1 National Accreditation Board for Hospitals and Healthcare Providers THE ROADMAP TO NABH

National Accreditation Board for Hospitals & Health Care Providers 2 QCI QCI is an autonomous body set up by Govt. of India to establish and operate accreditation structure in the country.

National Accreditation Board for Hospitals & Health Care Providers 3 Structure of QCI Quality Council of India National Accreditation Board for Certification Bodies (NABCB) National Board for Quality Promotion (NBQP) National Accreditation Board for Testing and Calibration Laboratories (NABL) National Registration Board for Personnel and Training (NRBPT) Quality Information and Enquiry Service National Accreditation Board for Hospitals & Health Care Providers (NABH)

National Accreditation Board for Hospitals & Health Care Providers 4 NABH is an institutional member of the International Society for Quality in Health Care (ISQua)

National Accreditation Board for Hospitals & Health Care Providers 5 Getting Started – The Roadmap

National Accreditation Board for Hospitals & Health Care Providers 6 The Roadmap

National Accreditation Board for Hospitals & Health Care Providers 7 Application for accreditation Prescribed application form. Prescribed application fees The applicant hospital must apply for all its facilities and services being rendered from the specific location. (NABH accreditation is only considered for hospital’s entire activities and not for a part of it).

National Accreditation Board for Hospitals & Health Care Providers 8 Scrutiny of application Scrutiny of application is done for its completeness in all respect Acknowledgement letter is issued to the hospital with a unique reference number. (The hospital shall be required to quote this reference number in all future correspondence with NABH.)

National Accreditation Board for Hospitals & Health Care Providers 9 Self Assessment Self-Assessment toolkit for self-assessing itself against NABH Standards (and submit to NABH secretariat). A signed copy of ‘Terms and Conditions’ for Maintaining NABH Accreditation. (available free on the web-site). Hospital shall submit their documents as per NABH standards and the procedure manuals.

National Accreditation Board for Hospitals & Health Care Providers 10 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

National Accreditation Board for Hospitals & Health Care Providers 11 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 assessment and original sent to NABH Secretariat. The hospital shall be required to pay the requisite Annual fee before the final assessment.

National Accreditation Board for Hospitals & Health Care Providers 12 Final Assessment The hospital is required to take necessary corrective action to the nonconformities pointed out during the pre-assessment. The final assessment involves comprehensive review of hospital functions and services. NABH shall appoint an assessment team. The team shall include Principal assessor (already appointed) and the assessors. The total number of assessors appointed shall depend on the number of beds and services provided.

National Accreditation Board for Hospitals & Health Care Providers 13 Final Assessment The date of final assessment shall be agreed upon by the hospital management and assessors. Assessment activities include interviews, visit to patient care areas, 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 the Principal assessor in a format prescribed by NABH.

National Accreditation Board for Hospitals & Health Care Providers 14 Scrutiny of assessment report NABH shall examine the assessment report and seeks clarification and documentation from the Assessment Team and hospital, if required. The hospital shall take necessary corrective action on the nonconformity and shall submit a report to NABH Secretariat within a pre-decided time period. On receipt of evidence of corrective action, the report is placed before the Accreditation Committee.

National Accreditation Board for Hospitals & Health Care Providers 15 Scrutiny of assessment report The Accreditation Committee shall review the assessment report & make appropriate recommendations regarding accreditation of a hospital to the Chairman, NABH. In case the accreditation committee finds deficiencies in the assessment report to arrive at the decision, the Secretariat obtains clarification from the Principal assessor/assessors/hospital concerned.

National Accreditation Board for Hospitals & Health Care Providers 16 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.

National Accreditation Board for Hospitals & Health Care Providers 17 Surveillance and Reassessment NABH conducts one surveillance of the accredited hospitals in one 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 at least six months before the expiry of validity of accreditation. NABH may call for un-announced visit, based on any concern or any serious incident reported upon by an individual or organization or media.

National Accreditation Board for Hospitals & Health Care Providers 18 NABH Quality Council of India Thank You