NABH Introduction, Process, Indicators, Documents for Full Accreditation & Entry Level

1. NABH Basics &
Process
Ms.Nikethana R Nair, M.Sc (Nsg), MBA (HA), M.Sc (Psy), M.Phil (HHSM),
Nursing Superintendent,
Meenakshi Mission Hospital & Research Center, Madurai

2. Quality Council of India (QCI)
• Established in 1997 through a Cabinet decision of the Government of
India.
• QCI is an autonomous organization under the Department for
Promotion of Industry and Internal Trade, Ministry of Commerce &
Industry.
• It was established as the national body for accreditation & quality
promotion in the country.
• The Council was established to provide a credible, reliable
mechanism for third-party assessment of products, services &
processes which is accepted & recognized globally.

3. Accreditation Boards of QCI
• National Accreditation Board for Hospitals and Healthcare Providers
(NABH)
• National Accreditation Board for Certification Bodies (NABCB)
• National Accreditation Board for Testing and Calibration
Laboratories (NABL)
• National Accreditation Board for Education and Training (NABET)
• National Board for Quality Promotion (NBQP)

4. NABH Program and Activities
• Accreditation
• Certification
• Empanelment
• Training and Education

5. NABH Accreditation Programs
Hospitals
Small healthcare Organization
Blood Bank
Blood Storage Centre
Medical Imaging Services
Allopathic Clinic
Dental Facilities/
Dental Clinics
Oral Substitution Therapy Centre
AYUSH Hospitals
Community Health Care
Eye Care Organization
Primary Health Care
Panchkarma Clinic
Clinical Trial (Ethics Committees)
Wellness Centre
Integrated Rehabilitation Centres for Addict

6. Certification
NABH is operating various certication program
• Entry Level Hospitals,
• Entry Level SHCO,
• Entry Level AYUSH Hospitals,
• Entry Level AYUSH Centres,
• Nursing Excellence,
• Medical Laboratory Program &
• Standards for Emergency Department in Hospitals.

7. Empanelment
• A network of ECHS and CGHS empanelled hospitals can also apply
for NABH accreditation to provide Quality Medicare to
beneficiaries and their dependents.
• As per the empanelment protocols, the accreditation helps the
hospitals to ensure cashless transactions, as far as possible, for the
patients.

8. Training and Education - Conducts various awareness
and educational workshops such as
• Programme on Implementation of NABH Standards for
Hospitals,
• Programme on Implementation of NABH Standards for Blood
Bank,
• Programme on Implementation of NABH Standards for
Nursing Excellence CertiFcation,
• Programme on Implementation of NABH Standards for Entry
Level Hospital, etc.

9. Benefits of NABH Certification and Accreditation
• Patients
• Healthcare Organization
• Healthcare Staff
• Regulatory Bodies

10. • Patients - Patients are the biggest beneficiaries among all the
stakeholders as certification results in high quality of care & patient
safety and ensures the whole system is patient-centric.
• Healthcare Staff
 It improves the overall professional development of the hospital staff
and provides leadership for quality improvement in various techniques.
 It also creates a good working environment where the staff can
continuously learn and take ownership of their roles and
responsibilities.

11. Healthcare Organization
• Certification to a healthcare Organization stimulates continuous
improvement.
• It enables the organization to demonstrate a commitment to quality care.
• It raises community confidence in the services provided by the health
care Organization.
• It provides an opportunity for the healthcare units to benchmark with the
best and benefits from financial incentives given under various
government schemes to such accredited hospitals.

12. Regulatory Bodies
• Certification provides access to reliable and certified information on
facilities,infrastructure & level of care, which can be used by
insurance organizations & other third parties
• Thus, reducing uncertainties while making a public decision &
getting assurance about the capabilities of the healthcare
organization.

13. NABH
• Aims: Establishing a common framework for HCO to demonstrate &
practice compliance with patient safety protocols thus ensuring that
HCO are providing quality care & high-quality services to the
patients
• Mission: Is to operate accreditation and allied programs in
collaboration with stakeholders focusing on patient safety & quality
of healthcare by adopting various national & international best
practices.
• Global Recognition: NABH is an Institutional Member as well as a
Board member of the International Society for Quality in Health Care
(lSQua) & on the board of the Asian Society for Quality in Healthcare
(ASQua).

