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1 NATIONAL ACCREDITATION BOARD FOR HOSPITALS & HEALTHCARE PROVIDERS (NABH) OBJECTIVE OF NABH: To establish and operate accreditation programme for Health Care Organizations Enhancing Health system & promoting Continuous quality improvement and patient safety NEED FOR HOSPITAL ACCREDITATION Public Recognition by a National Healthcare Accreditation Body Single most important approach for improving the quality of hospitals Promotes hospitals and ensures quality of care Ensures Transparent system of control ABOUT NABH Constituent Board of Quality Council of India Accreditation to Hospitals in a non-discriminatory manner regardless of ownership, legal status, size and degree of independence NABH is approved and a member of International Society for Quality in Healthcare (ISQua) Standards for Hospitals has been approved by International Society for Quality in Healthcare (ISQua) NABH is a founder member of proposed Asian Society for Quality in Healthcare (ASQua) being registered in Malaysia. NABH is a member of International Steering Committee of WHO collaborating Centre for Patient Safety as a nominee of ISQua Accreditation Council NABH is in consonance with the Global Benchmarks set by ISQua BENEFITS OF ACCREDITATION: BENEFITS FOR PATIENTS: High Quality of Care and Patient Safety Patients are serviced by Credential Medical staff Rights of patients are respected and protected Patients satisfaction is regularly evaluated Provides Boost to Medical Tourism

2 BENEFITS FOR HOSPITALS: Stimulates Continuous Improvement Enables in demonstrating commitment to Quality Care Raises Confidence in the services provided Provided opportunity to benchmark with the best BENEFITS FOR HOSPITAL STAFF Staff are more satisfied Provides continuous learning, good working environment, leadership Ownership of all clinical processes Improves Overall Professional development of clinicians and para medical staff Provides leadership for quality Improvement with medicine & Nursery BENEFITS TO PAYING & REGULATORY BODIES Objective system of empanelment by Insurance & other third parties Provides access to reliable and certified information on facilities, infrastructure and level of care NABH STANDARDS Prepared by Technical Committee Complete set of standards for evaluation of hospitals for grant of accreditation Provides framework for quality of care for patients and quality improvements for hospitals Helps to build a quality culture at all levels and across all functions of hospital Has 10 chapters incorporating 100 standards and 514 objective elements OUTLINE OF NABH STANDARDS PATIENT CENTERED STANDARDS Access, Assessment and Continuity of Care (AAC) Care of patients (COP) Management of Medication (MOM) Patient Right & Education (PRE) Hospital Infection & Control (HIC) ORGANIZATION CENTERED STANDARDS

3 Continuous Quality Improvement (CQI) Responsibility of management (ROM) Facility Management & Safety (FMS) Human Resource Management (HRM) Information Management System (IMS) NABH ACCREDITATION PROCESS FLOW Application for Accreditation Gap Assessment (Consultant) Implementation to NABH Standard Pre Audit of Hospital Final Audit of Hospital Review & Recommendation Issue the Certificate

4 FREQUENTLY ASKED QUESTIONS 1. What is NABH? National Accreditation Board for Hospitals & Healthcare Providers (NABH) is a constituent board of Quality Council of India (QCI), set up to establish and operate accreditation programme for healthcare organizations. The board while being supported by all stakeholders including industry, consumers, government, have full functional autonomy in its operation. For details, please read About NABH. 2. What is 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. 3. What are the benefits of Accreditation? Accreditation benefits all Stake Holders. Patients are the biggest beneficiaries. 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. 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. The Staff in an accredited hospital are satisfied lot as it provides for continuous learning, good working environment, leadership and above all ownership of clinical processes. It improves overall professional development of Clinicians and Paramedical staff and provides leadership for quality improvement within medicine and nursing. 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. 4. What are the programs being offered by NABH? Currently, NABH is offering accreditation programs for Hospitals, Small Health Care Organizations/Nursing Homes, Blood Banks and Transfusion Services, Oral Substitution Therapy (OST) Centres and Primary and Secondary Health Centres.

5 A couple of more programs such as Medical Imaging services, Dental Hospitals/Centres, AYUSH Hospitals are being developed. 5. How to apply for NABH Accreditation? The organizations can obtain the application form for NABH Accreditation from NABH Secretariat or download it from the web-site. The application form should be accompanied with the required application fee. Hospitals should also submit a signed document Terms and Conditions for Maintaining NABH Accreditation'. The same can be downloaded from the website. For more details please see Accreditation Documents'. 6. How can an organization prepare itself for NABH Accreditation? An organization planning to go for NABH accreditation may obtain a copy of NABH accreditation standards and carry out a self assessment on the status of compliance with the standards to ensure that the standards are implemented and integrated with the hospital functioning. What is the role of NABH in preparing organizations for accreditation? NABH provides information on documents and procedures. NABH also organizes awareness programs in general as well as on request of individual organizations. It also guides the applicant organization on different requirements at various stages of accreditation. However NABH do not provide consultancy. For the convenience of applicant organizations, NABET, which is another constituent Board of QCI has a program for registering qualified consultants/consulting organizations. These registered individuals/organizations are involved in providing consultancy to various health care organizations for NABH standards implementation within their organizations. 7. Is NABH accreditation a one-time phenomenon? NABH accreditation is not a one-time phenomenon. Once the organization gets accredited, accreditation shall be valid for a defined period. NABH conducts a regular surveillance of the accredited organization. The surveillance visit will be planned during the 2 nd year. 8. Does NABH have any International Linkages? NABH is an institutional member of International Society for Quality in Health Care (ISQua) as well as member of its Board and Accreditation Council. NABH standards for hospitals has been accredited by ISQua. The accreditation of NABH standard for hospitals authenticates that NABH standards are

6 in consonance with the global benchmarks set by ISQua and thus hospitals accredited by NABH will have international recognition. International Society for Quality in Health Care (ISQua) is an international body which grants approval to Accreditation Bodies in the area of healthcare as mark of equivalence of accreditation programme of member countries. NABH is also one of the founder members of newly emerging Asian Society for Quality in Healthcare (ASQua). This initiative is to strengthen the Asian representation at international level and improve the quality structure in healthcare. 9. How to get information about NABH accredited organizations? Please refer to Accreditation Register for the list of accredited and applicant organizations under different programs. One can also see the services being offered by accredited organizations in this section.