Why Hospitals and Healthcare Providers Should Obtain NABH Accreditation?

Every healthcare facility has internal operational rules and regulations. However, accreditation ensures that the organization complies with the norms and criteria established by a recognized, external organization. Accreditation provides an external validation mark for your company, demonstrating that they comply with industry standards and best practices. However, certification in healthcare is more than just a matter of reputation. Going through the certification process helps to streamline processes, enhance treatment quality, and foster confidence among patients and the community.

NABH offers a wonderful opportunity for healthcare businesses to create standards and processes while also improving the dependability of service operations. Accreditation is beneficial to all stakeholders in a hospital, but it is especially beneficial to patients. It encourages continual improvement in governance, operations, and activities for a hospital (clinical and administrative). Staff is imbued with a feeling of ownership and clinical competence. Accreditation is entirely optional, and in today’s competitive market, hospitals are more interested in establishing their quality-of-service delivery.

Accreditation is described as the public acknowledgment of a health organization’s achievement of accreditation requirements established by a National Health Accreditation agency. The National Accreditation Board for Hospitals and Healthcare Providers (NABH) is a component of the Quality Council of India (QCI), which was established in 2006 to oversee and certify healthcare providers and hospital programs. IRDA, on the other hand, is the primary independent top statutory board that governs the Indian insurance business.

Hospital accreditation is NABH’s flagship program, with the primary goal of encouraging patient safety and quality improvement in public and commercial hospitals. It creates a uniform framework for hospitals and other healthcare institutions to adopt compliance patient safety measures. NABH’s quality standards have been approved by the International Society for Quality in Healthcare. Not only this, but it may also be essential for a variety of other reasons. For example, did you know that having accreditation can make the process simple and safe? It can be almost just as important as what we believe it to be for you to have access to NABH awareness training and other opportunities. The followings are the significance and benefits of NABH accreditation:

  • The most beneficiaries are the patients: With NABH accreditation and the adoption of its requirements at the hospital, patients benefit the most from efficient services and excellent treatment. NABH supports improved patient happiness, which leads to improved clinical results. When the hospital obtains greater patient satisfaction numbers, it results in profit for all stakeholders and staff. It naturally motivates them to put in more effort and obtain cutting-edge technologies to raise the bar for better patient care.
  • Establishes a sense of social trust: NABH Accreditation contributes to improved community confidence in the services offered by the hospital’s certified medical team by enhancing the patient experience and staff productivity.
  • For insurance and third-party services, the IRDA requires NABH Accreditation: The Insurance Regulatory and Development Authority of India (IRDA) has now required all hospitals impaneled with it to enroll in NABH to provide treatment under Cashless Insurance Schemes (CIS). As it cuts down on inflated invoices and inconsistencies, NABH accreditation assures a fair billing procedure and quality care in hospitals.
  • Improved workplaces for employees: The training, updates, and skill development, proper NABH Documents that the personnel of NABH Accredited hospitals receives is comparable to those of their equivalents in worldwide hospitals. A positive work atmosphere and increased clinical process expertise are advantageous to the workforce of hospitals with NABH accreditation.
  • Hospitals benefit from an edge in marketing: The hospital that receives NABH accreditation benefits from increased medical care since it improves its reputation and sets it apart from other hospitals. NABH accreditation can increase patient confidence in the quality of services and healthcare facilities provided by the hospital, which supports in the growth of healthcare services at the hospital.

What is the NABH Accreditation Process for Hospitals in India?

The Government of India established the National Accreditation Board for Hospitals and Healthcare Providers (NABH) in 2005 to improve the country’s healthcare quality. The Quality Council of India (QCI) governs this autonomous agency, which is in charge of developing policies and maintaining QCI standards. Some international healthcare standards, such as the Japan Council for Quality in Health Care, the Australian Council on Healthcare Criteria, and the United States National Committee for Quality Assurance, are identical to the NABH accreditation standards.