14. What is Accreditation?
• It is a process to measure the performance of an organization against
a set of nationally recognized, practice-focused & evidence-based
standards. The process of validation is a series of steps carried out to
measure the quality of the organization's functions and services and is
valid only for a specified period.
• The goal is continuous development, quality improvement, and the
overall performance of the organization.

15. Benefits of Accreditation
• Raises community confidence and trust
• Enhances the quality of patient care &safety
• Roadmap for standardization
• Improved patient satisfaction levels
• Provides for continuous learning, good working environment
• Provides an objective system of empanelment by insurance, other
third parties.

16. Difference B/W
NABH Accreditation
&
Entry Level Certification

17. Accreditation
 NABH has designed an
exhaustive list of healthcare
standards for hospitals &
healthcare providers.
 The standards consists of more
than 600 stringent objective
elements for the hospital to
achieve in order to get the
NABH Accreditation.
Entry Level Certification
 As numerous hospitals were facing
challenges and difficulties in implementing
the complete Accreditation Standards as
per the system provided by them.
 Therefore, NABH has developed an Entry
Level Certification program with
simplified & comprehended objective
elements, in consultation with various
stakeholders in the country, as a stepping
stone for enhancing the quality of patient
care and safety.
 It could also be the First step towards
NABH Accreditation.

18. Entry Level Certification Programme
• NABH has partnered with Insurance Regulatory & Development
Authority (IRDA) to carry out entry level certification of hospitals
which has been made mandatory for providing cashless insurance
facility to the citizens at their premises.
• NABH ensures high quality of care & patient safety, the objective of
this certification process is to build a quality culture at all level &
across all the function of the healthcare organisations

19. HOPE - Healthcare Organizations Platform for Entry
Level Certification
• Revamped portal for entry level certification process of Hospitals
and Small Healthcare Organizations.
• Includes registration, documentation and fee submission to be
carried out on HOPE web portal and a parallely developed mobile
application.
• Multifarious platform for certification process of healthcare
organizations.
• Holds complete information about the simplified certification
process, requirements and compliances

20. Challenges in Implementation
• Lack of Awareness of Standards
• Fear of Unknown
• Fear of Exposing their Vulnerabilities
• Old Infrastuctures & Licences
• Manpower Requirement
• SOPs & Mannuals
• Training of all Categories of Staffs
• Inadequate Resourses

21. Entry Level - HCO Entry Level - SHCO

22. Full Accreditation SHCO Accreditation

23. NABH Steps & Levels
• Pre Accrediation (Entry Level)
• Pre Accrediation (Progressive Level)
• Accrediation

24. Set of Standards
No
.
Accrediation/Certification Beds Chapters Standards
Objective
Elements
1 NABH Full Accred (5th Edition) 10 105 683
2 NABH SHCO (3rd Edition) 50 10 72 384
3 Entry Level Certification - Under
HCO Category (1st Edition)
50 10 45 167
4 Entry Level Certification - Under
SHCO (1st Edition)
50 10 41 149
Note: NABH SHCO - Polyclinic Diagnostic Centres Exclusion

25. Patient Centred
Standards

26. Chapter Description
Access, Assessment &
Continuity of Care (AAC)
The chapter lays down key safety and process elements that the Hospital should
meet, in the continuum of patient care within the hospital and till discharge.
Care of Patients (COP) This chapter aims to guide and encourage patient safety as the overall principle
for providing care to patients. Patients in the Emergency Department are
provided urgent care including ambulance services in consonance with their
clinical requirements.
Management of
Medication
(MOM)
The hospital has a safe & organized process of administration of medication or
intervention. The hospital should have a mechanism to ensure that the emergency
medication/ intervention is standardized throughout the hospital, readily
available & replenished on time
Patient Rights and
Education (PRE)
The Hospital should define the patient & family's rights and responsibilities.
Also, the staff should be trained to protect patient's rights and patients are
informed of their rights and educated about their responsibilities at the time of
admission.
Hospital Infection Control
(HIC)
The standards guide the provision of an effective infection control program in the
Organization. Their program should be documented and aimed at
reducing/eliminating infection risks to patients, visitors & providers of care while

