3. COMPLIANCE
• Legal, statutory, regulatory requirements
• Patients' requirements: stated and implied
• Employees' requirements, especially safety
• Hospital's own policies and procedures
• Start preparing for N A B H Accreditation
4. NABH organisation
Quality Council of India
National Accreditation Board for Hospital &
Health Care Providers
Appeals
Committee
Accreditation
Technical
Committee Panel of
Committee
Assessors
Secretariat
5. N A B H Accreditation Programmes
• Hospitals : 51 + beds
• Small Health Care Organisations
• Ayurveda, Yoga, Unani, Siddha, Homoepathy
• Wellness
• Imaging
• Blood Banking
• Clinical Laboratories
6. S H C O Standards
• Small Health Care Organisations
• 20 – 50 beds, & Day care and ambulatory
surgical centres
• 10 chapters, 258 requirements
• Exclusions clamed must be justified
• 'Apex' Quality Manual, Documented Policies,
Standard Operating Procedures, System of
maintaining patient records
7. Patient Centred
• Access, Assessment & Continuity of Care
• Care of Patients
• Management of Medication
• Patients’ Rights & Responsibilities
• Hospital infection Control
8. Organisation Centred
• Continuous Quality Improvement
• Responsibilities of Management
• Facilities Management and Safety
• Human Resources Management
• Information Management System
9. Top Management
• Identify and follow all applicable laws
• Establish & support the Quality Dept
• Identify & monitor key indicators of volume,
quality and performance
• Standard billing practices
• Conduct mock drills: Fire, CPR, disaster
• Conduct internal quality audits
10. Take Home Messages
• Quality Management Team > integral to the
practice of medicine and surgery today
• Compliances: Legal, Patient requirements,
Employee related, Hospital policies
• Management: Material, Medicines, Methods,
Manpower (their motivation), Machines,
Milieu, MONEY !
• Visit the website: www.nabh.co
