NABH

(NATIONAL ACCREDITION FOR BOARD FOR HOSPITAL AND HEALTH CARE)

10 CHAPTERS 100 STANDARDS 514 OBJECTIVE ELEMENTS

definition
"The success of any quality assurance programme depends almost entirely on the commitment and interest of the administrators, nurses, paramedical staff and physicians. OR A self-assessment and external peer assessment process used by healthcare organizations to accurately assess their level of performance in relation to established standards and to implement ways to continuously improve'.

Rom-1The responsibilities of the management are well defined.

Governance is the activity of governing. "Governance" is what a "government" does. It relates to decisions that define expectations, grant power, or verify performance. It consists either of a separate process or of a specific part of management or leadership processes. Sometimes people set up a government to administer these processes and systems.

Objective Element

Interpretation

Remarks For definition of mission refer to glossary.

a) Those responsible for governance lay down the organizations mission statement.

It is not only the head of the HCO members of the board of governors (where applicable)who need to define it. The governing board and the leader shall define and develop the process for strategic and operation plans so as to achieve the organizational mission statement

b)Those responsible for governance lay down the strategic and operational plans commensurate to the organizations missio n in consultation with the various stake holders.

Refer to glossary for strategic and operational plans. Stake holders include the community the organization serves.

OUR MISSION
to Improve The quality Of Life Of All By Providing Accessible And Affordable , Quality Health Care With Excellent Service Delivery.

Objective Element c)Those responsible for go vernance approve the organizations budget and allocate the resources required to meet the organizations mission. d)Those responsible for g overnance monitor and measure the performance of the organization against the stated mission. e)Those responsible for g overnance establish the organizations organogram.

Interpretation The governing board and the leaders of HCO shall have the policy for budgeting and resource allocation for attaining its mission and periodically review it. The governing board and the head of the HCO shall develop quarterly performance reports based on the strategic and operational plans. The HCO shall have a well defined organization structure/chart and this shall clearly document the hierarchy , line of control ,along with the functions at various levels.

Remarks

Objective Element

Interpretation

Remarks
Senior leader include the first two rungs of organogram. It is not only the head of the HCO but the members of the board of governors who need to support this.

f)Those responsible for g Self Explanatory overnance appoint the senior leaders in the organization. g)Those responsible for g overnance support research activities and quality improvement plans. h)The organization complies with the laid down and applicable legislations and regulations. Self Explanatory

Self Explanatory The responsibility of compliance lies with the first two level of the hierarchy. For eg. Free camps , out reach programmes , adoption of villages, PHCs etc.

i)Those responsible for g The governing board and overnance address Head of HCO shall the organizations social willfully develop social responsibility. responsibility policy and accordingly address it.

Rom-2 The services provided by each department are documented.

Objective Element a) Each organizational program, service, site or department has effective leadership. Interpretation There needs to be a minimum qualification and relevant experience of the leader. The leader should have domain knowledge of that particular department. Each dept. activity is to be predefined . This could be documented either at individual department level or the HCO could have a brochure detailing the scope of each department. For ex nephrology dept. could do all activities like biopsy , shunts , fistulas , dialysis etc Remarks

b)Scope of services of each department is defined.

Objective Element c)Administrative policies and procedures for each department is maintained.

Interpretation This shall include administrative procedures like attendance , leave, conduct , replacement etc. Self explanatory

Remarks It could be common for the entire HCO.

d)Departmental leaders are involved in monitoring & surveillance activities and quality improvement.

To effectively implement this , each could have its dept. objectives/key performance indicators and the responsibility of achieving them could be that of the leader.

Rom-3 The organization is managed by the leaders in an ethical manner.

Objective Element Interpretation Remarks For definition of mission refer to glosssary.

a)The leaders make public The HCO shall have a the mission statement of mission statement and the the organization. same shall be displayed prominently. b)The leaders establish the organizations ethical management. c)The organization discloses its ownership. The HCO shall function in an ethical manner

A good reference guide is code of medical ethics2002 published by MCI.

The ownership of the The disclosure could be in hospital e.g. trust , private, the registration certificate/ public has to be disclosed quality manual etc.

Objective Element d)The organization honestly portrays the services which it can and cannot provide.

Interpretation Self explanatory

Remarks Here portrays implies that the HCO conveys to the patient clearly what it can and cannot provide . The services that it cannot provide could also be conveyed verbally. Refer to AAC also.

e)The organization honestly portrays its affiliations and accreditations.

Here portrays implies that the HCO conveys its affiliation , accreditation for specific department or whole hospital wherever is applicable. Self explanatory Also refer to PRE 5. the tariff could be devised by a tariff committee.

f)The organization accurately bills for its services based upon a standard billing tariff.

Rom-4 A suitably qualified and experienced individual heads the organization..

Objective Element
a)The designated individual has requisite and appropriate administrative qualifications.

Interpretation
Self explanatory

Remarks
This implies to the individual looking after the day to day operations and not to the chairman of the board of governors. Appropriate implies qualification in hospital management/administrati on.

b)The designated Self explanatory individual has requisite and appropriate administrative experience.

Appropriate implies administrative experience in a HCO.

Rom-5 Leaders ensure that patient safety aspects

and risk management issues are an integral part of
patient care and hospital management.

Objective Element

Interpretation

Remarks
This group could have a mix of administrators engineers , doctors and nurses. Refer to glossary for definition of safety programme. Refer to glossary for definition of adverse events and sentinel events .rewpoting of accident should not just be based on severity of the incident. In fact , all incident must be reported.

a)The organization has an Self explanatory interdisciplinary group assigned to oversee the hospital wide safety programme.

b)The scope of the programme is defined to include adverse events ranging from no harm to sentinel events.

The HCO shall have a system of reporting of all the incident/accident.

Objective Element c)Management ensures implementation of systems for internal and external reporting of system and process failures.

Interpretation The HCO has a system in place for internal and external reporting of system and process failures. Contingency plan shall be in place to deal with the situation of system and process failure anticipated within the organization. There shall be sufficient resources kept as contingency to address the risk reduction activities as and when the leaders proactively suggest. The end result of these shall result in preventive actions.

Remarks For ex. MRI machine of the HCO breaks down. In this case internal reporting is to be done to CEO and external reporting to be done to the patients.

d)Management provides resources for proactive risk assessment and risk reduction activities.

Refer to glossary for definition of risk assessment and risk reduction.

Thank You for your

time and attention.

Take care and stay safe!!