merely assuring compliance with minimum acceptable standards.

Accreditation cannot be done without the cooperation of hospital staff especially the medical staff. The medical staff has direct involvement in patient care, and major standards of accreditation are related to them. Hence, there is a need to assess the attitude of medical staff on accreditation and to know the knowledge level of staff on accreditation standards. This brings out the need of the topic "Knowledge and Attitude of Medical Staff on NABH Accreditation".²

The demand for the latter has inevitably resulted in poor quality of medical care services with poor health outcomes.

It is simple to compute the direct costs for various medical services; however, to compute the cost of quality is not only difficult but rather elusive, which has resulted in overdependence on subjective criteria.³ Various modalities like manpower ratios, infrastructure, medical technological capabilities, accreditation and quality assurance policies and mortality rates have been considered as quality indicators and have been used to evaluate the quality of health care services. The paper attempts to explore the implication of these quality indicators on the direct expenses incurred by patients while they seek health care services across India.

Economic growth has a positive effect on health of people by increasing their level of income (Gangadharan, 2008).⁴ In the age of globalisation and liberalisation, India has achieved certain growth in its economy by increasing the standard of living of people which increases the consumers’ expectation on quality in health care service (Pahuja and Vohra, 2012, Kumaraswamy, 2012).⁵

Literature survey

In the globalised competitive hospital environment, service quality has been increasingly identified as the main factor in distinguishing between services and building competitive advantage. Unlike in the earlier days when hospitals were judged by the medical services they provided, they are now also judged on the quality of service they give, that is, personalised services rendered by courteous, caring and friendly staff. Hospitals will do even better if they could possibly combine high tech with a high touch. Service quality is designed to measure functional quality i.e. the manner in which the health care service is delivered to the patient. However, functional quality in a health care setting cannot be sustained without accurate diagnoses and procedures. Such technical quality is the focus of research that is being conducted by a number of health care professional organisations, including Joint Commission International (JCI), National Accreditation Board for Hospitals & Health care Providers (NABH) and Quality Council of India (QCI), etc. For the long-run success of a health care organisation, both functional and technical quality has to be monitored and managed effectively (Babakus Emin & W Glynn Mangold, 1992). Hence, the need to focus on the management aspects of hospitals has become more relevant than before. Measuring service quality as perceived by patients is one step to improve management of the hospitals. In this context, it is very essential to study the service quality in Indian hospitals. The present study is an attempt to develop an instrument for measuring perceived in-patent service quality in the context of Indian hospitals.⁶

The gap score for each statement is calculated as the perception score minus the expectation score. A positive gap score implies that expectations have been met or exceeded and a negative score implies that expectations are not being met. Gap scores can be analysed for individual statements and can be aggregated to give an overall gap score for each dimension. Early studies during 1980s concentrated on determining what service quality meant for customers and developing strategies to meet customer expectations (Parasuraman 1985).⁷

Service Quality, the well-documented service quality model i.e. SERVQUAL of Parasuraman et al (1985) has created a revolution in measuring the customers’ perceptions towards the service delivered by the provider in various service sectors. Along with all service sectors, the model is also widely used for measuring service quality in health care including hospitals. According to SERVQUAL model, service quality occurs when expectations are met (or exceeded) (Parasuraman et al 1985).⁸ The changing health care environment with revised hospital accreditation guidelines have sharpened the clinical and administrative hospital staff’s concern for evaluating the quality of care they provide. Clinicians now see accreditation standards as a framework by which organisational processes will be improved and their patients will receive better care. Physicians and administrators now must face the challenge of establishing comprehensive and vigorous systems of quality assurance and learn to avoid the traps that impede implementation of such systems. Quality assurance is a very simple process that deals with finding problems and fixing them.

A comprehensive definition of quality health care would be, “the optimal achievable result for each patient, the

avoidance of physician-induced (iatrogenic) complications, and attention to patient and family needs in a manner that is both cost effective and reasonably documented.”⁷

MATERIALS AND methodS

Research design

Study design was descriptive in nature.

Research setting

Krishna hospital - The information about the level of knowledge and attitude of medical staff about NABH was collected by questionnaire.

Population

The population of the study

Nurses, doctors and supportive staff. All the doctors, nurses, supportive staff of the organisation with experience more than 6 months were included in the study.

The tool and technique adopted for the data collection was questionnaire presented at beginning and 6 months of the start of the accreditation process. A questionnaire was prepared to collect the information on the level of knowledge and attitude of doctors and nurses and supportive staff on NABH accreditation.

Sample technique

Simple random sample technique method.

Tool

Questionnaire to doctors and nurses.

Section I

Demographic data and general information about the respondents.

Section II

This section assessed the medical staff's attitude towards NABH accreditation and standards.

Section III

This section assessed the effects of accreditation on services.

Section IV

This section assessed the effects of accreditation of patient care.

Section V

This section assessed the attitude of medical staff towards infection control practices.

Section VI

This section assessed the HR management.

The investigator obtained the NABH standards from the guide book of NABH standards. Questionnaires were prepared based on that material and distributed among the sample groups of doctors and nursing staff to get feedback about the attitude and knowledge on NABH accreditation

Inclusion criteria

Doctors and nurses who had working experience for at least 6 months in the particular hospital were only included in the sample group.

Exclusion criteria

Staff that had less than 6 months experience.

Data analysis

Statistical calculation was done using SPSS 15 with the percentage, mean and standard deviation as a measure for descriptive analysis.

Results

SA: Strongly Agree, A: Agree, D: Disagree.

On the first assessment, 20% thought it was name sake, 60% considered it to be beneficial to patient and 52.72% would help the health care professionals, 49% considered it as a benefit for the organisation, whereas post exposure these figures changed to 16.6%, 61.81%, 65.45%, 45%.

SA: Strongly Agree, A: Agree, D: Disagree

On the first assessment, 45.45% considered that accreditation improves the quality of service, 34.54% considered it is for better outlook about services, 40% thought that it makes the work systematic, 40% thought that it would help the health care professionals whereas post-exposure 30% thought it provides good image to the hospital and these figures changed to 61.81%, 34.54%, 63.63%, 60%, 69.09% (Table 2).

SA: Strongly Agree, A: Agree, D: Disagree.

On the first assessment, 58.18% respondents found that accreditation increases workload of the staff, 18.18% found it increases the documentation process, 5.45% found it is an unnecessary management intervention, 18.18% thought with accreditation there is a high chance for legal action by patient, 9.09% considered it increases the stress level of the staff, 7.27% feel it affects the productivity of the staff, and 1.81% considered it decreases job satisfaction level, whereas post exposure these figures are 27.27%, 21.81%, 5.45%, 9.09%, 21.81%, 26.63%, 10.90% considered it decreases job satisfaction (Table 3).

After 6 months, 96.35% respondents considered that the initial assessment for patients must be documented within time frame and considered that every medical renewal entry should be dated and timed. 98.18% respondents agreed that medical record should be named and signed. 96.29% wanted care plan to be countersigned by the clinician in-charge of the patient within 24 hours. 92.71% felt it decreases medical error and 100% felt it improves patient’s rights and satisfaction compared to pre-exposure (Table. 4).

Attitude towards infection control policies, morbidity and mortality outcomes improved due to better implementation of injection control policies with knowledge as majority of the staff used better techniques. (Table 5)

Majority employees agreed that NABH policy improves job satisfaction, feeling of security, better work conditions. (Table 6.)