaviour expected of a professional person or company.

11.5Self-assessment equations:

1. Define Code of conduct? Discuss about code of conduct required for Health Professionals
with an example?

2. Discuss about job description of quality manger & qualities required to perform their job
responsibilities effectively?

3. Explain the responsibilities of quality manager in hospitals?

11.6 Further readings:

 Quality Management in Hospitals,By S K Joshi,Jp Medical Ltd; UK ed. edition 2014.

 Mukherjee, N.P. (2006), Total Quality Management, PHI Learning Pvt. Ltd.
 Ron Basu, “Implementing Quality: A Practical Guide to Tools and Techniques”,
2006, THOMPSON.

Lesson -12 Quality Steering Committee, Obstacles to the practice of Quality in

Hospitals.
  What is Quality Steering Committee?
 What are the Obstacles to the practice of Quality in Hospitals?

Structure:
12.1 Quality Steering Committee
12.2 Committee Member Responsibilities

12.3 Responsibilities of the Quality Committee

12.4 Reports of quality steering committee

12.5 Obstacles to the practice of quality in hospitals

12.6 Summary

12.7 Key words:

12.8 Self-assessment questions

12.9 Further readings

12.1 Quality Steering Committee:

The Quality Committee assists the board in overseeing and ensuring the quality of clinical care,

patient safety, and customer service provided throughout the organization.

A steering committee is an advisory group that makes directional decisions on various

organizational projects. Its members directly support project managers working toward

strategic company directions. An effective Steering Committee should be focused on fast

decision-making and not simply listening to reporting from the Project Team members.

The QIC is the senior level committee accountable directly to the Board of Directors. The

purpose of the QIC is to provide oversight and direction in assessing the appropriateness of

care and service delivered and to continuously enhance and improve the quality of care and

services provided to members.

The committee meets at least six times a year, or when necessary at the call of the committee

chair. Meeting dates and times should be specified a year in advance.

The committee charter should include a list of the committee members as well as thestaff

supporting the committee. Members often include physicians, nurses and otherhealth

professionals, healthcare management professionals, executives with experiencein industrial

quality or customer service, and attorneys.

12.2 Committee Member Responsibilities

1. Review all relevant material before committee meetings.

2. Attend committee meetings and voice objective opinions on issues.

3. Pay attention to association activities that affect or are affected by the committee's

work.

12.3 The responsibilities of the Quality Committee include:

• Reviewing and recommending a multi-year Strategic Quality Plan with long-term and

annual improvement targets.

• Reviewing and recommending quality/safety-related policies and standards.

• Approving and monitoring a dashboard of key performance indicatorscompared to

organizational goals and industry benchmarks. Report insummary fashion to the full board.

• Reviewing sentinel events and root cause analyses; if appropriate, recommend corrective

action.

• Monitoring summary reports of hospital and medical staff quality and patientsafety

activities.

• Reviewing management’s corrective plans with regard to negative variancesand serious

errors.

• Overseeing compliance with quality- and safety-related accreditationstandards.

• Making recommendations to the board on all matters related to the quality ofcare, patient

safety, customer service, and organizational culture.

12.4 Reports of quality steering committee:

The committee will report to the board at least quarterly, including an in-depth annualquality

review. Regular reports will include:

• Quality indicators in dashboard format, including roll-up measures of clinicalquality, patient

safety, and customer service (quarterly).

• Progress on major performance improvements and patient safety goals(quarterly or twice a

year).

• Root Cause Analysis (as they occur)

• Sentinel event summary (at least quarterly).

• Patient satisfaction/perceptions (quarterly and annual in-depth report).

• Physician satisfaction/perceptions (annual)

• Employee satisfaction/perceptions (annual).

• Patient safety culture (annual in depth report).

• Accreditation (when received).

• Audit of credentialing process (at least every two years).

12.5Obstacles to the practice of quality in hospitals:

Modern present day hospital is a complex matrix organisation with amalgam of social

architecture and latest technology. The present hospital function has unique components of its

own apart from functioning as a business organisation, research laboratory, and a provision

store.It is important to strike a balance between internal operations and external connections

with emphasis on planning, development, efficient operation and cost containment.Over and
above all these the administrator has to manage with present day innovations technologies,

legislation, optimum utilisation of scare resource and compliance to various acts and rules.

These include lack of funding, lack of staff training and resources, lack of support from

management, lack of buy-in from clinicians, lack of leadership, poor communication,

resistance to change and lack of data systems and analytics infrastructure.

The main challenges confronting the hospitals today are as follows:

 Deficient infrastructure.

 Deficient manpower.

 Unmanageable patient load.

