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The Scope and Challenges for Accreditation of Quality Care in Mental Health – Perspectives from India

Sahu, Prashant; Gowda, Guru S.,; Vijaykumar, K. G.; Ganjekar, Sundarnag; Murthy, Pratima; Thippeswamy, Harish

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Journal of Psychiatry Spectrum: Jan–Jun 2022 - Volume 1 - Issue 1 - p 21-26
doi: 10.4103/jopsys.jopsys_6_21
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The concept of quality in health care is based on the principles of patient safety, effective evidence-based services, and patient-centred care.[1] There has been an increase in the felt need among stakeholders across the world for quality in healthcare.[2] The quality of care and subsequent outcomes have remained suboptimal for people suffering from mental illnesses.[3] Achieving quality in mental health care has remained a challenge despite mental health laws, policies, and regulations mandating the improvement in standard of mental health care and protection of the rights of people with mental illnesses. The World Health Organization has developed a 5 pronged strategy to improve quality in mental health care-alignment of policy and legislation and involvement of key partners; alignment of funding; development and application of accreditation procedures; development and use of standards; and integrating quality improvement into routine service management and delivery.[4] Further, the quality of health care is broadly measured through the components: (a) Structure (facility in which care is provided), (b) process (interaction between patient and health providers), and (c) outcome (impact of health care).[5]

There is an emphasis on quality care through the accreditation of mental health services, especially in developed countries. The Joint Commission,[6] the Council on Accreditation,[7] and the Commission on Accreditation of Rehabilitation Facilities[8] are involved in the accreditation of the services such as child welfare, behavioral health, opioid treatment programs, and community-based social services in the USA. The Care Quality Commission in the United Kingdom approves accreditation of various subspecialties within the mental health sector through Accreditation for Inpatient Mental Health Services (AIMS), Quality Network for Older Adults Mental Health Services, Quality Network for Community CAMHS, Accreditation Program for Psychological Therapies Services.[9] The National Safety and Quality Health Service Standard is the regulatory body in Australia to monitor for safety and quality in mental health services.[10] The last two decades have seen a growing emphasis on quality in mental health care in India. The 2001 Erwadi tragedy in Tamil Nadu, India in which mentally ill persons died in a fire incident at a faith-based mental asylum was the triggering event for attention on safety and quality in mental health care.[11] The National Institute of Mental Health and Neurosciences and National Human Rights Commission have played a key role in reviewing and upgrading mental health services in India.[12] Further, National Commission for Women, National Legal Services Authority, and National Institute of Social Defence have also played a role in shaping the momentum for quality in mental health care.[13]

The recently enacted Mental Healthcare Act (MHCA) 2017, India advocates for quality in mental health care through setting the standards for facilities and services for persons with mental illness.[14] Accreditation facilitates the development and implementation of processes aimed to enhance quality. Accreditation involves training of health care workers in communication and professional skills in a patient-friendly infrastructure. The National Accreditation Board for Hospitals and Healthcare Providers (NABH), India is an accreditation body that certifies a healthcare facility for quality in care.[15] The process of adaptation of the NABH certification guidelines that are applicable for general medical facilities to the mental care facilities is associated with certain challenges. Our article addresses the scope and the challenges involved in the accreditation of a hospital providing mental health care, hereafter referred to as psychiatry services.


Several key challenges need to be addressed during the accreditation of psychiatry services.

Patient Safety

Persons with mental illness are more vulnerable for concerns related to safety[1617] The safety concerns include involuntary admission, use of seclusion and restraints, prescription errors, risk of self-harm, absconding and missing tendencies, aggression and violence, adverse drug consequences, and communication errors.

