Pillars of Quality

An overview of NABH
Dr. A. M. Joglekar

Quality
Quality in Hospitals is all about meeting expectations of:
Patients
Statutory / Legal bodies
Internal Customers
Owners / Trust
Others
Third parties (NABH)

NABH has simplified matters by laying down accreditation

standards for Hospitals and Healthcare providers

NABH
3rd Edition (Nov. 2011)

Accreditation standards for Hospitals and

healthcare providers

NABH 3rd edition

636 (514) Objective Elements
102 (100) Standards
10 Chapters

Patient safety and Continuous Quality

improvement have been given emphasis
Standards are non-prescriptive
Guidance (remarks, interpretations) is integrated
Shall/should
vs.
can/could
Intent of each chapter explained

Key issues addressed

NABH
Patient
3
related

NABH
Multi disciplinary approach at Hosmac
Doctors
MHAs (Administrators)
Bio medical Engineers
Civil Engineers
Architects
Technical experts

References
MTP Act
PNDT Act
NACO policies on HIV/AIDS
SOPs by NACO
WHO Guidelines
CDC guidelines
Control of Hospital infection guidelines (CDC)
NABH guidelines for OTs
NABL guidelines
AERB for Radiology
Critical Care guidelines
Clinical Audit guidelines
ICMR guidelines for research and research related
FDA Act
National list of essential medicines
Code of Medical ethics by MCI
Organ Transplantation Act
BIS Standards
Clinical establishment Act

NABH Standards - Recap

Patient centered Standards
Access, Assessment and Continuity of Care (AAC)
Care of patients (COP)
Management of Medication (MOM)
Patients rights and education (PRE)
Hospital Infection Control (HIC)

NABH Standards - Recap

Organization centered Standards
Continuous Quality improvement (CQI)
Responsibility of Management (ROM)
Facility management and safety (FMS)
Human Resource Management (HRM)
Information management system (IMS)

Impact of improvement
Patient centered
AAC 15/14 ; 78/86

UID, Std. reports, DAR, OPD follow up, etc.

COP 18/20 ; 105/136
Nursing care std, Blood transfusion, Special groups, etc.
MOM 61/73
Rational use of drugs, Audit of prescriptions, patient
counseling on prosthesis/devices, etc.
PRE 5/7 ; 30/46
Info to patients, consents, complaint redressal, etc.
HIC 46/51
IC officer, Hand hygiene, safe inj and inf practices,
reprocessing, etc.

Impact of improvement
Organization centered
CQI 6/8 ; 39/57

Analyzing complains, feedback and incidences,

regular audits, review of nursing care, patient safety program, etc.
ROM 5/6 ; 25/38
Senior leaders and committee performance, service standards,
outsourced services, etc.
FMS 9/8 ; 43/54
Disaster management, Alt sources for gases, vacuum and comp.
air, etc.
HRM 13/10 ; 47/52
Recruitment procedure, manpower planning, etc.
IMS 41/43
24 hr access to medical records, records to contain test results

NABH Accreditation Process

Application for Accreditation (By Healthcare
organizations)
Acknowledgement & Scrutiny of the Application (By NABH
Secretariat)
Self assessments by Healthcare organizations (Toolkit
provided by NABH)
Pre-Assessment visits (By Assessment
Team)
Final Assessment of Hospital (By
Assessment Team)
Review of Assessment Report (By NABH
Secretariat)
Recommendation for Accreditation (By
Accreditation Committee)
Approval for Accreditation (By Chairman,
NABH)
Issue of Accreditation Certificates (By NABH
Secretariat)

Feedback to
Healthcare
Organizatio
ns
And
Necessary
Corrective
Actions
Taken
By
Healthcare
Organizatio
ns

Surveillance and Re
assessment
Accreditation to a hospital shall be valid for a period of three
years.
NABH conducts one surveillance of the accredited hospitals in
one accreditation cycle of three years.
The surveillance visit will be planned during the 2nd year i.e.
after 18 months of accreditation.
The hospitals may apply for renewal of accreditation at least
six months before the expiry of validity of accreditation for
which reassessment shall be conducted.
NABH may call for un-announced visit, based on any concern
or any serious incident reported upon by an individual or
organization or media.

