2. WHAT IS QUALITY
The standard of something as measured against other things of a similar kind; the
degree of excellence of something.
Meeting the needs and exceeding the expectations of the patients
Delivering all and only the care that the patient and family needs
A doctor may say: “The kind of care that may relive the pain and suffering and restore
health to the best possible level”
A patient may say, “The best possible treatment that is timely, safe and affordable,
and can restore his health to his earning capacity at the earliest”
3. WHAT IS QUALITY
Quality Gets Attention
“ Quality is not an act, it is a habit ”
“ Quality means doing it right when no one is looking ”
“ Quality is never an accident; it is always the result of intelligent effort ”
Approaches :
TQM
LEAN MANAGEMENT
SIX SIGMA
ISO
NABH
JCI
4. INTRODUCTION
NABH - National Accreditation Board for Hospitals & Healthcare
Hospital Accreditation
Constituent board of Quality Council of India
International Linkage – lSQua & ASQua
Mission, Vision & Values
Structure
5. BENEFITS OF ACCREDITATION
Benefits for Patients
Biggest beneficiary
High quality of care and patient safety
Rights of patients
Patients satisfaction
Commitment to quality care
Community confidence
Benchmarking
Benefits for Hospital Staff
Staff satisfaction
Improves overall professional development
Benefits to paying and regulatory bodies
Benefits for Hospitals
CQI
6. NABH Standards has,
10 Chapters, 102 Standards, 636 Objectives Elements
Outline of NABH Standards
Patient Centered Standards
Chapters
Std
1. Access, Assessment and
Continuity of Care (AAC)
14
2. Care of Patient (COP) 20
3. Management of Medication
(MOM)
13
4. Patient Right and Education
(PRE)
07
5. Hospital Infection Control (HIC) 09
Organization Centered
Standards Chapters
St
d
6. Continuous Quality
Improvement (CQI)
08
7. Responsibility of Management
(ROM)
06
8. Facility Management and
Safety (FMS)
08
9. Human Resource Management
(HRM)
10
10. Information Management
System(IMS)
07
7. 1. ACCESS, ASSESSMENT AND CONTINUITY OF
CARE
AAC 1: The organization defines and displays the services that it can provide.
AAC 2. The organization has a well-defined registration and admission process.
AAC 3. There is an appropriate mechanism for transfer (in and out) or referral of patients.
AAC 4. Patients cared for by the organization undergo an established initial assessment.
AAC 5. Patients cared for by the organization undergo a regular reassessment.
AAC 6. Laboratory services are provided as per the scope of services of the organization.
AAC 7. There is an established laboratory-quality assurance programme.
8. 1. ACCESS, ASSESSMENT AND CONTINUITY OF
CARE
AAC 8. There is an established laboratory-safety programme.
AAC 9. Imaging services are provided as per the scope of services of the organization.
AAC 10. There is an established quality-assurance programme for imaging services.
AAC 11. There is an established radiation-safety programme.
AAC 12. Patient care is continuous and multidisciplinary in nature.
AAC 13. The organization has a documented discharge process.
AAC 14. Organization defines the content of the discharge summary.
9. 2. CARE OF PATIENTS
COP 1: Uniform care to patients is provided in all settings of the organization and is
guided by the applicable laws, regulations and guidelines.
COP 2: Emergency services are guided by documented policies, procedures and
applicable laws and regulations.
COP 3: The ambulance services are commensurate with the scope of the services
provided by the organization.
COP 4: Documented policies and procedures guide the care of patients requiring
cardio-pulmonary resuscitation.
COP 5: Documented policies and procedures guide nursing care.
10. 2. CARE OF PATIENTS
COP 6: Documented procedures guide the performance of various procedures.
COP 7: Documented policies and procedures define rational use of blood and blood
products.
COP 8: Documented policies and procedures guide the care of patients in the Intensive
care and high dependency units.
COP 9: Documented policies and procedures guide the care of vulnerable patients
(elderly, physically and/or mentally-challenged and children).
11. 2. CARE OF PATIENTS (Continue..)
COP 10: Documented policies and procedures guide obstetric care.
COP 11: Documented policies and procedures guide pediatric services.
COP 12: Documented policies and procedures guide the care of patients undergoing
moderate sedation.
COP 13: Documented policies and procedures guide the administration of anesthesia.
12. 2. CARE OF PATIENTS (Continue..)
COP 14: Documented policies and procedures guide the care of patients undergoing
surgical procedures.
COP 15: Documented policies and procedures guide the care of patients under restraints.
COP 16: Documented policies and procedures guide appropriate pain management.
COP 17: Documented policies and procedures guide appropriate rehabilitative services.
