1. Dr. A. M. Joglekar

2. Quality
 Quality in Hospitals is all about meeting expectations of:
 Patients
 Statutory / Legal bodies
 Internal Customers
 Owners / Trust
 Others
 Third parties (NABH)
NABH has simplified matters by laying down accreditation
standards for Hospitals and Healthcare providers

3. NABH
 3rd Edition (Nov. 2011)
 Accreditation standards for Hospitals and healthcare
providers

4. NABH – 3rd edition
 636 (514) Objective Elements
 102 (100) Standards
 10 Chapters
“Patient safety” and “Continuous Quality improvement” have
been given emphasis
 Standards are non-prescriptive
 Guidance (remarks, interpretations) is integrated
 Shall/should vs. can/could
 Intent of each chapter explained

5. Key issues addressed
NABH 3rd
edition
Regulatory Organization NABH
Patient Employee
related policies Standard
related related
related related

6. NABH
 Multi disciplinary approach at Hosmac
 Doctors
 MHAs (Administrators)
 Bio medical Engineers
 Civil Engineers
 Architects
 Technical experts

7. References
 MTP Act  Critical Care guidelines
 PNDT Act  Clinical Audit guidelines
 NACO policies on HIV/AIDS  ICMR guidelines for research
 SOPs by NACO and research related
 WHO Guidelines  FDA Act
 CDC guidelines  National list of essential
 Control of Hospital infection medicines
guidelines (CDC)  Code of Medical ethics by MCI
 NABH guidelines for OTs  Organ Transplantation Act
 NABL guidelines  BIS Standards
 AERB for Radiology  Clinical establishment Act

8. NABH Standards - Recap
Patient centered Standards
 Access, Assessment and Continuity of Care (AAC)
 Care of patients (COP)
 Management of Medication (MOM)
 Patient’s rights and education (PRE)
 Hospital Infection Control (HIC)

9. NABH Standards - Recap
Organization centered Standards
 Continuous Quality improvement (CQI)
 Responsibility of Management (ROM)
 Facility management and safety (FMS)
 Human Resource Management (HRM)
 Information management system (IMS)

10. Impact of improvement
Patient centered
 AAC 15/14 ; 78/86
UID, Std. reports, DAR, OPD follow up, etc.
 COP 18/20 ; 105/136
Nursing care std, Blood transfusion, Special groups, etc.
 MOM 61/73
Rational use of drugs, Audit of prescriptions, patient counseling
on prosthesis/devices, etc.
 PRE 5/7 ; 30/46
Info to patients, consents, complaint redressal, etc.
 HIC 46/51
IC officer, Hand hygiene, safe inj and inf practices, reprocessing,
etc.

11. Impact of improvement
Organization centered
 CQI 6/8 ; 39/57
Analyzing complains, feedback and incidences,
regular audits, review of nursing care, patient safety program, etc.
 ROM 5/6 ; 25/38
Senior leaders and committee performance, service standards, outsourced
services, etc.
 FMS 9/8 ; 43/54
Disaster management, Alt sources for gases, vacuum and comp. air, etc.
 HRM 13/10 ; 47/52
Recruitment procedure, manpower planning, etc.
 IMS 41/43
24 hr access to medical records, records to contain test results

12. NABH Accreditation Process
Application for Accreditation (By Healthcare organizations)
Acknowledgement & Scrutiny of the Application (By NABH Secretariat) Feedback to
Healthcare
Self assessments by Healthcare organizations (Toolkit provided by NABH) Organizations
Pre-Assessment visits (By Assessment Team) And
Final Assessment of Hospital (By Assessment Team) Necessary
Corrective
Review of Assessment Report (By NABH Secretariat) Actions Taken
Recommendation for Accreditation (By Accreditation Committee) By Healthcare
Organizations
Approval for Accreditation (By Chairman, NABH)
Issue of Accreditation Certificates (By NABH Secretariat)

13. Surveillance and Re assessment
 Accreditation to a hospital shall be valid for a period of three years.
 NABH conducts one surveillance of the accredited hospitals in one
accreditation cycle of three years.
 The surveillance visit will be planned during the 2nd year i.e. after 18 months
of accreditation.
 The hospitals may apply for renewal of accreditation at least six months
before the expiry of validity of accreditation for which reassessment shall be
conducted.
 NABH may call for un-announced visit, based on any concern or any serious
incident reported upon by an individual or organization or media.