27. Organization Centred
Standards

28. Chapter Description
Patient Safety and
quality (PSQ)
The quality and safety program should be documented and involve all areas of
the hospital and all staff members. The hospital should identify and collect data
on Clinical and Managerial structures, processes, and outcomes.
Responsibilities of
Management (ROM)
The standards encourage the governance of the hospital professionally &
ethically. The hospital ensures that patient safety and risk-management issues
are an integral part of patient care & hospital management.
Facility Management
& Safety (FMS)
The standards guide the provision of a safe and secure environment for patients,
their families, staff, and visitors. To ensure this, the Organization conducts
regular facility inspection rounds and takes the appropriate action to ensure
safety.
Human Resource
Management (HRM)
The goal of human resource management is to acquire, provide, retain and
maintain competent people in the right numbers to meet the needs of the
patients and community served by the organization.
Information
Management
System (IMS)
The chapter emphasizes the requirements of a medical record in the hospital as
it is an important aspect of continuity of care and communication between the
various care providers. The hospital will lay down policies and procedures to
guide the contents, storage, security, issue, and retention of medical records.

29. Hospital Preparation
1. Strong Management Commitment
2. Quality Coordinator
3. Quality Team (Multidiscipline)
4. Training on the Standards
5. Form Committees
6. Baseline assessment to identify
gaps
7. Assign Responsibilities
8. Ensure Involvement of Staff
9. Prepare Implementation Checklist
10. Statutory and legal requirements
11. Identify Infrastructural requirements
12. Documentation
13. Training
14. Initiate Audits
15. Continuous Follow up
16. Capture Indicators
17. Keep updating the champions and all
staff
18. Do an internal assessment/ invited
external assessment

30. Strong Management Commitment
• Top management should actively involve
• Prepare the strategy for implementation
• Responsibility for implementation should lie with the top
• management

31. Quality Coordinator
• Choose the right person
• Quality Manager - Knowledgeable, Team Player & Leader,
Assertive, Listener, Persererance, Learner, Work Around People,
Communicator, Trainer, Presenter, Manipulator, Always Smiling,
Should Remain Calm, Public Relations, Impartial

32. Training on the Standards
• Attend in-depth training program on NABH Standards
• Nominate three members atleast to attend the program – doctor,
nurse and administrator
• Understand the intent of every objective element

33. Form Committees
• Multidisciplinary team for NABH implementation
• Form Committees
Quality Committee
Safety Committee
Infection Control
Pharmacy
Transfusion
• Form sub-committees depending on issues

34. Ensure Involvement of Staff
• Identify Key Personnel in each area
• These individuals can be made as quality champions
• Train on the requirements of their areas

35. Identify Infrastructural requirements
• Adequacy of fire detection, alarms and fire fighting systems
• Patient and material flow in CSSD and OT
• Special provisions like baby care room, play room, handicapped
toilet as per the scope of the hospital
• Adequacy of equipments as per scope
• Prepare the plan for addressing them

36. Documentation
Help the relevant stake holders in preparation of the policies and
procedures that comply with the NABH standards
Many sample documents available – customize to your hospital
Standardize
Keep them simple
Trial and implement

37. Statutory and legal requirements
• Identify which are the relevant licenses to be obtained/renewed
Hospital Registration
Biomedical Waste authorization, Air, Water Consent
AERB licenses
Pharmacy licenses
Blood bank licenses
PC PNDT
MTP
Transplant licenses (if applicable)
Note: Identify what are the requirements to be fulfilled as per
prevailing laws

38. Training
• Prepare the Training Matrix and Training Calendar
• Identify and implement training requirements
Identify Faculty
Plan training calendar, roll out training
• Interact / educate the end users regarding the same
Including doctors
Train, Train, Train

39. Initiate Audits
• Chart Documentation Audits
• Quality Team Audit
• Stateholders Audit

40. Continuous Follow up
• By Quality Manager
• Quality Team
• Committees
• Documented
• Presented to the Top Management
Follow up, Follow up, Follow up

