It is about NABH its chapters, standards and objective elements

1. NABH
 By Monica Pradeep Sharma

2. Quality Council of India (QCI) was set up jointly
by the Government of India and the Indian
Industry

3. Structure of QCI
3
Quality Council of
India
National
Accreditation Board
for Certification
Bodies (NABCB)
National Board for
Quality Promotion
(NBQP)
National Accreditation
Board for Testing and
Calibration
Laboratories (NABL)
National
Registration Board
for Personnel and
Training (NRBPT)
Quality Information
and Enquiry Service
National Accreditation
Board for Hospitals &
Healthcare Providers
(NABH)
National Accreditation Board for Hospital & Health Care Providers

4. 4
National Accreditation Board for Hospitals
and Healthcare Providers

5. 5
NABH is a constituent
board of QCI
It is established to provide accreditation services to
hospitals and healthcare providers
NABH is an institutional member of the International
Society for Quality in Health Care (ISQua)

6. 6
Structure of NABH
National Accreditation Board for Hospitals & Healthcare
Providers
Technical
Committee
Panel of
Assessor/Expert
Accreditation
Committee
Appeals
Committee
Quality Council of India
Secretariat

7. Need of accreditation
Medical
tourism
Increase
in
awareness
Demanding
customers

8. 8
NABH Standards
 Technical Committee of NABH has prepared
standards against which applicant will be evaluated
for grant of accreditation.
 Standards provide framework for quality assurance
and quality improvement.
 Focus on patient safety and quality of care.
 Equally applicable to hospitals and nursing homes
in govt. as well as in private sector.

9. Process for Quality Improvement
DocumentationPlan
Implementation
Monitoring

10. 10
NABH Standards as per 4th edition
10 chapters
105 standards
683 objective elements

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Section I:
Patient-Centered Standards
 Access, Assessment and Continuity of Care (AAC)
 Patients Rights and Education (PRE)
 Care of Patients (COP)
 Management of Medications (MOM)
 Hospital Infection Control (HIC)

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Section II:
Management Standards
 Continuous Quality Improvement (CQI)
 Responsibilities of Management (ROM)
 Facility Management & Safety (FMS)
 Human Resource Management (HRM)
 Information Management Systems (IMS)

13.  The organization defines & display the services that it can provide
 The Organization has well define registration & admission process
 There is appropriate mechanism for transfer or referral of the
patient
 During Admission Pt. & the family member educated to make
informed decision
 Patient care by the organization undergo an established initial
assessment
 Patient care by the organization undergo an regular reassessment
assessment
 Laboratory services provided as per the scope of services of the
organization
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14. Imaging services provided as per the scope of services of the
organization
There is established Imaging services quality assurance
programme.
There is an established Radiation safety programme
There is established laboratory quality assurance
programme.
There is an established laboratory safety programme.
The care is continues & multidisciplinary in nature
The organization has documented discharge process
Organization defines the content of discharge summary
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15.  Uniform care of patients is guided by the applicable laws & regulations
 Emergency services guided by the policy, procedure, applicable laws &
regulations
 Ambulance services are commensurate with the scope of the services
provided by the organization
 Polices & Procedures guide the care of patients requiring CPR
 Documented policies & procedures guide nursing care
 Documented procedure guide the performance of various procedure
 Policies & procedures defines rational use of blood & blood product
 Policies & procedures guide the care of patients in the intensive care &
High dependency unit
 Policies & procedure guide the care of vulnerable patients
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Policies & procedure guide Obstetric care
Policies & procedure guide the pediatric services
Policies & procedure guide the care of patients undergoing
moderate sedation
Policies & procedure guide the Administration of anesthesia
Policies & procedure guide the care of patients undergoing
surgical procedure
Policies & procedure guide the care of patients under restraint
Policies & procedure guide the appropriate pain management
Policies & procedure guide the appropriate rehabilitative services
Policies & procedure guide for all research activities
Policies & procedure guide nutritional therapy
Policies & procedure guide the End of life care
Policies & procedure guide the storage of medication

