NABH ENTRY LEVEL PROJECT

By: Mr. Kirankumar Ghanapuram

Consultant - Healthcare Management
kiranghanapuram@gmail.com
+91 9011017501
ABOUT NABH
• NABH - National Accreditation Board for Hospitals & Healthcare Providers
• Constituent board of Quality Council of India
• International Linkage – lSQua & ASQua
• NABH standards are in consonance with the global benchmarks
• Objective : Enhancing health system & promoting continuous quality improvement
and patient safety
• Vision : To be apex national healthcare accreditation and quality improvement body,
functioning at par with global benchmarks
• Mission : To operate accreditation and allied programs in collaboration with
stakeholders focusing on patient safety and quality of healthcare based
upon national/international standards, through process of self and external
evaluation

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ABOUT ENTRY LEVEL
• A stepping stone for enhancing the implementing all the Accreditation
quality of patient care and safety Standards
• Aim : To introduce quality and • Self-assessment against NABH Pre
accreditation to the HCOs as their first Accreditation Entry Level standards
step towards awareness and capacity after implementing it for at least 3
building months before submission of
• Objectives : To operate accreditation application
and allied programs in collaboration
with stakeholders focusing on patient
safety and quality of healthcare
• Next stage - Progressive Level and
finally to Full Accreditation NABH
Accreditation
• Practical methodology provides a step Progressive
Level Pre-
by step and staged approach for the Accreditation

HCOs face challenges and difficulties in Entry Level Pre-

Accreditation

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QUALITY DEFINITION
• Quality ?
– Degree to which a set of inherent characteristics fulfills requirements (as per
ISO 9000:2000)
– Characteristics imply a distinguishing feature
– Requirement are a need or expectation that is stated generally implied or
obligatory
– Degree of adherence to pre-established criteria or standards
• Quality Assurance : Part of quality management focused on providing confidence
that quality requirements will be fulfilled
• Quality Improvement : Ongoing response to quality assessment data about a
service in ways that improve the process by which the process by which services are
provided to patients

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Continue..
• The standard of something as measured against other things of a similar kind; the
degree of excellence of something
• Meeting the needs and exceeding the expectations of the patients
• Delivering all and only the care that the patient and family needs
• A doctor may say: “The kind of care that may relive the pain and suffering and
restore health to the best possible level”
• A patient may say, “The best possible treatment that is timely, safe and affordable,
and can restore his health to his earning capacity at the earliest”

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IMPORTANT DEFINITIONS
• Accreditation is self-assessment and external peer review process used by the
healthcare organizations to accurately assess their level of performance in relation
established standards and to implement ways to continuously improve the
healthcare system.
• Accreditation Assessment is the evaluation process for assessing the compliance of
an organization with the applicable standards for determining its accreditation
status.
• Objective Element is that component of standard which can be measured
objectively on a rating scale. The acceptable compliance with the measurable
elements will determine the overall compliance with standard.
• Objective is a specific of a desired short-term condition or achievement includes
measurable end-results to be accomplished by specific teams or individuals within
time limits.
• Standard is a statement of expectation that defines the structure and process that
must be substantially in place in an organization to enhance the quality of care.

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BENEFITS OF PRE ACCREDITATION
ENTRY LEVEL STANDARDS
• Benefits for Patients continuous improvement
– Patients are the biggest beneficiary – It enables hospital in
among all the stakeholders demonstrating commitment to
– Pre Accreditation Entry Level quality care. It raises community
standards result in improved confidence in the services provided
quality care and patient safety by the hospital
– The patients are serviced by – International recognition
trained & skilled medical staff – Provide boost to medical tourism
– Rights of patients are respected
and protected
• Benefits for Hospitals
– Pre Accreditation Entry Level
Standards for a hospital will
stimulate a journey towards

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Continue…
• Benefits for Hospital Staff
– The staff in a Pre Accreditation Entry Level certified hospital is sensitized over
the quality & patient safety & is satisfied as it provides for continuous learning,
good working environment, leadership and above all ownership of clinical
processes
– It improves overall professional development of Clinicians and Para Medical
Staff and provides leadership for quality improvement with medicine and
nursing
• Benefits to paying and regulatory bodies
– Finally, Pre Accreditation Entry Level Certification provides an objective system
of empanelment by insurance and other third parties
– It provides access to reliable and certified information on facilities,
infrastructure and level of care

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ORGANIZATIONAL STRUCTURE

National Accreditation Board for Hospitals and Healthcare

Providers (NABH)

