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NABHYANAMALA VIJAY RAJBT14M004MTECH IN CLINICAL ENGIIT MADRAS & CMC VELLORE & SCTIMST

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2WHAT IS QUALITY

The standard of something as measured against other things of a similar kind; the degree of excellence of something.

Meeting the needs and exceeding the expectations of the patients Delivering all and only the care that the patient and family needs A doctor may say: “The kind of care that may relive the pain and suffering

and restore health to the best possible level” A patient may say, “The best possible treatment that is timely, safe and

affordable, and can restore his health to his earning capacity at the earliest”

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3Quality

Quality in Hospitals is all about meeting expectations of:

Patients Statutory / Legal bodies Internal Customers Owners / Trust Others Third parties (NABH)

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4Quality in Hospitals

In India, Heath System currently operates within an environment of rapid social, economical and technical changes. Such changes raise the concern for the quality of health care.

Hospital is an integral part of health care system. Accreditation would be the single most important approach for improving the quality

of hospitals. Accreditation is an incentive to improve capacity of national hospitals to provide

quality of care

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5What is NABH?

National Accreditation Board for Hospitals & Healthcare Providers (NABH) is a constituent board of Quality Council of India (QCI), set up to establish and operate accreditation programme for healthcare organizations.

The board while being supported by all stakeholders including industry, consumers, government, have full functional autonomy in its operation.

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6ISQua (International Society for Quality in HealthCare )

ISQua is an international body which grants approval to Accreditation Bodies in the area of healthcare as mark of equivalence of accreditation program of member countries.

NABH is a member of ISQua Accreditation Council. NABH is an Institutional Member as well as a member of the Accreditation Council of the

International Society for Quality in HealthCare (ISQua). NABH is the founder member of proposed Asian Society for Quality in Healthcare

(ASQua) being registered in Malaysia. NABH is a member of International Steering Committee of WHO Collaborating Centre for

Patient Safety as a nominee of ISQua Accreditation Council

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7BENEFITS OF ACCREDITATION

Benefits for Patients

Biggest beneficiary

High quality of care and patient safety

Rights of patients

Patients satisfaction

Commitment to quality care

Community confidence

Benchmarking

Benefits for Hospital Staff

Staff satisfaction

Improves overall professional development

Benefits to paying and regulatory bodies Benefits for Hospitals CQI

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8What are the programs being offered by NABH?

Currently, NABH is offering accreditation programs for Hospitals, Small Health Care Organizations/Nursing Homes, Blood Banks and Transfusion Services, Oral Substitution Therapy (OST) Centres and Primary and Secondary Health Centres.

A couple of more programs such as Medical Imaging services, Dental Hospitals/Centres, AYUSH Hospitals are being developed.

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9Organizational structure of NABH

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The main functions of Accreditation Committee are as follows: Recommending to board about grant of accreditation or otherwise based on

evaluation of assessment reports & other relevant information. Approval of the major changes in the Scope of Accreditation include enhancement and

reduction, in respect of accredited hospitals. Recommending to the board on launching of new initiatives

Accreditation Committee

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The main functions of Technical Committee are as follows: Drafting of accreditation standards and guidance documents Periodic review of standards

Technical Committee

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Appeals Committee

The Appeal Committee addresses appeals made by the hospitals againstany adverse decision regarding accreditation taken by the NABH. The adverse decisions may relate to the following: refusal to accept an application, refusal to proceed with an assessment, corrective action requests, changes in accreditation scope, decisions to deny, suspend or withdraw accreditation, and any other action that impedes the attainment of accreditation

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The Secretariat coordinates the entire activities related to NABH Accreditation to hospitals and healthcare organizations.

NABH Secretariat

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Panel of Assessors and Experts NABH has a panel of trained and qualifiedassessors for assessment of hospitals. Principal AssessorThe Principal Assessor is overall responsible for conducting the pre assessments and final assessments of the hospitals. AssessorsNABH has empanelled experts for assessment of hospitals. They are trained by NABH on hospital accreditation and various assessment techniques. The assessors are responsible for evaluating the hospital’s compliance with NABH Standards

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15NABH Standards

NABH Standards for hospitals prepared by technical committee contains complete set of standards for evaluation of hospitals for grant of accreditation.

The standards provide framework for quality of care for patients and quality improvement for hospitals.

The standards help to build a quality culture at all level and across all the function of hospital.