Principles
NABH system integrates the following for managing
Hospital
assurance programs
quality
atQuality
HCOs:

Transition
Quality Improvement programs

NABH

Process bashing in lieu of person

What NABH gives

HCOs ??
Patient focused
Support from Top Management (by personal

examples)
Quality is everyones business
Process or system approach
UALITY
Q
Rationality and logic in
decision making
Continuous improvement

NABH a journey

Approach at GMH
New hospital v/s Old hospital
Quality system were focused
Defined vision Quality, affordability, rationality,
ethics and focus on emergency care
Framing policies in support of the vision
Process and procedures defined
Forms and formats designed and developed in

accordance to above

Approach at GMH
Hospital design validated

according to BIS standards.

Operation theatre according to ASHRAE standards.
Biomedical equipments from standard reputed
companies complying with quality standards.
Support and auxiliary equipments also from firms
complying quality standards.
All statutory/legal authorizations obtained and
complied with.
All personnel deployed were appropriately
qualified and experienced.

Approach at GMH
Prepared policy and process/other

manuals
Installed processes as per process manuals
Regular training to orient personnel
Formulated committees (Medical/non medical)
Designated medical departmental coordinators
Instituted patient feedback and analysis
system from Day 1
NABL accreditation for hospital lab obtained
prior to NABH

Approach at GMH
Senior management attended

NABH Assessor's course and

assessed other HCOs.
Conducted several self assessments.
Middle management/Doctors/Staff attended
various NABH workshops and participated in
NABH sponsored projects. (Six Sigma)
GMH was NABH accredited in June 2009, followed by a
surveillance visit.
Re-accreditation was accorded in June 2012 .

Quality Concepts
Quality was conceptualized, defined,

implemented, monitored, measured, reinforced

and constantly improved.
Apex body (Think Tank) was for
generating quality ideas, defining
benchmarks and quality indicators.
Hospital committees and others
advised and gave feedback to
the Apex body.

Quality Concepts

Approach to Assessment
At assessment, non compliances/partial

compliances were considered as opportunities

to improve rather than a matter of dispute,
maximizing benefits to the organization.
NABH system is a continuous NABH

quality improvement journey

Assessment Experience
Doctor interviews
Medical Documentation
Patient Interviews
Hand Wash facility
Registration of Staff
Credentialing and privileging
BMW Storage (bins)
Safety (Grab bars)
Fatal case analysis
Infection Control
Police verification
Question of affordability ??
Question on Ethicality

Assessment Experience
Fire Safety Fire NOC, Fire alarms, expired extinguishers, Fire training and drills,
Fire officer

Medical Documentation Illegible, Date and time, Name, designation of doctors,

completeness

Calibration of equipments Balances, centrifuges and Bio Med equipments

Testing water, air, RO water
Consents, time out and PA check
Marking of Surgical sites
Medical Audits
Committee meeting and MOM
MLC Reporting on discharge
Discharge at request (DAR)
Signage Fire, emergency exits, scope of services, clinical protocols, etc.
CPR Analysis
Others

Col. S. K. M. Rao has conducted a detailed scientific study of the deficient

Current scenario for NABH in India

Accredited
Hospitals
138
Huge improvement
opportunity for hospitals

Applicant Hospitals
471

Benefits of Accreditation
Patients :

High quality of care & safety.

Service by credentialed medical staff.
Rights of patients are safeguarded.
Patient satisfaction is the focused.

Hospitals :

Systemized approach rather than personalized approach.

Process driven rather than person driven.
Stimulates constant improvement in the healthcare
organization.
Demonstrates commitment to quality care.
Raises community confidence in the healthcare organization.
Opportunity for the healthcare organization to benchmark
itself against the best.

Benefits of Accreditation
Hospital Staff :
Improves staff satisfaction due to continuous learning, good

working environment, leadership and ownership of clinical

processes.
Improves overall development of medical & paramedical
staff.

Paying & regulatory bodies :

Objective system of empanelment for insurance bodies and

other third parties.

Access to reliable and certified information on facilities,
infrastructure and level of care.

NABH
NABH encourages us to do, what we should be

doing in the first place.

Quality is made to happen via sincere efforts of a

HCO. NABH makes the task easier.

Being good is difficult enough, demonstrating

goodness (by evidence) requires far more efforts.

NABH a journey of continuous

quality improvement.

Final
assessme
nt
Pre
assessme
nt
Self
assessme

Reaccreditati
on
Surveillanc
e

THANK YOU