COP 18: Documented policies and procedures guide all research activities.
COP 19: Documented policies and procedures guide nutritional therapy.
COP 20: Documented policies and procedures guide the end of life care.
13. 3. MANAGEMENT OF MEDICATION
MOM 1: Documented policies and procedures guide the organization of pharmacy
services and usage of medication.
MOM 2: There is a hospital formulary.
MOM 3: Documented policies and procedures exist for storage of medication.
MOM 4: Documented policies and procedures guide the safe and rational prescription of
medications.
MOM 5: Documented policies and procedures guide the safe dispensing of medications.
14. 3. MANAGEMENT OF MEDICATION
MOM 6: There are documented policies procedures for medication management.
MOM 7: Patients are monitored after medication administration.
MOM 8: Near misses, medication errors and adverse drug events are reported and
analyzed.
MOM 9: Documented procedures guide the use of narcotic drugs and psychotropic
substances.
MOM 10: Documented policies and procedures. guide the usage of chemotherapeutic
agents.
15. 3. MANAGEMENT OF MEDICATION
(Continue…)
MOM 11: Documented policies and procedures govern usage of
radioactive drugs.
MOM 12: Documented policies and procedures guide the use of
implantable prosthesis and medical devices.
MOM 13: Documented policies and procedures guide the use of medical
supplies, and consumables.
16. 4. PATIENTS RIGHTS AND RESPONSIBILITY
PRE 1: The organization protects patient and family rights and informs them about their
responsibilities during care.
PRE2: Patient and family rights support individual beliefs, values and involve the patient
and family in decision-making processes.
PRE3: The patient and/or family members are educated to make informed decisions and
are involved in the care-planning and delivery process.
PRE4: A documented procedure for obtaining patient and/or family's consent exists for
informed decision making about their care.
17. 4. PATIENTS RIGHTS AND RESPONSIBILITY
PRE5: Patient and families have a right to information and education about their
healthcare needs.
PRE 6: Patient and families have a right to information on expected costs.
PRE 7: Organization has a complaint redressal procedure.
18. 5. HOSPITAL INFECTION CONTROL
HIC 1: The organization has a well-designed, comprehensive and coordinated
Hospital Infection Prevention and Control (HIC) programme aimed at reducing/
eliminating risks to patients, visitors and providers of care.
HIC 2: The organization implements the policies and procedures laid down in the
Infection Control Manual.
HIC 3: The organization performs surveillance activities to capture and monitor infection
prevention and control data.
HIC 4: The organization takes actions to prevent and control Healthcare Associated
Infections (HAl) in patients.
19. 5. HOSPITAL INFECTION CONTROL
HIC 5: The organization provides adequate and appropriate resources for prevention and
control of Healthcare Associated Infections (HAl).
HIC 6: The organization identifies and takes appropriate actions to control outbreaks of
infections.
HIC 7: There are documented policies and procedures for sterilization activities in the
organization.
HIC 8: Bio-medical waste (BMW) is handled in an appropriate and safe manner.
20. 5. HOSPITAL INFECTION CONTROL
(Continue…)
HIC 9: The infection control programme is supported by the management and includes training of staff and
employee health.
21. 6. CONTINUAL QUALITY IMPROVEMENT
COI 1: There is a structured quality improvement and continuous monitoring programme
in the organization.
COI 2: There is a structured patient-safety programme in the organization.
COl 3: The organization identifies key indicators to monitor the clinical structures,
processes and outcomes which are used as tools for continual improvement.
COl 4: The organization identifies key indicators to monitor the managerial structures,
processes and outcomes, which are used as tools for continual improvement.
COl 5: The quality improvement programme is supported by the management.
22. 6. CONTINUAL QUALITY IMPROVEMENT
COl 6: There is an established system for clinical audit.
COl 7: Incidents, complaints and feedback are collected and analyzed to ensure continual
quality improvement.
COl 8: Sentinel events are intensively analyzed.
23. 7. RESPONSIBLITIES OF MANAGEMENT
ROM 1: The responsibilities of those responsible for governance are defined.
ROM 2: The organization complies with the laid-down and applicable legislations and
regulations.
ROM 3: The services provided by each department are documented.
ROM 4: The organization is managed by the leaders in an ethical manner.
ROM5: The organization displays professionalism in management of affairs.
ROM 6: Management ensures that patient-safety aspects and risk-management issues
are an integral part of patient care and hospital management.
24. 8. FACILITY MANAGEMENT AND SAFETY
FMS 1.The organization has a system in place to provide a safe and secure
environment.
FMS 2.The organization’s environment and facilities operate to ensure safety of
patients, their families, staff and visitors.
