WHAT IS NABH?
National Accreditation Board for Hospitals and Health Care Providers (NABH) is a constituent Board of QCI, set up with co-operation of the Ministry of Health & Family Welfare, Government of India and the Indian Health Industry. In India concerns about how to improve health care quality have been frequently raised by the general public and a wide variety of stakeholders, including government, professional associations, private providers and agencies financing health care. This Board will cater to the much desired needs of the consumers and will set standards for progress of the health industry. This Board while being supported by the stakeholders including industry, consumers, Government, will have full functional autonomy in its operations.
WHY NABH?
• The main purpose of NABH accreditation is to help planners to promote, implement, monitor and evaluate robust practice in order to ensure that occupies a central place in the development of the health care system.
• Current policies and processes for health care are inadequate or not responsive to ensure health care services of acceptable quality and prevent negligence. Problems range from inadequate and Inappropriate treatments, excessive use of higher technologies, and wasting of scarce resources, to serious problems of medical malpractice and negligence.
• Quality Assurance should help improves effectiveness, efficiency and in cost containment, and should address accountability and the need to reduce errors and increase safety in the system.
• Thus the objective of NABH accreditation is on continuous improvement in the organizational and clinical performance of health services, not just the achievement of a certificate or award or merely assuring compliance with minimum acceptable standards.
AIM:-To launch an accreditation program in a mission mode at your hospital so as to prepare the facility for accreditation by NABH.
OBJECTIVES:-
• To assess the existing service delivery standards of the hospital.
• To identify the baseline level of all quality indicators.
• To benchmark the indicators.
• To suggest and implement alterations in structural designs of the facilities.
• To lay down standard operating procedures for various activities in all levels of care.
• To train the key personnel in these processes.
• To review the outcome.
• To instill the concepts to practice modalities of best practices in the minds of the personnel so as to achieve continuous quality improvement.
• To prepare the hospital so as to enable it to be in readiness for the assessment team of NABH.
ADVANTAGES OF ACCREDITATION:-
• Improves the systems.
• Improves the Services.
• Improves the client satisfaction.
• Improves the staff morale and confidence.
• Benchmarks and adopts the best practices across the globe.
• Gives scope for continues quality improvement.
Patient Centered Standard:-
• Access, Assessment and Continuity of Care (ACC).
• Care of Patient (COP).
• Management of Medication (MOM).
• Patient rights and Education (PRE).
• Hospital Infection Control (HIC).
Organization Centered Standards:-
• Continuous Quality Improvement (CQI).
• Responsibilities of Management (ROM).
• Facility Management and Safety (FMS).
• Human Resource Management (HRM).
• Information Management System (IMS).
With reference to the IRDAI Circular IRDAI/HLT/GDL/CIR/114/07/2018 dated 27th July, 2018, all the existing Network Providers shall comply with the following:
1. Register with registry of Hospitals (ROHINI) maintained by IIB.
2. Obtain either Pre-entry level Certificate (or higher level certificate) issued by NABH/NABL or State Level Certificate (or higher level certificate) under NQAS issued by NHSRC.
PROPOSED CALENDAR OF ACTIVITIES FOR ENTRY LEVEL NABH:-
1. Initiating the Project
• Structural Gap/s identification.
• Processes/ Gap/s identification.
• Outcome Gap/s identification.
• Creation of Committees, writing their purpose (scope of work) and prepare meeting schedules.
• Prepare Gap Report.
• Present Gap Report before stakeholders.
• Handover Draft Report to concern for decisions.
2. Develop Policy & Procedure Manual
• Identify all Policies (Clinical, Administrative & Support Services).
• Provide prototypes for all policies listed to concern.
• Frame all Policies/ Guidelines (for regulation)- Universal category.
• Frame all Policies/ Guidelines (for regulation)- Department specific.
• Process Mapping & Activity Listing- Clinical.
• Write protocols according to identified processes & responsibility matrix- Clinical.
