The National Accreditation Board Hospitals & Healthcare Providers (NABH) an institutional member of ISQuA – International Society for Quality in Healthcare, has granted certification to the Central Referral Hospital (CRH), Tadong, Gangtok. CRH is the first hospital in Sikkim to be granted this NABH Certification. NABH is a constituent of the Quality Council of India, which was set up to establish and operate accreditation programme for healthcare organisations. It is structured to cater to the much desired needs of the consumers and to set benchmarks for progress of health industry. Hospital Accreditation encompasses 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. Third party accreditation and certifications by reputed organisation like NABH, enables healthcare organisations to standardise practices to improve the confidence of stakeholders and partners.
Central Referral Hospital in its commitment to provide quality health care to its patients, embarked on the quality journey in 2018, by formally publishing it as its midterm goal. To fulfil this commitment to the goal of CRH to ensure quality services to all its patients, multidimensional efforts were launched with unstinting support and encouragement from the leadership of the Manipal Group and Sikkim Manipal University. These earnest endeavours fructified with CRH obtaining the quality certification by NABH for its 550 bedded multi-speciality, tertiary care, teaching hospital, in the geographically challenged location in the north east state of Sikkim.
This significant achievement is due to the praiseworthy contribution of the all Women team at Central Referral Hospital, ably led by Dr Mingma L Sherpa, erstwhile Head Operations, Mrs Breenila Targain, Assistant Manager Operations, Ms Bandana Moktan, Chief Nursing Educator and Dr Mala Sharma, Operations Executive, who spearheaded the strategies to achieve this quality certification. A considered decision was taken to engage internal stakeholders and not outsource to a consultancy which is standard practice in most healthcare organisations. This was to ensure continuity and enable internalisation of quality practices at all levels and at all times. Amidst scepticism and speculation, the team started with ‘continual self-improvement’ as a motto. Accordingly, the Quality Department of CRH was established and the road-map was formulated which included training, self-assessment for baseline readiness, internal and external audits, budgeting, infrastructure upgrades, updates and reassessment. In September 2019, Dr Sherpa conducted the Dr TMA Pai Endowment fund supported 3 day NABH certified ‘Programme on Implementation’ training for 35 members which included stakeholders from all departments including clinicians, faculty, paramedics, administration, engineering, HR, IT and support staff. This gave the much needed impetus to undertake the arduous processes to enshrine quality in the work ethos of Central Referral Hospital.
There were a flurry of activities to create Standard Operating Procedures, to meet the statutory requirements, training and retraining, creating and placing quality indicators and monitoring of each to meet the minimum requirements of the standards. The existing best practices of Hospital Infection Control and Surgical Safety Checklists to name a few, were used as launchpads to introduce hospital wide quality practices and establish quality indicators. Repeated internal and external audits of processes and documentation, identification of gaps and addressing the identified gaps were some of the activities that were taken up with commendable zeal and resolute tenacity.
Central Referral Hospital completed and submitted the comprehensive list of documents and evidence in the NABH online Hope Portal, Quality Council India on January 15th 2020. The process undertaken by NABH was verification of submitted online documents with raising of non-conformities and onsite assessment. The online non conformities were resolved and closed by the Central Referral Hospital within a record time of 7 days and the desk top assessment clearance was received in 22nd April 2020. Onsite assessment was thereafter delayed by about a year due to the onslaught of Covid 19 pandemic. The onsite virtual assessment was successfully completed on 7th May 2021. Central Referral Hospital is happy to announce the receipt of Entry level Certification for Health Care Organisation by National Accreditation Board for Hospital, Quality Council of India, for the first time in the state of Sikkim.
The Vice Chancellor, SMU, Dean SMIMS and Medical Superintendent CRH, congratulated the quality and the steering team, during the event to acknowledge this momentous accomplishment by CRH. Central Referral Hospital, Manipal, is now the first NABH, QCI certified hospital in Sikkim, which is committed to provide high quality, multi-speciality, tertiary care in its steadfast commitment to serve the citizens of the state.