FMS 3.The organization has a programme for engineering support services.
FMS 4.The organization has a programme for bio-medical equipment management.
FMS 5.The organization has a programme for medical gases, vacuum and compressed
air.
25. 8. FACILITY MANAGEMENT AND SAFETY
FMS 6.The organization has plans for fire and non-fire emergencies within the facilities.
FMS 7.The organization plans for handling-community emergencies, epidemics and other
disasters.
FMS 8.The organization has a plan for management of hazardous materials
26. 9. HUMAN RESOURCE MANAGEMENT
HRM 1: The organization has a documented system of human resource planning.
HRM 2: The organization has a documented procedure for recruiting staff and orienting
them to the organization’s environment.
HRM3: There is an ongoing programme for professional training- and development of
the staff.
HRM4: Staff is adequately trained on various safety-related aspects.
HRM5: An appraisal system for evaluating the performance of an employee exists as an
integral part of the human resource management process.
27. 9. HUMAN RESOURCE MANAGEMENT
HRM6: The organization has documented disciplinary grievance handling policies and
procedures.
HRM7: The organization addresses the health needs of the employees.
HRM8: There is a documented personal record for each staff member.
HRM9: There is a process for credentialing and privileging of medical professionals
permitted to provide patient care without supervision.
HRM 10: There is a process for 'credentialing and privileging of nursing professionals,
permitted to provide patient care without supervision.
28. 10. INFORMATION MANAGEMENT SYSTEM
IMS 1: Documented policies and procedures exist to meet the information needs of the
care providers, management of the organization as well as other agencies that require
data and information from the organization.
IMS 2: The organization has processes in place for effective management of data.
IMS 3: The organization has a complete and accurate medical record for every patient.
IMS 4: The medical record reflects continuity of care.
IMS 5: Documented policies and procedures are in place for maintaining confidentiality,
integrity and security of records, data and information.
29. 10. INFORMATION MANAGEMENT SYSTEM
IMS 6: Documented policies and procedures exist for retention time of records, data and
information.
IMS 7: The organization regularly carries out review of medical records.
30. ACCREDITATION PROCEDURE
Self-Assessment
Application for accreditation
Pre - Assessment visit
Final Assessment of hospital
Issue of Accreditation Certificate
Surveillance
Re assessment
31. PREARATION FOR ACCREDITATION
Make a definite plan of action for obtaining accreditation
Nominate a responsible person to co-ordinate all activities related to accreditation.
Must have conducted self-assessment against NABH standards at least 3 months before
submission of application and must ensure compliance
32. PRE ASSESSMENT
Check the preparedness of the hospital for final assessment
Commitment to quality goals and consonance to laid down standards
Review of the documentation system of the hospital
Explain the methodology to be adopted for assessment.
FINAL ASSESSMENT
Compliance with the NC’s pointed out during the pre-assessment.
Comprehensive review of hospital functions and services
33. LEVEL - ACCREDITATION
ENTRY LEVEL ACCREDITATION
All the regulatory legal requirements should be fully met.
No individual standard should have more than two zeros.
The average score for individual standard must not be less than 5.
The average score for individual chapter must be more than 5.
The overall average score for all standards must exceed 5.
Validity period min 6 months to max 18 months.
Cannot apply for assessment before 6 months.
34. PROGRESSIVE LEVEL
All the regulatory legal requirements should be fully met.
No individual standard should have more than two zeros.
The average score for individual standard must not be less than 5.
The average score for individual chapter must be more than 6.
The overall average score for all standards must exceed 6.
Validity period min 3 months to max of 12 months.
Cannot apply for assessment before 3 months.
35. LEVEL – ACCREDITATION (Continue…)
ACCREDITATION
All the regulatory legal requirements should be fully met.
No individual standard should have more than one zero to qualify.
The average score for individual standards must not be less than 5.
The average score for individual chapter must not be less than 7.
The overall average score for all standards must exceed 7.
Validity period is 3 years
36. SURVEILLANCE & RE-ASSESSMENTS
One surveillance visit in one accreditation cycle of three years.
Will be planned during the 2nd year i.e. after 18 months of accreditation.
May apply for renewal of accreditation at least six months before the expiry of validity
NABH may call for un-announced visit, based on any concern or any serious complaint or
incident reported
37. METHODOLOGY
Random Structured interviews
To determine their level of awareness and compliance with organization policies and
procedures.
To assess their awareness levels of their rights, privileges and patient rights.
To determine their satisfaction levels
38. METHODOLOGY
Observation
Visits to various areas
Facility surveys and tours
Review of documents
Adherence to statutory obligations