To minimize medical errors, NABH requires hospitals to follow standardized SOPs (standard operating procedures). Additionally, SOPs enhance healthcare quality, efficiency, waste reduction, and employee happiness. NABH accreditation is only granted to hospitals that follow the SOPs. Let’s take a closer look at NABH and the stages involved in the NABH accreditation process for hospitals.

To get NABH certification, hospital administration must establish an action plan and choose an individual or organization to handle all accreditation-related activities. The steps for qualifying for NABH accreditation are as follows:

  1. The hospital seeking accreditation must hire a quality assurance officer who is familiar with the existing system. This assists the officer in identifying flaws and areas for improvement.
  2. The officer must have a comprehensive understanding of the NABH accreditation process. 
  3. The selected officer must confirm the implementation of higher standards in the hospital. 
  4. Before completing the application form, the hospital shall conduct a self-assessment against NABH criteria.

As a result, some of the processes that enable NABH accreditation for hospitals, which is a seven-step processes. The steps for obtaining NABH accreditation in India are as follows:

Step 1: Application Submission to NABH: After following the NABH standards for at least three months, the hospital should apply to NABH using the required application form. The following information is contained in the application form:

  1. Self-declaration of terms and conditions described by NABH
  2. Self-assessment, as suggested by NABH 
  3. Hospital manual/ quality standards as per prescribed NABH standards 
  4. Relevant documents to be uploaded with the application

Step 2: Review of Application by NABH: Following the submission of the NABH application, the NABH officers will review the forms as well as any documents. Before issuing accreditation, the department will ask the applicant to explain or correct any anomalies it finds in the form. If the application is appropriate and complete, the department will issue a letter of acknowledgment and a special reference number to the hospital.

Step 3: Pre-Assessment: The NABH department assigns a principal inspector or assessment team to pre-assess the hospital within three months of fee deposition as the next step in the accreditation process. Pre-assessments can be completed on-site, remotely, on a desktop, or in a hybrid format. The following are the same’s objectives: –

  1. Evaluate the hospital’s preparation for the final assessment
  2. Determine the number of assessors required and the duration of the accreditation process
  3. Review the authenticity of NABH documents / SOPs of the hospital
  4. Explain the practice to be adopted for the evaluation of the hospital

Step 4: Final Assessment: Within six months of the fee being deposited, the final assessment is completed in an onsite, remote, desktop, or hybrid format. It contains a thorough analysis of all the duties and products the hospital provides. To address any discrepancies or questions identified during the pre-assessment, the prospective hospital must take the appropriate corrective action.

Step 5: Review of Assessment Report: The chief assessor examines the assessment report after the last assessment. The following grading on a scale of 0, 5, and 10 is used to evaluate the assessment report and acknowledged some Conditions for qualifying for NABH accreditation:

  1. Compliance with the requirement
  2. Partial compliance with the requirement
  3. Non-compliance with the requirement

To be eligible for NABH accreditation, an organization must completely comply with all applicable regulatory and legal criteria. No individual standard may include more than one zero, and the average score for each standard cannot be less than five. The ultimate average score for all criteria must be greater than seven and the average score for each chapter cannot be less than seven.

Step 6: Approval and Issue of certification by Accreditation Committee: Within three months after the final evaluation, the accreditation committee approves and issues a certification of accreditation to the hospital if it meets the requirements for NABH accreditation. Also, the NABH accreditation certificate is effective for three years.

Step 7: Reassessment and Surveillance: Upon the announcement of the certificate of accreditation, the NABH team will perform annual surveillance and reassessments for the following three years. At least six months before the NABH accreditation’s validity expires, the hospital must apply for renewal of accreditation.

