The document discusses the NABH Nursing Excellence Certification Programme. It was launched in 2014 with the aim of improving clinical outcomes, patient safety and satisfaction. The certification has 7 chapters covering 48 standards and 216 objectives related to nursing resource management, nursing care of patients, medication management, education and communication, infection control, empowerment and governance, and nursing quality indicators. Obtaining the certification benefits patients through high quality care, benefits hospitals by demonstrating quality commitment, and benefits nursing staff through recognition of their skills.

1. B Y
M A N I S H P A T G I R I
Q U A L I T Y C E L L ( B M J H )
E X E M P L O Y E E - F O R T I S , R G C I R C , D H C S
M H A , B M L T , C E R T I F I E D S I X S I G M A I N
H E A L T H C A R E , C E R T I F I E D I N T E R N A L A U D I T O R
N A B H , T Q M ( I I T )
NABH NURSING EXCELLENCE
CERTIFICATION PROGRAMME

2. NABH INTRODUCTION
 INTRODUCTION:National Accreditation Board for Hospitals & Healthcare Providers
(NABH) is a constituent board of Quality Council of India, set up to establish and
operate accreditation programme for health care Industry. The board while being
supported by all stakeholders including industry, consumers, government, have full
functional autonomy in its operation.
 International Linkage
 NABH is an Institutional Member as well as a Board member of the International Society
for Quality in Health Care (lSQua).
 NABH is a member of the Accreditation Council of International Society for Quality in
Health Care (ISQua).
 NABH is on board of Asian Society for Quality in Healthcare (ASQua).
 NABH Operating Year:It was formed in the year 2005.
 Head quarter:New Delhi

3. Various Certification Programme
 NABH had various certification and accreditation programmes
 Nursing excellence is certification programme not accreditation
 Nursing Excellence Certification:The Nursing Excellence
certification program was launched in the year February 2014. The need for starting
a nursing excellence certification program was envisaged in the year 2011 during a
national conference on reshaping nursing professionals held in the year January
2011 at Chennai to improve clinical outcomes, patient safety and satisfaction with a
fine balance between cost, quality and safety. Subsequently a nursing core
committee was formed in the year 2011 under NABH, Quality Council of India. This
committee met three times and the final draft of the standards was released in the
year February 2014. The target audience for this program would be all Allopathic
Hospitals.
 Till now nursing excellence first edition is running on that is February 2014

4. Nursing Excellence
 Nursing excellence standard have 7 chapters
incorparating 48 standards and 216 objectives
 Seven Chapters of NABH Nursing Excellence
Standards
1. Nursing Resource Management (NRM).
2. Nursing Care of Patient (NCP).
3. Management of Medication (MOM).
4. Education, Communication and Guidance (ECG).
5. Infection Control Practices (ICP).
6. Empowerment and Governance (EG).
7. Nursing Quality Indicators (NQI).

5. Benefits of Certification
1. Stimulates continuous quality improvement
2. Safe, effective, competent and ethical nursing care
3. Regulating, guiding and promoting professional
nursing practice
4. Raises community confidence
5. Guidelines to nurse administrators and
supervisors for supporting and facilitating nursing
care
6. Opportunity to healthcare unit to benchmark with
the best

6. BENEFITS OF NURSING EXCELLENCE
 Patients benefits-patients are the biggest beneficiary
among all
 Patients are serviced by credential nursing staff
which results in high quality of care and patient
safety.
 Hospital benefits-the certificate programme shows
continuos’improvement.
 It shows the hospital commitment to quality care

7.  Benefit to Nursing staff-It recognizes and rewards
nursing skill and best of it
 Professional growth

8. Seven Chapters of NABH Nursing
Excellence& Standards
 CHAPTER 1- Nursing Resource Management (NRM).
 It had 7 Standards.
 NRM.1. -The organization has a documented system of
nursing resource planning.
 NRM.2. -The organization has structures and processes
for induction and for enhancing the transition of novices to
competent nursing professionals.
 NRM.3. -The organization has processes in place for
induction training, In-service education and Continuous
Nursing Education (CNE) programmes and for
documentation of the same in the personal files.
 NRM.4. -There is a process for credentialing and
privileging of nursing professionals, permitted to provide
patient care without supervision.

9.  NRM.5.- An appraisal system for evaluating the performance of
nursing staff exists as an integral part of the nursing resource
management process
 NRM.6.- There is a provision for acknowledging outstanding
performances/ contributions of nursing professionals.
 NRM.7. -There is an established process in place to identify and
manage problems related to incompetent, unsafe or unprofessional
conduct.
 NRM.8. -The organization demonstrates workplace safety for nursing
professionals and protection of their rights.
 NRM.9.- The organization has a documented and established
grievance handling system.


