NATONAL ACCREDITATION FOR

HOSPITAL & HEALTH CARE PROVIDERS

(NABH)
WHAT IS QUALITY ?
Appropriate application of medical knowledge with due

regard to the balance between the hazard inherent in

every medical intervention and the benefits expected
from it
It is, however more complex than this.
QUALITY FROM WHOSE POINT
OF VIEW ?
Provider of Health care Services

Recipient of the Health care services

Organizer of the Health care services

PROVIDERS CONCERNS
To provide care as per established norms
Adequate resources
Self satisfaction with the final outcome
Should contribute to enhancement of skills, competence
and add to experience
RECIPIENTS CONCERNS
Accessibility
Affordability
Prompt attention
Less waiting time
Early diagnosis and cure
Return to Productivity as early as possible
Humane Treatment ie to be treated with empathy , respect
and concern
ORGANISERS CONCERNS
Responsible to the Society for the funds spent on health care

To ensure safety of public and prevent inappropriate or

suboptimal care
To meet the requirements of the recipient and provider of the

health care services at Acceptable costs

WHAT IS ACCREDITATION
Accreditation is an external review of quality with
four principal components:

 It is based on written and published standards

 Reviews are conducted by professional peers
 The accreditation process is administered by an
independent body
 The aim of accreditation is to encourage organizational
development.
Focus of standards
Patient Safety

Staff and employee safety

Environment and community safety

Information Education and Communication

NABH STANDARDS
NABH Standards

10 Chapters

100 Standards

503 Objective Elements

Section I:
Patient-Centered Standards

STD OE
Access, Assessment and Continuity of Care (AAC) 15 78

Patients Rights and Education (PRE) 05 29

Care of Patients (COP) 18 105

Management of Medications (MOM) 13 61

Hospital Infection Control (HIC) 09 44

60 317
Section II:
Health Care Organization Management
Standards
STD OE
Continuous Quality Improvement (CQI) 6 37
Responsibilities of Management (ROM) 5 20

Facility Management & Safety (FMS) 9 41

Human Resource Management (HRM) 13 47
Information Management Systems (IMS) 7 41
40 186
 Accreditation Process

 Applications
 Screening of the Applications
 Pre-assessment survey
 Assessment Survey
 Review of the recommendations of the assessing body by
the Accreditation Committee
 Recommendations to the board
 Accreditation decision
WHO CAN APPLY
Any Health Care Organisation
Requirements
Currently in operation as a HCO
Preferably registered or licensed
Willing to assume responsibility for improving quality of
care
Should be able to meet the prescribed standards of the
accrediting organisation
HOW CAN ONE APPLY
Basic Ingredients
Organisations apply on prescribed format giving details as

required
Submission of a self assessment form indicating the

outcomes of its QMS and Internal Audits

Extent of adherence to the laid down standards
SCREENING OF APPLICATIONS

Completeness

Accuracy

Clarifications sought if required

PREASSESSMENT SURVEY
To ascertain the readiness of the organisation for
Accreditation
Overview of the organizational preparedness and
commitment to quality goals and consonance to laid down
standards
Deficiencies noticed informed to the organisation
Advice rendered on the methodology to be followed
during the Accreditation Survey
Time frame worked out for the survey in mutual
consultation
ACCREDITATION SURVEY
Carried out by a team of Assessors depending upon the
size, complexity and facilities provided by the organisation
Scope will include all standards related functions and all
patient care settings
Onsite survey will consider specific cultural and legal
factors which may influence or shape decisions regarding
the provision of care and /or policies and procedures
METHODOLOGY OF SURVEY
Initial presentation by the hospital

Document Review

Adherence to statutory obligations

Visits to various areas

Facility surveys and tours

Random structured interviews

INITIAL PRESENTATION BY THE
HOSPITAL
Organogram
Quality management Team
Methodology followed for Quality Improvement
Facilities provided
Inputs on resources provided for Quality Improvement
Identified high Risk Areas for patient care and safety
Sentinel Events being monitored
INITIAL PRESENTATION BY THE
HOSPITAL
Key Monitoring Indicators
Resource
Volume
Utilization
Performance

Control charts
Problems faced and remedial measures undertaken/ being
undertaken
DOCUMENT REVIEW
• Quality Manual
• Various Policies and Procedures
• Minutes of Meetings of various committees
• Medical Records
• Medical / Nursing Audit
• Adverse Events
• HAI
• Action Taken Reports
• Personal Records of Staff
OBSERVATIONS
• Facility Safety

• Level of compliance with laid down policies and procedures

• BMW Management

• Standard Precautions

• Patient care

• Fire Safety

• Equipment Management
INTERVIEW
• Staff Interview
• To determine their level of awareness and
compliance with organisation policies and
procedures
• To assess their awareness levels of their rights,
privileges and patient rights
• To determine their satisfaction levels
• Patient and family Interview
• To assess their level of awareness of the care
process and their rights
• To determine their satisfaction levels
SCORING PATTERN
NABH has laid down the following pattern
Non-compliance 0
Partial compliance 5
Full compliance 10

No standard can have more than one zero

The average for a standard must exceed 5
The overall average score must exceed 7
No zeros in legal requirements
OUTCOMES OF ACCREDITATION SURVEYS
Accredited
HCO shows acceptable compliance with laid down standards
in all areas
Includes the scope of services for which accredited
Any increase in scope the survey has to be done for the
increased scope
Accreditation denied
HCO is consistently non compliant with standards
Accreditation withdrawn
HCO withdraws voluntarily
Due to consistent non compliance or non adherence to safe
and ethical practices
DURATION OF ACCREDITATION AWARDS
Generally three years with one Reassessment survey to
ensure continued compliance and to assess the CQI
programme
If during accreditation The Accreditation organisation
receives inputs that the organisation is substantially out
of compliance with the current standards then
Resurvey or withdrawal of accredited decision may be
resorted to
How to Go About
Create willingness
Initial impetus from Top management
Requires involvement of all staff
This requires repeated training and briefing
Once consensus is there identify core coordinating or
Quality management Team
How to Go About
Examine what are you doing

Find what you should be doing

Document the gaps

Compare with the standards

Complete gap analysis

Identify areas for improvement

How to Go About
Focus on uniform training of all employees in key areas
Encourage by financial and / or non-financial incentives
Initially prepare to provide extra resources
Avoid disappointments if initial benefits do not accrue as
expected
Be prepared for a longer gestation period for benefits to
accrue
PROBLEMS AND CHALLENGES
HCOs are very enthusiastic

Ill prepared

Initial preparation is shoddy

Resources required initially

Benefits have a longer gestation period

PROBLEMS AND CHALLENGES
Quality Consciousness at all levels will take time
Sustenance and consistency of efforts will be required
Commitment on a consistent basis
High rates of attrition will require repeated and
continual training
Public Sector will take a longer time to get into the
process
Quality and consistency of assessors and assessments
 These May Look Difficult

Initially, But the First steps are

Never easy.
Also Nothing Is Impossible

For,
 Impossible

Means

I’ M Possible
Quality Norms and Accreditation??

Response of Medical Fraternity

Expected Response
THE CURRENT STATUS OF
ACCREDITATION IN INDIA
Initializing phase is over.

Phase of consolidation.

The initial steps have been difficult but the journey has

begun.
The journey has to continue……….

Especially since ---------------------------

ACCREDITATION IS A JOURNEY

AND

NOT A DESTINATION.