 Equivocal quality of services.

 High out of pocket expenditure.

Major issues facing in healthcare today:

 Adopting Advanced Health Technology

 Information and Integrated Health Services

 Rising Healthcare Costs

 Investment in IT healthcare

 Payment Processing and Invoicing

 Pressure on Pharmaceutical Prices

 Healthcare Regulatory Changes

 Healthcare Staffing Shortages

 External Market Disruption

12.6 Summary:

The QIC evaluates and manages the ability to determine the appropriateness of care and

services received. Today, the modern hospital is a sophisticated matrix with a broader focus

on structure and processes and cutting-edge technology. It is essential to maintain a healthy

balance between internal operations and external relations.

12.7 Key words:

Quality Committee: A committee whose functions are concerned with the arrangements for

the purpose of monitoring and improving the quality of healthcare services.

Quality Indicators (QIs): These indicators are standardized, evidence-based measures of

health care quality that can be used with readily available hospital inpatient administrative

data to measure and track clinical performance and outcomes.

Sentinel event/summary: A document consisting of information about an unexpected

occurrence involving death or serious physical or. Psychological injury, or the risk thereof.

Serious injury specifically includes loss of limb or function.

Steering committee:A group of high-level advisors who have been appointed to provide an

organization or project with direction.

12.8 Self-assessment questions:

1. Discuss the quality steering committee and its responsibilities?

2. Discuss obstacles to the practise of quality in hospitals?

3. How to explain the reports of the quality steering committee?

12.9 Further readings:

 Charantimath M. Poornima (2009), Total Quality Management, Pearson Education.

 Nigam, Shailendra (2009), Total Quality Management, Excel Books, India.

 Mukherjee, N.P. (2006), Total Quality Management, PHI Learning Pvt. Ltd.
 UNIT - V
Hospital Accreditation

Lesson - 13 Concepts of Hospital Accreditation & ISO:2000 & 14000

Learning objectives:It also provides quality managers with knowledge about accreditation
issues. helps to understand the quality standards in the hospital industry..

 What is Hospital Accreditation?

 Concept of Hospital Accreditation
 ISO: 2000 & 14000

Structure:
13.1 Introduction- Hospital Accreditation
13.2 Concept of Hospital Accreditation:
13.3 Need for Accreditation
13.4 Benefits of Accreditation
13.5 ISO 2000 & 14000
13.6 Objectivesof ISO 14000
13.7 Advantages of ISO 14000
13.8 ISO 14000 Policy
13.9Summary
13.10 Key words
13.11 Self-assessments
13.12 Further readings
13.1 Introduction- Hospital Accreditation:

NABH is a constituent board of Quality Council of India (QCI) set up to establish and
operate accreditation programme for healthcare organizations. The hospital accreditation
program was started in the year 2005. It is the flagship program for NABH. This program
was started with intent to improve healthcare quality and patient safety at public and private
hospitals.
Accreditation is a voluntary process. Its standards are usually regarded as optimal and
achievable. It provides a visible commitment by an organization to improve the quality of
patient care, to ensure a safe environment and to continually work to reduce risks to patients
and staff. Accreditation has gained worldwide attention as an effective quality evaluation and
management tool.
The focus of accreditation is on continuous improvement in the organizational and clinical
performance of health services, not just the achievement of a certificate or award or merely
assuring compliance with minimum acceptable standards.
Accreditation to a health care organisation stimulates continuous improvement. It enables the
organisation in demonstrating commitment to quality care. It raises community confidence in
the services provided by the health care organisation. It also provides opportunity to
healthcare unit to benchmark with the best.

The main objective of NABH for accreditation is to enhance the health system & promoting
continuous quality improvement and patient safety.
It provides accreditation to hospitals in a non-discriminatory manner regardless of their
ownership, legal status, size and degree of independence.

13.2 Concept of Hospital Accreditation:

"The Hospital Accreditation "approach is a concept and practice that yields the beneficial
results to the patients customers, hospital personnel, the hospital, Faculty of Medicine, the
society and the country as a whole.
Process in creating collective organizational commitment of Quality improvement,
Organizational analysis, Self -assessment, Strategic formulation of the organizational
development planning, Human resources development, Team work and service systems
focusing on patient-oriented mindedness.
Hospital accreditation has been defined as “A self-assessment and external peer assessment
process used by health care organizations to accurately assess their level of performance in
relation to established standards and to implement ways to continuously improve”.
Accreditation focuses on learning, self-development, improved performance and reducing “A
self-assessment and external peer assessment process used by health care organizations to
accurately assess their level of performance in relation to established standard and then to
implement ways to continuously improve it”.
“A process in which an independent entity, separate and distinct from the hospital, usually
but not necessarily non-governmental, assess the hospital to determine if it meets a set of
requirements designed to improve the quality of health care being rendered by the hospital”

