Accreditation of Eye Care Centres: The 10-Step Simplified Guide

Dr Nirmal Fredrick T
Dr. Sunitha Nirmal
Dr Niranjan Karthik Senthil Kumar
Published Online: October 24th, 2022 | Read Time: 9 minutes, 50 seconds


The quality of health care and the initiatives taken to address various risk and safety issues in hospitals has become a subject of debate. Many countries and organizations are exploring various means to improve the quality of healthcare services.

“Accreditation is a status that is conferred on an organization that has been assessed as having met particular standards”. The two conditions for accreditation are an explicit definition of quality (i.e., standards) and an independent review process aimed at identifying the level of congruence between practices and quality standards. This article simplifies the process of accreditation into concise and simplified ten steps.

Step 1: Deciding to Get Accredited

Accreditation is not a goal but a journey. Accreditation is a continuous process rather than a final destination.

Step 2: Assessing the Current Situation and Doing Background Research

What stage is your organization at with regard to implementing quality standards?

  • Considering options – whether to go for accreditation now or later
  • Reviewing standards and preparing for implementation
  • Preparing materials for Accreditation/ Certification
  • Already Accredited / Certified
  • Assessed unsuccessfully, preparing for re-assessment
  • Assessed unsuccessfully / Not prepared.

Acquiring basic knowledge from available material

Collecting and assimilating knowledge regarding accreditation can be important in the initial stages. The required knowledge is made available in the form of books and guides, which include NABH Standards ( can be downloaded from the NABH website), NABH Guidebooks for ECO ( can be bought from NABH) and Resources on accreditation ( AIOS ARC booklet on Accreditation of Eye Centres - Edited by Dr Nirmal Fredrick) and articles published in the various journals. The NABH standards and guidelines book are strategically divided into ten chapters, focusing on Patient Safety and Quality to reduce the risk for patients and give an indication of Standards of care and provide professional satisfaction for Ophthalmologists and allied medical professionals.

Forming a good team to lead and implement the standards

A core team consisting of a quality coordinator is to be formed, which is to comprise different departmental teams, including Quality Committee, Safety Committee, CPR Committee, Clinical Audit Committee, Infection Control Committee and Pharmacy Committee.

Step 3: Conducting Gap Analysis and Build Action Plan

Gap Analysis and Follow up

1. Review the activities and task within the five domains every 3months.

2. Activities/ tasks assessed as being: Fully Met/ Partially Met/Not Met

Discuss and plan on how to reach the Fully met requirements

Step 4: Standards Awareness Training

Training the management and staff is an important step in the implementation of accreditation requirements. Training of all faculty, including ophthalmologists, optometrists, nursing staff, pharmacists, technicians and all staff, is an essential component of the process. This ensures that everyone is aware of what is expected from them and their role in the process of accreditation. Training can be done in several ways. Various methodologies include didactic lectures, workshops, and practical skill assessment programs, which can be in multiple sessions to systematically train and qualify the health personnel to work up to the standards of accreditation. It is important to take feedback and also audit the outcomes of the training by an effective pretest and post-test questionnaire.

Step 5: Emphasizing Documentation

Documentation is an important aspect and a cornerstone in the process of accreditation. Documentation takes multiple forms, as depicted in the quality pyramid (Fig 2). Each sub-component has comprehensive information regarding various guidelines in patient care. Of these, the Apex manual, Quality and infection control manuals form the core of documentation. For a Single speciality eye centre, they can be broadly divided into four categories (Fig 3)

Fig 2: Quality Pyramid for Accreditation

Manuals and SOPs addressing the ten chapters and some of the important processes in the hospital have to be written by the staff and administrators. Essentials the documentation should reflect the care provided in the hospital – DO WHAT YOU WRITE: WRITE WHAT YOU DO.

Step 6: Mentoring and Coaching for Implementation

Domains to be covered in training healthcare personnel are classified into patient and organizational standards. They include many subcomponents (Fig 4), which have to be dealt with in detail to all healthcare personnel for efficient knowledge transfer.

Following implementation, it is of high importance to repeatedly assess the practice patterns among the different strata of healthcare workers in the form of internal audits and identify the lacunae in successful implementation. New and simplified methods have to be adopted and changes made in order to overcome these obstacles and to ensure smooth implementation of the specified standards.

Step 7: Implementating of New System Requirements

The quality has to be evaluated objectively at three different levels, namely service level, quality control and customer satisfaction, as shown in the table below.

S. No

Quality Objectives

Performance Indicators


Measurement Criteria




Service Level

Staff availability

Hod, HR Manager

Duty Roster/ Attendance record


Staff skills

Hod, Training coordinator

Staff job description and staff resumes

Half yearly

Investigation time

HOD, Imaging Services

Imaging department patient registration record imaging department procedure record


Coordination between all staff

Quality coordinator or administrator

Patient Feedback Form



Quality Control

Internal quality control process

Quality coordinator or administrator

Quality Control Records


External quality control

Quality coordinator or senior administrator or top management

Quality Control Records

Half yearly


Customer Satisfaction

Courtesy level

Chairperson, Quality Committee PRO

Patient Feedback Form


wait time and convenient reports collection

Quality team and PRO team

Patient Feedback Form


Step 8: Audit & Continuous Quality Improvement

Systematic implementation of the process at two different levels, namely the “drivers”, “enablers”, can ensure a fruitful outcome in the form of customer satisfaction (Fig 5)

Step 9: Challenges in The Process

In the journey of implementation, several hurdles are to be anticipated and appropriately handled.

