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.

Introduced Documentation Kit for Pre Entry Level Accreditation for Hospital Online

The Hospitalaccreditation.in, leading information sharing website for hospital accreditation and documentation consultancy services is announced that introduced new product Pre Entry Level for Hospital Documentation kit required for hospitals having facilities above 50 beds for patients.

The Hospitalaccreditation.in is offering Pre Entry Level for Hospital Accreditation Consultancy as well as selling Ready-to-use documentation kit, which saves time and cost of certification process. Pre Entry Level for Hospital document kit is having sample documents required for implementation of health safety system based on NABH as per latest NABH standard (1st Edition April, 2014) for Pre Accreditation entry level standards for Hospital.

The readymade Pre Level Accreditation for Hospital Documentation consists of following list of documents:

1. Hospital Manual
2. System Procedures
3. Standard Operating Procedures
4. Blank Formats
5. Hospital Committee
6. Hospital Audit Checklist

The complete sets of Pre Entry Level for Hospital documents are prepared by the highly experienced team of people with rich experience of hospitals system establishment and process improvement and many hospitals are appraised successfully.

The ready to use Pre Entry Level for Hospital documents priced at USD 599, which covers sample templates that are written in simple English and easily editable format. The user can update total documentation templates as per organization working system and create own documents for their company in quick time.

Free demo of the product can be download that help to learn list of documents covered in this product in details, visit: http://www.hospitalaccreditation.in/download/D145.pdf