Steps for entry level certification

1. Registration

HCOs/SHCOs can register online on www.hope.qcin.org. An account will be created after filling the user registration form. User can login with the username and password received on their registered mail id and has to submit all the required details through web portal and mobile application followed by the fee payment. The details entered by applicant for registration on the HOPE website cannot be edited once the details are submitted. Please make sure that the details are filled accurately. Please ensure that you change your password as per your convenience once you login to your account.

Sections to be filled on HOPE Portal

a) General Information

This section covers basic information of the hospital and is divided into the following categories:

Contact Details- Covers details such as the Name of the Hospital, Address, the person responsible for coordinating and implementing the quality improvement programme. It also includes the City and State in which the hospital islocated.
Hospital Information- Covers details related to hospital establishment like Registration Number, Registration Date, Type of Ownership.

b) Statutory Compliances

This section covers the following things –

Statutory Compliances – This section states the types ofstatutory compliances the organization must provide. It includes acquired licenses such as, the AERB license for X-Ray, Mobile X-Ray, OPG, CT scan, radiotherapy, IMRT, Cobalt, Linear Accelerator, Brachytherapy etc. In addition, license number, status, issuing authority etc. are also evaluated.
Details of MoU of various outsourced services related to the hospital – This part of the statutory compliance validates the various outsourced services and details of the same.

c) Hospital Staffing

This section covers details pertaining to the Hospital Staff such as name, designation, qualification, type of degree, registration number, working department etc. It is divided into the following categories:

General duty medical officers
Nurses
Paramedical staff
Administrative and support staff

d) Clinical Services

Details This section covers the type of clinical service details in the hospital such as OPD / IPD data, Average Occupancy Rate, ICU Data, Scope of Services, etc. The Scope of Service include the name of the service offered, details of full time / part time / visiting consultants, doctors name, graduation, post- graduation, etc. Additional information required from the HCOs/SHCOs is as follows:

Ten most frequent clinical services where admissions take place
Ten most frequent diagnoses for in-patients
Ten most frequent surgical procedures at your hospital
Choose the type of sterilization modes used in the hospital

e) Physical Infrastructure

This section focuses on the physical infrastructure of the hospital. It gives a clear indication of the kind of medical facilities available at the hospital. It covers the following details:

Bed Strength-Seeks information about the number of operational bed for categorieslike Emergency ward, ICU, HDU, General, private and semi-private ward.
Service Offered- Seeks location details of the services offered like Anesthesia, blood bank, cardiac OY, cath lab, CCU, ICU, labour room, medical ward, NICU, nuclear medicine, OT, ortho ward etc.
Laboratory Services- Requires information of laboratory services which includes Clinical Bio-chemistry, Clinical Microbiology and Serology, Clinical Pathology, Cytopathology, Genetics, Haematology, Histopathology, Toxicology and Molecular Biologylabs.
Diagnostic Imaging- Validates details of service offered like Bone Densitometry, CT Scanning, DSA Lab, Gamma Camera, Mammography, MRI, Nuclear medicine, PET, ultrasound, Urodynamic Studies and X-Ray.
Others- Covers the remaining services offered by the hospital like 2D Echo, Audiometry, EEG, EMG/EP, holter monitoring, Spirometry-PFT and Tread Mill Testing. Apart from these clinical services this section includes questions like Availability of electrical supplies, water supplier, elevators, Type of trolleys present at the hospital, Ambulance Accessibility, Uniform signage system in the Facility etc.

f) Quality Improvement Process

This section covers all the vital areas related to patient care, the details are as follows-

Committee/Coordinator- Answers questions, whether the hospital has a committee /coordinator for activities such as quality safety, infection control, pharmacy and therapeutic, blood transfusion and medical record.
Registration, Admission and Billing process- Focuses on parameter for patient identification, patients rights and responsibilities and documentation of registration and admission of patients.
Patient and Family Education-Consists of consent records required from patient and family end – Blood and Blood Products Transfusion Consent, Blood Donation Consent, Anesthesia Consent, Surgery Consent.
Patient Related Process- Information pertaining to UHID of patient and his/her corresponding document forms for OPD, IPD, emergency, MLC etc. arechecked.
Nursing Care Process- Includes nursing documentation like medication administration record, nursing monitoring charts and nurses notes.
Medication Management- Includes documentation like storage of medication, emergency medication, prescription, medication order etc
Human Resource Training- Verifies trainings conducted by HCOs on scope of services, Safe practices in Laboratory, Safe practices in Imaging, care of Emergency patients in consonance with the scope of the services of hospital, Child Abduction Prevention, Disciplinary procedures etc.
Infection Control- Focuses on Hand Hygiene, General Cleanliness, Standard Precaution & Personal Protective Equipment, Occupational Health, Bio Medical Waste, Water Testing etc.
Management Process- Seeks information regarding Medication Error and Adverse Drug Reaction, Laboratory, Blood Bank etc.
Safety Management- Requires photographs to be uploaded for the safety management devices/procedures like Adequate safety devices that are available in the lab, Aprons and shields usage for shielding of body parts of staff and patients, Department where radioactive drugs are used, Filled WHO Surgical Safety checklist used for every surgery.
Record Management- Documents pertaining to Medical Records and Fire Extinguishers in the Medical Record Department (MRD) are required.

g) Documentation

This section covers all the important documents related to General Information, Statutory Compliances, Hospital Staffing, Clinical Services Details, Physical Infrastructure and Quality Improvement Process. Documentation will be done by using web portal.

2. Fee Submission

The fee to be submitted by HCO (Hospitals with More than 50 Sanctioned beds) and SHCO (Hospitals up to 50 Sanctioned beds) is as follows:

HCO – Entry Level Certification Fee: Rs 52,000 + GST
SHCO – Entry Level Certification Fee: Rs 21,000 + GST

3. Desktop Assessment

Desktop Assessment of HCOs will be done online through web portal and mobile application by DA team. DA team will raise NCs and HCOs/SHCOs will have a specified timeline to close all the non-compliances. The DA team will have to verify all the replies within a specific period of time.

4. On Site Assessment

After closing all non-compliance(s) generated at DA stage, HCOs will be moved to next stage of on-site assessment followed by the assessment planning. On-Site Assessment will be done by the assessor. Final quality check of the assessment will be done by the experts and NCs(if any) will be raised for any clarifications or missing pieces. HCOs will be having a defined time to close all the NCs.

5. Certification

Application will be sent to certification committee after closure of all the NCs from HCOs and quality check team. Final decision taken by the committee will be notified 13 to the HCOs. If the application gets rejected at committee stage, HCOs will be having an appeal facility after paying the appeal fees. Digital Certificate will be provided to all the hospitals that the accreditation committee approves.