Step 10: Applying & Being Ready for Assessment

After implementing the above steps and after a round of internal audits, if we are satisfied that the hospital is ready for the third-party assessment, an online application is made. All these details and resource materials are available at It is important to go through all the resource materials and have thorough discussions with those who have implemented the standards and experts who can facilitate the understanding and help in implementation.

Quality of care or services has become an essential part of the management and evaluation of health care. It has become a prime consideration to ensure patient satisfaction. Therefore, Accreditation standards promote continual training and development programs for doctors and hospital staff, thereby helping to improve service quality and patient satisfaction.


  1. Nirmal Fredrick T, Nirmal S Accreditation of Eye Hospitals – A Review. DJO 2014;25:118-124
  2. Quality and accreditation in health care services A GLOBAL REVIEW. Evidence and Information for Policy, Department of Health Service Provision (OSD) World Health Organization, 1211 Geneva 27, Switzerland. 2003.
  3. Kimberley A, Galt K A: Foundation in Patient Safety for Health Professionals. Jones & Bartlett Publishers, LLC, 2011.
  4. Accreditation Board for Hospitals and Healthcare Providers General Information Brochure, 2013.
  5. National Accreditation Board for Hospitals and Healthcare Guidebook to NABH Standards 2012.
  6. Myers S A. Patient Safety and Hospital accreditation A model for ensuring success. Springer Publishing Company, LLC, New York, 2012
Dr Nirmal Fredrick T
Managing Director, Nirmals' Eye Hospital, Tambaram
Prof. Dr. T. Nirmal Fredrick, (M.B.B.S., D.O., M.S.(Oph.)., Dip. N.B.(oph), FICO (UK), P.G.D.H.M., FMMC., FIMSA, FAICO.,MBA) is currently the Chief Eye Surgeon & MD at Nirmals' Eye Hospital, Tambaram. He plays multiple roles beyond a clinician including those such as Principal Assessor at (NABH) Quality Council of India, Assessor at Emirates international Accreditation ,Member secretary at NABH Eye care standards, and Eye Bank Accreditation ,Executive committee member at Ocular Trauma Society of India, Advisor at TNOA Journal of Ophthalmic Science and Research & JIMA, Chairman of, Insurance committee, IMA TNSB & co chair, National IMA PDB and is currently the President Elect, Tamilnadu ophthalmic association. He has given more than 1200 lectures and presentations in national and international conferences. He has over 40 publications, 12 book chapters and 5 books as author, Chief Author and Member secretary, NABH Eye Care Standards, Editor of NABH Guide book to Eye Care,AIOS book on Accreditation of Eye centers. He has won several awards and achievements at national and internal levels He has received over 40 named awards and orations including ,The prestigious TNOA Dr. Joseph Gnanadickam Oration 2017,Prof VVR IMA NHB oration,Dr. DL Shukla award for outstanding contribution to National IMA,Received the AIOS Priti Natarajan award 2017 for Best Eye clinic/Hospital administration. Nirmals Eye Hospital has been recognized as Centre for Quality Promotion by CAHO and QCI and Quality Champion by CAHO at CAHOCON 22.
Dr. Sunitha Nirmal
Medical Superintendent, Senior Consultant Ophthalmologist, Nirmals' Eye Hospital, Tambaram
Dr.Sunitha Nirmal completed her MS Ophthalmology at RIO-GOH(Madras Medical College). She had worked as a consultant at several private hospitals including Malar hospitals and Voluntary health Services, Adyar, Chennai. She started her journey in 1999 as a consultant at Nirmals Eye Clinic , Chennai and from 2006 till present, working as Consultant Eye Surgeon and Medical Superintendent, Nirmals Eye Hospital, Chennai. She had delivered talks in Instruction courses and other modules in many state and national conferences on important topics like operations theatre safety, NABH implementation, Documentation in NABH, Equipments needed in medical emergencies.
Dr Niranjan Karthik Senthil Kumar
Consultant Ophthalmologist, Nirmals' Eye Hospital, Tambaram
Dr. Niranjan Karthik Senthil Kumar, completed MBBS from Kasturba Medical College, Manipal, Karnataka in the year 2018. He secured the coveted Dr. T.M.A.Pai Gold Medal for Best Outgoing Student in his undergraduation. Completed his post-graduation from Asias oldest eye hospital , RIOGOH , Chennai. Currently pursuing his fellowship in Comprehensive Ophthalmology at Nirmals Eye Hospital, Tambaram Chennai. He has won several accolades in quizzes at regional and national level conferences including AIOS , TNOA etc. He has presented e-papers and posters in state and regional level conferences. He has 10+ articles in peer-reviewed journals. He has keen interest in subspecialties of Orbit & Oculoplasty and Medical Retina
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