13.3 Need for Accreditation:

Ensures a Quality Index for Health Consumers. A growing number of hospitals in India are
turning to accreditation agencies worldwide to both standardize their protocols and project
their international quality of health care delivery. It is a Public Recognition of the
achievement of accreditation standards by a healthcare organization, demonstrated through an
independent external peer assessment of that organization's level of performance in relation to
the standards. It promotes to attract foreign patients. The process of accreditation is envisaged
to result in a process of fundamental change in the technical procedures of service delivery, in
the appropriate use of available technologies, in the integration of relevant knowledge, in the
way the resources are used, and in the efforts to ensure social participation.

13.4 Benefits of Accreditation:

The accreditation process is designed to create a culture of safety and quality within an
organization that strives to continually improve patient care processes <br />and results. In
doing so, organizations:
 Patients are the biggest beneficiary as implementation of accreditation standards
ensures Patient safety, commitment to quality care resulting in good clinical
outcomes.
 Improves patient satisfaction and increases community confidence as services are
provided by credentialed medical staff.
 Accreditation status provides good marketing advantage in the competitive
healthcare.
  The HCO standards has been accredited by ISQua giving the accreditation an
international recognition which will boost medical tourism
 Accreditation provides an objective system of empanelment by insurance and other
third parties
 Improve public trust that the organization is concerned for patient safety and quality
of care
 Provide a safe and efficient work environment that contributes to worker
satisfaction,listen to patients and their families, respect their rights, and involve them
in the care process as partners.
 Create a culture that is open to learning from the timely reporting of adverse events
and safety concerns
 Establish collaborative leadership that sets priorities for and continuous leadership
for quality and patient safety levels
 Identify systemic break-downs and close gaps or loopholes
 Define key interfaces between processes, departments and staff
 Streamline work flow and maximize resource utilization
 Proactively prevent problems from occurring
 Provide ways to detect and correct errors and problems
 Ensure conformance to and effectiveness of documented processes
 Focus on patient and provider needs and expectations
 Maximize customer satisfaction

13.5 ISO 2000 & 14000:

ISO 2000: ISO 9001:2000 specifies requirements for a quality management system where an
organization.ISO 9001:2000 is a company level certification based on a standard developed
and published by the International Organization for Standardization (ISO) titled "Quality
Management Systems-Requirements". This standard revises ISO 9001:1994 to follow a more
logical format, to be more compatible with the environmental standard, ISO 14001 and to
place more of an emphasis on customer satisfaction by expecting organizations to
communicate with customers and measure and monitor customer satisfaction. This revision
also combines the ISO 9002 and ISO 9003 standards. The 2000 version has now been revised
by ISO 9001:2008.
ISO 9001:2000 is a non-industry specific certification that indicates that gives guidelines and
requirements on how to implement and maintain a quality management system. The standard
lists clauses related to topics such as documentation and personnel dedication required to
sustain a certified quality management system.
Certifications are issued by third party certifying bodies. Annual audits are conducted by the
certifying body where portions of an organization will be evaluated for continued
certification. A recertification audit is conducted every three years in which the entire
organization is reviewed during the audit.

 Needs to demonstrate its ability to consistently provide product that meets customer
and applicable regulatory requirements, and
 Aims to enhance customer satisfaction through the effective application of the system,
including processes for continual improvement of the system and the assurance of
conformity to customer and applicable regulatory requirements.

ISO 14000: ISO 14000 is a set of standards created to help companies around the world
reduce their adverse impact on the environment. It's a framework for improved and more
environmentally-conscious quality management systems by organizations large and small.
ISO 14000 is a family of standards related to environmental management that exists to help
organizations minimize how their operations negatively affect the environment; comply with
applicable laws, regulations, and other environmentally oriented requirements; and
continually improve in the above. The entire business process is considered, from product
manufacturing to product performance and, ultimately, product disposal.
The ISO 14000 standards can be applied to large and small business & industry service
sectors (hospitals, hotels, etc.) government organizations all types of organizations, of all
sizes anywhere in the world.

13.6 Objectives of ISO 14000:

 Reduce waste generation by recycling.
 Reduce energy consumption by use of alternative lighting.
 Reduce energy consumption by reduction of compressed air leaks.
 Improve chemical management system software.
 Improve management of Industrial Waste water.
  Improve hazard waste management through solvent recovery.

