Accreditation is a journey and not a destination – Dr (Col) R.R. Pulgaonkar (CEO, Jaslok Hospital) at TAPMI

July 26, 2013, TAPMI, Manipal

Dr. (Col.) R. R. Pulgaonkar, CEO, Jaslok Hospital & Research Center enlightens future business leaders of TAPMI about ‘Making of a NABH Accredited hospital – Redefining healthcare delivery system’


Top: Dr. Pulgaonkar addressing the students
Top: Dr. Pulgaonkar addressing the students
Bottom left: Dr. Pulgaonkar addressing the questions raised Bottom right: Dr. Pulgaonkar receiving the token of appreciation from Dr. Neha Kaushik (PGDHCM 2012-14)

The highly energetic and enthusiastic future managers of T. A. Pai Management Institute (TAPMI), Manipal welcomed Dr. (Col.) R. R. Pulgaonkar, Chief Executive Officer, Jaslok Hospital & Research Center on a quiet and rainy morning. The reason of visit of Dr. Pulgaonkar was to discuss with the students many practical aspects of healthcare management – especially the quality management process and different accreditations available for hospitals and how to go about achieving one.

Dr. Pulgaonkar step by step demystified the process of achieving of National Accreditation Board for Hospitals & Healthcare Providers (NABH) and the reasons behind the importance of this accreditation.

To begin with he told that the certification is necessary to establish the fact that processes are thoroughly checked by a third party which is trust worthy. A degree of excellence possessed by a product or person is known as quality and this fact is reaffirmed by acquiring the internationally known certifications. According to him there three distinct dimension from which the health care system and service provided can be viewed. They are the views of the provider of healthcare services, recipient of healthcare services and organizer of healthcare services.

He focused on different concerns of the providers. He said “it is very important to provide care as per the established norms. To provide such service adequate resources are needed. In the end of the process, Self-satisfaction is generated with final outcome. This should also contribute to enhancement of skills and competence of the staff and employees of the healthcare service provided”.

On the Concerns of recipient he said that the service should be accessible, affordable and attention should be immediate in nature, first of all. Waiting time for patients also minimized in all processes starting from the admission to discharge. The diagnosis should be early and accurate and after the treatment the patient should be able to return to productivity as early as possible. One on the most important concern is also the human treatment as the patients and the relatives accompanying him/her are emotionally vulnerable.

Regarding the Concerns of the organizers he explained that they share the responsibility to the society for the fund spent on healthcare, and they have to ensure safety of public and prevent inappropriate or suboptimal care. They should also institute proper control mechanism to meet the requirement of the recipients of the recipient and provided of the health care services at acceptable costs.

The discussion then moved on to Accreditation process. Accreditation is an external review of quality. Maintaining the safety in the environment as sensitive as hospital is very important. So the Focus on Standards should be to maintain patient safety, staff and employee safety, environment and community safety and information education and communication (to the relations, patients, doctors). The accreditation provides this patient safety and CQI. The Journey of accreditation process in multi-stage process including Application, Screening, Pre-assessment survey, Assessment survey, Recommendations, Review of Recommendations and Implementation and monitoring. To achieve the accreditation first willingness should be created and the initial impetus from the top management is necessary. This also requires involvement of all staff and involves repeated training and briefing.

The Essentials for achieving accreditation smoothly is to focus on uniform training of all employees in key areas, encourage by incentives, initially prepare to provide extra resources, avoid disappointments if initial benefits don’t accrue as expected and be prepared for a longer gestation period for benefits to accrue.

There are also certain challenges associated with the process. They are HCO are enthusiastic and under prepared while initial resource requirements are high. Sometimes the preparations are shoddy initially. The benefits accrued takes considerable time. Also Sustenance and consistency of efforts will be required along with repeated intervention to check high rates of attrition. Some of the practical problems faced can be Allocation of budgets, designation of accreditation coordinator, and formulation of committee, statutory requirements, signage and color coding, documentation, making disaster plans, credentialing and competency mapping, privileging of clinical staff, annual health check-up and OPD assessment and IPD assessment documented uniformly.

There followed the question-answer session and the students brought about new dimension to the discussion and Dr. Pulgaonkar replied with equal enthusiasm. To the question of a healthcare graduate Mr. Ganesh Kamath regarding the opportunity and benefits of deploying Information Technology in healthcare system, the guest replied that this subject is of paramount importance as it integrates process across organization and streamlines them. There is need of young and enthusiastic breed of managers like the lot at TAPMI, to take up this implementation and partner in the progress of healthcare system.

Finally he brought end to the discussion by quoting “Accreditation is a journey and not a destination” and the students presented him with a token of appreciation to mark the end of the discussion. □


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