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International Journal of Business Management & Research (IJBMR) ISSN 2249-6920 Vol. 3, Issue 4, Oct 2013, 9-18 © TJPRC Pvt. Ltd.

HOSPITAL PREPAREDNESS FOR NABH ACCREDITATION WITH RESPECT TO PATIENT RIGHTS AND EDUCATION D. SHREEDEVI Associate Professor, Apollo Institute of Hospital Administration, Hyderabad, Andhra Pradesh, India

ABSTRACT Indian health care system is currently operating within an environment of rapid social, economical and technical changes and hospitals are an integral part of health care system. Accreditation would be the single most important approach for improving the quality of hospitals. National accreditation system for hospitals ensures that hospitals, whether public or private, national or expatriate, play their expected roles in national health system. Accreditation results in high quality of care and patient safety. Patient rights encompass legal and ethical issues in the provider-patient relationship, including a person’s right to privacy, right to quality medical care without prejudice, right to make informed decisions about care and treatment options, and right to refuse treatment. This study assesses the NABH Accreditation preparedness of the hospital with respect to the patient rights and education. The results of this study reveal that existing patient’s right practices are not on par with the NABH standards. Concrete steps in terms of initiating a mechanism of action to ensure strict adherence to patients’ rights and upgradation of the existing practices is necessary.

KEYWORDS: Accreditation, Health Care Providers, Informed Decision, Medical Intervention, NABH (National Accreditation Board for Hospitals and Health Care Providers), Patient Care, Patient Rights

INTRODUCTION The notion of patient rights was developed on the basis of fundamental dignity and equality of all human beings recognizing “the inherent dignity” and the “equal and unalienable rights of all members of the human family.” [Universal Declaration of Human Rights, 1948]. Concerns on quality of health facilities have been generated lately because of increasing awareness among the consumers. Market forces such as medical tourism, insurance and corporate sector have accelerated the demand for quality in healthcare services i.e. paternalistic model to informative model or from physician-centered care to patient-centered care. Health care quality improvement movement began in the early 1900s with assessments of hospital conditions and establishment of standards of service. The Joint Commission International (JCI) Accreditation for hospitals has established comprehensive voluntary standards of care covering safety, environment of care, patient education, assessments, staff qualifications, human resources records, internal quality improvement activities, medical errors and more. Realizing the need for establishing a national accreditation structure that was suitable to the Indian conditions and credible in the eyes of international markets, National Accreditation Board for Hospitals and Healthcare Providers (NABH) has been setup to establish and operate accreditation programme for healthcare organizations.

REVIEW OF LITERATURE Healthcare embraces a full range of services covering health promotion and protection, disease prevention, diagnosis, treatment, care and rehabilitation.


D. Shreedevi

A. Brazinov, E. Jansk, R. Jurkovi1 share the experience of promoting patients' rights in the Slovak Republic. To evaluate the public understanding of patients' rights issues, a questionnaire survey was deployed in both initial and final phases of the project with a time difference of one year. Initial survey showed that less than 60% of population was aware that the rights of patients are encoded in legislation, and more than 80% thought that these rights were not observed. The identical survey after one year revealed that public awareness on the issue increased in several areas. A.M. Kanerva, T. Suominen and H. Leino-Kilpi2 studied patient rights in the context of short-stay surgery which was based on a definition according to which informed consent consists of five elements: consent, voluntariness, disclosure of information, understanding and competence. The results indicated some problems in the realization of informed consent. There were also certain problems with information. The respondents were least well informed about the drawbacks of anaesthesia and about alternative forms of treatment. Hakan Ozdemir M, Ozgür Can I, Ergönen AT, Hilal A, Onder M, Meral D3 tried to determine the level of awareness of patients' rights among midwives and nurses. No significant differences were observed in midwives' answers compared with nurses' answers. The study indicated that violation of patients' rights and health professionals' ignorance of appropriate practice means that there is an urgent need to reconsider how to approach this issue. K. Merakou, P. Dalla-Vorgia, T. Garanis-Papadatos and J.Kourea-Kremastinou5 studied the way in which patients’ rights were being exercised in everyday hospital practice and found that patients ignore the fact that special regulations exist regarding their rights. Ruth Elzer7 stressed that in recent years, increased media attention on “Never Events” and the prevalence of information on the Internet have made patients and families more informed and more keenly focused on quality of clinical care. E. Razavi, N. A. Khalili, A. Saidi and F. Shidfar8 tried to study the awareness of the patients and physicians regarding observance of patients’ rights. They concluded that unawareness of the patients of their rights may limit their expectations from the physician and if they become aware of the content of the patients rights charter their satisfaction from current situation may alter. Woogara J11 tried exploring the concept of patients' right to privacy. Privacy is a basic human right, and that its respect by health professionals is vital for a patient's physical, mental, emotional and spiritual well-being. He argued that health professionals can violate patients' privacy in a variety of ways. Yousuf R M, Fauzi A R M, How S H, Akter S F U, A. Shah12 conducted a cross-sectional survey to know the awareness level of the hospitalized patients about their rights. They found that 90% of the patients were aware of their rights, and 85 % had enough information regarding their illness and modality of treatment. However, treatment options were discussed with 45 % of cases only, and 65% of patients were informed of their duration of treatment. Almost all patients (99%) said that their religious beliefs were respected by the staff and they had no problems in accessing them in times of need.