13.7 Advantages of ISO 14000:

a) Reduces environmental liability.
b) Enhances public image and reputation.
c) Assures customers.
d) Satisfies investor criteria.
e) Reduces your consumption of materials and energy.
f) Facilitates permits & authorizations.
g) Reduces the cost.
h) Improve industry-government relations.

ISO 14000 policy:

 Prevention of pollution.
 Continual Environmental Improvement.
 Commitment to comply with Environmental Laws and Regulations.
 Establish framework for setting and reviewing objectives and targets.
 Documented, implemented, maintained, and communicated to employees.
 Available to the public

13.9 Summary:
Accreditation is the recognition given to a hospital that they follow all those standards that
are necessary for providing good quality and safe medical care to patients. The standards are
decided by an accreditation body and a hospital must comply with all of them in order to be
recognised as an accredited hospital. Accreditation is viewed as a reputable tool to evaluate
and enhance the quality of health care.

13.10 Key words:

Accreditation:A voluntary program in which trained external peer reviewers evaluate a
healthcare organization's compliance and compare it with pre-established performance
standards.
ISO 14000: A set of standards created to help companies around the world reduce their
adverse impact on the environment. It's a framework for improved and more
environmentally-conscious quality management systems by organizations large and small.

ISQua:It is a member-based, not-for-profit community and organisation dedicated to

promoting quality improvement in health care.

NABH: A constituent board of Quality Council of India set up to establish and operate
accreditation programme for healthcare organizations.

13.12 Self-assessments:

1. What is the definition of accreditation? Discuss accreditation in detail?

2. List out the benefits of accreditation?

3. What are the goals and benefits of ISO 14000?

4. Write a short note on the ISO 14000 policy?

5. Discuss hospital accreditation organisations in India?

13.13 Further readings:

 Besterfield, Dale H. (2011), Total Quality Management, Pearson Education, India.

 Hospital and Healthcare AccreditationByRajoriyaBrajkishore,Jaypee Brothers Medical

Publishers, 2017.
 Lesson - 14
NABL, NABH, JCI & JCAHO; Accreditations Scenario in India and abroad;
Organizations and authorities for accreditations in India

Learning objective:To understand the role and significance of accreditation bodies

involved in the hospital accreditation process.

Structure:
14.1 NABL
14.2Scope of NABL Accreditation
14.3NABH
14.4Scope of NABH
14.5 NABH Structure
14.6Joint Commission International (JCI)
14.7Goals and Objectives of the JCAHO
14.8Accreditations Scenario in India and abroad
14.9Healthcare Accreditation Bodies in India
14.10 Organisations and authorities for accreditations in India
14.11Summary
14.12 Key words
14.12 Self-assessment questions
14.13 Further readings
14.1 NABL:

NABL: National Accreditation Board for Testing and Calibration Laboratories (NABL)
provides conformity assessment body's accreditation to Medical Labs as per International
Laboratory Accreditation Cooperation (ILAC). National Accreditation Board of Testing and
Calibration Laboratories (NABL) gives accreditation to Conformity Assessment Bodies i.e.
Laboratories
NABL is an autonomous society providing Accreditation (Recognition) of Technical
competence of a testing, calibration, medical laboratory & Proficiency testing provider (PTP)
& Reference Material Producer (RMP). NABL has agreements with ILAC (International
Laboratory Accreditation Conference) and APLAC (Asia Pacific Laboratory Accreditation
Cooperation). These are especially valuable for International recognition and mutual
acceptance of test results.
In short NABL accreditation has worldwide acceptance.NABL is an autonomous body under
the aegis of Department of Science & Technology, Government of India, and is registered
under the Societies Act. It is only one of its kinds that assess laboratories in India for quality
and consistency in the results. The concept of Laboratory Accreditation was developed to
provide a means for third- party certification of the competence of laboratories to perform
specific type(s) of testing.
NABL vision to be the world’s leading accreditation body and to enhance stakeholders’
confidence in its services. NABL mission to strengthen the accreditation system accepted
across the globe by providing high quality, value driven services, fostering APLAC/ILAC
MRA, empanelling competent assessors, creating awareness among the stake holders,
initiating new programs supporting accreditation activities and pursuing organisational
excellence.