NABH Standards has ten chapters incorporating 102 standards and 636 objectiveelements.

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16Outline of NABH Standards

NABH has 10 Chapters, 102 Standards, 636 Objectives Elements

Patient Centered Standards

• Access, Assessment and Continuity of Care (AAC)• Care of Patient (COP)• Management of Medication (MOM)• Patient Right and Education (PRE)• Hospital Infection Control (HIC)

Organization Centered Standards

• Continuous Quality Improvement (CQI)• Responsibility of Management (ROM)• Facility Management and Safety (FMS)• Human Resource Management (HRM)• Information Management System(IMS)

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17NABH Standards

Patient Centered Standards Chapters

Std

1. Access, Assessment and Continuity of Care (AAC)

14

2. Care of Patient (COP) 20 3. Management of Medication (MOM)

13

4. Patient Right and Education (PRE)

07

5. Hospital Infection Control (HIC)

09

Organization Centered Standards

Chapters

Std

6. Continuous Quality Improvement (CQI)

08

7. Responsibility of Management (ROM)

06

8. Facility Management and Safety (FMS)

08

9. Human Resource Management (HRM)

10

10. Information Management System(IMS)

07

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18Assessment Criteria

A hospital willing to be accredited by NABH must ensure the implementation of NABH standards in its organization.

The assessment team will check the implementation of NABH Standards in organization.

The Hospital shall be able to demonstrate to NABH assessment team that all NABH standards, as applicable, are followed

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19Preparing for NABH Accreditation

Hospital management shall first decide about getting accreditation for its hospital from NABH. It is important for a hospital to make a definite plan of action for obtaining accreditation and nominate a responsible person to coordinate all activities related to seeking accreditation.

An official nominated should be familiar with existing hospital quality assurance system. Hospital shall procure a copy of standards from the NABH Secretariat against payment. Further clarification regarding standards can be got form NABH Secretariat in person, by

post, by e-mail or on telephone. The hospital looking for accreditation shall understand the NABH assessment procedure. The hospitals shall ensure that the standards are implemented in the organization.

The hospitals can download the application form for NABH Accreditation from the web-site.

The applicant hospital must have conducted selfassessment against NABH standards atleast 3 months before submission of application and must ensure that it complies with NABH Standards.

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20Preparing for NABH Accreditation

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21NABH Accreditation Procedure

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22Self-Assessment

This toolkit is for self-assessing itself against NABH Standards. The self assessment shall be done by the hospital in a stringent manner and if at the

time of pre-assessment it is found that there is a significant difference between the self assessment and the pre-assessment report then the organization shall apply for final assessment not earlier than six months from the date of completion of pre-assessment.

The applicant hospital must apply for all its facilities and services being rendered from the specific location.

NABH accreditation is only considered for hospital’s entire activities and not for a part of it.

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23Pre-Assessment:

NABH appoints a Principal Assessor/ Assessment Team who is responsible for pre assessment of healthcare organization.

Objective of Pre-assessment: Check the preparedness of the hospital for final assessment Review the scope of accreditation and ascertain the requirement of the number of

assessors and the duration of the accreditation Review of the documentation system of the hospital Explain the methodology to be adopted for assessment.

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24Final Assessment:

The hospital is required to take necessary corrective action to the nonconformities pointed out during the pre-assessment.

The final assessment involves comprehensive review of hospital functions and services.

NABH shall appoint an assessment team. The team shall include Principal assessor (already appointed) and the assessors.

The total number of assessors appointed shall depend on the number of beds and services provided.

The date of final assessment shall be agreed upon by the hospital management and assessors.

Assessment shall be conducted on hospital’s department and services. Based on the assessment by the assessors, the assessment report is prepared by the Principal assessor in a format prescribed by NABH

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25GUIDELINES FOR USE OF NABH ACCREDITATION MARK

The use of this Mark by the Hospitals/ SHCO/ Blood Banks/ Primary Health Centre (PHC)/ Community Health Centre (CHC) will be under the control of NABH. Compliance with the guidelines is required when using the NABH accreditation Mark.

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26POLICIES AND PROCEDURES FOR DEALING WITH ADVERSE AND OTHER DECISIONS AGAINST HCOs

Various categories of decisions are as follows:

A. Adverse decisions against applicant HCO A.1 Inactive and Closed

B. Adverse decisions against accredited HCO B.1 Shifting of Renewal Date B.2 Expiry of Accreditation B.3 Abeyance B.4 Suspension B.5 Forced Withdrawal

C. Other decisions against accredited HCO

C.1 Voluntary Withdrawal C.2 Extension of Validity of Accreditation Certificate

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27Inactive and Closed

Conditions: When a HCO has submitted incomplete application and has not submitted

required information, application fee etc. within three months even after a reminderis sent.