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Policies & procedure guide the organization for pharmacy
services & usage of medication
There is a hospital formulary
Policies & procedure guide the safe & rational prescription of
medication
Policies & procedure guide the safe dispensing of medication
Documented Policies & procedure for medication management
Patients are monitored after administration of drug
Near miss, ADR & medication error reported & analyzed
Policies & procedure guide the narcotic drugs & psychotropic
substances

18.  Documented Policies & procedure guide the use of implantable
prosthesis & medical devices
 Documented Policies & procedure to guide the use of medical
supplies & consumables
Documented Policies & procedure for the use of
chemotherapeutic agents
Policies & procedures govern usage of radioactive drugs

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The organization protects patients & family rights and inform
them about their responsibilities during care
Patient & family rights support individual beliefs, values &
involve the patient & family in decision making process
The patient & Family member are educated to make informed
decisions & are involved in delivery process
Documented procedure for obtaining patient or family consent
exist for informed decision making about their care
Patient & families have right to information & education about
their healthcare needs
Patient & family have right to information on expected cost
Organization has complain redressal system

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The organization has a well designed, comprehensive &
coordinated hospital infection control programme aimed at
reducing/ eliminating risk to patients, visitors & providers of care
The organization implements the policies & procedures laid dawn
in infection control manual
The organization performs surveillance activities to capture &
monitor infection prevention & control data
The organization takes actions to prevent & control healthcare
associated infection in patients
The organization provides adequate & appropriate resources for
prevetion & control of healthcare associated infection

21.  The organization identifies & takes appropriate action to
control outbreaks of infection
Documented polices & procedures for sterilization activities in
the organization
Bio medical waste is handled in an appropriate & safe manner
The infection control programme is supported by hospital
management & Employee health

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There is a structured quality improvement & continuous monitoring programme in the
organization
There is structured patient safety programme in the hospital
The organization identifies key indicator to monitor the clinical structures, processes
& outcome which used as tools for continual improvement
The organization identifies key indicator to monitor the managerial structures which
are used as tools for continual improvement
The quality improvement programme is supported by the management
There is established system for clinical audit
Incident, complaints & feedback are collested & analysed to ensure continual quality
improvement
Sentinel events are intensively analyzed

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The responsibilities of those responsible for governance are defined
The organization complies with the laid down and applicable
legislations and regulations
The services provided by each department are documented
The organization is managed by the leaders in an ethical manner
The organization displays professionalism in management of affairs
Management ensures that patient safety aspects and risk management
issues are an integral part of patient care and hospital management
The organization has a complete & accurate medical record for every
patient

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The organization has a system in place to provide a safe and secure
environment
The organizations environment & facility operate to ensure safety of
patients, their families, staff & visitors
The organization has a programme for engineering support services
The organization has a programme for bio medical equipment
management
The organization has a programme for medical gases, vaccum &
compressed air
The organization has plans for fire and non fire emergencies within the
facilities
The organization has a plans for handling community emergencies,
epidemics & other disaster
The organization has a plan for management of hazardous materials

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The organization has a documented system of human resource
planning
The organization has a documented procedure for recruiting staff
& orienting them to the organizations environment
There is an ongoing programme for professional training &
development of the staff
Staff are adequately trained on various safety related aspect
An appraisal system for evaluating the performance of an
employee exists as an integral part of the human resource
management process

26.  The organization has documented disciplinary and grievance
handling policy & procedures
 The organization addresses the health needs of the employees
 There is documented personal information for each staff member
There is a process for credentialing & privileging of medical
professionals, permitted to provide patient care without supervision
There is a process for credentialing & privileging of nursing
professionals, permitted to provide patient care without supervision

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Documented policy & procedure exist to meet the information
needs of the care providers, management of the organization as
well as other agencies that require data & information from the
organization
The organization has processes in the place for effective
management of data
The medical record reflect continuity of care
Documented policies & procedures are in place for maintaining
confidentiality, integrity & security of record, data & information
Documented policies & procedures exist for retention time of
records, data & information
The organization regularly carried out review of medical records