14.2 Scope of NABL Accreditation:

Testing Laboratories Fluid-Flow
Biological Mechanical
Chemical Non-Destructive Testing
Electrical Optical and Photometry
Electronics Radiological
Fluid-Flow Thermal
 Mechanical Forensic
Non-Destructive Testing Calibration Laboratories
Optical and Photometry Electro-Technical
Radiological Mechanical
Thermal Radiological
Forensic Thermal
Testing Laboratories Optical
Biological Fluid-Flow
Chemical Medical Laboratories
Electrical Clinical Biochemistry
Electronics Clinical Pathology
Fluid-Flow Genetics
Testing Laboratories Cytopathology
Biological Hematology&Immuno-haematology
Chemical Histopathology
Electrical Microbiology& Serology
Electronics Nuclear Medicine (only in-vitro tests)

14.3 NABH:
National Accreditation Board for Hospitals & Healthcare Providers, abbreviated as NABH,
is a constituent board of Quality Council of India, set up to establish and operate
accreditation programme for healthcare organizations. Formed in 2005, it is the principal
accreditation for hospitals in India.
NABH is a constituent board of Quality Council of India (QCI), set up to establish and
operate accreditation programme for healthcare organizations.NABHand Healthcare
providers is India's healthcare governing body that ensures quality healthcare and peerless
patient experience at hospitals through its regulations.
NABH certification stimulates continuous improvement. It unravels a hospitals' commitment
to the provision of quality care services. Furthermore, it boosts the confidence of its staff
which furnishes these services to the best of their knowledge and practice.
14.4 Scope of NABH
 Accreditation of healthcare facilities.
 Quality promotion: initiatives like Nursing Excellence, Laboratory certification
programs.
 IEC activities: public lecture, advertisement, workshops/ seminars
 Education and Training for Quality & Patient Safety.
 Recognition: Endorsement of various healthcare quality courses/ workshops.

14.5 NABH Structure:

14.6 Joint Commission International (JCI):

Since 1994, Joint Commission International (JCI) is an independent, not-for-profit
organization, accredits and certifies health care organizations and programs across the globe.
Joint Commission International accreditation and certification is recognized as a global
leader for health care quality of care and patient safety.
JCI identifies measures, and shares best practices in quality and patient safety with the
world.t works in conjunction with the ministries of health as well as global health care
organizations in over 80 countries. Its standards were developed by a committee of
international experts in the field of medicine, health care professionals, who set specific and
achievable expectations.JCI holds these worldwide facilities to a standard and the
accreditation process is not quick and easy. While the bar is high, the JCI has developed an
international standard, taking into account cultural issues and health care systems.
Joint Commission International accredits eight types of health care programs: hospitals,
academic medical center hospitals, ambulatory care facilities, clinical laboratories, home care
facilities, long term care facilities, medical transport organizations, and primary care centers.
JCI focuses on patient care and patient safety. JCI consultants and surveyors are highly
trained clinicians and advocates and work with health care organizations, seeking ways to
improve care through accreditation, certification, advisory and educational services. They
look for a particular level of international quality such as favourable practices; risk reduction
and a reduction of reducing adverse events. The JCI lends expertise in prescription safety,
infection control, facility safety, and compliance with hospital accreditation standards.
Being a JCI certified hospital means that health care organizations have access to a variety of
benefits, services, and resources, connecting them to an international medical community.
They provide educational consulting to international health care providers, helping them to
develop their own clinical services with practical solutions. JCI strives to improve the quality
of patient care, boost patient safety practices, decrease and control risk, as well as to attain
international standards.

14.7 Joint Commission on Accreditation of Healthcare Organizations (JCAHO):

Joint Commission on Accreditation of Healthcare Organizations (JCAHO), was founded in
1951.The Joint Commission on Accreditation of Healthcare Organizations, or JCAHO, is a
non-profit organization based in the United States that accredits over 20,000 healthcare
organizations and programs in the country
The Joint Commission consists of a 21-member Board of Commissioners that include health
care providers, educators and advocates. The commission employs over 1000 surveyors
dedicated to improving the quality of patient care.

14.7 Goals and Objectives of the JCAHO:

“To continuously improve health care for the public, in collaboration with other
stakeholders, by evaluating health care organizations and inspiring them to excel in
providing safe and effective care of the highest quality and value.”
A major objective of the Joint Commission is to continually improve and enhance the quality
and safety of healthcare delivery in the United States.
Provides accreditation and safety protocols to improve patient safety in a wide range of
healthcare settings.
Provides a certification process for programs and services within the organization. These
certifications are program or treatment area specific. The benefits of certification include
reduction in clinical process variations to improve patient care and a structural and
management framework for the program.

14.8 Accreditations Scenario in India and abroad:

Accreditation has been phenomenal in transforming the healthcare scenario and is basically
aframework, which helps healthcare organizations to establish objective systems aimed at
patient safety and quality care developed through holistic approach of Total Quality
Management.
Standards tend to be dynamic giving rise to continuous quality improvement. An
excellenthealthcare infrastructure forms the backbone for growth of any country and
accreditation provesto be competent of ensuring that the patient can count on the hospital for
delivery of excellentservices. Hospitals are now thus under continuous pressure of
maintaining and retaining theirquality and move towards accreditation process to be
recognized and become credible ofdelivering quality in their services leading to enhanced
patient satisfaction.

