Star Management · PDF filein consonance with the global benchmarks set by ISQua and thus...

Star Management Consultants

Plot No.3180, LIG-1, 6th Block, TNHB, Avadi, Chennai-54

Phone: 044-64551003, Mobile: 98407 51003, E-mail: [email protected], Website: www.starmanagementconsultants.com

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NATIONAL ACCREDITATION BOARD FOR HOSPITALS &

HEALTHCARE PROVIDERS (NABH)

OBJECTIVE OF NABH:

To establish and operate accreditation programme for Health Care Organizations

Enhancing Health system & promoting Continuous quality improvement and patient safety

NEED FOR HOSPITAL ACCREDITATION

Public Recognition by a National Healthcare Accreditation Body

Single most important approach for improving the quality of hospitals

Promotes hospitals and ensures quality of care

Ensures Transparent system of control

ABOUT NABH

Constituent Board of Quality Council of India

Accreditation to Hospitals in a non-discriminatory manner regardless of ownership, legal

status, size and degree of independence

NABH is approved and a member of International Society for Quality in Healthcare (ISQua)

“Standards for Hospitals has been approved by International Society for Quality in

Healthcare (ISQua)

NABH is a 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

NABH is in consonance with the Global Benchmarks set by ISQua

BENEFITS OF ACCREDITATION:

BENEFITS FOR PATIENTS:

High Quality of Care and Patient Safety

Patients are serviced by Credential Medical staff

Rights of patients are respected and protected

Patients satisfaction is regularly evaluated

Provides Boost to Medical Tourism




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BENEFITS FOR HOSPITALS:

Stimulates Continuous Improvement

Enables in demonstrating commitment to Quality Care

Raises Confidence in the services provided

Provided opportunity to benchmark with the best

BENEFITS FOR HOSPITAL STAFF

Staff are more satisfied

Provides continuous learning, good working environment, leadership

Ownership of all clinical processes

Improves Overall Professional development of clinicians and para medical staff

Provides leadership for quality Improvement with medicine & Nursery

BENEFITS TO PAYING & REGULATORY BODIES

Objective system of empanelment by Insurance & other third parties

Provides access to reliable and certified information on facilities, infrastructure and level of

care

NABH STANDARDS

Prepared by Technical Committee

Complete set of standards for evaluation of hospitals for grant of accreditation

Provides framework for quality of care for patients and quality improvements for hospitals

Helps to build a quality culture at all levels and across all functions of hospital

Has 10 chapters incorporating 100 standards and 514 objective elements

OUTLINE OF NABH STANDARDS

PATIENT CENTERED STANDARDS

Access, Assessment and Continuity of Care (AAC)

Care of patients (COP)

Management of Medication (MOM)

Patient Right & Education (PRE)

Hospital Infection & Control (HIC)

ORGANIZATION CENTERED STANDARDS




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Continuous Quality Improvement (CQI)

Responsibility of management (ROM)

Facility Management & Safety (FMS)

Human Resource Management (HRM)

Information Management System (IMS)

NABH ACCREDITATION PROCESS FLOW

Application for Accreditation

Gap Assessment (Consultant)

Implementation to NABH Standard

Pre Audit of Hospital

Final Audit of Hospital

Review & Recommendation

Issue the Certificate




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FREQUENTLY ASKED QUESTIONS

1. What 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. For details, please read “About NABH”.

2. What is Accreditation?

A public recognition of the achievement of accreditation standards by a healthcare organization,

demonstrated through an independent external peer assessment of that organization's level of

performance in relation to the standards.

3. What are the benefits of Accreditation?

Accreditation benefits all Stake Holders. Patients are the biggest beneficiaries.

Accreditation results in high quality of care and patient safety. The patients get services by credential

medical staff. Rights of patients are respected and protected. Patient satisfaction is regularly

evaluated.

Accreditation to a Hospital stimulates continuous improvement. It enables hospital in

demonstrating commitment to quality care. It raises community confidence in the services provided

by the hospital. It also provides opportunity to healthcare unit to benchmark with the best.

The Staff in an accredited hospital are satisfied lot as it provides for continuous

learning, good working environment, leadership and above all ownership of clinical processes. It

improves overall professional development of Clinicians and Paramedical staff and provides

leadership for quality improvement within medicine and nursing.

Accreditation provides an objective system of empanelment by insurance and

other Third Parties. Accreditation provides access to reliable and certified information on facilities,

infrastructure and level of care.

4. What 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.




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

Hospitals are being developed.

5. How to apply for NABH Accreditation?

The organizations can obtain the application form for NABH Accreditation from NABH Secretariat or

download it from the web-site. The application form should be accompanied with the required

application fee. Hospitals should also submit a signed document ‘Terms and Conditions for

Maintaining NABH Accreditation'. The same can be downloaded from the website. For more details

please see ‘Accreditation Documents'.

6. How can an organization prepare itself for NABH Accreditation?

An organization planning to go for NABH accreditation may obtain a copy of NABH accreditation

standards and carry out a self assessment on the status of compliance with the standards to ensure that

the standards are implemented and integrated with the hospital functioning.

What is the role of NABH in preparing organizations for accreditation?

NABH provides information on documents and procedures. NABH also organizes awareness

programs in general as well as on request of individual organizations. It also guides the applicant

organization on different requirements at various stages of accreditation. However NABH do not

provide consultancy.

For the convenience of applicant organizations, NABET, which is another constituent Board of QCI

has a program for registering qualified consultants/consulting organizations. These registered

individuals/organizations are involved in providing consultancy to various health care organizations

for NABH standards implementation within their organizations.

7. Is NABH accreditation a one-time phenomenon?

NABH accreditation is not a one-time phenomenon. Once the organization gets accredited,

accreditation shall be valid for a defined period. NABH conducts a regular surveillance of the

accredited organization. The surveillance visit will be planned during the 2 nd year.

8. Does NABH have any International Linkages?

NABH is an institutional member of International Society for Quality in Health Care (ISQua) as well

as member of its Board and Accreditation Council. NABH standards for hospitals has been accredited

by ISQua. The accreditation of NABH standard for hospitals authenticates that NABH standards are




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in consonance with the global benchmarks set by ISQua and thus hospitals accredited by NABH will

have international recognition.

International Society for Quality in Health Care (ISQua) is an international body which grants

approval to Accreditation Bodies in the area of healthcare as mark of equivalence of accreditation

programme of member countries.

NABH is also one of the founder members of newly emerging Asian Society for Quality in

Healthcare (ASQua). This initiative is to strengthen the Asian representation at international level and

improve the quality structure in healthcare.

9. How to get information about NABH accredited organizations?

Please refer to “Accreditation Register” for the list of accredited and applicant organizations under

different programs. One can also see the services being offered by accredited organizations in this

section.

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