41. Capture Indicators
• Start capturing basic and relevant indicators
• Explain the indicators and their relevance to the
stakeholders
• Involve the stakeholders and analyze the data

42. Keep Updating the Champions & All Staff
• Continuous update to all staff on overall progress- through
• meetings, newsletters etc.
• Keep them engaged
• Update the departments and stakeholders on the levels of
• compliances
• Celebrate successes

43. Revised Questionnaire for Hospital Accreditation Program
• Part I – General Information
• Part II – Statutory Compliances
• Part III – Scope of Service
• Part IV – Access, Assessment and Information (AAC)
• Part V – Care of Patient (COP)
• Part VI – Management of Medication (MOM)
• Part VII – Patient Right and Education (PRE)
• Part VIII – Hospital Infection Control (HIC)
• Part IX – Patient Safety and Quality (PSQ)
• Part X – Responsibility of Management (ROM)
• Part XI – Facility Management and Safety (FMS)
• Part XII – Human Resource and Management (HRM)
• Part XIII – Information Management System (IMS)

44. Methodology of Survey
• Initial Presentation by Hospital
• Document Review
• Adherence to Statutory Obligations
• Vists to Various Areas
• Facility Surveys & Tours
• Random Structured Interviews

45. Initial Presentation by Hospital
• Organogram
• Quality Mangaement Team
• Methodology Followed by Quality Improvement
• Facilites Provided
• Inputs on Resources Provided For Quality Improvement
• Identified High Risks Area For Patient Care & Safety
• Sentinel Events being Monitored

46. Initial Presentation By Hospital
• Key Monotoring Indicators
• Resourses
• Volume
• Utilization
• Performance
• Control Charts
• Problems Faced & remedial Measures Undertaken or Being Under taken

47. Documents Review
• Quality Manual
• Variuos Policies & Procedures
• MOM of various meetings
• Medical Records
• Medical & Nursing Audits
• Adverse Events
• HAI
• Action Taken Reports
• Personal Recods of Staffs

48. Observtions
• Facility Safety
• Level of Compliance with laid down policies & Procedures
• BMW Management
• Standard Precautions
• Patient Care
• Fire Safety
• Equipment Management

49. Interview
• Staff Interview:
To Determine their level of awareness & Compliance with
Organisation polices & Procedures
To assess their awareness level of their rights, privileges & patient
rights
To determine their satisfaction level
• Patient & Family Interview
To assess their level of awareness of the care process & their rights
To determine their satisfaction level

50. Process Of Accreditation
• Initial Application including Self Assessment as per the laid down
standards
• Screening of the Application
• Pre Assessement Surveys
• Assessment Surveys
• Accreditation Committee Recommendatations
• If Required Verfification Visit
• Approval Of Accreditation by the NABH
• Re - Assessment Surveys

51. Outcome of Accreditation Surveys
• Accrediated:
HCO shows acceptable compliance with laid down standards in al
areas
Include the Scopes of Services for which accreditated
• Accreditation Denied: HCO is consistently Non Compliant with
Standards
• Accreditation Withdrawn:
HCO Withdraws Voluntarily
Due to Consistent Non Compiance or Non Adherence to Safe &
Ethical Practices

52. How to go about
• Examine What you are doing
• Find what you shuld be doing
• Document the gaps
• Compare with the standards
• Complete Gap Analysis
• Identify areas of Improvemnt
• Focus Uniform Training of all employees in Key AReas
• Encourage by Financial &Non Financial INCENTIVES

53. 5th Edition Scoring System
Further the objective elements have been classified into -
 Commitment - Used during Final Assessment
 Achievement - Used during Surveillance Assessment
 Excellence - Used during Re-Accreditation Assessment

54. Scoring Changes
• To be carried out during site assessment
• The scoring criteria have been remodelled and changed fully
• The earlier system gave 0 for non-compliance, 5 for partial and 10 for
full compliance. New system uses scale of 1 to 5. Each score has
corresponding reason for grades awarded.

56. Salient Features
• Minimising of Objective Elements which could only be scored as
“All or None”
• The phrase “written guidance” has been used to guide
implementation
• A section devoted to documentation.

