National Accreditation Board for Hospitals and Healthcare Providers
National Accreditation Board for Hospitals and Healthcare Providers (NABH) is a constituent board of Quality Council of India, set up to establish and operate accreditation programme for healthcare organizations. The board is structured to cater to much desired needs of the consumers and to set benchmarks for progress of health industry. The board while being supported by all stakeholders including industry, consumers, government, have full functional autonomy in its operation.
Accreditation “A public recognition of the achievement of accreditation standards by a healthcare organization, demonstrated through an independent external peer assessment of that organization’s level of performance in relation to the standards”.
Accreditation benefits all stake holders. Patients are the biggest beneficiary. Accreditation results in high quality of care and patient safety. The patients get services by credential medical staff. Rights of patients are respected and protected. Patient satisfaction is regularly evaluated.
The staff in an accredited hospital is satisfied lot as it provides for continuous learning, good working environment, leadership and above all ownership of clinical processes.
Accreditation to a hospital stimulates continuous improvement. It enables hospital in demonstrating commitment to quality care. It raises community confidence in the services provided by the hospital. It also provides opportunity to healthcare unit to benchmark with the best.
Finally, accreditation provides an objective system of empanelment by insurance and other third parties. Accreditation provides access to reliable and certified information on facilities, infrastructure and level of care.
NABH standards for hospitals have been drafted by Technical committee of NABH and contain complete set of standards for evaluation of hospitals for grant of accreditation. The standards provide framework for quality assurance and quality improvement for hospitals. The standards focus on patient safety and quality of care. The standards call for continuous monitoring of sentinel events and comprehensive corrective action plan leading to building of quality culture at all levels and across all the functions. The standards are equally applicable to hospitals and nursing homes in the government as well as in the private sector.
Outline of NABH Standards Access, Assessment and continuity of Care (AAC) Patient Rights and Education (PRE) Care of Patient (COP) Management of Medication (MOM) Hospital Infection control (HIC) Continuous Quality Improvement (CIQ) Responsibility of Management (ROM) Facility Management and Safety (FMS) Human Resource Management (HRM) Information Management System
The Accreditation process involves comprehensive review of hospital’s compliance with NABH’s standards. Cardinal principles of assessment are;
- Hospital operations are based on sound principles of system based organization
- NABH standards are implemented and institutionalize into hospital functioning.
- Patient safety and quality of care, as core values, are established and owned by management and staff in all functions and at all levels.
- There is structured quality improvement programme based on continuous monitoring of patient care services.
Ten steps to accreditation:
- Step 1 Obtain copy of NABH standards
- Step 2 Carry out self assessment on status of compliance with the NABH standards.
- Step 3 Identify gap areas and prepare action plan to bridge the gaps.
- Step 4 Ensure that NABH standards are implemented and integrated with hospital functioning.
- Step 5 Obtain copy and submit application form for assessment.
- Step 6 Pay the accreditation fee.
- Step 7 Receive from NABH the assessment programme including dates and names of assessors.
- Step 8 Facilitate the assessment.
- Step 9 Receive recommendation on accreditation.
- Step 10 Maintain quality improvement programme based on continuous monitoring of patient care services.
NABH has on its panel, qualified and trained assessors for objective evaluation of hospitals. The assessment team will include two or more healthcare professionals. The team will comprise of clinicians, healthcare administrators, nursing supervisors, specialists (where required) depending on the size and scope of services being rendered by hospitals. For example in a team having two assessors, one will be clinician and one hospital administrator. The team of three or more assessors will comprise amongst clinicians, administrators, nursing supervisors, specialists (where required).
Criteria for NABH Assessors:
1) 1.1) For clinician: MBBS with 10 years of experience of which 5 years should be in a hospital
1.2) For administrator: PG in Management or Hospital Administration with minimum of 10 years of experience of which 5- years being in the hospital administration.
1.3) For Nursing assessor: B. Sc. / M. Sc. Nursing with 10 years of experience or diploma in general nursing and midwifery with 15 years of experience. In both the cases, minimum of 5 years experience should be in supervisory capacity in a hospital.
2) 2.1) The persons having credentials, as above would need to qualify in 5 days NABH assessors training programme. NABH would conduct these programmes as per schedule published from time to time
2.2) The successful candidates from the training programme would be formally empanelled with NABH as per criteria of registration.
