NABH Documents List: To Become an Accredited Eye Care Organization

Hospital quality issues, including levels and variances, are not brand-new. For decades, we’ll have recognized that hospitals vary in their capacity to deliver high-quality treatment to patients. Accreditation has been our country’s primary approach for guaranteeing and enhancing care. The idea is straightforward: use an outside, independent organization that applies objective standards to make sure hospitals are following evidence-based procedures to improve patient outcomes. The effectiveness of this strategy has not been made evident, despite the possibility of good logic.

In September 2016, the criteria of the eyecare organization were introduced. Prior to this, the SHCO program was used to consider eye hospitals for NABH accreditation; however, as time went on, it became clear that the majority of SHCO-related NABH standards did not apply to eyecare organizations due to specific compliance requirements, clinical process requirements, organizational requirements, manpower planning requirements, and equipment management requirements. The main advantages are positive clinical outcomes, highlighting the best clinical practices, analyzing the data for quality improvement, and reducing liabilities through risk management and reduction.

Eye care Organisations are an essential component of the healthcare system, and certification would be the most crucial strategy for raising the standard and safety of eye treatment for patients. Eye surgery complications, such as high post-surgical infection rates, need an emphasis on quality and patient safety at such facilities. Adherence to accrediting criteria in these environments enhances the quality of services, resulting in positive therapeutic results.

Not only should eye care facilities be safe for patients, but also for workers and other stakeholders. Quality and patient safety in eye care organizations is of major concern to government entities, non-governmental organizations (NGOs), insurance companies, and professional organizations representing healthcare personnel and patients. Accreditation is concerned with establishing quality and safety in relation to predefined requirements. Accreditation motivates eye care organizations to strive for continuous excellence. Organizations must first prepare the documentation in order to acquire accreditation. Here is a list of NABH documents for eye care hospitals may need to be created as part of the accreditation documentation preparations.

• General information brochure
• NABH standard for eye care organization
• policies & procedures for assessment, surveillance, and re-assessment of HCO
• NABH standard accreditation agreement 
• policy and guidelines for use of NABH accreditation/ certification mark
• desktop surveillance assessment issue 1
• NABH policy and procedure for focus visits to an accredited hospital
• NABH policy and procedure for surprise visits to an accredited hospital
• NABH policies and procedures for dealing with adverse and other decisions
• procedure for handling appeals
• policy & procedure for handling complaints
• NABH policy and procedure for change of name of an accredited certified healthcare organization

Use the comprehensive NABH document templates for Eye Care Organisation (ECO) from hospitalaccreditation.in to make the documentation development process simple and efficient. The document package contains sample papers that are needed to execute NABH hospital accreditation in accordance with the most recent guidelines from the National Accreditation Board of Hospitals. Many hospitals are successfully assessed, and the papers are created by a highly skilled team of individuals with extensive expertise in hospital system development and process improvement. Because the editable documents are written in plain English and are available for purchase in editable format, it is extremely simple to alter the content of the NABH accreditation handbook, NABH audit checklist, SOPs, formats, etc., and upgrade them in accordance with organizational needs.

Challenges That Healthcare Organizations Often Face When Preparing for NABH Accreditation?

According to hospitals and healthcare organizations, patients, staff, and other stakeholders should all be safe. The government, non-governmental organizations (NGOs), insurance companies, professional groups, and patients are concerned about the quality and security of healthcare services. The Quality Council of India (QCI) established NABH to provide accreditation services to healthcare enterprises. NABH’s official name in the medical industry is National Accreditation Board for Hospitals and Healthcare Services. Its primary purpose is to urge healthcare systems to improve and safeguard patients on an ongoing basis. Furthermore, NABH promotes medical tourism in the country and recognizes accredited institutions on a global basis. Here are a few of the challenges that organizations typically encounter while they are preparing for NABH accreditation.

1. A limitation of Core Team members: The representatives of the nursing team, quality assurance, human resources, NABH awareness training, engineering, microbiologists, housekeeping, front office, food and beverage, MRD, and pharmacy must all be a part of the core team. The core team, along with functional leaders, must conduct a thorough gap analysis involving the objective elements of accrediting requirements across all divisions. To complete the responsibilities & meet the necessary standards for the firm, the core team will have the full backing of the upper management.
2. Inconsistent procedures and procrastination: Most departments not have documented and implemented SOPs. Before embarking on the accreditation journey, the core accreditation team must face the major issue of breaking the inertia and ensuring that the SOPs are prepared on time by each department. The implementation of SOPs at the ground level is critical to the success of accreditation, which is accomplished through interdepartmental training. The audit observations, gap analysis, and gap correction are related to a department’s major result areas to ensure minimal non-compliance.
3. Unsafe Environment: To guarantee a safe environment for patients and workers, the organization must try to enhance the hospital infrastructure.
   • Adherence to national building codes on fire standards.
   • Reworking the bilingual signs is necessary.
   • HEPA filtering and OT direct excess should be managed; the air conditioning and laminar flow in OT must be improved.
   • The objectives for patient safety should be met.
   • All necessary committee meetings must be held properly by the organization, with thorough documentation.
4. Improper Documentation: The errors in the NABH documents and records, such as unsigned treatment orders, incomplete discharge forms, and incomplete prescription orders, need to be addressed most. The highest levels of government must recognize how sensitive the subject is and take action. The resident medical officers are essential in minimizing these mistakes. A team of medical officers must oversee the activity at the ward and the medical records office while developing a checklist to verify patient files.
5. Untrained Staff for Emergency Preparedness: The training department must determine the training requirements for the entire hospital as well as each department. It is necessary to identify and map the trainers for each activity in the training schedule. It is required to perform both laboratory and practical emergency training, and feedback from both must be critically assessed and presented to the core team.
6. Lack of acceptance of the Data-Driven Approach: As committees record and analyse quality indicators/metrics like surgical site infection and patient satisfaction index, accreditation forces a healthcare company towards a data-driven strategy. So, the hospital can proceed towards the road of everlasting improvement with the support of the top management effort in quality improvement initiatives.
7. Partial implementations of Laws and Regulations: Obtaining and maintaining permits for blood banks, pharmacies, and lifts are included in the list of regulatory requirements before accreditation. Additionally, the hospital needs to centralize tracking of all of these before applying for accreditation. Also, all department heads must begin prioritizing the sharing of all documents with management and the legal department.
8. Inconsistent Work: The timetable is crucial for obtaining accreditation. After the accreditation body’s pre- and post-evaluation, there is a set amount of time for non-compliances to be corrected. All of the staff of the healthcare business must be eager and enthusiastic to complete the optimal quality work on time. The core group will continue to assist the staff in advancing this process.
9. Having Misconceptions regarding Accreditation:  All stakeholders must know that Accreditation benefits them all. Accreditation also demonstrates a commitment to quality care. Accreditation also provides access to reliable and certified information on facilities, infrastructure, and level of care.
10. Inadequate Inventory Control Measures: Considering the large number of stores across the healthcare organizations, and drugs and consumables kept in each sub-store and patient area, it is a major challenge to identify expired and near-expiry drugs.

