NABH -The Future of our Hospitals

National Accreditation Board for Hospitals & Health care Providers (NABH) is a matter of great importance for the hospitals. Even more important is to understand the process of getting the NABH accreditation and its benefits.

What are Benefits of NABH

The benefits of NABH include the following-

1-Continuation of existing TPA because due to IRDA Circular NABH Entry-level mandatory for a hospital providing TPA Facilities.

2-NABH certification will help in new empanelment of TPA due to certified information on facilities, infrastructure, and quality of care.

3-Cash patient will increase due to an increase in community confidence,

 4-CGHS Empanelment and 10% extra than Non-NABH.

5-ECHS Empanelment and 10% extra than Non-NABH.

What is NABH? NABH -The Future of our Hospitals

NABH is a constituent board of Quality Council of India , under the guidance of the Ministry of Commerce, Government of India, set up to establish and operate accreditation program for healthcare organizations. It was established in 2006, it is the principal accreditation for hospitals in India.

Has designed a detailed healthcare  standard for hospitals and healthcare providers. To comply with NABH standards, the hospital has to adopt a process-driven approach in all aspects of hospital activities, from registration, admission, pre-surgery, peri-surgery, and post-surgery protocols, discharge from the hospital to follow up with the hospital after discharge. NABH aims at streamlining the complete operations of a hospital.

Is equivalent to JCI and other International standards and the National Committee for Quality Assurance in the United States of America. Its standards have been accredited by ISQUA the apex body accrediting the accreditations, so NABH accreditation is equivalent to the world’s most leading hospital accreditation.

 NABH provides accreditation to a healthcare organization in a non-discriminatory manner. The hospitals which are accredited by NABH have international recognition which will boost up medical tourism.

Accreditation Process.

Accreditation is a public recognition of the achievement of accreditation standards by a healthcare organization, demonstrated through an independent external assessment of that organization’s level of performance to the standards. A hospital willing to get accreditation from NABH must implement NABH standards at all levels in its organization.

The hospital must implement NABH standards three months before application.

The assessment team will then check the implementation of NABH standards in the organization. The hospital shall be able to demonstrate to the NABH assessment team that all NABH standards applicable to hospitals are implemented otherwise they will raise Non-Conformity (NC).

The accreditation process is a systematic approach designed to ensure that an organization meets predefined standards of quality and excellence. This process involves several stages, from initial preparation to the final assessment by the accrediting body. Here’s a detailed overview of the typical steps involved in achieving accreditation:

1. Understanding Accreditation Requirements

Objective: To gain a comprehensive understanding of the standards and criteria set by the accrediting body.

• Research Accrediting Bodies: Identify the appropriate accrediting body relevant to your industry or sector.
• Review Standards and Criteria: Obtain the accreditation standards, guidelines, and criteria. Thoroughly review these documents to understand the requirements.
• Attend Workshops and Seminars: Participate in training sessions or workshops offered by the accrediting body to gain deeper insights into the accreditation process.

2. Commitment from Leadership

Objective: To secure the commitment and support of top management.

• Communicate the Benefits: Explain the importance and benefits of accreditation to the leadership team.
• Allocate Resources: Ensure that sufficient resources (budget, personnel, and time) are allocated to the accreditation process.
• Appoint a Champion: Designate a senior leader to champion the accreditation process and provide ongoing support.

3. Form an Accreditation Team

Objective: To assemble a dedicated team responsible for managing the accreditation process.

• Team Composition: Include representatives from relevant departments (e.g., quality, compliance, operations).
• Roles and Responsibilities: Define clear roles and responsibilities for each team member.
• Training: Provide training to the team on accreditation standards and the process.

4. Conduct a Gap Analysis

Objective: To identify gaps between current practices and accreditation standards.

• Assess Current Practices: Evaluate existing policies, procedures, and practices against accreditation standards.
• Identify Gaps: Document areas where current practices fall short of the standards.
• Prioritize Areas for Improvement: Prioritize gaps based on their impact on achieving accreditation.

5. Develop an Action Plan

Objective: To create a detailed plan to address identified gaps and achieve compliance with accreditation standards.

• Set Objectives: Define clear, measurable objectives for addressing each gap.
• Action Steps: Outline specific actions required to meet the standards.
• Timelines: Establish realistic timelines for completing each action.
• Assign Responsibilities: Assign responsibilities to team members for each action item.

6. Policy and Procedure Development

Objective: To develop or revise policies and procedures to align with accreditation standards.

