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ORIGINAL ARTICLE

Study to evaluate change of attitude

toward acceptance of NABH guidelines:
An intra-institutional experience
Abstract

Background and Objective: The next decade shall see a great change in the health
care sector and there is a need for standardization of health care delivery at all levels,
which at the moment is lacking in India. The standardization can come if we adopt
some sort of uniform accreditation. For proper deliverance of health care, the role of
medical staff is significant. This asks for an assessment on the attitude of medical
staff toward accreditation and then the knowledge on accrediting standards. This
study is conducted with the objectives to identify the attitude level of medical staff
on accreditation, as well as their knowledge level on NABH standards.
Research Methodology: The study was conducted on 10 doctors and 40 nurses
of the hospital before and 6 months after the start of accreditation process in the
hospital. Samples were selected by simple random method. A questionnaire was
used to collect the information about the attitude and knowledge of medical staff
about NABH accreditation.
Results: The study revealed that medical staff had a positive attitude and improved
knowledge about accreditation after 6 months working in a hospital on the way to
NABH. The attitude reflected in their positive approach in managing patients under
better work atmosphere thus, indirectly reflecting on the benefit to the society as whole.
Conclusion: The sound knowledge and a positive attitude toward NABH accreditation
among the medical staff are very important. And the same can be accomplished
with proper training and good hospital environment.

Key words: Accreditation, attitude, Doctors, knowledge, NABH

Mandeep, Naveen Chitkara,

Sandeep Goel
INTRODUCTION
Department of Neurosurgery,
NASA Brain and Spine Centre,
Jalandhar, Punjab, India
Since the quality is crucial factor in health care, initiatives to address the quality of health care have become
a worldwide phenomenon. A commitment to quality enhancement throughout the whole of health
Address for correspondence: care system involving all professional and service groups is essential to ensure that high quality in the
Dr. Mandeep,
NASA Brain and Spine Centre,
health care is achieved, while minimizing the inherent risks associated with modern health care delivery.
Jalandhar, Punjab, India.
E-mail: doc_mandeep@ One method that is being proposed is an accreditation system. The focus of accreditation is on
yahoo.com continuous improvement in organizational and clinical performance of health services and not just the
achievement of certificate or award or merely assuring compliance with minimum acceptable standards.
Access this article online
Accreditation cannot be done without the cooperation of hospital staff especially the medical staff.
Website: www.nabh.ind.in
The medical staff has direct involvement in patient care, and major standards of accreditation are
DOI: 10.4103/2348-6139.151303 related to them. Hence, there is the need to access the attitude of medical staff on accreditation
Quick Response code: 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”.

RESEARCH METHODOLOGY

The study is descriptive in nature. The information about the level of knowledge and attitude
of medical staff about NABH was collected by questionnaire. Written consent forms were

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Mandeep, et al.: Attitude regarding NABH guideline

duly signed. The population consisted of nurses and doctors.
The study sample consists of 10 doctors and 40 nursing staffs
of the hospital. All the doctors and nurses of the organization
with experience more than 6 months were included in the study.
The tool and technique adopted for the data collection were
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 on NABH accreditation. The pilot study
was done to check its validity.
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.
Apart from the demographic details the questionnaire consisted
of 28 questions under 7 headings, grouped under 4 areas.
Attitude level was evaluated using a 4-point rating scale. These
items were scored as 1-4 in case of positive statement and 4-1
in case of the negative statement, depending on the agreement.
The exposure and knowledge level was assessed using “yes” or
“no” format questionnaire.
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
1. Supportive staff.
2. Staff who had less than 6 months experience.
DATA ANALYSIS
Statistical calculation was done using SPSS 15 with the percentage,
mean and standard deviation as measures for descriptive analysis.
RESULTS
Medical staff’s attitude toward NABH accreditation
and standards
Description
Medical staff ’s attitude and previous exposure to NABH
accreditation and standards:
On the first assessment, 20% respondents agreed to the need for
accreditation, 40% thought it was name sake, 10% considered it to be
beneficial to patients and 10% thought that it would help the health
care professionals, whereas post exposure, these figures changed to
90%, 60%, 100% and 80% respectively. 90% of persons agreed that
it was not for the benefits of organization alone [Table 1].
Effects of accreditation on services (positive effects)
Description
Positive effects
On first assessment, 10% considered that accreditation
improves the quality of service, 20% considered it is for better
outlook about the services, 20%thought that it makes the work
systematic, 10% thought it provides good image to the hospital,
10% thought it helps the healthcare professionals to update
themselves, whereas postexposure, these figures changed to
100%, 80%, 70%, 96% and 100%, respectively [Table 2].
Effects of accreditation on services (negative effects)
Description
Negative effects
On the first assessment, 30% respondents found that
Accreditation increases the workload of the staff, 60% thought