List of Standard Operating Procedures (SOP) Required for Pre-Accreditation Entry Level Standards for Hospital

Hospital Accreditation is a public acceptance by the National Accreditation Board of Hospitals and Healthcare. It is the achievement of accreditation standards by a Healthcare Organization, which is demonstrated through an independent external peer assessment of that organization’s level of performance about the standards. NABH aims to operate accreditation and associated programs in collaboration with stakeholders focusing on patient safety and quality of healthcare. It also encourages health care organizations (HCOs) to join the quality journey, which is why the NABH has developed Pre-Accreditation Entry Level certification standards, in consultation with various stakeholders as a stepping stone for enhancing the quality of patient care and safety. The goal is to introduce quality and accreditation to HCOs as a first step toward raising awareness and capability. After achieving Pre-Accreditation Entry Level Certification, the HCO can prepare to advance to the next stage – “Progressive” Level Certification, and finally “Full Accreditation” status. This methodology offers a step-by-step and staged approach that is suitable for any HCOs.

To implement the pre-accreditation Entry Level for hospitals, they must have facilities above 50 beds for patients. It enables hospitals in demonstrating a commitment to quality care. It raises community confidence in the services provided by the hospital. Implement the Pre-accreditation entry-level standards for hospitals beginning with document preparation. Also, the documents cover Manuals, Procedures, SOPs, etc. Individuals can start preparing with the Standard operating procedures. The pre-accreditation NABH documents – SOP contains Access, assessment, and continuity care (AAC), Care of patient (COP), continuous quality improvement (CQI), Management of Medicine (MOM), and patient rights and education (PRE) departments. The list of SOPs is given below:

Access, assessment, and continuity care (AAC)

  • SOP for the scope of services
  • SOP for registration
  • SOP for assessment policy
  • SOP for laboratory safe practices
  • SOP for radiology services
  • SOP for discharge procedure

Care of patient (COP)

  • SOP for uniform care of the patient
  • SOP for ambulance services
  • SOP for emergency care
  • SOP for the handling of medical-legal cases
  • SOP for rationale use of blood & blood products
  • SOP for the care of the vulnerable patient
  • SOP for the administration of anesthesia
  • SOP for the care of the patient under surgical procedure
  • SOP for quality assurance Program- surgical services
  • SOP for prevention of adverse events in the surgical patient
  • SOP for the pediatric patient

Continuous quality improvement (CQI)

  • SOP for continuous quality improvement

Management of Medicine (MOM)

  • SOP for Pharmacy services
  • SOP for Storage of Medication
  • SOP for Prescription of Medicines
  • SOP for Dispensing of medication
  • SOP for Medication Administration
  • SOP for Use of Radioactive drugs

Patient rights and education (PRE)

  • SOP for patient rights
  • SOP for informed consent
  • SOP for protection of patient rights
  • SOP for communication

Implementing a Pre-Accreditation entry-level standard for the hospital can help to improve the level of community confidence and trust, also it gets quality and patient safety into focus. It also provides an external recognition. Pre-accreditation can Improve patient satisfaction levels as well as Improve healthcare outcomes. It makes a patient-centered culture in the hospital.

Overview of a NABH Accreditation for Hospitals & Healthcare

National Accreditation Board for Hospitals and Healthcare Providers is known as NABH. Implementing and managing an accreditation program for healthcare and hospital organizations is the main objective of NABH. To create goals and benchmarks for the improvement of the health sector, the constituent board of the Quality Council of India attends to the consumers’ highly demanded criteria. Various parties, including the public, the government, and businesses, support the NABH.

How to prepare for NABH accreditation?
To become the Hospital accredited by NABH, the administration should prepare a plan of action to obtain a goal. The first stage is to choose a person to oversee all the activities that apply for accreditation and organize their coordination. 

  • The initial step is to suggest a candidate who is acquainted with the current quality assurance system. The officer can identify the gaps where the hospital needs to work and what needs to be improved in this way.
  • The applicant hospital must have a thorough understanding of the NABH assessment process.
  • The hospital should employ officers to create benchmarks and oversee the application of higher standards.
  • The hospital should conduct a self-assessment drive before presenting the quality criteria to the NABH team. They can proceed with submitting the application form if they determine that everything is correct.