When HCO has not undergone pre-assessment within three months of submittingapplication.

When HCO has not undergone assessment within six months of conducting pre-assessment.

When the assessment of the HCO has been conducted and HCO has not takenappropriate corrective actions, if required for non-conformities within three months.

Action by NABH

A communication is sent to the HCO that it has been put under “Inactive” category andapplication will be closed.

Name of the HCO shall be deleted from the list of applicants on NABH website

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28Shifting of Renewal Date

Condition If a HCO has not applied 6 months prior to the expiry of accreditation and is unable to

complete formalities for re-accreditation before the expiry of accreditation.

Action by NABH The HCO will not remain in accredited category and cannot use NABH

Accreditation Mark. No extension will be granted after the expiry of accreditation.

Accreditation status will be granted when the HCO undergoes the re-assessment; is able to complete the corrective actions on the non-conformances after Reassessment and the Accreditation Committee recommends renewal of accreditation.

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295.2 Expiry of Accreditation

Condition When the HCO has not submitted the application for renewal before expiry of

accreditation.

Action by NABH NABH Officer shall inform the HCO at least one month before expiry of accreditation

that it shall not claim accreditation status and shall not use NABH. Accreditation Mark in letterheads, publicity matters etc. After the expiry of

accreditation, NABH website will be updated to show the expired status

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30Abeyance

Condition When a HCO had undergone a Surveillance or Re-assessment visit and has not taken

any corrective action within 3 months of Surveillance/ Re-assessment visit.

When a HCO has not paid the Accreditation fees and the accreditation expenses, beyond three months’ liability.

When a HCO does not appropriately respond to the queries as requested by NABH, even after two reminders.

When a total system failure or gross negligence in technical aspects is identified at the time of Surveillance or Re-assessment visit.

Action by NABH:

• The abeyance status is given to a HCO for no longer than three months.

• The HCO in abeyance status is not published, however if inquires are made the HCO is referred to as under abeyance and working towards re-accreditation.

• To regain accreditation status, the HCO in abeyance status must notify to NABH of its desire and agree to undergo full assessment, paying the re-assessment charges and other outstanding payments.

• Abeyance status will continue till reassessment is completed and a decision is taken.If the HCO does not proceed further or respond or notify NABH about its inability of being reassessed within 3 months of the abeyance status, action shall be initiated to suspend the accreditation of the HCO.

• The HCO during the period of abeyance cannot use accreditation mark and claim accreditation.

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31Suspension

Condition When a HCO continues to be in ‘Abeyance’ status for three months, When a HCO violates the conditions of maintaining accreditation such as:

1) non co-operation with NABH2) refusal to allow examination of documents & records3) denial of access to NABH & its assessor to its services and patient care areas4) wrong representation of scope of accreditation5) misuse of accreditation mark6) misleading reporting of facts7) brings NABH into disrepute in any manner etc.8) result of complaint analysis or any other information, which indicates that the HCO no longer complies with requirements of NABH.

Action by NABH

1. The HCO is notified in writing.2. After 30 days, if issues are not resolved, a suspension letter is issued.3. The suspension status of HCO is published.4. A HCO can remain in suspension status for a maximum period of three months.5. If the HCO does not respond to the actual suspension letter or refuses to meet theconditions to lift the suspension, ‘Withdrawal’ action is initiated. If, even aftersuspension, the HCO continues to violate the conditions of accreditation, an actionon withdrawal of accreditation shall be initiated by NABH.

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32Forced Withdrawal

Condition

1. When a HCO remains in ‘Suspended status’ for three months and have not met the condition for lifting the suspension even after three months. Action by NABH

1. The HCO is notified in writing.2. The withdrawal status is published.3. In case the HCO has been withdrawn from the accreditation programme it is debarred to participate in the accreditation programme for at least 1 year. The HCO can be re-enrolled in the programme by giving valid justification of earlier withdrawal by applying as a new HCO and paying full fees and assessment charges, applicable at time.4. After the HCO accreditation status is withdrawn, the HCO shall not use accreditation mark or claim accreditation.

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