57. Cumulative Score Required
• Minimum of 2244 out of 2805 out of 561 OEs for the Final
Assessment
• Minimum of 2484 out of 3105 out of 621 OEs for the Surveillance
Assessment
• Minimum of 2604 out of 3255 out of 651 OEs for the Re-
accreditation Assessment

58. Overall Compliance Rate for Accreditation
Accreditation
Towards
Implementation
Compliance
Rate
Required
Elements
80% Core Total
Commitment Final Assessment 80% 461 100 561
Achievement
Surveillance
Assessment
80%
561 60 621
Excellence
Re-Accreditation
Assessment
80%
621 30 651

59. Few Examples of New Objective Elements
(But Not Limited to)

60. • AAC.4. g- The care plan includes the identification of special needs
regarding care following discharge.
• AAC.7. f-The programme addresses the clinicopathological
meeting(s)
• COP.1.e - Clinical care pathways are developed, consistently
followed across all the settings of care and reviewed periodically.
• COP.1.g- Multi disciplinary and multi-speciality care where
appropriate is planned based on best clinical practice guidelines and
delivered in a uniform manner across the organisation.
• MOM.4. d- The organisation has a mechanism to assist the clinician
in prescribing appropriate medication.

61. • PSQ.1. e - Designated clinical safety officer (s) coordinates implementation of
the clinical aspects of patient safety programme.
• PSQ.1. g - the hospital performs proactive analysis of patient safety risks and
makes improvements accordingly.
• ROM1.h - Those responsible for governance inform the public of the quality and
performance of services.
• FMS.1. e - Before construction renovation & expansion of the existing hospital
risk assessment is carried out.
• HRM.4. e - Evaluation of the training effectiveness is done by the organisation
• IMS.1. f - The organisation ensures that information resources are accurate and
meet the stakeholders’ requirements.
• PSQ.6. a - The management creates a culture of safety.
• PSQ.5.c - Medical and nursing staff participates in clinical audit.

62. Documents related
to
Access, Assessment and
Continuity of Care

63. • Registration and admission of patients (OPD, IPD & Emergency)
• Managing patients during non-availability of beds
• Transfer-in of the patient to the hospital & Transfer out/referral of Stable & Unstable Pts to Another Facility
• Initial assessment of patients (Out-patients, in-patients & emergency patients)
• Laboratory scope of tests, quality assurance programme, Safety Programme
• Ordering of lab tests, collection, identification, handling, transportation, processing & disposal of specimen
• Time-frame for the availability of lab test results
• Critical results of lab and its timely intimation
• Outsourcing of lab tests
• Imaging scope of tests
• Identification and safe transportation of patients to and from the imaging department
• Time-frame for the availability of imaging results
• Critical findings of imaging and its timely intimation
• Outsourcing of imaging tests
• Imaging quality assurance programme & Radiation safety programme
• Discharge process (including MLC discharge and absconding cases)
• Discharge against medical advice
• Death discharge

64. Documents related
to
Care of Patients

65. • Uniform care policy
• Handling of medico-legal cases
• Triage of patients in emergency
• Managing dead on arrival cases
• Identification of likely community emergencies, epidemics and disasters likely
• Plan for handling all probable disaster situation
• Handling of mass casualty situation
• Clinical protocols of managing various emergency cases (for adults and children)
• Quality assurance programme of emergency services
• Checklist of equipment and emergency medicine in Ambulance
• Cardio-pulmonary resuscitation and code blue process
• Rational use of blood and blood products
• Transfusion of blood and blood products
• Availability and transfusion of blood/blood components in an emergency situation
• Care of patients in ICU and HDU

66. • Admission and discharge criteria for ICU
and HDU
• Managing situation of bed shortage in ICU
• Quality assurance programme of ICU
• Care of vulnerable patients, Paediatric
Patients
• Provision of obstetric care services
• Administration of moderate Anaesthesia
• Monitoring of patients under anaesthesia
• Criteria for discharge from recovery area
• Care of surgical patients
• Surgical safety policies and practices
• Quality assurance programme of surgical
services
• Organ transplant policy and process
• Standard treatment protocols
• Restraint of patient
• Pain management
• Provision of rehabilitative services
• Conduction of clinical research
activities
• Nutritional assessment, re-assessment
and nutritional therapy
• End of life care