14.9 Healthcare Accreditation Bodies in India:

 CRISIL RATING of Hospitals / Nursing Homes (Credit Rating Information
Services of India Ltd.): It is a global analytical company providing ratings, research and
risk and policy advisory services. It’s grading of healthcare institutions is an opinion on
the relative quality of healthcare delivered by the institutions to its patients. The grading
scale has two components –The Hospital classification and the hospital’s service quality
grading within that classification on a four-point scale (Grade A – Good quality, Grade B-
Good but lower than Grade A quality, Grade C – Average quality, Grade D – Poor
quality).
 ICHA (Indian Confederation for Healthcare Accreditation) is the mechanism created
in2002 and established as a not for profit organization (under section 25 (now 8) of the
 companies act in 2004. ICHA is an autonomous body, globally recognized most optimal
andcredible platform. ICHA has its values and guiding principles embedded in three
pillars ofexcellence- TRUST, TRANSPARENCY, TRANSACTIONS (communication).

 Quality Council of India (QCI): QCI is an autonomous body, and its constituent
National Accreditation Board for Hospitals and Healthcare providers (NABH) is the
leading accreditation body in India. QCI works under the guidance of Ministry of
Commerce. NABH as a constituent of QCI was established in 2006.

 NABH: The NABH standards provide a framework for quality assurance and quality
improvement, while focusing on patient safety and quality of care. The standards are in
consonance with the framework specified by ISQua (International Society for Quality in
Healthcare Inc).

Initial responses indicate that with accreditation in place, visible benefits have been noticed.
These include a strong culture of safety that has been inculcated, a decrease in the incidence
of adverse events, constant monitoring of quality within the system, etc. The best impact
assessment criteria would be the success rates for various diagnostic and therapeutic
procedures and the cure rates for various therapeutic applications. However, such
comprehensive quantitative data is not available at present to measure parameters like
infection control rates, mortality rates, surgical outcomes, etc. Apart from selecting outcome
criteria, a patient satisfaction survey could also be carried out to capture the interpersonal
aspects of care. NABH would need to start a process of impact assessment post-accreditation,
on the basis of quantitative indicators. The possible parameters for assessment need to be
determined and a standardised mechanism of measurement needs to be evolved to enable
uniform assessment of hospitals, benchmarked against established national standards.

14.10 Organisations and authorities for accreditations in India:

These agencies include the Joint Commission on Accreditation of Healthcare Organizations
(JCAHO), the National Committee for Quality Assurance (NCQA), the American Medical
Accreditation Program (AMAP), the American Accreditation HealthCare
Commission/Utilization Review Accreditation Commission (AAHC/URAC), and the
Accreditation Association for Ambulatory HealthCare (AAAHC). In addition, the Foundation
for Accountability (FACCT) and the Agency for Healthcare Research and Quality (AHRQ)
play important roles in ensuring the quality of healthcare.
National Accreditation Board for Hospitals & Healthcare Providers), abbreviated as NABH,
is a constituent board of Quality Council of India (QCI), set up to establish and operate
accreditation programme for healthcare organizations.
An independent, not-for-profit organization, The Joint Commission is the nation's oldest and
largest standards-setting and accrediting body in health care.
These agencies include the Joint Commission on Accreditation of Healthcare Organizations
(JCAHO), the National Committee for Quality Assurance (NCQA), the American Medical
Accreditation Program (AMAP) and the American Accreditation HealthCare
Commission/Utilization Review Accreditation Commission (AAHC/URAC) & others.
.International Society for Quality in Healthcare (ISQua) has accredited “Standards for
Hospitals” developed by National Accreditation Board for Hospitals & Healthcare Providers
(NABH, India ). The approval of ISQua authenticates that NABH standards are in
consonance with the global benchmarks set by ISQua. The hospitals accredited by NABH
will have international recognition This will provide boost to medical tourism.
International Society for Quality in Health Care (ISQua ) is an international body which
grants approval to Accreditation Bodies in the area of healthcare as mark of equivalence of
accreditation program of member countries.

14.11Summary:
NABL is an independent organisation that accredits (recognises) testing, calibration, and
medical laboratories, as well as proficiency testing providers. Accreditation certification
bodies are accredited by the National Accreditation Board for Testing and Calibration
Laboratories (NABL). NABL works with the International Laboratory Accreditation
Conference and the American Public Laboratory Accreditation Conference.

