15 sep 2008 national accreditation board for hospitals and health care workers (nabh) accreditation...
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15 Sep 2008
National Accreditation Board for Hospitals and Health Care Workers (NABH)
ACCREDITATION STANDARDS
FOR HOSPITALS
15 Sep 2008
Accreditation
• Official approval of an organization
• Accredited– Officially approved
• Accreditation Standard
– is a statement of an expectation or requirement which
makes it possible to deliver quality care or services
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Accreditation: Definition
“A process in which an independent entity, separate
and distinct from the hospital, usually but not
necessarily non-governmental, assess the hospital
to determine if it meets a set of requirements
designed to improve the quality of health care being
rendered by the hospital”
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HEALTH CARE ORGANIZATION
OUTCOME
PROCCESS
STRUCTURE
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ORGANIZATION OF NABH
QUALITY COUNCIL OF INDIA
QUALITY COUNCIL OF INDIA
NABHNABHInternational Society for
Quality in Health Care(ISQua)
International Society for Quality in Health Care
(ISQua)
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ORGANIZATION OF NABH( Contd)
National Accreditation Board for Hospitals & Health-care workers
(NABH)
Accreditation Committee
Technical Committee
Secretariat
AppealsCommittee
Panels of Assessors& Experts
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Preparing for Accreditation
Obtain Copy of NABH Stds
Get Accustomed to Stds & Implement
Collect Application Form
Submit Application Form
Pay Accreditation Fee
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Accreditation Procedure
Application for Accreditation
Ack & Scrutiny of Application
Self-Assessment by HCOTool-kit provided by NABH
Pre-assessment visit by NABH team
Final Assessment of HospitalBy NABH Team
Feed back to & necessary corrective action by Health Care Organization
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Accreditation Procedure (Contd)
Review of Assessment Report(by NABH Sect)
Recommendation for Accreditation(By Accreditation Committee)
Approval Accreditation (Chairman NABH)
Issue of Certificate(NABH Sectt)
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Assessment Parameters
• 10 Chapters
• 100 Accreditation Standards
• 503 Objective Elements
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Grading of Standards
0 – Non Compliance
5- Partial Compliance
10 – Complete Compliance
Statutory provisions will require complete compliance
Satisfactory Total Score = 70
0 5 10
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Standards for Accreditation
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Standards: 2 sets
PATIENT CENTERED
1. Access, Assessment & Continuity of Care (AAC)
2. Pts Right & Education (PRE)
3. Care of Patient (COP)
4. Mgt of Medication (MOM)
5. Hosp Infection Control (HIC)
ORGANIZATION CENTERED
6. Continuous Quality Improvement (CQI)
7. Responsibility of Mgmt (ROM)
8. Facility Mgmt & Safety (FMS)
9. Human Resource Mgmt (HRM)
10.Information Mgmt System (IMS)
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Chapter 1 Access, Assessment and Continuity of Care (AAC)
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15 Sep 2008
Chapter 1 Access, Assessment and Continuity of Care (AAC)
• AAC.1. The organization defines and displays the services that it can provide.
• AAC.2. The organization has a well defined registration & admission process
• AAC.3. An appropriate mechanism for transfer or referral of patients who do not match the Org resources
• AAC.4. During admission the patient and I or the family members are educated to make informed decisions.
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Chapter 1. Access, Assessment and Continuity of Care (AAC)
• AAC.5. Patients cared for by the organization
undergo an estd initial assessment.
• AAC.6. All patients cared for by the organization
undergo a regular reassessment
• AAC.7. Lab services are provided as per the
requirements of the patients.
• AAC.8. There is an established laboratory quality
assurance programme.
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Chapter 1. Access, Assessment and Continuity of Care (AAC)
• AAC.9. There is an established laboratory safety programme.
• AAC.10. Imaging services are provided as per the requirements of the patients.
• AAC.11. There is an established quality assurance programme for imaging services.
• AAC.12. There is an established radiation safety programme.
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Chapter 1 Access, Assessment and Continuity of Care (AAC)
• AAC.13. Patient care is continuous and
multidisciplinary in nature.
• AAC.14. The organization has a documented
discharge process.
• AAC.15. Organization defines the content of
the discharge summary.
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Chapter 2 Care of Patients (COP)
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Chapter 2 Care of Patients (COP)
• COP.1. Uniform care of patients is provided in all settings of
the organization & is guided by the applicable laws,
regulations & guidelines.
