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NATIONAL ACCREDITATION BOARD FOR HOSPITALS& HEALTHCARE PROVIDERS (NABH)Hospital Accreditation ProgramGeneral Information BrochureAugust 2020

NATIONAL ACCREDITATION BOARD FOR HOSPITALS& HEALTHCARE PROVIDERS (NABH)About NABHNational Accreditation Board for Hospitals and Healthcare Providers (NABH) is aconstituent board of Quality Council of India (QCI), set up to establish and operateaccreditation programme for healthcare organizations. NABH has been established withthe objective of enhancing health systems & promoting continuous quality improvementand patient safety. The board while being supported by all stakeholders, includingindustry, consumers, government, has full functional autonomy in its operation.NABH offers accreditation services to hospitals and other clinical establishments. NABHprovides accreditation in a non-discriminatory manner regardless of their ownership, legalstatus, size, and degree of independence.International Society for Quality in Healthcare (ISQua) has accredited NABH as anOrganization. The hospitals accredited by NABH have international recognition. Thisprovides boost to medical tourism in the country.NABH is an Institutional Member as well as a member of the Accreditation Council of theInternational Society for Quality in HealthCare (ISQua). NABH is one of the foundermember of Asian Society for Quality in Healthcare (ASQua).There has been demand from SAARC/ASIAN countries for NABH accreditation and to meetthis requirement, NABH has launched NABH International and to begin with Philippines isthe first overseas destination for extending NABH accreditation services.Page 2

NATIONAL ACCREDITATION BOARD FOR HOSPITALS& HEALTHCARE PROVIDERS (NABH)About NABHNABH provides accreditation to Healthcare organisations in a non-discriminatory mannerregardless of their ownership, legal status, size and degree of independence.The objective of NABH standards is to improve healthcare quality and patient safety.NABH currently operates the following accreditation, certification and empanelmentprogramsAccreditation programs:1. Hospitals2. Small Healthcare Organizations3. Blood Banks4. Medical Imaging Services5. Dental Facilities/Dental Clinics6. Allopathic Clinics7. AYUSH Hospitals8. Primary Health Centre9. Clinical Trail (Ethics Committee)10. Panchakarma Clinics11. Eye Care OrganizationCertification programs:1.2.3.4.5.6.7.8.Entry Level HospitalEntry Level Small Healthcare OrganizationsEntry Level AYUSH CentreEntry Level AYUSH HospitalNursing ExcellenceMedical Laboratory ProgrammeEmergency DepartmentMVTF Empanelment CertificationEmpanelment programs:NABH is the nodal body representing Quality Council of India for conducting assessmentsof healthcare organizations for empanelment under Central Government Health Scheme(CGHS) and Ex-Servicemen Contributory Health Scheme (ECHS).Page 3

NATIONAL ACCREDITATION BOARD FOR HOSPITALS& HEALTHCARE PROVIDERS (NABH)Introduction to AccreditationHospitals and Healthcare Organizations should be places of safety not only for patients butalso for staff and other stakeholders. Quality and patient safety at hospitals andhealthcare services is of great interest to government bodies, NGOs, insurance agencies,professional organizations representing healthcare workers and patients. Accreditationfocuses on establishing quality and safety in relation to predetermined standards.Accreditation encourages healthcare organization to pursue continual excellence.According to ISQua “A self-assessment and external peer review process used byhealth and social care organisations to accurately assess their level of performancein relation to established standards and to implement ways to continuouslyimprove the health or social care system.”In India, Health System currently operates within an environment of rapid social,economic and technical changes. Such changes raise the concern for quality and patientsafety in health care. Accreditation would be the single most important approach forimproving the quality of hospitals. Accreditation is an incentive to improve capacity ofnational hospitals to provide quality care and ensure patient safety. National accreditationsystem ensures that healthcare organizations, whether public or private, play theirexpected roles in health system.The hospital accreditation program was started in the year 2005. It is a flagship programfor NABH. This program was started with an intent to improve healthcare quality andpatient safety at public and private hospitals, has subsequently grown to greater heights,with the standards being recognised internationally at par with other global healthcareaccreditation standards and accredited by ISQua (International Society for Quality inHealthcare).Page 4