Appeals Committee

Accreditation Technical
Secretariat
Committee Committee

Panel of Assessors &

Experts

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Continue…
• Accreditation Committee : The main functions of Accreditation Committee are as
follows:
– Recommending to Board about grant of Certification or otherwise based on
evaluation of assessment reports & other relevant information
– Approval of the major changes in the scope of Certification
– Recommending to the board on launching of new initiatives
• Technical Committee : The main functions of Technical Committee are as follows:
– Drafting of standards and associated documents
– Periodic review of standards
• NABH Secretariat : The Secretariat coordinates the entire activities related to NABH
Accreditation to hospitals and healthcare organizations
• Panel of Assessors and Experts : NABH has a panel of trained and qualified
assessors for assessment of hospitals

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ENTRY LEVEL STANDARDS
• NABH Pre Accreditation Entry Level Standards for Hospitals has 10 chapters
incorporating 45 standards and 167 objective elements
• Outline of NABH Chapters
Patient Centered Standards Organization Centered Standards

• Access, Assessment and • Continuous Quality

Continuity of Care (AAC) Improvement (CQI)
• Care of Patient (COP) • Responsibility of Management
• Management of Medication (ROM)
(MOM) • Facility Management and
• Patient Right and Education Safety (FMS)
(PRE) • Human Resource Management
• Hospital Infection Control (HIC) (HRM)
• Information Management
System(IMS)

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PREPARING FOR NABH
PRE ACCREDITATIONENTRY LEVEL
Obtain a copy of NABH Pre Accreditation Entry Level Standards for hospitals
(From NABH office)

Get accustomed to the standard & implement them

(By health care organization)

Fill the Application Form online

(On NABH web site)

Submit the Application Form + Self- Assessment toolkit + Application Fee + Document
(to NABH Secretariat)

Pay the Certification fee before the final assessment

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PREPARING FOR NABH
PRE ACCREDITATIONENTRY LEVEL
Application form + Self-Assessment Tool Kit + Documents + Application Fee

Acknowledgment and Scrutiny of application

(by NABH Secretariat) Feedback to
Health care
Certification Fee submitted to NABH Secretariat before Final Assessment
Organization
Final Assessment of hospital
And
(by Assessment Team) Necessary
Corrective Action
Review of Assessment Report
Taken By
(by NABH Secretariat) Healthcare
Review of report & Recommendation for Pre Accreditation Entry Level Certificate Organization
(by Accreditation Committee)

Issue of Pre Accreditation Entry Level Certificate for 2 years, 6 monthly report on
defined indicators to be submitted to NABH Secretariat

Renewal, Go for Pre Accreditation Progressive Level/ Full Accreditation

(by NABH Secretariat)

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Chapter 1: ACCESS, ASSESSMENT AND
CONTINUITY OF CARE (AAC)
• AAC.1: The organization defines and • AAC.6 Imaging services are provided as
displays the services that it can provide. per the scope of the hospital’s services
• AAC.2: The organization has a and established radiation safety
documented registration, admission programme.
and transfer process. • AAC.7 The organization has a defined
• AAC.3 Patients cared for by the discharge process.
organization undergo an established
initial assessment.
• AAC.4 Patient care is continuous and all
patients cared for by the organization
undergo a regular reassessment.
• AAC.5 Laboratory services are provided
as per the scope of the hospital’s
services and laboratory safety
requirements.

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Chapter 2: CARE OF PATIENTS
(COP)
• COP.1: Care of patients is guided by the scope of services provided by
accepted norms & practice. hospital.
• COP.2: Emergency services including • COP.6: Documented procedures guide
ambulance are guided by documented the care of pediatric patients as per the
procedures. scope of services provided by hospital.
• COP.3: Documented procedures define • COP.7: Documented procedures guide
rational use of blood and blood the administration of anesthesia.
products. • COP.8: Documented procedure guides
• COP.4: Documented procedures guide the care of patients undergoing surgical
the care of patients as per the scope of procedures.
services provided by hospital in
Intensive care and high dependency
unit.
• COP.5: Documented procedures guide
the care of obstetrical patients as per

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Chapter 3: MANAGEMENT OF
MEDICATION (MOM)
• MOM.1: Documented procedures guide the organization of pharmacy services and
usage of medication.
• MOM.2: Documented policies & procedures guide the storage of medications.
• MOM.3: Documented procedures guide the prescription of medications.
• MOM.4: Policies & procedures guide the safe dispensing of medications.
• MOM.5: There are defined procedures for medication administration.
• MOM.6: Adverse drug events are monitored.
• MOM.7: Documented policies & procedures govern usage of radioactive drugs.