14.12 Key words:

Accreditation Committee (AC):A group of member assigned as a subcommittee that reports
to the Committee on Special task with required assessed documents.

Accreditation:A voluntary program in which trained external peer reviewers evaluate a

healthcare organization's compliance and compare it with pre-established performance
standards.
National Accreditation Board for Testing and Calibration Laboratories (NABL): It provides
accreditation to Conformity Assessment Bodies in India.

14.12 Self-assessment questions:

1. Discuss the role of NABH and its functions in the accreditation of hospitals?
2. What is the purpose of NABL accreditation and what does it entail?
3. What are your thoughts on healthcare accreditation bodies in India?
4. Write short notes on: a) JCAHO b) JCI

14.13 Further readings

 Besterfield, Dale H. (2011), Total Quality Management, Pearson Education, India.

 Hospital and Healthcare Accreditation ByRajoriyaBrajkishore,Jaypee Brothers

Medical Publishers, 2017.

 Patient Safety and Hospital Accreditation: A Model for Ensuring Success by Sharon
Ann Myers,2011.
 Lesson -15 Accreditation process; Role of the government in developing an
accreditation system.

Learning objectives: This lesson explores the knowledge of students relevant to the hospital
accreditation process and the role of the government in executing the accreditation system.

 What is the Process of Accreditation?

 Role of the government in developing an accreditation system in hospital industry.

Structure:
15.1Accreditation process
15.2 Procedure for NABH Accreditation
15.3 Documents required for obtaining NABH
15.4 Role of the government in developing an accreditation system:

15.1 Accreditation process:

Accreditation is a procedure that evaluates whether the programmes
fulfil specified quality requirements. Accreditation has been defined as "A self-assessment
and external peer assessment process used by health care organisations to accurately assess
their level of performance in relation to established standards and to implement ways to
continuously improve".The accreditation standard for hospitals focuses on patient safety and
quality of the delivery of services by the hospitals in a changing healthcare environment.

The accreditation process, the institution or program must accomplish the following:
 Set or re-articulate the program’s goals and standards
 Investigate existing accrediting bodies to determine the most appropriate accrediting
body for the program
 Contact the intended accrediting body for information about eligibility, criteria and
accreditation mechanisms
 Undergo a preliminary self-study and a study of the requirements of the intended
accrediting body to determine feasibility of accreditation
 Establish mechanisms to collect data on the program’s parameters and activities
 Develop mechanisms to use data to reaffirm or reform program activities
 Undergo a thorough self-study
 Request an accreditation visit and review, by submitting a formal application to the
intended accrediting body

15.2 Procedure for NABH Accreditation:

Step-1 Submission of the application to NABH

The healthcare establishment or hospitals will apply to NABH in the prescribed application
form. The application is consist of information:
Self-declaration as per the NABH requirement
Self-assessment as suggested by NABH
Hospital manual/ quality as per the prescribed standards
Documents to be attached along with the application:
 Polices and procedure of Hospital
 NOC related to MC
 NOC from Police
 NOC from Pollution department
 Directors ID and Address proof
 List of shareholder and their details
 The objective of the company (of the proposed company)
 MOA and AOA (of an existing company)
 Other relevant document related to hospital approval

Step-2 Submitted application will be verified/ scrutinized by the department

Department will meticulously scrutinize the submitted form along with the respective
attachments and if any discrepancy in the application or if any clarifications are needed, then
the department ask the applicant to rectify or explain the same before granting registration. If
the application is fit and proper then acknowledgment letter with a unique reference number
will be issued by the department to the applicant.
Step-3 Pre-assessment:
Department will align a principal inspector/valuation team who is accountable for pre-
assessment of the hospitals.

Step-4 Final Assessment:

Applicant hospital(s) need to take corrective measures to rectify any queries/discrepancies
raised by the department during the process of PRE-ASSESSMENT in order to achieve
successful final assessment. In final assessment a full review of hospital functions and
services offered by them
Issuance of Accreditation certificate: On passing the final assessment NABH will issue a
certificate of accreditation to the hospital for a period of 3 years.

Step-5 Reassessment and surveillance:

NABH team will re-assess and conduct regular surveillance for the next three years after
issuance of a certificate on regular intervals.

