1. Presented by LT COL (DR) PRATIMA SINGH- QCI and NABH CERTIFIED CONSULTANT

2. QCI/NABHECHS CGHS STATE GOVT TPA Insurance Company Medicolegal Clinical est. act Medical tourism corporate

3. QCI NABH Accreditation committee Technical committee Secretariat Panel of experts/assessors Appeals committee Institutional member of ISQua NABH/NABL /NABET std for hco/shco/dental/m is/blood bank/phc

4.  REGISTRATION HOSPITAL  POLLUTION CONTROL DEPT-WATER/AIR/SOUND  BMW MANAGEMENT  AERB –RADIOLOGY  USG REGISTRATION AND TRACKER SONOGRAPHY  PHARMACY LICENSE  LIFT LICENSE  NARCOTIC DRUG LICENSE  CANTEEN LICENSE  SPIRIT  DIESAL STORAGE  COMPRESSED GASES  FIRE SAFETY

5. Front office managment registration admission transfer opd mgt Emergency Documentation Transfer Codes Disaster trg Lab Sample collection Processing Reporting Outsourcing Urgent report Internal quality External quality Documentation /forms/records/ Equipment and inventory mgt X ray/usg Legal mandatory Records Quality control Radiation safety Documentatio n /forms/report ing/ Quality assurance Equipment /inventory mgt

6. Icu Equipment Staff Medicines Bmw SOP/Protocols Documentations Infection control OT Anesthesia Surgery Consent Surgical safety checklist PAC Post op care High risk cases mgt SOP/Protocol Equipment Staff Material mgt Bmw/infection control documentaion Emergency services Gynae/obs Paed Ambulance Blood transfusion

7. Pharmacy License Narcotic drugs First in first out Procurement Storage Dispensing Documentation Opd/ipd/icu/ot/emergency Drugs doccumentaion 7 Rs of drug admin Reduce medication errors High risk drugs mgt Indent/store/dispense medicine safely

8. PATIENT RIGHTSPATIENTS RESPCONSENT INFORMED DECISION MAKING HIGH RISK COUNSELLING

9. Infection control manual Staff/patient Attendent HAI Infection control commiitee Infection control surveillance BMW/sterilization Disinfection Housekeeping Equipment disinfection CSSD OT/ICU/Emergency

10. Quality commitee Other hospital commiitees Quality indicators Quality manual Procedures Sops records All dept Audit

11. Management commitee Finance Policy Management review meeting All committees review Quality policy Ethics Safety pts and staff

12. Safety commitee Safety of staff patients.attendents visitors Disaster Fire Water Elect Gas Vaccum Radiation Equipment safety

13. Staff recruitment Personnel file Medical exam documentation Training retention Regular training Assessments competency Employee rights and resp Grievance Disciplinary

14. Med record Safety confidentiality completeness Mrd commiitee Med audit Medicolegal aspect Insurance companies/tpa Death cases LAMA cases Transfer cases Document check

15. MINIMUM LEVEL PREACCREDITATION ENTRY LEVEL CONTINUAL PROGRESSION PREACCREDITATION PROGRESSIVE LEVEL OPTIMUM LEVEL FULL CERTIFICATION

16. 1 COPY OF STANDARDS FORM NABH SECT GAP ANALYSIS WRT STANDARDS AND CLOSURE OF GAPS 2 SELF ASSESSMENT WRT STANDARDS QUALITY DOCUMENTATION COMPLETION 3 APPLICATION TO NABH +FEES +DOCUMENTS SELF ASSESSMENT TOOLKIT 4 SCRUTINY APPLICATION BY NABH CHECKING READINESS OF HCO AND DOCUMENT REVIEW 5 ASSESSMENT BY NABH ASSESSORS NON CONFORMANCE TO STANDARDS AND REVIEW 6 CLOSURE OF NC RAISED BY ASSESSOR ACCEPTANCE BY NABH ACCREDITATION COMMIITTEE 7 GRANT OF PREACCREDITATION STATUS ENTRY LEVEL

17.  Valid 2 years  6 monthly report indicators to NABH  Renewal/progressive level/full accreditation

18. THINK,DREAM,BELIEVE IN BEST PRACTICES Lets move together !! THANK YOU