1 national accreditation board for hospitals and healthcare providers the roadmap to nabh

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National Accreditation Board for National Accreditation Board for

Hospitals Hospitals and Healthcare Providersand Healthcare Providers

THE ROADMAP TO NABHTHE ROADMAP TO NABH

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National Accreditation Board for Hospitals & Health Care Providers

QCIQCI

QCI is an autonomous body set up by Govt. of India to establish and operate accreditation structure in the country.

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Structure of QCIStructure of QCI

Quality Council of India

National Accreditation Board

for Certification Bodies (NABCB)

National Board for Quality Promotion

(NBQP)

National Accreditation Board for Testing and

Calibration Laboratories (NABL)

National Registration Board for Personnel

and Training (NRBPT)

Quality Information

and Enquiry Service


(NABH)

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NABH is an institutional member of NABH is an institutional member of the International Society for Quality the International Society for Quality

in Health Care (ISQua)in Health Care (ISQua)

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Getting Started – The RoadmapGetting Started – The Roadmap

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The RoadmapThe Roadmap

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Application for accreditationApplication for accreditation

Prescribed application form.

Prescribed application fees

The applicant hospital must apply for all its facilities and services being rendered from the specific location.

(NABH accreditation is only considered for hospital’s entire activities and not for a part of it).

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Scrutiny of applicationScrutiny of application

Scrutiny of application is done for its completeness in all respect

Acknowledgement letter is issued to the hospital with a unique reference number.

(The hospital shall be required to quote this reference number in all future correspondence with NABH.)

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Self AssessmentSelf Assessment

Self-Assessment toolkit for self-assessing itself against NABH Standards (and submit to NABH secretariat).

A signed copy of ‘Terms and Conditions’ for Maintaining NABH Accreditation. (available free on the web-site).

Hospital shall submit their documents as per NABH standards and the procedure manuals.

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Pre-Assessment

NABH appoints a Principal Assessor/ Assessment Team who is responsible for pre assessment of healthcare organization.

NABH forwards the application form, documents, procedures, Self assessment toolkit to the Principal Assessor/ Assessment Team.

It is done on-site

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Objective of Pre-assessment

Check the preparedness of the hospital for final assessment

To review the scope of accreditation & Documentation

Explain the methodology to be adopted for assessment.

Copy of the report is handed over to the organization after the assessment and original sent to NABH Secretariat.

The hospital shall be required to pay the requisite Annual fee before the final assessment.

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Final Assessment The hospital is required to take necessary corrective action to the

nonconformities pointed out during the pre-assessment.

The final assessment involves comprehensive review of hospital functions and services.

NABH shall appoint an assessment team.

The team shall include Principal assessor (already appointed) and the assessors. The total number of assessors appointed shall depend on the number of beds and services provided.

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Final Assessment

The date of final assessment shall be agreed upon by the hospital management and assessors.

Assessment activities include interviews, visit to patient care areas, record reviews and facility tours.

Details of non-conformity(ies) are handed over to the hospital.

Based on the assessment, the report is prepared by the Principal assessor in a format prescribed by NABH.

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Scrutiny of assessment report

NABH shall examine the assessment report and seeks clarification and documentation from the Assessment Team and hospital, if required.

The hospital shall take necessary corrective action on the nonconformity and shall submit a report to NABH Secretariat within a pre-decided time period.

On receipt of evidence of corrective action, the report is placed before the Accreditation Committee.

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Scrutiny of assessment report

The Accreditation Committee shall review the assessment report & make appropriate recommendations regarding accreditation of a hospital to the Chairman, NABH.

In case the accreditation committee finds deficiencies in the assessment report to arrive at the decision, the Secretariat obtains clarification from the Principal assessor/assessors/hospital concerned.

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Issue of Accreditation Certificate

On successful recommendation, NABH shall issue an accreditation certificate to the hospital with a validity of three years.

The certificate has a unique number and date of validity.

The certificate is accompanied by scope of accreditation.

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Surveillance and Reassessment

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.

For renewal of accreditation, reassessment shall be conducted at least six months before the expiry of validity of accreditation.

NABH may call for un-announced visit, based on any concern or any serious incident reported upon by an individual or organization or media.

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NABHNABHQuality Council of IndiaQuality Council of India

Thank You

1 national accreditation board for hospitals and healthcare providers the roadmap to nabh

Documents

nabh accreditation

accreditation structure

nabh standards

nabh secretariat

hospitals entire activities

nabh sha

applicant hospital

self assessment toolkit