To examine the awareness of patient rights among patients and their family members.

To study the awareness of patient rights among nurses and hospital’s contribution for patient education.

Hospital Preparedness for NABH Accreditation with Respect to Patient Rights and Education


RESEARCH METHODOLOGY Research design is exploratory and descriptive in nature with questionnaire based survey, personal interview and direct observation of the patients, their families, attendants and hospital employees and also studying relevant records of the hospital. Survey began with in-depth study of NABH guidelines and knowing the standards relating to patient rights and education. A self-assessment tool kit provided by the NABH was utilized to assess the existing gap in the practices on patient rights and education. The study was conducted to assess the awareness level of the nurses and inpatients regarding patients’ rights and responsibilities. A questionnaire was administered to 100 nursing staff and 100 inpatients/attendants. Convenience random sampling was adopted. Information was gathered by means of separate questionnaires for nursing staff and inpatients. The questionnaire for patients had 30 multiple choice questions covering patients’ right to respectful care and dignity, patient safety, informed consent, privacy, informed participation in decision making, right to information, and right to make choices. The questionnaire for nurses included 19 close and open-ended questions with an emphasis to identify patients’ rights and responsibilities, nurses’ attitude towards patient rights and information need of patients. Graphical analysis was performed to analyze the data.The study was conducted for a period of two months. The study is limited only to the selected hospital. Only inpatients, conscious and stable patients who could communicate and above the age of 10 years were included during the course of the study, hence, opinion of patients and their families visiting OPD and Casualty may differ. All patients who could not communicate due to their disease condition were excluded. As self-assessment questionnaire was used as study tool chances of personal bias cannot be ruled out.

RESULTS AND DISCUSSIONS Accreditation is an incentive to improve capacity of national hospitals to provide quality of care. Patients are the biggest beneficiaries among all the stakeholders. Accreditation results in high quality of care and patient safety as the patients are serviced by credential medical staff, rights of patients are respected and protected and patient’s satisfaction is regularly evaluated. The questionnaire was administered to 100 nurses, most of the participant nurses were in the age group of 2025years (50%), and many of them are females, who have a work experience between 0-5 years, holding a GNM degree. 90% of the participating nurses were staff nurse. Self Assessment The self assessment study is pointed towards the lacunas in the existing practices relating to patients rights in context of lack of patients rights and responsibility charter, absence of grievance redressal mechanism for dissatisfied patients and families, restricted information to patients regarding condition and treatment and cost estimates, scope of general consent and lack of patient education on patients rights. Awareness among Nurses Though 96% nurses said they were aware of patients’ rights, it was found that none of them had correct information on content of charter of patients’ rights and responsibilities. Majority 59% felt that there was no need to display patients’ rights & responsibilities in a public area as this would provide patients with additional knowledge and hence they would be more demanding leading to harassment of the