10. 2. Nursing Care of Patient (NCP).
 NCP.1. -Nursing manual shall be established and reviewed
periodically as defined by the HCO.
 NCP.2. -The initial assessment shall be done by the nursing
professionals in predetermined format at prescribed time and/or as
per the needs of the patients.
 NCP.3. -The reassessment shall be done by the nursing
professionals in predetermined format at prescribed time.
 NCP.4. -For provision of nursing care, appropriate number of
nursing professionals shall be maintained as per workload.
 NCP.5. -The nursing care planned and provided by the nursing
professionals is recorded.
 NCP.6. -The nursing care is individualized to address the needs of
patient and family.


11.  NCP.7.-Information is exchanged and documented during each staffing
shift, between shifts, and during transfers between units/departments.
 NCP.8. -There shall be established policies and protocols for vascular
access devices. (VADs)
 NCP.9. -The nursing care of inpatients shall be supervised by senior
nursing professionals.
 NCP.10. -The nursing care of vulnerable patients (elderly, children,
physically and/or mentally challenged) shall be supervised by senior
nursing professionals.
 NCP.11. -The nursing care of patients under restraints (physical and/or
chemical) shall be supervised by senior nursing professionals.
 NCP.12. -Appropriate pain management practices shall be supervised
by senior nursing professionals.
 NCP.13. -Appropriate end of life care shall be provided to patients
needing the same by the nursing professionals.

12. MEDICATION OF MANAGEMENT
 MOM.1.-Indenting of required medication and stores will be done and
supervised by nursing staff made responsible for this function. Storage
of medication in the wards and other therapeutic areas shall be
supervised by responsible nursing professionals.
 MOM.2. -The dispensing, administration and accounting of medicines
shall be carried out by the concerned personnel and should be
appropriately supervised by senior nursing staff.
 MOM.3. -The monitoring of patients after medication administration
is supervised by responsible personnel.


13.  MOM.4. -The nursing professionals must report near
misses, medication errors and adverse drug events as
per the policy of the HCO for analysis by the
appropriate staff predefined and identified by the
HCO. Feedback is provided to staff which includes the
results of analysis and recommended preventive
measures for implementation by the nursing staff
wherever appropriate.
 MOM.5. -The organization shall ensure that it has a
policy on verbal orders which will be applicable to
doctors, nursing professionals and technicians
uniformly.

14. CHAPTER: 4
EDUCATION, COMMUNICATION AND
GUIDANCE
 ECG.1. -The organization shall ensure that nursing
professionals are trained in communication skills.
 ECG.2. -Nursing professionals shall maintain
confidentiality of all patient information.
 ECG.3. -Nursing professionals communicate with patient,
family and relevant team members to reflect continuity of
care as and when required.
 ECG.4. -Patient and family are educated where essential
and in case of any change in nursing care plan.

15. CHAPTER: 5
INFECTION CONTROL PRACTICES
 ICP.1. -Infection control nurse (s)shall be designated
by the organization
 ICP.2. -Nursing professionals shall adhere to standard
precautions and hand hygiene guidelines at all times.
 ICP.3. -The nursing professionals shall adhere to
handling, storage and disposal of bio medical waste as
per the bio medical waste management Act, 1998.
 ICP.4. -The designated nursing staff shall perform
surveillance activities to capture and monitor infection
control and prevention data.

16. ICP.5. -Isolation (barrier and reverse barrier nursing)
practices shall be supervised by senior nursing professionals.
ICP.6. -Infection Control Nurse maintains records of all
occupational injuries and pre- and post-exposure
prophylaxis

17. CHAPTER: 6
EMPOWERMENT AND GOVERNANCE
 EG.1. -The responsibilities of those responsible for
nursing management are defined.
 EG.2. -The Head of the Nursing service ensures that
suitable mechanisms exist to govern the nursing
Service.
 EG.3. -Nursing professionals are involved and
participate in decision making related to
organization and nursing services.
 EG.4. -The Management empowers nursing staff


18.  EG.5. -The organization has an established process
for proactive risk assessment and error management.
 EG.6. -The infection control programme is
supported by the management and includes training
of staff

19. CHAPTER: 7
NURSING QUALITY INDICATORS
 NQI.1. -There is a structured quality improvement
and continuous monitoring program for nursing
service.
 NQI.2. -The organization identifies key indicators to
monitor the structures, processes and outcomes,
which are used as tools for continual improvement
for nursing service.
 NQI.3. -The nursing quality improvement
programme is supported by the management.

20.  NQI.4. -There is an established system for nursing
audit.
 NQI.5. -Incidents, complaints and feedback from
nursing professionals are collected and analysed to
ensure continual quality improvement.

21. AT LAST