• COP.2. Emergency services are guided by policies,
procedures and applicable laws and regulations.
• COP.3. The ambulance services are commensurate with
the scope of the services provided by the organization.
• COP.4. Policies and procedures guide the care of patients
requiring cardio-pulmonary resuscitation.
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Chapter 2 Care of Patients (COP)
• COP.5. Policies and procedures define rational use of blood and blood products
• COP.6. Policies and procedures guide the care of patients in the Intensive Care and High Dependency Units.
• COP.7. Policies and procedures guide the care of vulnerable physically and/or mentally challenged and children).
• COP.8. Policies and procedures guide the care of high risk obstetrical patients.
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Chapter 2 Care of Patients (COP)
• COP.9. Policies and procedures guide the care of Pediatric patients.
• COP.10. Policies and procedures guide the care of patients undergoing moderate sedation.
• COP.11. Policies and procedures guide the administration of anesthesia.
• COP.12. Policies and procedures guide the care of patients undergoing surgical procedures
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Chapter 2 Care of Patients (COP)
• COP.13. Policies and procedures guide the care of patients under restraints.
• COP.14. Policies and procedures guide appropriate pain management.
• COP.15. Policies and procedures guide appropriate rehabilitative services.
• COP.16. Policies and procedures guide all research
activities.
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Chapter 2 Care of Patients (COP)
• COP.17. Policies and procedures guide nutritional
therapy.
• COP.18. Policies & Procedures Guide the End of
Life Care.
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Chapter 3 Management of Medication (MOM)
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Chapter 3 Management of Medication (MOM)
• MOM.1. Policies and procedures guide the organization of pharmacy services and usage of medication.
• MOM.2. There is a hospital formulary.
• MOM.3. Policies and procedures exist for storage of medication.
• MOM.4. Policies & procedures exist for prescription of medications.
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Chapter 3 Management of Medication (MOM)
• MOM.5. Policies & Procedures Guide the Safe Dispensing of Medications.
• MOM.6. There are defined procedures for medication administration.
• MOM.7. Patients and family members are educated about safe medication and food- drug interactions.
• MOM.8. Patients are monitored after medication administration.
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Chapter 3 Management of Medication (MOM)
• MOM.9. Policies and procedures guide the use of narcotic drugs and substances.
• MOM.10. Policies & procedures guide the usage of chemotherapeutic agents.
• MOM.11. Policies and procedures govern usage of radioactive drugs.
• MOM.12. Policies and procedures guide the use of implantable prosthesis.
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Chapter 3 Management of Medication (MOM)
• MOM.13. Policies and procedures guide the
use of medical gases.
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Chapter 4 Patient Rights and Education (PRE)
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15 Sep 2008
Chapter 4 Patient Rights and Education (PRE)
• PRE.1. The organization protects patient & family rights & informs them about their responsibilities during care.
• PRE.2. Patient and family rights support individual beliefs, values and involve the patient and family in decision making processes.
• PRE.3. A documented process for obtaining patient and/ or family's consent exists for informed decision making about their care.
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Chapter 4 Patient Rights and Education (PRE)
• PRE.4. Patient and families have a right to
information and education about their healthcare
needs.
• PRE.5. Patient and families have a right to
information on expected costs.
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Chapter 5 Hospital Infection Control (HIC)
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Chapter 5 Hospital Infection Control (HIC)
• HIC.1. The organization has a well-designed,
comprehensive and coordinated infection control
pgme aimed at reducing/ eliminating risks to
patients, visitors and providers of care.
• HIC.2. The organization has an infection control
manual, which is periodically updated.
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Chapter 5 Hospital Infection Control (HIC)
• HIC.3. The infection control team is responsible for
surveillance activities in the identified areas of the
organization
• HIC.4. The organization takes actions to prevent or
reduce Associated Infections (HAl) in patients and
employees.
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Chapter 5 Hospital Infection Control (HIC)
• HIC.5. Proper facilities & adequate resources are
provided to support the infection control
programme.
• HIC.6. The organization takes appropriate actions to
control outbreaks of infections.
• HIC.7. There are documented procedures for
sterilization activities in the organization.
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Chapter 5 Hospital Infection Control (HIC)
• HIC.8. Statutory provisions with regard to Bio-
medical Waste (BMW) management are complied
with.
• HIC.9. The infection control programme is
supported by the management and includes
training of staff and employee health.