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Chapter 4: PATIENT RIGHTS AND
EDUCATION (PRE)
• PRE.1: Patient rights are documented displayed and support individual beliefs,
values and involve the patient and family in decision making processes.
• PRE.2: Patient and families have a right to information and education about their
healthcare needs.

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Chapter 5: HOSPITAL INFECTION
CONTROL (HIC)
• HIC.1: The hospital has an infection control manual, which is periodically updated
and conducts surveillance activities.
• HIC.2: The hospital takes actions to prevent or reduce the risks of Hospital
Associated Infections (HAI) in patients and employees.
• HIC.3: Bio-medical Waste (BMW) management practices are followed.

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Chapter 6: CONTINUOUS QUALITY
IMPROVEMENT (CQI)
• CQI.1: There is a structured quality improvement, patient safety and continuous
monitoring programme in the organization.
• CQI.2: The organization identifies key indicators to monitor the structures,
processes and outcomes which are used as tools for continual improvement.

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Chapter 7: RESPONSIBILITIES OF
MANAGEMENT (ROM)
• ROM.1: The responsibilities of the management are defined
• ROM.2: The organization is managed by the leaders in an ethical manner.
• ROM.3: The organization has set up multi-disciplinary committees to oversee
specific areas of quality and patient safety.

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Chapter 8: FACILITY MANAGEMENT
AND SAFETY (FMS)
• FMS.1: The organization’s environment and facilities operate to ensure safety of
patients, their families, staff and visitors.
• FMS.2: The organization has a program for clinical and support service equipment
management.
• FMS.3: The organization has provisions for safe water, electricity, medical gas and
vacuum systems.
• FMS.4: The organization has plans for fire and non-fire emergencies within the
facilities.

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Chapter 9: HUMAN RESOURCE
MANAGEMENT (HRM)
• HRM.1: The organization has staffing commensurate with patient care needs.
• HRM.2: There is an ongoing programme for professional training and development
of the staff.
• HRM.3: The organization has a well-documented disciplinary and grievance
handling procedure.
• HRM.4: The organization addresses the health needs of the employees
• HRM.5: There is documented personal record for each staff member

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Chapter 10: INFORMATION
MANAGEMENT SYSTEM (IMS)
• IMS.1: The organization has a complete and accurate medical record for every
Patient
• IMS.2: The medical record reflects continuity of care.
• MS.3: Documented policies and procedures are in place for maintaining
confidentiality, integrity and security of records, data and information.
• IMS.4: Documented procedures exist for retention time of records, data and
information.

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ONSITE ASSESSMENT ACTIVITIES
• Opening Meeting
• Orientation of assessors to the organization’s services
• Document review
• Functional interview
• Visit to patient care areas and selected department
• Facility tour
• Special interview/ issue resolution
• Closing Meeting

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ENTRY LEVEL AWARD MEANS
That the organization ensures:
• Commitment to create a culture of quality , patient safety, efficiency and
accountability towards patient care.
• Establishment of protocols and polices as per national/ international standards for
patient care, medication management, consent process, patient safety, clinical
outcomes, medical records, infection control and staffing.
• Patients are treated with respect, dignity and courtesy at all times.
• Patients are involved in care planning and decision making.
• Patients are treated by qualified and trained staff.
• Feedback from patients is sought and complaints (if any) are addressed.
• Transparency in billing and availability of tariff list.
• Continuous monitoring of its services for improvement.
• Commitment to prevent adverse events that may occur.

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CONTACT US FOR
Our consulting services are
• NABH (All Level)
• NABH Safe I
• ISO 9001:2015
• Nursing Excellence
• Medical Laboratory Programme
• Emergency Department Standards
• Medical Facilitator Programme

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 Mr. Kirankumar Ghanapuram
Consultant - Healthcare Management
kiranghanapuram@gmail.com
+91 9011017501

kiranghanapuram@gmail.com
IT’S VERY SIMPLE

“Success is a Journey, Not a Destination!”

“In order to succeed, we first believe that we can!”

“Alone we can do so little, Together we can do so much!”

“The achievements of an organization are the results of the combined effort of each
and every individual!”

“As there is nothing training cannot do, Nothing is above its reach, Training can turn
bad morals to good, Destroy bad principles & recreate good ones, It can lift men to
performing excellence!”

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