15.3 Documents required for obtaining NABH:

 Registration certificate of the applicant establishment
 MOA/AOA/COI (if the establishment is in the form of the company)
 Certificate of Registration in case of business entities other than Companies
 Fire NOC
 Lift NOC (if the hospital is equipped with lift facility)
 Police NOC
 Pollution NOC
 Id and address proof of owners (applicant)/ Director (in case of a company)
 Address proof of the establishment
 List of shares allotted and details of shareholders
 Other relevant information and documents of hospital as may be demanded by the
Authority
15.4 Role of the government in developing an accreditation system:
Accreditation is defined as the procedure by which an authoritative body gives formal
recognition that an institution/organization/body or person is competent to carry out specific
tasks.
It is the responsibility of the government to prevent and treat illness, provide proper health
facilities like health centres, hospitals, laboratories for testing, ambulance services, blood
bank and so on for all people. These services should be within the reach of every patient of
the remotest corners.Government has taken initiatives for strengthening Quality health care.
Government has increased the expenditure on health has in recent years gone toward
healthcare services, improvement and refurbishment of clinics, and other activities aimed at
addressing the effects of HIV/ AIDS and tuberculosis (TB) and improving access to
healthcare services.
Govt funding and policy emphasis has led to infrastructure improvement in the form of new
facilities, particularly in the primary healthcare sector through (Medical Counselling
Committee) MCC.
Government has developing new regulations and requirements. Measuring compliance with
regulatory and legal requirements.
Allocating resources, technical and financial- parliamentary cluster assessing the quality of
health services.
It is the responsibility of the government to improve the infrastructural resources which
includes the availability of water, electrical grid, telecommunication, road etc. The central
government allocates budget to State Government for these functions.

The Planning Commission of India among its various functions formulates a plan for the
most effective and balanced utilization of the country’s resources. Every state has its own
State Planning Commission. The State Planning Commission, in addition to other functions,
is primarily responsible for giving necessary support to all the Urban Local Bodies.

It is the responsibility of the government to prevent and treat illness, provide proper health
facilities like health centres, hospitals, laboratories for testing, ambulance services, blood
bank and so on for all people. These services should be within the reach of every patient of
the remotest corners.
15.5 Healthcare Services in India:
 India has a mixed health-care system, with both public and private
providers.However, the majority of private healthcare providers are centred in metrop
olitan India, where they offer secondary and tertiary health care services.
 India has the world’s largest number of medical colleges and number of medical
professionals qualifying every year.
 India is one of the world’s largest producers and biggest exporters of medicines.
 There is a considerable increase in the healthcare facilities.
 A large number of medical tourists visit India every year for treatment. They get
treatment in world class and high-end hospitals.
 Hospitals, medical devices, clinical trials, outsourcing, telemedicine, medical tourism,
health insurance, and medical equipment all fall under the category of healthcare. The
Indian healthcare system is growing quickly because of more coverage, more
services, and more money from both public and private groups.
 India, a country recognised for its warm hospitality and the perfect blend of vibrant
art and culture, is also one of the most preferred countries for medical tourism.
Healthcare services in India are cost-effective. The low medical cost, alongside
superior quality healthcare service, is what makes people from all around the world
fly to India for their treatment. Furthermore, India excels in terms of cutting-edge
medical facilities, reputable healthcare professionals, high-quality nursing care, and
traditional healthcare therapies.

 Additionally, the government is investing extensively in developing new technologies

to improve the infrastructure and healthcare services in India. Nations with limited
resources or relatively expensive medical facilities are also contributing to the growth
of medical tourism in India.

15.6 Summary:

Accreditation of health institutions is a process by which the government regulates the quality
assurance system in the health sector. The healthcare sector is touched by a wide range of
elements, including corporate expansion, commercial competition, medical tourism, and
medical insurance. Quality has declined, and patient expectations have soared. The
government might help by giving money, making sure there is enough infrastructure, setting
up corrective processes, and speeding up the process.
15.7 Key words:

Accreditation:A process of officially recognizing someone as having a particular status or

being qualified to perform a particular activity.

NABH:NABH standards focus on patient safety and quality of the delivery of services by the
hospitals in the changing healthcare environment.

NABL: It provides conformity assessment body's accreditation to Medical Labs as per

International Laboratory Accreditation Cooperation (ILAC).

15.8 Self-assessment questions:

1. Discuss the accreditation process and the steps involved in it.

2. What documents are required for obtaining NABH accreditation?

3. Discuss the scenario of healthcare services in India?

4. Can you explain the role of the government in developing an accreditation system?

15.9Further readings:
 Hospital and Healthcare Accreditation ByRajoriyaBrajkishore,Jaypee Brothers
Medical Publishers, 2017.
 Patient Safety and Hospital Accreditation: A Model for Ensuring Success by Sharon
Ann Myers, 2011.
 Ron Basu, “Implementing Quality: A Practical Guide to Tools and Techniques”,
2006, THOMPSON.