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Chapter 6
Continuous Quality
Improvement (CQI)
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15 Sep 2008
Chapter 6 Continuous Quality Improvement (CQI)
• CQI.1. There is a structured quality programme in
the organization.
• CQI.2. The organization identifies key indicators to
monitor the clinical structures, processes and
outcomes which are used as tools for continual
improvement.
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Chapter 6 Continuous Quality Improvement (CQI)
• CQI.3. The organization identifies key indicators to
monitor the managerial structures, processes and
outcomes which are used as tools for continual
improvement.
• CQI.4. The quality improvement programme is
supported by the management.
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Chapter 6 Continuous Quality Improvement (CQI)
• CQI.5. There is an established system for audit of
patient care services.
• CQI.6. Sentinel events are intensively analyzed.
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Chapter 7
Responsibilities of
Management (ROM)
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15 Sep 2008
Chapter 7 Responsibilities of Management (ROM)
• ROM.1. The responsibilities of the management are
defined.
• ROM.2. The services provided by each department
are documented.
• ROM.3. The organization is managed by the
leaders in an ethical manner.
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• ROM.4. A suitably qualified and experienced
individual heads the organization.
• ROM.5. Leaders ensure that patient safety aspects
and risk management issues are an integral part of
patient care and hospital management.
Chapter 7 Responsibilities of Management (ROM)
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Chapter 8
Facility Management and
Safety (FMS)
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15 Sep 2008
Chapter 8 Facility Management and Safety (FMS)
• FMS.1. The organization is aware of and complies with the relevant rules and regulations, laws and byelaws and requisite facility inspection requirements.
• FMS.2. The organization's environment and facilities operate to ensure safety of patients, their families, staff and visitors.
• FMS.3. The organization has a program for clinical and support service equipment management.
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• FMS.4. The organization has provisions for safe
water, electricity, medical gases and vacuum
systems.
• FMS.5. The organization has plans for fire and non-
fire emergencies within the facilities
• FMS.6. The organization has a smoking limitation
policy.
Chapter 8 Facility Management and Safety (FMS)
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• FMS.7. The organization plans for handling
community emergencies, epidemics and other
disasters.
• FMS.8. The organization has a plan for
management of hazardous materials.
• FMS.9. The organization has systems in place to
provide a safe and secure environment.
Chapter 8 Facility Management and Safety (FMS)
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Chapter 9
Human Resource
Management (HRM)
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Chapter 9 Human Resource Management (HRM)
• HRM.1. The organization has a documented system
of human resource planning.
• HRM.2. The staff joining the organization is
socialized and oriented to the hospital environment.
• HRM.3. There is an ongoing programme for
professional training and development of the staff.
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Chapter 9 Human Resource Management (HRM)
• HRM.4. Staff members, students and volunteers are
adequately trained on specific job duties or
responsibilities related to safety.
• HRM.5. An appraisal system for evaluating the
performance of an employee exists as an integral
part of the human resource management process.
• HRM.6. The organization has a well-documented
disciplinary procedure.
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Chapter 9 Human Resource Management (HRM)
• HRM.7. A grievance handling mechanism exists in
the organization.
• HRM.8. The organization addresses the health
needs of the employees.
• HRM.9. There is a documented personal record for
each staff member.
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Chapter 9 Human Resource Management (HRM)
• HRM.10. There is a process for collecting, verifying & evaluating the credentials (education, registration, training & experience) of medical professionals permitted to provide patient care without supervision.
• HRM.11. There is a process for authorizing all medical professionals to admit and treat patients & provide other clinical services commensurate with their qualifications.
15 Sep 2008
Chapter 9 Human Resource Management (HRM)
• HRM.12. There is a process for collecting, verifying and evaluating the credentials (education, registration, training and experience) of nursing staff.
• HRM.13. There is a process to identify job responsibilities and make clinical work assignments to all nursing staff members commensurate with their qualifications and any other regulatory requirements.
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Chapter 10 Information Management System (IMS)
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Chapter 10 Information Management System (IMS)
• IMS.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.
• IMS.2. The organization has processes in place for effective management of data.
• IMS.3. The organization has a complete and accurate medical record for every patient.
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Chapter 10 Information Management System (IMS)
• IMS.4. The medical record reflects continuity of
care.
• IMS.5. Policies and procedures are in place for
maintaining confidentiality, integrity and security of
information.
• IMS.6. Policies and procedures exist for retention
time of records, data and information.
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Chapter 10 Information Management System (IMS)
• IMS.7. The organization regularly carries out review
of medical records.
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