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TRANSCRIPT
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National Accreditation Board for Hospitals
and Healthcare Providers
THE ROADMAP TO NABH
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National Accreditation Board for Hospitals & Health Care Providers
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QCI
QCI is an autonomous body
set up by Govt. of India toestablish and operate
accreditation structure in the
country.
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Structure of QCI
NationalAccreditation Board
for CertificationBodies (NABCB)
National Board forQuality Promotion
(NBQP)
National AccreditationBoard for Testing and
CalibrationLaboratories (NABL)
National RegistrationBoard for Personnel
and Training(NRBPT)
Quality Information
and Enquiry Service
National AccreditationBoard for Hospitals &Health Care Providers
(NABH)
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NABH is an institutional member of
the International Society for Quality
in Health Care (ISQua)
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Getting Started The Roadmap
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The Roadmap
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Application for accreditation
Prescribed application form.
Prescribed application fees
The applicant hospital must apply for all its facilitiesand services being rendered from the specific location.
(NABH accreditation is only considered for hospitalsentire activities and not for a part of it).
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Scrutiny of application
Scrutiny of application is done for its completeness in all respect
Acknowledgement letter is issued to the hospital with a uniquereference number.
(The hospital shall be required to quote this reference number in allfuture correspondence with NABH.)
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Self Assessment
Self-Assessment toolkit for self-assessing itself against NABHStandards (and submit to NABH secretariat).
A signed copy of Terms and Conditions for Maintaining NABHAccreditation. (available free on the web-site).
Hospital shall submit their documents as per NABH standardsand the procedure manuals.
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Pre-Assessment
NABH appoints a Principal Assessor/ Assessment Team who is
responsible for pre assessment of healthcare organization.
NABH forwards the application form, documents, procedures,
Self assessment toolkit to the Principal Assessor/ Assessment
Team.
It is done on-site
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Objective of Pre-assessment
Check the preparedness of the hospital for final assessment
To review the scope of accreditation & Documentation
Explain the methodology to be adopted for assessment.
Copy of the report is handed over to the organization after the assessmentand original sent to NABH Secretariat.
The hospital shall be required to pay the requisite Annual fee before thefinal assessment.
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Final Assessment
The hospital is required to take necessary corrective action to thenonconformities pointed out during the pre-assessment.
The final assessment involves comprehensive review of hospitalfunctions and services.
NABH shall appoint an assessment team.
The team shall include Principal assessor (already appointed) and theassessors. The total number of assessors appointed shall depend onthe number of beds and services provided.
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Final Assessment
The date of final assessment shall be agreed upon by thehospital management and assessors.
Assessment activities include interviews, visit to patient careareas, record reviews and facility tours.
Details of non-conformity(ies) are handed over to the hospital.
Based on the assessment, the report is prepared by thePrincipal assessor in a format prescribed by NABH.
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Scrutiny of assessment report
NABH shall examine the assessment report and seeksclarification and documentation from the AssessmentTeam and hospital, if required.
The hospital shall take necessary corrective action onthe nonconformity and shall submit a report to NABHSecretariat within a pre-decided time period.
On receipt of evidence of corrective action, the reportis placed before the Accreditation Committee.
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Scrutiny of assessment report
The Accreditation Committee shall review the assessment report
& make appropriate recommendations regarding accreditation ofa hospital to the Chairman, NABH.
In case the accreditation committee finds deficiencies in theassessment report to arrive at the decision, the Secretariat obtains
clarification from the Principal assessor/assessors/hospitalconcerned.
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Issue of Accreditation Certificate
On successful recommendation, NABH shall issue an
accreditation certificate to the hospital with a validity of three
years.
The certificate has a unique number and date of validity.
The certificate is accompanied by scope of accreditation.
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Surveillance and Reassessment
NABH conducts one surveillance of the accredited hospitals inone accreditation cycle of three years.
The surveillance visit will be planned during the 2nd year i.e.after 18 months.
For renewal of accreditation, reassessment shall be conducted atleast six months before the expiry of validity of accreditation.
NABH may call for un-announced visit, based on any concernor any serious incident reported upon by an individual ororganization or media.
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NABH
Quality Council of IndiaThank You