NATIONAL ACCREDITATION BOARD FOR HOSPITALS& HEALTHCARE PROVIDERS (NABH)Hospital Standards 3rd Edition, launched in November 2011 was accredited for a cycle of4 years (April 2012 to March 2016), 4th Edition, launched in December 2015 accreditedfor a cycle of 4 years (April 2016 to March 2020). Now the current 5th Edition, launched inFebruary 2020 is also accredited for a cycle of 4 years (April 2020 to March 2024). Theapproval of ISQua authenticates that NABH standards are in consonance with the globalbenchmarks set by ISQua.Page 5

NATIONAL ACCREDITATION BOARD FOR HOSPITALS& HEALTHCARE PROVIDERS (NABH)Benefits of AccreditationBenefits for Patients Patients are the biggest beneficiary among all the stakeholders. Accreditation results in high quality of care and patient safety. The patients are serviced by credentialed medical staff. Rights of patients are respected and protected. Patient’s satisfaction is regularlyevaluated.Benefits for Organization Accreditation to a health care organization stimulates continuous improvement. It enables the organization in demonstrating commitment to quality care andpatient safety thereby ensures best clinical outcomes. It raises community confidence in the services provided by the health careorganization as services provided by credentialed medical staff. It also provides opportunity to healthcare unit to benchmark with the best. An accreditation status also provides marketing advantage in a competitive healthcare. The HCO standards having been certified by ISQua gives an internationalrecognition which will also help to promote medical tourism. Finally, accreditation provides an objective system of empanelment by insuranceand other third parties.Page 6

NATIONAL ACCREDITATION BOARD FOR HOSPITALS& HEALTHCARE PROVIDERS (NABH)Benefits of AccreditationBenefits for Staff The staff in an accredited Hospital is satisfied lot as it provides for continuouslearning, good working environment and leadership. Efficiencies and competencies of staff also gets improved in an accredited Hospital. It improves overall professional development, knowledge and competencies insystematic ways with defined ownership and accountability of all the staff includingMedical and Para Medical Staff.Benefits to paying and regulatory bodiesFinally, accreditation provides an objective system of empanelment by insurance andother third parties. Accreditation provides access to reliable and certified information onfacilities, infrastructure and level of care.Page 7

NATIONAL ACCREDITATION BOARD FOR HOSPITALS& HEALTHCARE PROVIDERS (NABH)NABH Standards for HospitalsThe hospital accreditation programme assesses the quality and operational systems whichare in place within the facility. The accreditation includes compliance with the NABHstandards, applicable laws and regulations.NABH Standards for Hospitals is prepared by the technical committee constituted by NABHthat has eminent persons from Clinical, Nursing and Medical Administration areas. Theaccreditation standards take into consideration the requirements of various laws andregulations and guidelines set by the government from time to time. NABH Standard has10 chapters incorporating 100 standards and 651 objective elements.Out of 651 objective elements 102 are in core category which are mandatorily assessedduring each assessment, 459 are in commitment category which will be assessed duringfinal assessment, 60 are in achievement category which will be assessed duringsurveillance assessment and 30 are in excellence category which will be assessed duringre-accreditation.Ten chapters of Hospital Standards are:1. Access, Assessment and Continuity of Care (AAC)2. Care of Patients (COP)3. Management of Medication (MOM)4. Patient Rights and Education (PRE)5. Hospital Infection Control (HIC)6. Patient Safety and Quality Improvement (PSQ)7. Responsibilities of Management (ROM)8. Facility Management and Safety (FMS)9. Human Resource Management (HRM)10. Information Management System (IMS)Page 8