67. Documents related
to
Management of Medication

68. • Uniform care policy
• Handling of medico-legal cases
• Triage of patients in emergency
• Managing dead on arrival cases
• Identification of likely community emergencies, epidemics and disasters likely
• Plan for handling all probable disaster situation
• Handling of mass casualty situation
• Clinical protocols of managing various emergency cases (for adults and children)
• Quality assurance programme of emergency services
• Checklist of equipment and emergency medicine in Ambulance
• Cardio-pulmonary resuscitation and code blue process
• Rational use of blood and blood products
• Transfusion of blood and blood products
• Availability and transfusion of blood/blood components in an emergency situation
• Admission and discharge criteria, Care of patients in ICU and HDU
• Managing situation of bed shortage in ICU
• Quality assurance programme of ICU
• Care of vulnerable patients
• Provision of obstetric care services
• Care of Paediatric patients

69. • Administration of moderate Anaesthesia
• Monitoring of patients under anaesthesia
• Criteria for discharge from recovery area
• Care of surgical patients
• Surgical safety policies and practices
• Quality assurance programme of surgical services
• Organ transplant policy and process
• Standard treatment protocols
• Restraint of patient
• Pain management
• Provision of rehabilitative services
• Conduction of clinical research activities
• Nutritional assessment, re-assessment and nutritional therapy
• End of life care

70. Documents related
to
Management of Medication

71. • Hospital formulary
• Process of acquisition of medicine in the formulary
• Process of acquisition of medicine not listed in the formulary
• Storage of medication, Safe storage and handling of look-alike and sound-alike medication
• List of emergency medicine and its storage
• Prescription of medicine, Policy and process on verbal orders of medication
• List of high risk medicines
• Safe Administration & dispensing of medicines
• Medication recall, Procedure for near expiry medicine, Labelling requirements of medicine
• Policy on patient’s self-administration of medicine
• Monitoring of patients after medication administration
• Recording and reporting of medication errors, adverse events and near misses
• Procedure for usage of narcotic drugs and psychotropic medications
• Usage of chemotherapeutic medications
• Disposal of waste medication (cytotoxic)
• Usage of radio-active drugs (safe storage, preparation, handling, distribution and disposal)
• Use of implantable prosthesis (procurement, storage, issuance, and record keeping)
• Acquisition of medical supplies and consumables

72. • Patients’ rights and responsibilities
• Informed consent taking process
• List of procedures for which informed consent is required
• Uniform pricing policy
• Effective communication with patient and family
• Patients complaint obtaining and handling system
Documents related to Patients’ Rights & Education

73. • Infection control programme, Infection surveillance
• Identification of high risk areas
• Standard Precaution/Universal Precaution for Infection Control
• Safe injection and infusion practices
• Cleaning, disinfection and sterilization practices
• Antibiotic policy & Infection control care bundles
• Laundry and linen management processes
• Kitchen sanitation and food handling
• Housekeeping procedures
• Handling outbreak of infections
• Sterilization process & Biomedical waste handling process
Documents related to Hospital Infection Control

74. • Organization wide quality improvement programme
• Quality indicators with their method, targets and monitoring
• Patient safety programme
• Clinical audit system
• 1Incident reporting, analysis and corrective preventive action system
• Definition and lists of sentinel events
• Analysis of sentinel events
Documents related to Continual Quality Improvement

75. • Vision, mission and values of the organization
• Strategic and operational plan of the organization
• Organogram
• Managing compliance to laws, regulations, licenses & permits
• Scope of services of each department
• Administrative policies and procedures (attendance, leave, conduct,
replacement etc.)
• Employee rights and responsibilities
• Service standards of the organizations
Documents related to Responsibilities of Management

76. • Disposal of non-functioning items and scrap materials
• Facility inspection round
• Up-to-date drawings and site layout
• Maintenance plan for the facility
• Preventive and breakdown maintenance plan
• Maintenance plan for water management
• Maintenance plan for electrical systems
• Maintenance plan for HVAC systems
• Maintenance plan for IT and communication network
• Equipment replacement and disposal
• Managing medical gases (procurement, handling, storage, distribution, usage and replenishment
• Handling of fire (Code Red alert) and non-fire emergencies
• List of hazardous materials in the organization
• Handling of hazardous materials (sorting, labelling, handling, storage, transporting and disposal)
• Managing spills of hazardous materials (including blood)
Documents related to Facility Management and Safety

