NABH – Pre-assessment: Opening Meeting Apollo Hospital, Bhubaneswar

16 & 17 March 2012

• Mrs. Gracy Mathai• Dr. Deepak Singla

Dr Deepak Singla• Senior consultant, Pediatrics at Maharaja Agrasen Hospital,

New Delhi• MBBS, MD – pediatrics and DCh from CMC Ludhiana.• MBA in Health care services & Diploma and Hospital and

Health Care Administration.• Certified Manager of Quality & Organizational

Excellence (CMQ/OE) by American Society of Quality (ASQ)

• Presently pursuing Six sigma cert. from ASQ• NABH assessor for the last 3-4yrs assessed

many multispecialty hospitals

Gracy Mathai• Head- Administration & Quality, DM Healthcare – India

Operations, Cochin• Graduate in Nursing, Hospital Administration TISS-

Mumbai, MHRDM - Mumbai University• Chief Operating Officer, MIMS-Kottakkal.• Hospital Administrator, General Manager, MIMS-Calicut,

1st NABH Accredited Super speciality Hospital in India.• Lead Auditor – ISO 9001:2000 & 14000.• Involved with NABH as Principal Assessor, Faculty

Assessor’s Course.• Member- Technical Committee -NABH

• Standard : NABH Std. 2007 2nd Edition, all 100 standards and all applicable objective elements.

• Confidentiality assured.• Pre-Assessment is NOT a full assessment.

Scope of Pre-Assessment activities

• Determine the extent to which requirements of NABH standard 2nd edition 2007 have been established, documented and are being effectively implemented.

• Establish channels of communications • Freeze the wording of the scope for

assessment• Perform a preliminary document review• Sample a few requirements of NABH standard• Visit some areas of the hospital

Contd.• Plan out the schedule for final assessment• Confirm assessment man - day requirements• Determine any special requirements for the

final assessment, e.g. need to visit outreach centres

• Determine logistics, accommodation and transport

• Explain the methodology to be adopted for the final assessment

Schedule

• Will try to cover representative areas.• Staff must be available when required, during

assessment. • Patient care must NOT be interrupted. • Please inform the assessors if an important

procedure or operation or emergency situation arises, particularly a patient requiring resuscitation.

• Noting of assessment samples: any adverse situation coming to the notice of the assessors, at that point in time and in that place, will be noted. Please cooperate with the assessment team in providing details. The aim is NOT to penalise a person or a department. All adverse events will be presented before the assessment team.

No fault-finding, only fact-finding

Definition of Assessment

• A systematic, independent and documented process for obtaining evidence, evaluating it objectively and determining the extent to which policies, procedures and requirements, including stated, implied and statutory and regulatory needs, are fulfilled.

• Improvement is the main goal of an assessment.

• The assessors are not authorised to offer any advice, solutions or guidelines.

• We can only suggest broad principles for taking further action.

• Corrective actions will be encouraged, and noted. • Please do not approach the team for closure of

non-conformances while the assessment is in progress. But it may be closed at 11am on 17/03/12, while the assessment report is being compiled.

• However, the deficiency that required the correction will also be noted.

Compliance• Patient requirements, care and safety, and the safety

and well being of the visitors and relatives.• Interest and safety of the employees, contract

workers, nurses, students, doctors including visiting consultants.

• Statutory and regulatory requirements, all applicable laws.

• The Hospital's documented procedures and policies• Applicable clauses, standards and elements from the

NABH 2nd edition 2007 all 10 chapters & objective elements.

Guides• Knowledgeable guides must please be

assigned to and accompany each assessor. • Guides must inform assessors about dress

change, cap, mask, safety, footwear and other protocols.

• Guides must introduce the assessors to the staff & patients. Female guides MUST be present when the assessors are with female patients.

• Guides must facilitate communication amongst the assessment team and the assessee, including interpretation if required.

Interviews

• The assessors will need to conduct confidential interviews with patients, their families and with staff. At this time, the assessors will request privacy and may request for interpreters who will translate, in confidence.

We seek your co-operation in:• attempting to maintain time schedules• not contravening your protocols• timely production of documents & records• avoiding confrontation or 'cover-ups'• general facilitation of a smooth, pleasant and

mutually satisfying assessment, in the best interests of our patients

• keeping your cell phones switched off (or in silent mode) when the assessment is going on in your area

Closing Meeting• Tentatively scheduled for approximately 16 hours on 17th March.• Participating assessee’s and others

interested are welcome to attend. However, patient care must not be interrupted.

• Details of findings are discussed with the management and Quality Team. Therefore we will NOT be going into specific details. A general summing up and identification of areas for improvement will be highlighted.

Thank you so much &Best of Luck