D. Shreedevi

nurses on duty. About 30% nurses came across instances where patient and their attendees tried interfering in their autonomy by threatening them of complaining to management or consultants. Right to Medical Treatment Majority patients reported as having trust and confidence in their treating doctors. They felt that they were given due respect by doctors and nurses and all their queries were answered depending upon the availability of time. 30% patients felt ignored by the doctors when discussing the disease condition and treatment modalities. It generally took 1-2 minutes for nurses to arrive for help after they used the call button. 27% respondents said it took 3-5 minutes for the nurses to arrive for help once they used the call. 59% respondents believed that hospital staff did everything they could to help control their pain. Majority of patients in general ward complained that there were not enough nurses to take care of them during night hours. Right to Care with Respect and Dignity Majority nurses reported to encountering rare friction with patients but a significant section (23%) were among those who encountered friction often, frequently or always. Staff behavior and the hospital environment impact patients’ dignity, and threats to patients’ human needs can lead to loss of dignity. Right to Complain If a patient wanted to file a complaint regarding unsatisfactory hospital services 86% nurses informed their immediate superiors but 7% directed them to management and 6% directly sent them to respective consultants. This is so because there is lack of patient grievance cell for filing complaints and taking care of patient grievances. Right to Information 59% nurses educate their patients regarding hospital rules and regulations by providing information brochure at the time of admission, whereas, 40% said they provided sufficient information verbally at the time of admission. In case of doubt, regarding accuracy of information, majority nurses sought help from their superiors, whereas, 5% directly sought information from management, 4% withheld information and 2% tried getting away by talking routine matters. They felt that if information is provided to inpatients by using brochure or displaying charter then it will reduce their burden and avoid misunderstandings between patients and nurses. According to the nurses the frequent queries from patients which were sought are in the order as shown in Table 1. Regarding communication, 72% nurses were able to communicate but 28% nurses felt that language became a barrier when they had patients speaking other than the native language. 69% respondents said they were given right amount of information. 46% respondents said that they were explained in detail regarding the risks and benefits of the operation/procedure/treatment in a simplified/understandable way. 45% respondents said hospital staff completely explained what would be done during the operation/procedure/treatment. 50% respondents said they were completely explained the purpose of the medicines they were to take at home, 38% said they were given some information regarding medication side effects which was not complete, 15% said they were not told about any medication side effects to watch for at home, 6% said they do not know or do not remember anything being said about medication side effects. 43% respondents said they were not told anything regarding the danger signs whereas 56% said they were never asked to give their views on the quality of care when they were in hospital.

Hospital Preparedness for NABH Accreditation with Respect to Patient Rights and Education


Right to Safety 45% patients said they were not aware if nurses washed/cleaned their hand between touching patients. Right to Privacy 64% respondents said they were always given privacy when discussing their condition or treatment. 35% of respondents said they sometimes had privacy and sometimes it was not possible especially in general ward. Only 1% said they never got privacy to discuss their condition or treatment. The complaints regarding privacy were mainly from general ward. The hospital has to ensure that the patients’ private sphere preserved during the treatment/consultation. Right to Make Informed Choice 55% respondents said their consent was obtained before initiating the operation/procedure/treatment. A striking 33% of respondents said they were not aware if their consent was obtained or not as it was not informed to them, they were simply made to sign some papers as a part of admission formality.54% respondents said they were as much involved in their decision about care and treatment as they wanted to be. Patient Responsibilities 30% nurses said they had came across instances where patient and their attendees tried interfering in their autonomy by threatening them complaining to management or treating consultants. 39% nurses believed that hospital property was tempered by inpatients and their attendants especially when they were not happy with treatment, had argument with nurses or when they have altered sensorium. Therefore, they felt the need to display patients’ responsibility charter so that admitted patients became aware of their duties and behave responsibly.