What are the NABH records required?
There are several statutory and no statutory documented records that the NABH team will ask you to update on their protocol. Other than primary NABH documents like Manual, procedures, SOPs, Plans, etc. following documented records required are listed below:

  • Hospital registration certificate
  • Details of doctors and support staff
  • List of the services provided
  • Hospital photographs
  • NOC from the Fire department
  • Lift NOC
  • SOPs for the various quality actions followed at the hospital
  • Any other Empanelment’s/ Accreditations
  • Bio-medical waste certificate

What are the benefits of NABH accreditation?
All healthcare centers with Full NABH or Entry-level NABH receive several benefits. The list below provides some significant benefits of NABH:

  • Hospitals get improved duties from insurance firms and government panels.
  • Foundation of huge recognition to the hospital, and helps build customer trust.
  • Decrease the costs by improving Operational Efficiency
  • Better staff utilization through training & clearer assignment of roles and responsibilities with credentialing and privileging
  • Optimizing usage of Materials with better Inventory Management, avoiding Stock-outs
  • Makes the hospital qualified for the service of global patients
  • Often monitored results help the workers and other staff members to ensure better services and amenities for the patients.
  • Reduction in Hospital Infections, Medical Errors, and Accidents resulting in dropping unnecessary stays at the hospital

How Your Organizations Get Benefits of Hospital Accreditation with NABH Consultancy?

In the recent times, demand for healthcare services has increased due to various market forces such as medical tourism, insurance, business growth and competition. As a result, the expectations of higher quality consumers have also increased, which has indeed lead to the introduction of national and international accreditation bodies to act as a quality assurance mechanism, thus enhancing customers access to better healthcare services.

National Accreditation Board for Hospitals and Healthcare Providers (NABH) defines Hospital Accreditation as a public recognition by a national or international healthcare accreditation body, of the achievement of accreditation standards by a healthcare organization, demonstrated through an independent external peer assessment of that organizations level of performance in relation to the standards.

NABH Accreditation Consultancy assists healthcare organizations to establish, comply, monitor and sustain the quality processes and helps in preparing the hospitals for the accreditation according to the latest standards & editions. NABH Consultancy provides complete guidance through implementation, NABH documentation as well as training required for quick accreditation.

Benefits of Hospital Accreditation with NABH Consultancy

Following are the key benefits that organization can achieve with implementation of NABH accreditation system in any hospitals and healthcare units.

  • Patients are benefited with Accreditation most.
  • 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 can be evaluated.
  • The staff are satisfied lot as it provides for continuous learning
  • Accreditation to a health care organisation stimulates continuous improvement.
  • It enables the organisation in demonstrating commitment to quality care.
  • It also provides opportunity to healthcare unit to benchmark with the best.
  • Accreditation provides access to reliable and certified information on facilities, infrastructure and level of care.

Introduced Readymade NABH Accreditation Documents for Eye Care Organization

Leading information sharing website for Hospital Accreditation and documentation consultancy services, Hospitalaccreditation.in introduced new product Documentation Kit for Eye Care Organization Accreditation.

Accreditation to Eye Care Organization (ECO) stimulates continuous improvement. It enables ECO in demonstrating commitment to quality care. It raises community confidence in the services provided by the ECO. It also provides opportunity to healthcare unit to benchmark with the best.

To accomplish this requirement, consultant form hospitalaccreditation.in with highly experienced in hospital accreditation have designed and offers Eye Care Organization NABH Documentation kit online to help Eye Care Organization. It covered all requirements of Eye Care Organization documentation. The document kit is having sample documents required for implementation of Eye Care Organization – NABH Accreditation as per latest National accreditation board of hospitals and healthcare provider standard (1st Edition September, 2016).

The complete set of eye care organization accreditation documents assists user to understand quality systems in hospitals and how to achieve fast and effective accreditation certification. Eye Care Organization Documentation kit contains documents like Manual, System Procedures, Process approach, Standard operating procedures, Eye Care Organization audit checklists, etc.

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