ACCREDITATION FOR HOSPITALS

Dr. A. K. KHANDELWAL
ASSESOR OF NATIONAL ACCREDITATION
BOARD FOR HOSPITAL AND HEALTH SERVICE
PROVIDER
MEDICAL DIRECTOR
ANANDALOKE HOSPITAL NEUROSCIENCES
CENTRE
SILIGURI

WHY ACCREDITATION?

The increasing role of health insurance

Rise in number of medico-legal cases

Awakening of patients about their rights

.Medical tourism .

Indian Hospitals would have to apply for Health

care accreditation standards that will make them
comply to Quality standards.
An accreditation system will help to monitor the
quality of hospitals and treatment given to
patients

A need for a uniform country-specific accreditation

standards and accrediting body, to implement these
is realised by healthcare providers across the
country.
International standards too expensive and may
ultimately not suit the majority of healthcare
organisations in India.
Therefore the need for developing our own standards
is now being urgently felt.

National Accreditation Board for Hospital and

Healthcare Service Providers (NABH) under the
aegis of Quality Council of India (QCI) with the
cooperation of ministry of Health & family
Welfare,Govt of India, is constituted
The draft was prepared after studying various
international standards like JCAHO, JCI, Australian,
European, Thai Standards, besides various Indian
models available.

How does NABH score over various ISO

standards?
ISO is a certification and not an
accreditation.
ISO is generic and not specific to healthcare
industry.
ISO does not call for clinical audits, it centres
only on systems.
Accreditation on the other hand, focuses on
competency in terms of its staff, equipment,
premises, facilities etc with respect to the
scope of services being rendered by the
healthcare organisation

What is Accreditation
A public recognition of the achievement of
accreditation standards by a healthcare
organization, demonstrated through an
independent external peer assessment of that
organization's level of performance in relation to
the standards.

Benefits of Accreditation

Accreditation provides high quality of care

and patient safety.
The staff in a accredited hospital are
satisfied.
Accreditation to a hospital stimulates
continuous improvement.
Accreditation provides an objective system
of empanelment by insurance and other
third parties.

Ten steps to Accreditation:

Step 1 Obtain copy of NABH standards

Step 2 Carry out self assessment on status of
compliance with the NABH standards.
Step 3 Identify gap areas and prepare action
plan to bridge the gaps.
Step 4 Ensure that NABH standards are
implemented and integrated with hospital
functioning
Step 5 Obtain copy and submit application
form for assessment

.Step

6 Pay the accreditation fee

Step 7 Receive from NABH the assessment

programme including dates and names of
assessors
Step 8 Facilitate the assessment
Step 9 Receive recommendation on accreditation
.Step 10 Maintain quality improvement
programme based on continuous monitoring of
patient care services.

Access ,Assessment, And Continuity of Care

1. The organization defines and displays the
services it can provide.
2. The organization has a well defined registration
and admission process.
3. There is an appropriate mechanism for transfer
or referral of patients who do not match the
organization resources.
4. During admission the patients and/ or the
family members are educated to make informed
decision.
5. Patients care for by the organization undergo
an established initial assessment.

6. All patients care for by the organization

undergo a regular assessment
7. Laboratory services are provided as per the
requirement of the patients.
8. There is an established laboratory quality
assurance programme.
9. There is an established laboratory safety
programme.
10.Imaging services are provided as per the
requirement of the patients.
11.There is an established quality assurance
programme for imaging services.

12.There is an established radiation safety

programme.
13.Patient care is continuous and multi
disciplinary in nature.
14.The organization has a documented discharge
process.
15.Organization defines the content of the
discharge summary.

Patients Rights and Education

1. The organization protects patients and family
rights during care.
2. Patients and family rights support individual
beliefs, values and involve the patient and the
family in the decision making process.
3. A documented process for obtaining patient
and/ or families consent exists for informed
decision making about their care.
4. Patients and families have a right to information
and education about their health care needs.
5. Patients and families have a right to information
on expected costs.

Care of patients
1. Uniform care of patients is guided by the applicable
laws and regulations.
2. Emergency services are guided by the policies,
procedure and applicable laws and regulations.
3. The ambuance services are commensurate with the
scope of the services provided by the organisation.
4. Policies and procedures guide the care of patients
requiring cardiopulmonary resuscitation.
5. Policies and procedures define rational use of
blood and blood products.
6. Policies and procedures guide the care of
vulnerable patients in the Intensive care and high
dependency units.

7. Policies and procedures guide the care of vulnerable

patients (elderly, physically and / or mentally challenged
and children )
8. Policies and procedures guide the care of high risk
obstetrical patients.
9. Policies and procedures guide the care of pediatric
patients.
10.Policies and procedures guide the care of patients
undergoing moderate sedation.
11.Policies and procedures guide the administration of
anesthesia.