Patient Satisfaction

Patient satisfaction leads to better compliance, continuity in care, and recovery[1819] Clinicians’ communication skills, professional competency, and hospital infrastructure play important roles in improving patient satisfaction.[20]

Monitoring of Cost-Effectiveness

Accreditation involves the cost in terms of infrastructure as well as human resource. The organizations, hospitals, and clinics that intend to go in for accreditation need to be aware of the one-time and recurring costs. It is important to note that the cost involved is to promote delivery of standardized care to patients who seek the service. Particularly, in a low- and middle-income (LAMI) country like India, affordability can be a significant barrier to adequate psychiatric care. High medication costs, inequality in geographical distribution of services, lack of insurance, burden on caregivers, and loss of productivity put a further strain on financial resources. Accreditation of psychiatry services puts in systems that can be used to assess cost-effectiveness of models of care and transparency in treatment costs which in turn could improve the accessibility to care.[21]

Trust in Health Care Settings

Transparency in hospital policies and treatment methods would aid in the development of trust in care seekers. Trust in care providers is paramount in psychiatry services, since clinical presentation and treatment vary with the complexities of human thinking, behavior, memories, and the concept of self and consciousness.[22]

Quality in Mental Health Care Setting and Mental Healthcare Act 2017, India

The MHCA 2017 act advocates about (a) the rights of persons with mental illness in India (b) providing quality in mental health services without discrimination (c) setting minimum quality standards of facilities and services in mental health care; and (d) developing quality and service provision norms for different types of mental health establishments (MHE).[23] However, the Act does not define the “quality” in mental health care.

Quality in Mental Health Care Setting and Insurance

MHCA, 2017 mentions the equivalent status for mental illness to a physical disease to access all healthcare facilities, including insurance.[23] Insurance has been an essential part of the health-care system, especially in the public sector. Some states in India have schemes such as Biju Swasthya Kalyan Yojana that covers psychiatric disorders.[24] Ayushman Bharat, a nationwide program covers diagnosis and treatment of mental illness in addition to physical illnesses. Procedures such as electroconvulsive therapy and transcranial magnetic stimulation are covered under Ayushman Bharat and the financial aid includes inpatient as well outpatient treatment.[25] However, the scheme is restricted to only public hospitals. Recently, the Insurance Regulatory and Development Authority of India has directed the insurance companies to include mental illness or psychological disorders in the health insurance policies.[26] Accreditation is likely to become mandatory for health care providers if the insurance providers cover the expenses to ensure the quality of care.

Quality in Mental Health Care Setting and Litigation

In the United States, approximately 40% of psychiatrists have faced litigations during their career.[27] In the United Kingdom’s National Health Service, litigations are commonly related to self-harm or suicide, deprivation of liberty, medication errors, incorrect psychiatric diagnosis, and inappropriate management of gender reassignment surgery or breach of confidentiality.[28] In India, the consequences of legally cognizable medical negligence are broadly classified as (i) criminal liability, (ii) monetary liability, and (iii) disciplinary action.[29] However, for criminal liability, there has to be evidence of “gross” medical negligence.[30] Medical negligence in India is primarily addressed through consumer courts.[31] High litigation costs, delayed and protracted litigation, and an overdependence on judicial discretion hampers the timely resolution of complaints.[32]

Accreditation through establishment of grievance redressal system, standard documentation policy and record maintenance, and steps for patients safety and satisfaction could reduce the litigations[33] and assist in dealing with litigations.[34]


A written policy and standard operating procedures in a health-care facility are essential for quality, fairness, and transparency in the treatment. In Western countries, there are assigned regulatory bodies for the health-care sector for mental health so that the best of the recommended standards is provided. In India, the MHCA 2017 bestows the authority to the Central Mental Health Authority (CMHA) (under the Union government) and the State Mental Health Authority (SMHA) (under the state government) to set minimum quality standards for facilities and services in mental health care. Additionally, the MHCA 2017 requires establishment of a Mental Health Review Board to oversee the implementation of the provisions of the act by mental health professionals and MHE.[14] However, the CMHA and SMHA are yet to set minimum quality standards, and therefore, the provisions under the NABH accreditation could be helpful in establishing quality in mental health care.

