NABH Standards for Hospitals

• The functioning of the hospital is based on sound principles of a system-based organization.
• There are implementation and institutionalization of the NABH standards in the healthcare unit’s operations.
• Integral core values of patient safety and care quality are completely established and owned by staff and management at all levels.
• Structured quality improvement programme is present based on a process of continuous monitoring of patient-care services.

1. Hospitals
2. Blood Banks
3. Dental Facilities
4. Wellness Centres
5. Small Healthcare Organisations
6. Diagnostic Centres
7. Medical  Imaging Services
8. Oral Substitution Therapy Centres
9. Ayush Hospitals

Benefits of NABH Accreditation

• Gauges the healthcare organization’s level of performance with NABH standards by accurate external peer assessment.
• Bestows a public recognition to the organization that gets accredited thereby promoting its image in society.
• Significantly benefits patients by ensuring

• Motivates staff by employee satisfaction and encouraging continuous learning, positive working environment, leadership capabilities and ownership of clinical processes.
• Stimulates continuous improvement in the organization and aids in a demonstration of commitment to quality of patient care.
• Enhances the level of community confidence in services offered by the healthcare organisation.
• Paves opportunity for healthcare units to benchmark themselves against the best in that segment.
• Enables an objective system of empanelment by insurance companies and other third party agents.
• Offers access to reliable and certified information on healthcare facilities, infrastructure and care levels.

How Can a Healthcare Consultancy assist in NABH Accreditation?

• Getting a copy of the NABH standards and helping the organization to do a self-assessment on the compliance status with respect to specified standards.
• Identifying the gap areas that need attention and devising a robust action plan to overcome them.
• Implementing the plan successfully to ensure that the NABH standards are seamlessly integrated into the organisation’s functional aspects.
• Assisting in the submission of the NABH assessment application form after obtaining a copy and subsequently paying the requisite fees.
• Co-ordinating with the NABH team for getting the assessment programme dates and names of assessors.
• Facilitating the NABH assessment which includes an onsite visit to patient rooms and selective departments. The assessment also involves interviews with patients, residents and staff. Additionally, HCF aids the assessment team in conducting facility tours for addressing problems related to medical devices, infrastructure, infection control mechanisms and security measures. All these steps are an integral part of the process.
• Receiving recommendations and getting the targeted NABH certification.
• Helping the organisation to maintain quality based continuous improvement programme for patient care services.

1. NABH has imposed standards for hospitals from two perspectives - patient and organization that varies with the size of the hospital and health care provider
2. Patient centric standards include AAC (Access, Assess and Continuity of care), COP (Continuity of Care), MOM (Management of Medication), PRE (Patients Right to Education) and HIC (Hospital Infection Control).
3. Organization centric standards include CQI (Continuous Quality Improvement), ROM (Responsibility of Management), FMS (Facility Management and Safety), HRM (Human Resource Management), IMS (Information Management System).

• In-patients procedures
• Out-patients procedures
• Procurement of medicines,  medical equipment including surgical equipment and maintaining adequate inventory to meet  ad hoc requirements
• Treatment procedures for in patient and outpatients
• Core committee framework to monitor clinical and managerial processes
• Periodic review meetings - To ensure continuous process improvement through key performance indicators.
• Quality standards have been imposed even for the waiting time for outpatients with regards to consultation and admission formalities for  in-patients
• Medication and treatment procedures should be documented for all cases
• ICU procedures and surgical procedures done should be documented with pre surgery and post surgery details for all cases
• Periodic clinical audits should be conducted.
• Dedicated complaint and grievance cell should be designated to address the grievance and complaints from patients
• Committee to follow up grievance addressed and resolved should be set up.
• Safety guidelines for employees and patients should be ensured at times of accidents and emergencies by the dedicated patients’ safety committee.
• Clinical risk committee should function monitoring and correcting clinical errors. Usually administrators, doctors and nurses are the core participants.
• There are specific guidelines for even needle pricks and anaesthetic procedures. Non-compliance with medical guidelines should be strictly prohibited and penalized
• Records proving rectifications in cases of errors occurred or quality guidelines violation, should be maintained for audit
• Quality standards are incorporated for wards and rooms in terms of size, facilities, hygiene, nutritional diets, planned nursing procedures etc.,
• Proper clinical disposal procedures should be practiced to avoid infections to patients and neighbourhood promoting environmental safety as clinical waste are serious health hazards