The National Accreditation Board for Hospitals & Healthcare Providers (NABH) was established to operate an accreditation program for healthcare organizations in India. NABH aims to accredit healthcare facilities, promote quality through various initiatives, provide education and training on quality and patient safety, and recognize quality healthcare courses. Accreditation benefits facilities by providing high quality care, patient safety, staff satisfaction, and an objective system for insurance empanelment. NABH standards are organized into 10 chapters covering patient-centric and organization-centric functions like access to care, infection control, management responsibilities, and human resource management. The human resource management standards address processes for staff planning, orientation, training, performance evaluation, credentialing

1. NABH- AN
INTRODUCTION

2. IN BRIEF-
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 healthcare organisations.

3. OBJECTIVES OF
NABH-
Accreditation of healthcare facilities;
Quality promotion: initiatives like Safe-I, Nursing
Excellence, Laboratory certification programs, etc.
IEC(Information, Education, Communication)
activities: public lecture, advertisement,
workshops/ seminars;
Education and Training for Quality & Patient
Safety;
Recognition: Endorsement of various healthcare
quality courses/ workshops.

4. Pre-
Accreditation
(Entry Level
Pre-
Accreditation
(Progressive
level)
Accreditation

5. WHY ACCREDITATION?
The increasing role of health Insurance.
Rise in number of medico-legal cases.
Awakening of patients about their rights.
Medical tourism.

6. HOW NABH DIFFERS FROM ISO
STANDARDS-
ISO is a certification and not an accreditation.
ISO is generic and not specific to healthcare
industry.
ISO does not call for clinical audits, it centres
only on systems.
Accreditation focuses on competency in terms
of its staff, equipment, premises, facilities etc
with respect to the scope of services being
rendered by the healthcare organisation.

7. BENEFITS OF ACCREDITATION-
Accreditation provides high quality of care and
patient safety.
Staff Satisfaction/Employee satisfaction.
Accreditation to a hospital stimulates continuous
improvement.
Accreditation provides an objective system of
empanelment by insurance and other third parties.

8. OUTLINE OF NABH
STANDARD-
There are total 10 chapters that define quality
standards. They can be categorised based
upon-
Patient-centric functions. (Chapter 1-5
Organisation-centric functions. (Chapter 6-
10)

9. Patient Centric Standards-
1. Access, Assessment
and Continuity of Care
(AAC).
2. Care of Patients (COP).
3. Management of
Medication (MOM).
4. Patient Rights and
Education (PRE).
5. Hospital Infection
Control (HIC).
Organisation Centric
Standards-
6. Continuous Quality
Improvement (CQI).
7. Responsibility of
Management (ROM)
8. Facility Management and
Safety (FMS).
9. Human Resource
Management (HRM).
10. Information
Management System (IMS).

10. HRM STANDARDS-
 The organization has a documented system of human
resource planning.
 The staff joining the organization is socialized and oriented
to the hospital environment .
 There is an ongoing programme for professional training
and development of the staff.
 Staff members, students and volunteers are adequately
trained on specific job duties or responsibilities related to
safety.
 An appraisal system for evaluating the performance of an
employee exists as an integral part of the human resource
management process.

11. There is a process for authorization all medical
professionals to admit and treat patients and provide
other clinical services commensurate with their
qualifications.
There is a process for collecting, verifying and
evaluating the credentials (education, registration,
training and experience ) of nursing staff.
There is a process to identify job responsibilities and
make clinical work assignments to all nursing staff
members commensurate with their qualifications and
other regulatory requirements.

12.  The organization has a well documented disciplinary
procedure.
 A grievance handling mechanism exists in the
organization.
 The organization addresses the health needs of the
employees.
 There is a documented personal record for each staff
member.
 There is a process for collecting, verifying and
evaluating the credentials (education, registration,
training and experience ) of medical professionals
permitted to provide patient care without supervision.

13. Thank You.