14. Principles
 NABH system integrates the following for managing quality
at HCOs:
Hospital
Quality
Quality
assurance
assurance
applications
programs
Quality Programs
assurance assessment
techniques and trends

15. Transition
Quality
NABH Improvement
programs
Crisis
Management
(Traditional)
Process bashing in lieu of person bashing 

16. What NABH gives HCOs ??
 Patient focused
 Support from Top Management (by personal
examples)
 Quality is everyone’s business
 Process or system approach
 Rationality and logic in
decision making
 Continuous improvement
NABH – a journey…

17. Approach at GMH
 New hospital v/s Old hospital
 Quality “system” were focused
 Defined vision – Quality, affordability, rationality, ethics
and focus on emergency care
 Framing policies in support of the vision
 Process and procedures defined
 Forms and formats designed and developed in
accordance to above

18. Approach at GMH
 Hospital design validated
according to BIS standards.
 Operation theatre according to ASHRAE standards.
 Biomedical equipments from standard reputed companies
complying with quality standards.
 Support and auxiliary equipments also from firms
complying quality standards.
 All statutory/legal authorizations obtained and complied
with.
 All personnel deployed were appropriately qualified and
experienced.

19. Approach at GMH
 Prepared policy and process/other
manuals
 Installed processes as per process manuals
 Regular training to orient personnel
 Formulated committees (Medical/non medical)
 Designated medical departmental coordinators
 Instituted patient feedback and analysis system from
Day 1
 NABL accreditation for hospital lab obtained prior to
NABH

20. Approach at GMH
 Senior management attended
NABH Assessor's course and
assessed other HCOs.
 Conducted several self assessments.
 Middle management/Doctors/Staff attended various
NABH workshops and participated in NABH
sponsored projects. (Six Sigma)
GMH was NABH accredited in June 2009, followed by a surveillance
visit.
Re-accreditation was accorded in June 2012 .

21. Quality Concepts
 Quality was conceptualized, defined, implemented,
monitored, measured, reinforced and constantly
improved.
 Apex body (Think Tank) was for
generating quality ideas, defining
benchmarks and quality indicators.
 Hospital committees and others
advised and gave feedback to
the Apex body.

22. Quality Concepts

23. Approach to Assessment
 At assessment, non compliances/partial compliances
were considered as opportunities to improve rather
than a matter of dispute, maximizing benefits to the
organization.
 NABH system is a continuous
quality improvement journey

24. Assessment Experience
 Doctor interviews
 Medical Documentation
 Patient Interviews
 Hand Wash facility
 Registration of Staff
 Credentialing and privileging
 BMW Storage (bins)
 Safety (Grab bars)
 Fatal case analysis
 Infection Control
 Police verification
 Question of affordability ??
 Question on Ethicality

25. Assessment Experience
 Fire Safety – Fire NOC, Fire alarms, expired extinguishers, Fire training and drills, Fire officer
 Medical Documentation – Illegible, Date and time, Name, designation of doctors, completeness
 Calibration of equipments – Balances, centrifuges and Bio Med equipments
 Testing – water, air, RO water
 Consents, time out and PA check
 Marking of Surgical sites
 Medical Audits
 Committee meeting and MOM
 MLC Reporting on discharge
 Discharge at request (DAR)
 Signage – Fire, emergency exits, scope of services, clinical protocols, etc.
 CPR Analysis
 Others
Col. S. K. M. Rao has conducted a detailed scientific study of the deficient areas in
Hospitals

26. Current scenario for NABH in India
Accredited Hospitals Applicant Hospitals
138 471
Huge improvement
opportunity for hospitals

27. Benefits of Accreditation
 Patients :
 High quality of care & safety.
 Service by credentialed medical staff.
 Rights of patients are safeguarded.
 Patient satisfaction is the focused.
 Hospitals :
 Systemized approach rather than personalized approach.
 Process driven rather than person driven.
 Stimulates constant improvement in the healthcare organization.
 Demonstrates commitment to quality care.
 Raises community confidence in the healthcare organization.
 Opportunity for the healthcare organization to benchmark itself against the
best.

28. Benefits of Accreditation
 Hospital Staff :
 Improves staff satisfaction due to continuous learning, good working
environment, leadership and ownership of clinical processes.
 Improves overall development of medical & paramedical staff.
 Paying & regulatory bodies :
 Objective system of empanelment for insurance bodies and other third
parties.
 Access to reliable and certified information on facilities, infrastructure and
level of care.

29. NABH
 NABH encourages us to do, what we should be doing in the
first place.
 Quality is “made to happen” via sincere efforts of a HCO.
NABH makes the task easier.
 Being good is difficult enough, demonstrating goodness (by
evidence) requires far more efforts.

30. NABH – a journey of continuous
quality improvement….

31. THANK YOU