CONCLUSIONS National Accreditation Board for Hospitals & Healthcare Providers (NABH) is a constituent board of Quality Council of India, set up to establish and operate accreditation programme for healthcare organizations. The board is structured to cater to much desired needs of the consumers and to set benchmarks for progress of health industry. To comply with these standard elements, the hospital will need to have a process-driven approach in all aspects of hospital activities. The study revealed that the existing practices related to patients’ rights and education are not up to the standards as directed by the NABH guidelines and there exists a gap that needs to be addressed by initiating suitable corrective actions.


Figure 1


D. Shreedevi

Figure 2

Source: Primary data Figure 3 What is the information that patients generally seek from you? (Rank 1to 10 with most sought after information) Table 1 Information Seeked COST SAFETY TREATMENT PLAN DISEASE CONDITION & PROGNOSIS VISITING TIME OF CONSULTANTS HOSPITAL FACILITIES HOUSEKEEPING AND CLEANLINESS LINEN & LAUNDRY DIET PHARMACY 

Rank Order 4 6 2 1 3 5 9 10 7 8

As per the study the most sought after information by patients are disease condition and prognosis followed by treatment plan, visiting time of consultants, cost of treatment, hospital facilities, safety, diet, pharmacy, housekeeping and cleanliness, linen and laundry. Patients and their attendants repeatedly seek this information from nurses on duty.

Source: Primary data Figure 4

Hospital Preparedness for NABH Accreditation with Respect to Patient Rights and Education


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Hospital Preparedness for NABH Accreditation with Respect to Patient Rights and Education

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Brazinov A, Em’lia Jansk, Richard Jurkovi, “Implementation of Patients' Rights in the Slovak Republic, Eubios Journal of Asian and International Bioethics 14 (2004), 90-91.


Anne-Maria Kanerva, Tarja Suominen, and Helena Leino-Kilpi, “Informed Consent for Short-Stay Surgery”, Nurs Ethics, November, 1999; vol. 6, 6: pp. 483-493.


Hakan Ozdemir M, Ozgür Can I, Ergönen AT, Hilal A, Onder M, Meral D. Midwives and Nurses Awareness of Patients' Rights. Midwifery, 2009 Dec;25(6):756-65.Epub2008 Mar17.


Helena Leino-Kilpi and Kristiina Kurittu, Patients' Rights in Hospital: An Empirical Investigation in Finland. Nurs Ethics, June 1995; vol. 2, 2: pp. 103-113.


Koula Merakou, Panagiota Dalla - Vorgia, Tina Garanis - Papadatos and Jeny Kourea-Kremastinou. “Satisfying Patients’ Rights: A Hospital Patient Survey”, Nurs Ethics, November 2001; vol. 8, 6: pp. 499-509.


Baillie L., Patient Dignity in an Acute Hospital Setting: A case study. International Journal of Nursing Studies 46 (2009) 23–37


Elzer R,“In 2010, Hospitals Must Take Patient Complaints Seriously”, Readiness, Hospital Accreditation & Compliance Journal.


Razavi E, Narjes A.K, Saidi A and Shidfar F. “An Evaluation of adherence to patients rights charter among patients and physicians at the emergency department of Imam Khomeini Hospital”, Tehran, DARU Suppl. No.1, Jan. 2006.


Joolaee S, Nasrabadi A.N, Yekta Z.P, Tschudin V, Mansouri I, “An Iranian Perspective on Patients' Rights”, Nurs Ethics, September 2006; vol. 13, 5: pp. 488-502.

10. Joolaee S and Hajibabaee F, “Patient rights in Iran: A review article”, Nurs Ethics, January 2012; vol. 19, 1: pp. 45-57., 11. Woogara J. “Patients’ Rights to Privacy and Dignity in the NHS”, Nurs Stand 2005 Jan 12-18; 19(18):33-7. 12. Yousuf R M, Fauzi A R M, How S H, Akter S F U, Shah A. Hospitalised Patients’ Awareness of their Rights: a Cross-Sectional Survey from a Tertiary Care Hospital on the East Coast of Peninsular Malaysia, Singapore Med J 2009; 50(5) : 494.

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Indian health care system is currently operating within an environment of rapid social, economical and technical changes and hospitals are a...