Table 1: Need for accredition

1st assessment 2nd assessment
Yes n (%) No n (%) Yes n (%) No n (%)
10 (20) 40 (80) 45 (90) 5 (10)
SA n (%) A n (%) D n (%) SD n (%) SA n (%) A n (%) D n (%) SD n (%)
Name sake 20 (40) 15 (30) 10 (20) 5 (10) 0 0 20 (40) 30 (60)
Benefit of the patients 5 (10) 10 (20) 25 (50) 10 (20) 30 (60) 10 (20) 5 (10) 5 (10)
Benefit of health care professionals 0 5 (10) 30 (60) 15 (30) 40 (80) 10 (20) 0 0
Benefit of the organization 30 (60) 10 (20) 15 (30) 30 (60) 30 (60) 15 (30) 5 (10) 0
SA: Strongly agree, A: Agree, D: Disagree, SD: Strongly disagree

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Mandeep, et al.: Attitude regarding NABH guideline

it increases the documentation process, 10% found it is an
unnecessary management intervention, 20% thought, with
accreditation; there is high chance of legal action by patient. 80%
agreed it affects the productivity of the staff, none considered
it decreases job satisfaction level, whereas, pre exposure, these
figures were 80%, 80%, 70%, 70%, 20%, 40% respectively
[Table 3].
Effects of accreditation on patient care
Description
Effects of accreditation on patient care
After 6 months, 100% respondents considered that the initial
assessment for inpatients must be documented within 2 h, 90%
considered that every medical renewal entry should be dated
and timed, 90% respondents agreed that medical records should
be named and signed 80% wanted care plan to be counter
signed by the clinician in-charge of the patient within 24 h.
90% agreed that accreditation improves the results, decreases
medical errors and improves patient’s rights and satisfaction.
This was a significant change noticed compared to pre-exposure
figures [Table 4].
Section V: Attitude towards infection control
policies
Description
Morbidity and mortality outcomes improved due to better
implementation of injection control policies. With knowledge,
more and more staff started to use better techniques which
helped in improving results [Table 5].

Table 2: Positive effects

1st assessment 2nd assessment
SA n (%) A n (%) D n (%) SD n (%) SA n (%) A n (%) D n (%) SD n (%)
Improves the quality of service 0 5 (10) 15 (30) 30 (60) 40 (80) 10 (20) 0 0
Improves the outlook about the 5 (10) 10 (20) 15 (30) 20 (40) 30 (60) 10 (20) 5 (10) 5 (10)
services to be rendered
Makes the work systematic 10 (20) 5 (10) 10 (20) 15 (30) 35 (70) 15 (30) 0 0
Improves image for the hospital 5 (10) 10 (20) 15 (30) 30 (60) 38 (76) 10 (20) 2 (4) 0
Helps the healthcare professionals 0 5 (10) 15 (30) 30 (60) 40 (80) 10 (20) 0 0
to update themselves
SA: Strongly agree, A: Agree, D: Disagree, SD: Strongly disagree

Table 3: Negative effects

1st assessment 2nd assessment
SA n (%) A n (%) D n (%) SD n (%) SA n (%) A n (%) D n (%) SD n (%)
Increases the workload of the staff 20 (40) 20 (40) 5 (10) 5 (10) 15 (30) 10 (20) 15 (30) 10 (20)
Increases in the documentation process 25 (50) 15 (30) 5 (10) 5 (10) 30 (60) 10 (20) 5 (10) 5 (10)
Unnecessary management intervention in our work 20 (40) 15 (30) 5 (10) 10 (20) 5 (10) 5 (10) 15 (30) 25 (50)
High chance of legal action by patients against us 25 (50) 10 (20) 5 (10) 10 (20) 10 (20) 10 (20) 10 (20) 15 (30)
Increases the stress level of the staff 20 (40) 15 (30) 15 (30) 0 20 (40) 10 (20) 5 (10) 15 (30)
Affects the productivity of the staff 5 (10) 5 (10) 10 (20) 30 (60) 40 (80) 5 (10) 5 (10) 0
Decreases job satisfaction level 10 (20) 10 (20) 10 (20) 20 (40) 0 5 (10) 10 (20) 35 (70)
SA: Strongly agree, A: Agree, D: Disagree, SD: Strongly disagree