77. Documents related to Human Resources Management
• Human resources plan of the organization
• Job specification and job description of each category of staff
• Recruitment and selection procedure
• Induction programme of new staff
• Training and development policy
• Employee appraisal system
• Disciplinary and grievance handling system
• Addressing health needs of employee
• Credentialing and privileging of medical professionals
• Credentialing and privileging of nursing professionals

78. Documents related to Information Management System
• Managing information needs of the organization
• Document control process
• Data management (dissemination, storage, retrieval)
• Policy on who is authorized to make entries in the medical record
• Medical record management
• Maintaining confidentiality, security and integrity of records, data and
information
• Retention of patient’s clinical record, data and information
• Destruction of medical records
• Medical record review

79. Checklist
of
Quality Indicators
for
NABH Accreditation preparation

80. • Average time taken for initial assessment of patients admitted in IPD
• Percentage of IPD patients for whom the initial assessment was
completed within defined timeframe
• Average time taken for initial assessment of patients coming to
emergency
• Percentage of emergency patients for whom the initial assessment was
completed within defined timeframe
• Percentage of in-patients wherein the plan of care with desired
outcomes is documented and countersigned by the clinicians
• Percentage of in-patients wherein screening for nutritional needs has
been done
• Reporting error rates (per 1000) in laboratory

81. • Percentage of re-dos in laboratory
• Percentage of lab reports co-relating with clinical diagnosis
• Percentage of adherence to safety precautions by employees
working in labs
• Reporting error rates (per 1000) in Imaging
• Percentage of re-dos in Imaging
• Percentage of Imaging reports co-relating with clinical diagnosis
• Percentage of adherence to safety precautions by employees
working in Imaging
• Medication error rate
• Percentage of adverse drug reactions
• Percentage of adverse drug reaction due to high-risk medicine

82. • Percentage of medical records with error-prone abbreviations
• Percentage of modification of anaesthesia plan
• Percentage of unplanned ventilation following anaesthesia
• Percentage of re-scheduling of surgeries
• Compliance rate to surgical safety practices
• Percentage of cases who received prophylactic antibiotic within
specified time-frame
• Percentage of transfusion reactions
• Percentage of blood and blood components wasted
• Percentage of blood component usage
• Turn-around time for the issue of blood and blood components
• % of blood and blood components issued within defined time frame

83. • Catheter associated Urinary Tract Infection (CA-UTI) rate
• Ventilator associated pneumonia (VAP) rate
• Central line catheter associated blood stream infection (CA-BSI) rate
• Surgical site infection (SSI) rate
• Gross & Net mortality rate
• ICU specific mortality rate
• Return to ICU within 48 hour
• Return to EMR within 72 hours with similar presenting complaints
• Re-intubation rate
• Percentage of research activities approved by ethics committee
• Percentage of patients withdrawing from clinical research

84. • % of protocol violations/deviations in clinical research study
• % of serious events in clinical research study reported to ethics
committee
• Error rates during shift hand-overs
• % of medical error due to wrong identification of patient
• Hand hygiene compliance rate
• Compliance rate to medication prescription in capitals
• % of procurement through local purchase & stockouts for EMR drugs
• % of drugs and consumables rejected before preparation of goods
receipt note
• Percentage of variation from procurement process

85. • Percentage of variations observed in mock drills
• Patient fall rate per 1000 patient days
• Hospital-associated pressure ulcer rate
• Percentage of staff provided pre-exposure prophylaxis
• Bed Occupancy Rate & Average Length of Stay (ALOS)
• OT & ICU utilization rate
• Percentage of downtime of Critical equipment
• Nurse patient ratio for wards & ICU
• Out & In patient satisfaction index
• Average waiting time for services & discharge time
• Employee satisfaction index, attrition rate, absenteeism rate
• Percentage of employee aware of employee rights