• Draft Policies: Create new policies or update existing ones to meet accreditation requirements.
• Review and Approval: Ensure that policies are reviewed and approved by relevant stakeholders.
• Documentation: Maintain comprehensive and accessible documentation of all policies and procedures.

7. Training and Awareness

Objective: To ensure that all employees understand their roles in achieving and maintaining accreditation.

• Training Programs: Develop and deliver training programs on accreditation standards and new policies.
• Awareness Campaigns: Conduct awareness campaigns to highlight the importance of accreditation.
• Ongoing Education: Provide continuous education and training opportunities for staff.

8. Implementation of Changes

Objective: To implement the necessary changes in processes, policies, and procedures.

• Pilot Testing: Pilot new or revised processes in selected areas before full-scale implementation.
• Monitor Progress: Regularly monitor the progress of implementation efforts.
• Adjustments: Make adjustments as needed based on feedback and monitoring results.

9. Internal Audits and Mock Surveys

Objective: To assess compliance with accreditation standards and prepare for the formal assessment.

• Internal Audits: Conduct regular internal audits to evaluate compliance.
• Mock Surveys: Perform mock surveys to simulate the accreditation review process.
• Corrective Actions: Address any issues identified during audits and mock surveys.

10. Continuous Monitoring and Improvement

Objective: To maintain compliance and drive continuous improvement.

• Monitoring Systems: Establish systems for ongoing monitoring of compliance.
• Feedback Mechanisms: Implement mechanisms for collecting feedback from employees and stakeholders.
• Improvement Initiatives: Continuously identify and implement improvement initiatives.

11. Application for Accreditation

Objective: To formally apply for accreditation.

• Prepare Documentation: Compile all required documentation and evidence of compliance.
• Submit Application: Submit the application to the accrediting body along with supporting documents.
• Application Fee: Pay any required application fees.

12. On-Site Assessment

Objective: To undergo an on-site assessment by the accrediting body.

• Preparation: Ensure that all areas are ready for inspection.
• Staff Readiness: Prepare staff to demonstrate compliance and answer questions.
• Conduct Assessment: Participate in the on-site assessment conducted by the accrediting body’s assessors.

13. Review and Feedback

Objective: To respond to feedback from the accrediting body.

• Review Findings: Review the findings and feedback provided by the accrediting body.
• Corrective Actions: Implement any required corrective actions to address identified issues.
• Submit Evidence: Provide evidence of corrective actions taken to the accrediting body.

14. Achieving Accreditation

Objective: To receive and celebrate accreditation status.

• Accreditation Decision: Await the final accreditation decision from the accrediting body.
• Celebrate Achievement: Announce and celebrate the achievement with employees, customers, and stakeholders.
• Accreditation Certificate: Receive the accreditation certificate and display it prominently.

15. Maintenance of Accreditation

Objective: To sustain compliance and prepare for periodic reassessments.

• Ongoing Compliance: Continuously monitor and maintain compliance with accreditation standards.
• Reassessment Preparation: Prepare for periodic reassessments or renewals as required by the accrediting body.
• Continuous Improvement: Keep improving processes to exceed accreditation standards.

Myths 

The biggest myth about NABH is that it is a very lengthy procedure. Another myth is that it is a very costly procedure. The truth is that it is not very costly but it’s a revenue-generating process for the future. It is the need of the hour.

Some people also have a big misunderstanding that NABH accreditation requires drastic changes in infrastructure. The reality is that it just requires a systematic modification to a certain extent to improve patient and hospital safety, and quality of care.

Steps 

The first step in NABH Entry level is Gap Analysis followed by preparation of infrastructure, manpower, equipment, and legal compliances, preparing apex, HIC & safety manuals, SOP, Formats, work instructions, preparing various committees and safety teams, training of all hospital staff members, mock drills, monitoring various managerial & clinical quality indicators, Filling form online and uploading all documents and evidence for desktop assessment. The assessor will check everything and indicate deficiency by NC. The hospital will close them, then the onsite assessment will be done, NC Closure will be done, review by NABH assessor & raising some deficiencies list, deficiency closure by hospital online, review by Accreditation Committee held monthly & raising some deficiencies. After that Committee recommends NABH Certification and then the approval of the NABH Chairman Certificate is issued for two years. After two years, one could go for the full Accreditation/ Renewal of Certification.

Who can go for NABH

NABH accreditation occurs in hospitals, Blood bank, Allopathic Clinics, Dental Centers, Medical Imaging System, AYUSH Hospitals, PHC/CHC & Eye Care Organizations. NABH Certification occurs in Hospitals, Emergency departments, and Medical Laboratory.