Table 4: Medical error

1st assessment 2nd assessment
Yes n (%) No n (%) Yes n (%) No n (%)
The initial assessment for inpatients should be done 20 (40) 30 (60) 50 (100) 0
and documented within specified time frame
Every medical renewal entry is dated and timed 10 (20) 40 (80) 45 (90) 5 (10)
All medical notes have to be name and signed 15 (30) 35 (70) 45 (90) 5 (10)
The care plan should be counter signed by the 10 (20) 40 (80) 40 (80) 10 (20)
clinician in-charge of the patients within 24 h
Better results 15 (30) 35 (70) 45 (90) 5 (10)
Decreases medication error 10 (20) 40 (80) 35 (70) 15 (30)
Improves patient’s rights 10 (20) 40 (80) 50 (100) 0
Improves patient’s satisfaction 10 (20) 40 (80) 50 (100) 0
SA: Strongly agree, A: Agree, D: Disagree, SD: Strongly disagree

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Mandeep, et al.: Attitude regarding NABH guideline

Table 5: Infection control practices

1st assessment 2nd assessment
Yes n (%) No n (%) Yes n (%) No n (%)
Use proper hand washing facilities in the critical area 15 (30) 35 (70) 45 (90) 5 (10)
Use the isolation/barrier nursing facilities 10 (20) 40 (80) 35 (70) 15 (30)
Use gloves, masks during procedures 10 (20) 40 (80) 50 (100) 0
Awareness about the sterilization practices in the hospital 10 (20) 40 (80) 50 (100) 0
Awareness about the bio medical waste management processes in the hospital 5 (10) 45 (90) 48 (96) 2 (4)
Inform the management about the injuries such as needle prick injuries 10 (20) 40 (80) 50 (100) 0
Aware of the infection control practices to be followed in ICUs and high dependent units 10 (20) 40 (80) 50 (100) 0
SA: Strongly agree, A: Agree, D: Disagree, SD: Strongly disagree, ICU: Intensive care unit

Table 6: HR management
1st assessment 2nd assessment
Yes n (%) No n (%) Yes n (%) No n (%)
Rights of staff-better taken care by organization 15 (30) 35 (70) 45 (90) 5 (10)
Decreases risk of disease transmission 10 (20) 40 (80) 35 (70) 15 (30)
Better work conditions 10 (20) 40 (80) 50 (100) 0
Better financial status 10 (20) 40 (80) 50 (100) 0
SA: Strongly agree, A: Agree, D: Disagree, SD: Strongly disagree

Section VI: HR management FUTURE RESEARCH

Description
HR management
Majority agreed that introduction of NABH policy improves
working condition, gives better job satisfaction and provides a
feeling of security [Table 6].
DISCUSSION
This study proved that the doctors and nurses had a positive
attitude towards accreditation after 6 months. The present study
was done to find out the level of attitude and knowledge level
of medical staff on NABH accreditation in a selected hospital,
which are on the way to NABH.
After training on NABH accreditation and standards, the
knowledge as well as attitude of the staff toward standardization
changed. Doctors and nurses had a positive attitude on
accreditation, 6 months later. Both the nurses and doctors were
found to be less worried about the negative effects of accreditation.
The knowledge level among medical staff on NABH standards
improved and a better compliant and harmonious working
atmosphere was created between doctors and nurses. Moreover,
patient care also improved. Staff was more satisfied with working
environment and their rights and in turn, Management was
satisfied because of better results delivered in patient care. No
similar study could be found on the web.
• Further studies can be conducted by increasing the sample size.
• Studies can be conducted by taking staff other than medical
staff as the subjects.
CONCLUSION
The patients in today time are well informed and expect a
standardized quality health care from hospitals.[1] Accreditation of
hospital is a good way to provide standardization in treatment.[2]
Getting the accreditation becomes easier if the efforts to do so
are both by management and staff. This study also supports that
the attitude and responsibilities of staff improves after their
exposure and training of accreditation process.
REFERENCES
1. Jyothi G, Bidhan D. Developing national accreditation systems: Needs,
challenges and future directions. Express Health Care Management;
2005.
2. Ross MM. Encyclopedia of Health Services Research. USA: SAGE
Publications, Inc.; 2009. p. 664.
How to cite this article: Mandeep, Chitkara N, Goel S. Study to
evaluate change of attitude toward acceptance of NABH guidelines:
An intra-institutional experience. J Nat Accred Board Hosp Healthcare
Providers 2014;1:52-5.
Source of Support: Nil, Conflict of Interest: None declared.

55 The Journal of National Accreditation Board for Hospitals & Healthcare Providers | Jul-Dec 2014 | Vol 1 | Issue 2