12.Policies and procedures guide the care of patients

undergoing surgical procedures.
13.Policies and procedures guide the care of patients
under restraints.
14.Policies and procedures guide appropriate pain
management.
15. Policies and procedures guide appropriate
rehabilitative services.
16.Policies and procedures guide all research activities.
17.Policies and procedures guide Nutritional therapy.
18.Policies and procedures guide the end of life care.

MANAGEMENT OF MEDICATION
1. Policies and procedures guide the organization of
pharmacy services and usage of medication.
2. There is a hospital formulary.
3. Policies and procedures exist for storage of
medication.
4. Policies and procedures exist for prescription of
medications.
5. Policies and procedures guide the safe dispensing
of medications.
6. Patients are monitered after medication
administration.

7. There are defined procedures for medication

administration.
8. Patients and family members are educated about safe
medication and food drug interactions.
9. Policies and procedures guide the use of narcotic drugs
and psychotropic substances.
10. Policies and procedures guide the usage of
chemotherapeutic agents.
11.Policies and procedures gover usage of radioactive or
investigational drugs.
12. Policies and procedures guide the use of implantable
prosthesis.
13.Policies and procedures guide the use of medical gases.

HOSPITAL INFECTION CONTROL

1. The organization has a well designed, comprehensive
and coordinated infection control programme aimed at
reduction / eliminating risk to patients, visitors and
providers of care.
2. The organization has an infection control manual,
which is periodically updated.
3. The infection control team is responsible for
surveillance activities in the identified areas of the
organization.
4. The organization takes actions to prevent or reduce
the risk of Hospital Associated infections (HIA) in
patients and employees.

5. Proper facilities and adequate resources are

provided to support the infection control
programme.
6. The organization takes appropriate actions to control
outbreak of infections.
7. There are documented procedures for sterilization
activities in the organization.
8. Statutory provisions with regard to biomedical
Waste (BMW) management are complied with.
9. The infection control programme is supported by the
organizations management and includes training of
staff and employee health.

CONTINUOUS QUALITY IMPROVEMENT

1. There is structured quality assurance and continuous
monitoring programme in the organization.
2. The organization identifies key indicators to monitor
the clinical structures, processes and outcomes.
3. The organization identifies key indicators to monitor
the managerial structures, processes and outcomes.
4. The quality improvement programme is supported by
the management.
5. There is an established system for audit of patient
care services.
6. Sentinel events are intensively analyzed.

RESPONSIBILITY OF MANAGEMENT
1. The responsibilities of the management are defined.
2. The services provided by each department are
documented.
3. The organization is managed by the leaders in an
ethical manner.
4. A suitably qualified and experienced individual heads
the organization.
5. Leaders ensures that patient safety aspects and risk
management issues are an integral part of patient care
and hospital management.

FACILITY MANAGEMENT AND SAFETY

1. The organization is aware of and complies with the
relevent rules and regulations, laws and byelaws and
requisite facility inspection requirement.
2. The organizations environment and facilities operate
to ensure safety of patients, their families, staff and
visitors.
3. The organization has a programme for clinical and
support service equipment management.
4. The organization has provisions for safe water,
electricity, medical gases and vacuum systems.

5. The organization has plans for fire and non-fire

emergencies within the facilities.
6. The organization has a smoking policy.
7. The organization plans for handling community
emergencies, epidemics and other disasters.
8. The organization has a plan for management of
hazardous materials.
9. The organization has systems in place to provide
a safe and secure environment.

HUMAN RESOURCE MANAGEMENT

1. The organization has a documented system of
human resource planning.
2. The staff joining the organization is socialized and
oriented to the hospital environment .
3. There is an ongoing programme for professional
training and development of the staff.
4. Staff members, students and volunteers are
adequately trained on specific job duties or
responsibilities related to safety.
5. An appraisal system for evaluating the performance
of an employee exists as an integral part of the
human resource management process.

6. The organization has a well documented disciplinary

procedure.
7. A grievance handling mechanism exists in the
organization.
8. The organization addresses the health needs of the
employees.
9. There is a documented personal record for each staff
member.
10.There is a process for collecting, verifying and
evaluating the credentials (education, registration,
training and experience ) of medical professionals
permitted to provide patient care without supervision

11.There ia a process for authorization all medical

professionals to admit and treat patients and provide
other clinical services commensurate with their
qualifications.
12.There is a process for collecting, verifying and
evaluating the credentials (education, registration,
training and experience ) of nursing staff.

13.There is a process to identify job responsibilities

and make clinical work assignments to all nursing
staff members commensurate with their
qualifications and other regulatory requirements.

INFORMATION MANAGEMENT SYSTEM

1. Policies and procedures exist to meet the information
needs of the care providers, management of the
organization as well as other agencies that require
data and information from the organization.
2. The organization has processes in places for
effective management of data.
3. The organization has a complete and accurate
medical record for every patient.
4. The medical record reflects continuity of care.

5. Policies and procedures are in place for maintaining

confidentiality, integrity and security of information.
6. Policies and procedures exist for retention time of
records, data and information.
7. The organization regularly carries out medical
audits.

THANK YOU