NATIONAL ACCREDITATION BOARD FOR HOSPITALS& HEALTHCARE PROVIDERS (NABH)Methodology for AccreditationHospitals willing to be accredited by NABH must be committed to ensure implementationof NABH standards in their organization.The assessment team look for the evidences of implementation of NABH Standards in theorganization. The Hospitals during the time of assessment should be able to demonstrateto NABH assessment team that all the requirements of NABH standard, as applicable, areimplemented & followed.Eligibility to apply for Hospital accreditationHealthcare organization (HCO) that fulfills the following requirements:oCurrently in operation as a healthcare provider, should be above 50 beds ashospitals below 50 beds will come under SHCO standards.oThe hospital has the minimum volume of patients which will help inassessing the quality of care given to the patients, which is currently 30%oThe organization that commits to comply with NABH standards andapplicable legal/statutory/ regulatory requirements.oHealthcare Organization should have been implemented NABH standards inthe HCO for a minimum of three months.These standards are to be used by the whole organisation and not for a specific servicewithin the organisation. Organisations offer multiple services and the standards areequally applicable to all services within the healthcare organisation.Page 9

NATIONAL ACCREDITATION BOARD FOR HOSPITALS& HEALTHCARE PROVIDERS (NABH)Methodology for AccreditationIt is important for the hospital to make a definite plan of action for obtaining accreditationand nominate a person to co-ordinate all activities related to seeking accreditation. Anofficial nominated by the hospital should be familiar with the latest standards of thehospital quality management system.The Hospitals standards are freely available for download from the NABH 05%20STD%20April%202020.pdfTheHospital accreditation guidebook need to be procured through the NABH website. One canpurchase the guidebook on standards by making the payment at the websitehttps://www.nabh.co/NABHStandards.aspxHow to apply?Once the standards are implemented in the hospital, the hospital can apply foraccreditation online from the website www.nabh.co(a) Use a new email id for registration(b) Choose ‘Hospital (Full Accreditation)’ as Application Type(c) NABH shall activate the email id and provide you the login and passwordUsing the above login and password – one can fill the application form.Page 10

NATIONAL ACCREDITATION BOARD FOR HOSPITALS& HEALTHCARE PROVIDERS (NABH)Accreditation ProcessPage 11

NATIONAL ACCREDITATION BOARD FOR HOSPITALS& HEALTHCARE PROVIDERS (NABH)NABH Accreditation ProcedurePreparation of Policies and Manuals:The Hospitals shall prepare the Quality Manual, Policies and Procedures and other Manualsrequired as per the NABH standard.Application for accreditation:The hospitals shall apply to NABH as per the instructions given in the online applicationportal. Hospitals should fill the application and provide the information details verycarefully as this is relevant to determine the scope of services and to take the processfurther.Scrutiny of application:Reference ID for the application is generated once the Hospital pays the application feesfrom ‘Make Payment’ option of the online application form. NABH officer shall scrutinizethe application form for its completeness. Hospital may correspond to NABH via writing in‘Remarks column’ of online portal of the hospital.Notification of Principal Assessor and Assessment Team:NABH shall appoint Principal Assessor who shall have the overall responsibility ofconducting the assessment for the Hospital and a team of other assessors. He/ She willevaluate the adequacy of all the documents including the quality manual, policies andprocedures and other departmental manuals as mandated by the standards.Types of Assessments conducted by NABHNABH in coordination with the hospital may choose to follow one of the following methodsfor conduct of the assessments based on environmental factors prevailing in the region inorder to ensure business continuity in its operations without compromising on quality.Page 12

NATIONAL ACCREDITATION BOARD FOR HOSPITALS& HEALTHCARE PROVIDERS (NABH)Onsite assessment: In onsite assessment, the assessors nominated by NABH makes avisit to the HCO for a predefined man days based on the bed strength of the hospital, theassessors verifies the documents, facilities and conducts interviews in person at the HCO.The Hospital needs to bear the cost of the assessor’s travel and stay.Desktop assessment: In this type of assessment the healthcare organization will submitinformation & documents as per the checklist which is based on applicable standards forHospitals & the same shall be reviewed by NABH assessor. The decision on continuation ofaccreditation shall be based on the recommendations made by the assessor.Remote assessment: In this type of assessment, the assessor (s) does not go to theHCO in person, but conducts the entire assessment from a remote location through theuse of virtual platforms. Hospital need to provide the online platform, there are nominaloverhead charges for hospi