4+Roadmap+to+NABH+ +Final

7/29/2019 4+Roadmap+to+NABH+ +Final

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National Accreditation Board for Hospitals

and Healthcare Providers

THE ROADMAP TO NABH


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National Accreditation Board for Hospitals & Health Care Providers

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QCI

QCI is an autonomous body

set up by Govt. of India toestablish and operate

accreditation structure in the

country.


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Structure of QCI

NationalAccreditation Board

for CertificationBodies (NABCB)

National Board forQuality Promotion

(NBQP)

National AccreditationBoard for Testing and

CalibrationLaboratories (NABL)

National RegistrationBoard for Personnel

and Training(NRBPT)

Quality Information

and Enquiry Service

National AccreditationBoard for Hospitals &Health Care Providers

(NABH)


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NABH is an institutional member of

the International Society for Quality

in Health Care (ISQua)


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Getting Started The Roadmap


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The Roadmap


7/18National Accreditation Board for Hospitals & Health Care Providers

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Application for accreditation

Prescribed application form.

Prescribed application fees

The applicant hospital must apply for all its facilitiesand services being rendered from the specific location.

(NABH accreditation is only considered for hospitalsentire activities and not for a part of it).



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Scrutiny of application

Scrutiny of application is done for its completeness in all respect

Acknowledgement letter is issued to the hospital with a uniquereference number.

(The hospital shall be required to quote this reference number in allfuture correspondence with NABH.)



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Self Assessment

Self-Assessment toolkit for self-assessing itself against NABHStandards (and submit to NABH secretariat).

A signed copy of Terms and Conditions for Maintaining NABHAccreditation. (available free on the web-site).

Hospital shall submit their documents as per NABH standardsand the procedure manuals.



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Pre-Assessment

NABH appoints a Principal Assessor/ Assessment Team who is

responsible for pre assessment of healthcare organization.

NABH forwards the application form, documents, procedures,

Self assessment toolkit to the Principal Assessor/ Assessment

Team.

It is done on-site



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Objective of Pre-assessment

Check the preparedness of the hospital for final assessment

To review the scope of accreditation & Documentation

Explain the methodology to be adopted for assessment.

Copy of the report is handed over to the organization after the assessmentand original sent to NABH Secretariat.

The hospital shall be required to pay the requisite Annual fee before thefinal assessment.



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Final Assessment

The hospital is required to take necessary corrective action to thenonconformities pointed out during the pre-assessment.

The final assessment involves comprehensive review of hospitalfunctions and services.

NABH shall appoint an assessment team.

The team shall include Principal assessor (already appointed) and theassessors. The total number of assessors appointed shall depend onthe number of beds and services provided.



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Final Assessment

The date of final assessment shall be agreed upon by thehospital management and assessors.

Assessment activities include interviews, visit to patient careareas, record reviews and facility tours.

Details of non-conformity(ies) are handed over to the hospital.

Based on the assessment, the report is prepared by thePrincipal assessor in a format prescribed by NABH.


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Scrutiny of assessment report

NABH shall examine the assessment report and seeksclarification and documentation from the AssessmentTeam and hospital, if required.

The hospital shall take necessary corrective action onthe nonconformity and shall submit a report to NABHSecretariat within a pre-decided time period.

On receipt of evidence of corrective action, the reportis placed before the Accreditation Committee.


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Scrutiny of assessment report

The Accreditation Committee shall review the assessment report

& make appropriate recommendations regarding accreditation ofa hospital to the Chairman, NABH.

In case the accreditation committee finds deficiencies in theassessment report to arrive at the decision, the Secretariat obtains

clarification from the Principal assessor/assessors/hospitalconcerned.


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Issue of Accreditation Certificate

On successful recommendation, NABH shall issue an

accreditation certificate to the hospital with a validity of three

years.

The certificate has a unique number and date of validity.

The certificate is accompanied by scope of accreditation.


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Surveillance and Reassessment

NABH conducts one surveillance of the accredited hospitals inone accreditation cycle of three years.

The surveillance visit will be planned during the 2nd year i.e.after 18 months.

For renewal of accreditation, reassessment shall be conducted atleast six months before the expiry of validity of accreditation.

NABH may call for un-announced visit, based on any concernor any serious incident reported upon by an individual ororganization or media.


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NABH

Quality Council of IndiaThank You

4+Roadmap+to+NABH+ +Final

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