Also, the employees must understand and know what the accrediting body is looking for, how to read and interpret the accreditation requirements and know what are the benefits of getting accredited. This will help them to work towards it with better focus and enthusiasm. If you are well-prepared and have good project management, you should be able to avoid these difficulties and achieve your accreditation.

How Does Accreditation Enhance the Quality of Healthcare Organizations and Services?

A healthcare organization may choose to become accredited as part of a voluntary process in which qualified external reviewers assess their performance and compare it to benchmarks that have already been set. In a healthcare system which was constantly changing, significant regulatory revisions happen quickly and regularly. As a result of the accreditation process, the standard for healthcare institutions has been raised significantly, and this has led to ongoing improvements. Here are some of the ways accreditation improves the quality of healthcare organizations and services.

• The business operations of healthcare organizations can be improved through accreditation: Healthcare organizations can profit more than ever by utilizing the enormous worth of accreditation. Many people only associate accreditation with a contract and the survey experience, but with the right partner, accreditation can be the beginning of a business relationship that can help foster performance improvement, operational efficiency, and risk management—all elements of a successful business growth strategy—while upholding regulatory compliance.
• The procedure of accreditation supports a healthcare organization’s performance improvement: Maintaining performance improvement should be the major objective of certification for every healthcare organization. Maintaining all other objectives, including meeting legal obligations, obtaining higher compensation, and enhancing competitive advantage, depends on performance improvement. Many studies have shown that accreditation improves outcomes for several different medical diseases. The practice of accreditation is integrated into daily policies and procedures to enhance the quality of treatment and strengthen the organization by actively incorporating everyone in the company—from administrators and practitioners to facility engineers and human resources—in a culture of growth. The concept of quality improvement is included in all accrediting assessments. The broad issues discussed may have their roots in clinical care and patient safety, but they also serve as the foundation for an organization that performs well. Incorporating specific, quantifiable goals into each service area to establish data-driven, evidence-based protocols is one element, as is fully communicating reports to ensure engagement and establish accountability spanning from frontline staff through the governing body. Other elements include developing a universally applicable program to touch every area of an organization through data collection activities.
• The organization is better equipped for any emergency thanks to accreditation: Healthcare organizations that have taken part in the accreditation process are improving quality. Accreditation has also had an impact on the creation of policies, programs, and goals by mandating NABH awareness training, requesting infrastructure improvements, and altering the organization’s behaviour and practices. It has improved the ability to handle any situation, whether internal or external while continuing to deliver safer treatment and top-notch services. These organizations are more likely to have emergency preparedness strategies and already have policies for best practices to protect rights and the public’s health in place.
• Control Measures are supported by accreditation: Maintaining performance improvement should be the major objective of gaining accreditation for any healthcare institution, including group practice clinics, corporate entities, and hospital systems. Infection Prevention and Control (IPC) Programs are well-organized in accredited organizations. These groups provide a stronger ability to improve their disaster management strategies and are better able to handle various circumstances (from triage to inpatient).
• Efficient Communication among the staff is enhanced through accreditation: These organizations have comprehensive policies and procedures that make use of standards and enable fast and precise decision-making and reliable communication. Employees have received IPC, functional safety, risk management, protocols, and protocol adoption training. The accredited organization has receptive committees that frequently bring personnel together to obtain critical information and monitor and improve procedures. Hospitals that have earned accreditation are more inclined to strengthen their ties to professional medical staff associations.
• An enhanced framework and operational excellence are provided by accreditation: Approved businesses comply with an ingrained culture and internal procedures for quality monitoring, including appropriate data collecting, trustworthy performance indicators, and appropriate hospital accreditation documents as well as patient records and clinical data. Accreditation standards provide a framework to assist organizations in creating more effective organizational structures. Healthcare executives should make operational and strategic decisions based on the accreditation process.
• Enhancing Service Quality and Increasing Efficiencies through Accreditation: The quality of care is strongly correlated with accreditation. It has a positive association with the number of clients having mental health therapy and physical assessment, two components of treatment comprehensiveness. Operational effectiveness is essential for success since healthcare businesses have limited operating margins. Administrators and other leaders are tasked with managing and reducing expenditures while complying with a complicated system of federal and state requirements. 

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