86. • Percentage of sentinel events analysed within a defined time frame
• Percentage of near misses
• Needlestick injury rate
• Percentage of medical records not having discharge summary
• Percentage of medical records not having ICD codes
• Percentage of medical records having incomplete and improper
consent
• Percentage of missing records

87. SHCO
• Exclusions:
Polyclinics
Diagnostic Centers
Super Speciality Centers (Single or Multiple)
• Exceptions:
• Speciality Day Care (Minimum Bed Strength not Mandatory)..Super
Speciality Centers are the centers which reflect requirement of
DM/MCH Or Equivalent qualified personnel
• Speciality Cemters are the Centers which reflect requirement of
MD/MS or Equivalent Qualified Personnel

88. Manuals
• Apex Manual - How we take decisions to run hospital - Main
Decision Making Body
• Safety Manual - Safety Precautions at Hospital
• Infection Control Manual - Infection Control Practices
• Disaster Manual - Details of how to face Internal & External
Disaster
• Departmental Mannuals

89. Requiremnts of Hospital Team
• Appointment of Coordinator by Hospital
• Streeing Committee to be formed with Senior Management or
HODs
• Other Major Teams or Committees
Quality & Safety Committees
Infection Control Committees
Blood Transfusion Committees
Pharmaco Therapeutic Committees
Medical Record Audit Committees

90. Main Phase
• Initial System Study With Gap Analysis
• General Awareness & Training
• System Design & Documentation
• Assistance in Maturity Measurement
• Accreditation Assistance

91. Initial System Study With Gap Analysis
• Study on the Existing Processes & Records
• Check Compliance to applicable Rules & Regulations, Licence, regstrations,
Waste Disposal, Fire & Safety Controls
• Bring out the Gaps in th existing practices with respect to meeting the Entry
Level Standards
• Management to identify & Appoint NABH Cordinator & the core committee
& other committee Members
• Duration: 7 days over 3 to 4 weeks

92. Areas Coverage
• Patient Care Areas
OP Handling
Imaging
In Patient Handling
EMR Department
OT
Pt Care in Wards/Rooms
Pt Cae in
ICU/NICU/PICU/HDU
• Clinical Support Areas
Lab - Pathology, Cytology,
Immunology, Hematoogy
Clinical Microbiology
Blood Bank
Dietary Functions
Pharmacy

93. Areas Coverage - Other Support Areas
• Medical Records
• Front Office
• Billing Counters
• Guest Relations
• Engineering Services
• F & B Services
• House Keeping Activities
• Human Resource Management
• Materials Management

94. Training
• General Awareness - Covering all staffs in Batches
• Duration: 5 days over 2 Weeks

95. System Design & Documentation
• Based on the Gap Analysis Report, the relevant forms, records &
Work Instructions SHOULD BE DISCUSSED
• Cordinator shuld guide HODs in preparing Drafts of policies &
Procedures
• Coordinator should be Supported by the CORE/Streeing Committee
members should initiate the Implementation
• Also development of Mission, Objectives, Organisatonal Structure,
Duties & Responsibilities of HOD's
• Based on the Policy & Procedure Document, assisatnce will be
provided to prepare all the mandatory Manuals
• Duration: Over 8 Weeks

96. Assistance in Maturity Measurement
• Train your Core Team in Audit Practices - To Examine if planned
systems is adequate
• This trained COre Team will conduct Cross Functional audits to
ascertain compliance level in each areas or departments
• Cordinator to assist the Auditees to address NCs with Suitable
corrective actions & its timely implementation
• Duration: 6 Weeks

97. Process
1. Application
2. Preparation
3. Self Assessment (NC & Its Compliance Closure)
4. Pre - Assessment (NC & Its Compliance Closure)
5. Main Assessment (NC & Its Compliance Closure)
6. Certification (NC & Its Compliance Closure)
7. Survellience Visit (NC & Its Compliance Closure)
8. Renewal & Application (NC & Its Compliance Closure)

98. Points to Remember
• Every Non-Compliance is an opportunity for improvement
• Accept NCs and improve on them
• Do not close NCs for the sake of closure
• Never get disheartened - Change in culture/ practice takes years
• Always remain positive – “Never give up”
• Continue to learn
• Establish the system for continuous monitoring and
• sustainability