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Nair TS, Memon P, Tripathi S, Srivastava A, Sunny Kujur M, Singh D, Bhamare P, Yadav V, Kumar Srivastava V, Prasad Pallipamula S, Usmanova G, Kumar S. Implementing a quality improvement initiative for private healthcare facilities to achieve accreditation: experience from India. BMC Health Serv Res 2023; 23:802. [PMID: 37501069 PMCID: PMC10375635 DOI: 10.1186/s12913-023-09619-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2022] [Accepted: 05/30/2023] [Indexed: 07/29/2023] Open
Abstract
BACKGROUND The Manyata program is a quality improvement initiative for private healthcare facilities in India which provided maternity care services. Under this initiative, technical assistance was provided to selected facilities in the states of Uttar Pradesh, Jharkhand and Maharashtra which were interested in obtaining 'entry level certification' under the National Accreditation Board for Hospitals and Healthcare Providers (NABH) for provision of quality services. This paper describes the change in quality at those Manyata-supported facilities when assessed by the NABH standards of care. METHODS Twenty-eight private-sector facilities underwent NABH assessments in the three states from August 2017 to February 2019. Baseline assessment (by program staff) and NABH assessment (by NABH assessors) findings were compared to assess the change in quality of care as per NABH standards of care. The reported performance gaps from NABH assessments were then also classified by thematic areas and suggested corrective actions based on program implementation experience. RESULTS The overall adherence to NABH standards of care improved from 9% in the baseline assessment to 80% in the NABH assessment. A total of 831 performance gaps were identified by the NABH assessments, of which documentation issues accounted for a majority (70%), followed by training (19%). Most performance gaps could be corrected either by revising existing documentation or creating new documentation (62%), or by orienting facility staff on various protocols (35%). CONCLUSION While the adherence of facilities to the NABH standards of care improved considerably, certain performance gaps remained, which were primarily related to documentation of facility policies and protocols and training of staff, and required corrective actions for the facilities to achieve NABH entry level certification.
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Affiliation(s)
- Tapas Sadasivan Nair
- Jhpiego - an affiliate of Johns Hopkins University, Prius Platinum, A Wing, 5th Floor, D3, P3B, Saket District Centre, Sector 6, Saket, New Delhi, Delhi, 110017, India
| | - Parvez Memon
- Jhpiego - an affiliate of Johns Hopkins University, Prius Platinum, A Wing, 5th Floor, D3, P3B, Saket District Centre, Sector 6, Saket, New Delhi, Delhi, 110017, India
| | - Sanjay Tripathi
- Jhpiego - an affiliate of Johns Hopkins University, Lucknow, Uttar Pradesh, India
| | - Ashish Srivastava
- Jhpiego - an affiliate of Johns Hopkins University, Prius Platinum, A Wing, 5th Floor, D3, P3B, Saket District Centre, Sector 6, Saket, New Delhi, Delhi, 110017, India
| | - Meshach Sunny Kujur
- Jhpiego - an affiliate of Johns Hopkins University, Ranchi, Jharkhand, India
| | - Deepti Singh
- Jhpiego - an affiliate of Johns Hopkins University, Prius Platinum, A Wing, 5th Floor, D3, P3B, Saket District Centre, Sector 6, Saket, New Delhi, Delhi, 110017, India
| | - Parag Bhamare
- Jhpiego - an affiliate of Johns Hopkins University, Prius Platinum, A Wing, 5th Floor, D3, P3B, Saket District Centre, Sector 6, Saket, New Delhi, Delhi, 110017, India
| | - Vikas Yadav
- Jhpiego - an affiliate of Johns Hopkins University, Prius Platinum, A Wing, 5th Floor, D3, P3B, Saket District Centre, Sector 6, Saket, New Delhi, Delhi, 110017, India
| | - Vineet Kumar Srivastava
- Jhpiego - an affiliate of Johns Hopkins University, Prius Platinum, A Wing, 5th Floor, D3, P3B, Saket District Centre, Sector 6, Saket, New Delhi, Delhi, 110017, India
| | - Suranjeen Prasad Pallipamula
- Jhpiego - an affiliate of Johns Hopkins University, Prius Platinum, A Wing, 5th Floor, D3, P3B, Saket District Centre, Sector 6, Saket, New Delhi, Delhi, 110017, India
| | - Gulnoza Usmanova
- Jhpiego - an affiliate of Johns Hopkins University, Prius Platinum, A Wing, 5th Floor, D3, P3B, Saket District Centre, Sector 6, Saket, New Delhi, Delhi, 110017, India.
| | - Somesh Kumar
- Jhpiego - an affiliate of Johns Hopkins University, Prius Platinum, A Wing, 5th Floor, D3, P3B, Saket District Centre, Sector 6, Saket, New Delhi, Delhi, 110017, India
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