Bai Jerbai Wadia Hospital for Children recognized as India’s first accredited hospital by American Accreditation Commission International

THE HOSPITAL ACCREDITATION JOURNEY

Under the leadership of our CEO – Dr. Minnie Bodhanwala, a core team was formed to work toward the accreditation. This team was accountable to top management through regular reporting to the Hospital Governing and Management Committee. Based on their expertise, experience, and passion, core team members were recruited from different disciplines, including clinical specialties, nursing, allied health, pharmacy, laboratory, administration, infection control, and quality and risk management. The collective wisdom from such diversified membership helped identify and analyze issues from different perspectives and ensure rational decision making after due consultation and consideration.

In preparation for accreditation, the hospital has undergone the process of self-assessment, staff engagement, and service improvements, all of which require well planned strategies to achieve successful outcomes.

The first step was to understand the standards of the AACI. The standards comprised of three modules, namely, governance, patient focused care, and ancillary services which in all had 29 standards.

AACI has developed standards for hospitals and other health-care organizations, addressing key areas of organizational performance. The standards are the basis of the accreditation services, providing a clear road map for health-care staff and delivering confidence to all stakeholders, including patients, board members, insurers, and regulatory agencies.

In addition, the standards maintain compliance with Centers for Medicare and Medicaid Serivces (CMS), International Society for Quality in healthcare (ISQua), World Health Organization (WHO), and other nationally and internationally recognized requirements. AACI is the only accreditation body to combine the Medicare Conditions of Participation with the management system standards including risk management consultation into a unified accreditation program. AACI has merged clinical requirements with some of the most recognized management standards in the world: ISO 9001, ISO 27001, and ISO 31000.

Due to our long legacy of over 90 years, Bai Jerbai Wadia Hospital for Children had a mature system of governance and operations in place. The hospital has a well-established culture of quality and safety in its routine day to day functioning by the virtue of the various national accolades and accreditations that the hospital has received. However, each standard was assigned a champion to perform the gap analysis exercise to eliminate blind spots and identify shortcomings, and focusing on various clinical and support criteria using the prescribed standards as reference. Our gap analysis rigorously scrutinized the system awareness, documentation, and implementation, the attainment of which represented the meeting of minimum accreditation requirement.

The gap analysis report underlined the additional requirements as per the international standards and helped the core team to identify gaps within the hospital, which was then presented to top management. To close these gaps, requisite corrective and preventive actions were implemented.

KEY FACTORS FOR ACCREDITATION

In the course of preparing the hospital for external evaluation, we identified a number of key factors which were essential for achievement of the accreditation. All employees and staff participated wholeheartedly and understood the importance of accreditation for the greater good of patients and a great learning experience from external health-care experts.

Another critical success factor was that ownership of all program improvements rested with the staff, which was the only way to fully engage them. If not, they are liable to feel isolated or manipulated by the issues. Empowerment and selection of the right stakeholders are essential in enhancing ownership.

The third key to success was the setting of clear objectives. At Bai Jerbai Wadia Hospital for Children, we impressed only three simple objectives on our staff. These were ensuring safety, augmenting efficacy, and enhancing the patient and staff experience. Such unambiguous objectives helped to keep the staff focused.

The final critical success factor was that the approach taken was that of a team effort, since overwhelming and rigid directives and measures only lead to dissent and resentment. The entire hospital performed as one shining team and we sailed together during the survey. The esteemed group of surveyors could also sense the positive enthusiasm and spirit of the hospital and palpable quality improvement measures that the hospital had undertaken.

ACHIEVEMENT

Bai Jerbai Wadia Hospital for Children underwent the Organization Wide Survey on August 25, 26, and 27, 2022, and was recommended for full accreditation status by AACI. The AACI accreditation certificate [Figure 1] and the AACI Management system certificate [Figure 2] were awarded to us on August 31, 2022.

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Figure 1:

American Accreditation Commission International accreditation certificate awarded to Bai Jerbai Wadia Hospital for Children.

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Figure 2:

American Accreditation Commission International management system certificate awarded to Bai Jerbai Wadia Hospital for Children.

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The organizational transformation seen in our systems, the enhanced quality culture and improved staff morale far exceeded what we had expected to accomplish in the course of this accreditation exercise.

CONCLUSION

Achieving the AACI accreditation is a means to further our quality journey to enhance the safety and patient experience. The ultimate target being able to provide quality services at par with international standards, especially to the most underprivileged of our society.