Table 1 shows the various objective elements and its relevance to mental health care and MHCA 2017 as per the NABH 5th edition.[15]

Table 1:
Objective elements under NABH and its relevance to Mental Health Care and MHCA, 2017


Indian Confederation for Healthcare Accreditation[37] is an autonomous body based on the principles of trust, transparency, and transactions (communication). International Organization for Standardization[38] is a global agency for health to ensure that individuals and communities receive the quality of care they deserve. Besides ensuring quality, transparency, accountability and safety, it makes it easier to compare health services, exchange information, aggregate data and safeguard the privacy of an individual’s health. The Joint Commission International (JCI)[39] standardizes global guidelines for psychiatric hospitals by proposing models of care in different settings such as emergency, inpatient, geriatric etc. The JCI provides resources which can be used a framework for efficient psychiatric evaluation, treatment plan, suicidal risk assessment, discharge summary, and safe environment.



Accreditation enhances hospital reputation in providing standardized quality care for problems related to mental health.[40] The overall quality of patient care, safety, and satisfaction improves treatment outcomes such as the length of stay in the mental hospital and compliance to treatment and continuity of care.[41]

Service Providers

Accreditation facilitates regular audits to minimize errors and improve the health care systems in terms of quality.[42] Documented guidelines on quality in care would ensure a standardised care across various MHE. An accredited mental health care institute is also likely to receive better funding.[43] Accreditation processes helps in skill building and skill retention among the service providers through periodic audits. Hospital policies addressing prescription errors, informed consents, risk management, and evidence-based clinical guidelines can help in preventing medical negligence and consequent litigations. Accreditation helps in providing an additional layer of accountability to improve the safety of care.[44]

Accreditation standards should be specific to the kind of services a facility can provide and accreditation standards must be relevant. The standards need to be arrived at after considering the ground realities so that the accreditations can provide standardized quality of care to the patients. There should be a periodic review of the accreditation standards so that the standards remain relevant and practical.


The initial process of setting up a system and sustaining the system for accreditation could be resource intensive in terms of both human and other resources. Hence, this could act as a barrier to hospitals to opt for the accreditation process. The fees for NABH accreditation INR 52,000 for 2 years and an annual renewal fees of INR 165,000 for up to 100 bedded hospitals.[45] Tackling financial limitations would require pragmatic solutions such as phasic administration of accreditation and public-private partnership. Public health care can serve as a role model for private establishments by opting for the accreditation process. Policy-makers can aid the process through guidelines and necessary support for allocation of finances to help the public health care achieve accreditation. Sharing of information by the organizations that have achieved accreditation regarding the challenges and costs involved during the accreditation process would help other hospitals and organizations to plan for accreditation. In this regard, professional bodies/societies can disseminate the information related to accreditation to a wider audience through continuing medical education programs on accreditation.


Measuring quality in mental health care has been a challenge, partly due to the ambiguity in defining patient recovery. Heterogeneity of service providers in mental care could also hinder the measurement of quality.[46] Further, there could be several outcome measures such as use of physical/chemical restraints, aggression/violence episodes, self-harm/suicide episodes, and duration of admission, follow-up rate which could make the choosing of indicators a difficult process. A solution for this difficulty in choosing quality indicators is to have separate indicators for outpatient, inpatient, and emergency services that are specific, relevant, and measurable.


Accreditation plays a key role in ensuring quality in mental health care. Although any accreditation involves a cost to the organization, the benefits are likely to outweigh the costs. In a Low and Middle Income country like India the challenge is fourfold with widespread stigma associated with mental health, staggering inequality among states in terms of skilled professionals, local differences in terms of needs based on varied population and region, and limitation in financial resources. These should not deny the people from quality mental health care. Accreditation in mental health care can be a stepping stone in this direction. Policy-makers should endorse the principles from standardized quality care and tailor it based on local needs. Upskilling the staff could help in sustainability of a mental health care facility geared towards quality in care. Policies such as incentives for the NABH accredited hospitals would encourage MHEs to opt for accreditation.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.


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