Basic about NABH Description

1. BASIC ABOUT NABH
Prepared BY:
Mr. Nakul Yadav
ICN Cum Nursing Educator
M.Sc Nursing (Community Health Nursing)

2. WHAT IS NABH

3. WHAT IS QUALITY
•To the patients: Quality means being treated with empathy,
respect and concern
• To the professional : Quality means delivering the most
advanced knowledge and medical scientific skills to help/
save the patient
• To the medical audit: Quality means having the best
achievable outcome for each patient

4. FOCUS OF NABH STANDARDS
•Patient safety
•Staff and employee safety
•Environment and community safety
•Information Education and Communication

5. NABH STANDARDS

6. Outline of NABH Standards
Patient Centered Standards
• Access, Assessment and Continuity of Care (AAC)
• Patient Right and Education (PRE)
• Care of Patient (COP)
• Management of Medication (MOM)
• Hospital Infection Control (HIC)

7. Organisation Centered Standards
• Continuous Quality Improvement (CQI)
• Responsibility of Management (ROM)
• Facility Management and Safety (FMS)
• Human Resource Management (HRM)
• Information Management System (IMS)
Outline of NABH Standards

8. NABH Accreditation Standard Contents
SHCO
• 10 Chapters
• 61 Standards
• 290 Objective Elements

9. NABH Accreditation Standard Contents
HCO
• 10 Chapters
• 105 Standards
• 683 Objective Elements

10. WHAT IS QUALITY ?

11. • Appropriate application of medical knowledge with due regard
to the balance between the hazard inherent in every medical
intervention and the benefits expected from it
• It is, however more complex than this.

12. QUALITY FROM WHOSE POINT OF VIEW ?

13. •Provider of Health care Services
•Recipient of the Health care services
•Organizer of the Health care services

14. PROVIDERS CONCERNS
• To provide care as per established norms
• Adequate resources
• Self satisfaction with the final outcome
• Should contribute to enhancement of skills, competence and add to
experience

15. RECIPIENTS CONCERNS
• Accessibility
• Affordability
• Prompt attention
• Less waiting time
• Early diagnosis and cure
• Return to Productivity as early as possible
• Humane Treatment ie to be treated with empathy , respect and
concern

16. ORGANISERS CONCERNS
• Responsible to the Society for the funds spent on health care
• To ensure safety of public and prevent inappropriate or
suboptimal care
• To meet the requirements of the recipient and provider of the
health care services at Acceptable costs

17. WHAT IS ACCREDITATION

18. Accreditation is an external review of quality
with four principal components:
It is based on written and published standards
Reviews are conducted by professional peers
The accreditation process is administered by an independent body
The aim of accreditation is to encourage organizational
development.

19. Focus of standards
• Patient Safety
• Staff and employee safety
• Environment and community safety
• Information Education and Communication

20. PREASSESSMENT SURVEY
• To ascertain the readiness of the organisation for Accreditation
• Overview of the organizational preparedness and commitment to quality
goals and consonance to laid down standards
• Deficiencies noticed informed to the organisation
• Advice rendered on the methodology to be followed during the
Accreditation Survey
• Time frame worked out for the survey in mutual consultation

21. ACCREDITATION SURVEY
• Carried out by a team of Assessors depending upon the size, complexity
and facilities provided by the organisation
• Scope will include all standards related functions and all patient care
settings
• Onsite survey will consider specific cultural and legal factors which may
influence or shape decisions regarding the provision of care and /or
policies and procedures

22. METHODOLOGY OF SURVEY
• Initial presentation by the hospital
• Document Review
• Adherence to statutory obligations
• Visits to various areas
• Facility surveys and tours
• Random structured interviews

23. INITIAL PRESENTATION BY THE HOSPITAL
• Organogram
• Quality management Team
• Methodology followed for Quality Improvement
• Facilities provided
• Inputs on resources provided for Quality Improvement
• Identified high Risk Areas for patient care and safety
• Sentinel Events being monitored

24. INITIAL PRESENTATION BY THE HOSPITAL
• Key Monitoring Indicators
• Resource
• Volume
• Utilization
• Performance
• Control charts
• Problems faced and remedial measures undertaken/ being undertaken

25. DOCUMENT REVIEW
• Quality Manual
• Various Policies and Procedures
• Minutes of Meetings of various committees
• Medical Records
• Medical / Nursing Audit
• Adverse Events
• HAI
• Action Taken Reports
• Personal Records of Staff

26. OBSERVATIONS
• Facility Safety
• Level of compliance with laid down policies and procedures
• BMW Management
• Standard Precautions
• Patient care
• Fire Safety
• Equipment Management

27. INTERVIEW
•Staff Interview
•To determine their level of awareness and
compliance with organization policies and
procedures
•To assess their awareness levels of their rights,
privileges and patient rights
•To determine their satisfaction levels
•Patient and family Interview
•To assess their level of awareness of the care
process and their rights
•To determine their satisfaction levels

28. How to Go About
• Create willingness
• Initial impetus from Top management
• Requires involvement of all staff
• This requires repeated training and briefing
• Once consensus is there identify core coordinating or Quality
management Team

29. HOW TO GO ABOUT
• Examine what are you doing
• Find what you should be doing
• Document the gaps
• Compare with the standards
• Complete gap analysis
• Identify areas for improvement

30. PROBLEMS AND CHALLENGES
• HCOs are very enthusiastic
• Ill prepared
• Initial preparation is shoddy
• Resources required initially
• Benefits have a longer gestation period

31. PROBLEMS AND CHALLENGES
• Quality Consciousness at all levels will take time
• Sustenance and consistency of efforts will be required
• Commitment on a consistent basis
• High rates of attrition will require repeated and continual training
• Public Sector will take a longer time to get into the process
• Quality and consistency of assessors and assessments

32. Also Nothing Is Impossible
For,

33. Impossible
Means
I’ M Possible