• Process Mapping & Activity Listing- Administrative.
• Write protocols according to identified processes & responsibility matrix- Administrative.
• Process Mapping & Activity Listing- Support Services.
• Write protocols according to identified processes & responsibility matrix- Support Services.
• Prepare draft Policy & Procedure Manual.
• Solicit Comments.
• Finalize the Manual.
• Distribute the copies of relevant sections to stakeholders (as identified).
3. Awareness and Training
• Initiate awareness program & scale up the same.
• Identify training needs.
• Develop training time table/ program.
• Identify potential trainers.
• Training of trainers.
• Preparing Training Manual (NABH Program).
• Conduct (General) training as per the schedule for staff at all levels.
• Conduct (Specific- Policy & Procedures related) training as per the schedule for staff at all levels.
4. Outcome & Performance Analysis
• To assess Hospital utilization rates- OPD, IPD, Equipment's, Manpower etc (1 times).
• To assess Patient satisfaction survey (1 times).
• Evaluate the Employees satisfaction (1 times).
5. Applications, Audits & Assessments
• Application to NABH for assessment.
• Internal Audit (1 times).
• Mock-drill & Rehearsals (1 time).
• Assessment.
• Review of the Assessment report.
• Correction of the deficiencies.
PROPOSED CALENDAR OF ACTIVITIES FOR FULL LEVEL NABH:-
1. Initiating the Project
• Discussion with Top Management.
• Formation of Core team.
• Training the core team.
• Sensitization Workshop involving (lead) representatives of all stakeholders group.
• Assessment & Scoring (Baseline).
2. Gap Analysis
• Structural Gap/s identification.
• Processes/ Gap/s identification.
• Outcome Gap/s identification.
• Creation of Committees, writing their purpose (scope of work) and prepare meeting schedules.
• Prepare Gap Report.
• Present Gap Report before stakeholders.
• Handover Draft Report to concern for decisions.
• Solicit Comments.
• Finalize Report (including recommendations for closing all gaps).
• Finalize Action Plan for completing gaps.
• Freeze Monitoring & Control Plans.
• Provide (concern) sectional drafts to various committees to take up in their agenda.
• Implement monitoring & supervision plan.
3. Develop Policy & Procedure Manual
• Identify all Policies (Clinical, Administrative & Support Services).
• Provide prototypes for all policies listed to concern.
• Frame all Policies/ Guidelines (for regulation)- Universal category.
• Frame all Policies/ Guidelines (for regulation)- Department specific.
• Process Mapping & Activity Listing- Clinical.
• Write protocols according to identified processes & responsibility matrix- Clinical.
• Process Mapping & Activity Listing- Administrative.
• Write protocols according to identified processes & responsibility matrix- Administrative.
• Process Mapping & Activity Listing- Support Services.
• Write protocols according to identified processes & responsibility matrix- Support Services.
• Prepare draft Policy & Procedure Manual.
• Solicit Comments.
• Finalize the Manual.
• Distribute the copies of relevant sections to stakeholders (as identified).
4. Awareness and Training
• Initiate awareness program & scale up the same.
• Identify training needs.
• Develop training time table/ program.
• Identify potential trainers.
• Training of trainers.
• Preparing Training Manual (NABH Program).
• Conduct (General) training as per the schedule for staff at all levels.
• Conduct (Specific- Policy & Procedures related) training as per the schedule for staff at all levels.
5. Outcome & Performance Analysis
• To assess Hospital utilization rates- OPD, IPD, Equipment's, Manpower etc (2 times).
• To assess Patient satisfaction survey (2 times).
• Evaluate the Employees satisfaction (2 times).
6. Applications, Audits & Assessments
• Application to NABH for pre-assessment.
• Internal Audit (2 times).
• Mock-drill & Rehearsals (2 times).
• Pre Assessment.
• Review of the Pre-Assessment report.
• Correction of the deficiencies.
• Final review.
• Re-training of all departments.
• Final Assessment.