NABH - Introduction, Process, Indicators & Documents

1
NABH - Basics,Process, Documents Indicators

• Ms.Nikethana R Nair, M.Sc (Nsg), MBA (HA), M.Sc
  (Psy), M.Phil (HHSM),
• Nursing Superintendent,
• Meenakshi Mission Hospital Research Center,
  Madurai

2
Quality Council of India (QCI)

• Established in 1997 through a Cabinet decision of
  the Government of India.
• QCI is an autonomous organization under the
  Department for Promotion of Industry and Internal
  Trade, Ministry of Commerce Industry.
• It was established as the national body for
  accreditation quality promotion in the country.
  
• The Council was established to provide a
  credible, reliable mechanism for third-party
  assessment of products, services processes
  which is accepted recognized globally.

3
Accreditation Boards of QCI

• National Accreditation Board for Hospitals and
  Healthcare Providers (NABH)
• National Accreditation Board for Certification
  Bodies (NABCB)
• National Accreditation Board for Testing and
  Calibration Laboratories (NABL)
• National Accreditation Board for Education and
  Training (NABET)
• National Board for Quality Promotion (NBQP)

4
NABH Program and Activities

• Accreditation
• Certification
• Empanelment
• Training and Education

5
NABH Accreditation Programs

Oral Substitution Therapy Centre
Clinical Trial (Ethics Committees)
Integrated Rehabilitation Centres for Addict
Small healthcare Organization
Medical Imaging Services
Eye Care Organization
Blood Storage Centre
Community Health Care
Primary Health Care
AYUSH Hospitals
Panchkarma Clinic
Dental Facilities/ Dental Clinics
Blood Bank
Allopathic Clinic
Wellness Centre
Hospitals
6
Certification NABH is operating various
certication program

• Entry Level Hospitals,
• Entry Level SHCO,
• Entry Level AYUSH Hospitals,
• Entry Level AYUSH Centres,
• Nursing Excellence,
• Medical Laboratory Program
• Standards for Emergency Department in Hospitals.

7
Empanelment

• A network of ECHS and CGHS empanelled hospitals
  can also apply for NABH accreditation to provide
  Quality Medicare to beneficiaries and their
  dependents.
• As per the empanelment protocols, the
  accreditation helps the hospitals to ensure
  cashless transactions, as far as possible, for
  the patients.

8
Training and Education - Conducts various
awareness and educational workshops such as

• Programme on Implementation of NABH Standards for
  Hospitals,
• Programme on Implementation of NABH Standards for
  Blood Bank,
• Programme on Implementation of NABH Standards for
  Nursing Excellence CertiFcation,
• Programme on Implementation of NABH Standards for
  Entry Level Hospital, etc.

9
Benefits of NABH Certification and Accreditation

• Patients
• Healthcare Organization
• Healthcare Staff
• Regulatory Bodies

10

• Patients - Patients are the biggest beneficiaries
  among all the stakeholders as certification
  results in high quality of care patient safety
  and ensures the whole system is patient-centric.
• Healthcare Staff
• It improves the overall professional development
  of the hospital staff and provides leadership for
  quality improvement in various techniques.
• It also creates a good working environment where
  the staff can continuously learn and take
  ownership of their roles and responsibilities.

11
Healthcare Organization

• Certification to a healthcare Organization
  stimulates continuous improvement.
• It enables the organization to demonstrate a
  commitment to quality care.
• It raises community confidence in the services
  provided by the health care Organization.
• It provides an opportunity for the healthcare
  units to benchmark with the best and benefits
  from financial incentives given under various
  government schemes to such accredited hospitals.

12
Regulatory Bodies

• Certification provides access to reliable and
  certified information on facilities,infrastructure
  level of care, which can be used by insurance
  organizations other third parties
• Thus, reducing uncertainties while making a
  public decision getting assurance about the
  capabilities of the healthcare organization.

13
NABH

• Aims Establishing a common framework for HCO to
  demonstrate practice compliance with patient
  safety protocols thus ensuring that HCO are
  providing quality care high-quality services to
  the patients
• Mission Is to operate accreditation and allied
  programs in collaboration with stakeholders
  focusing on patient safety quality of
  healthcare by adopting various national
  international best practices.
• Global Recognition NABH is an Institutional
  Member as well as a Board member of the
  International Society for Quality in Health Care
  (lSQua) on the board of the Asian Society for
  Quality in Healthcare (ASQua).

14
What is Accreditation?

• It is a process to measure the performance of an
  organization against a set of nationally
  recognized, practice-focused evidence-based
  standards. The process of validation is a series
  of steps carried out to measure the quality of
  the organization's functions and services and is
  valid only for a specified period.
• The goal is continuous development, quality
  improvement, and the overall performance of the
  organization.

15
Benefits of Accreditation

• Raises community confidence and trust
• Enhances the quality of patient care safety
• Roadmap for standardization
• Improved patient satisfaction levels
• Provides for continuous learning, good working
  environment
• Provides an objective system of empanelment by
  insurance, other third parties.

16
Difference B/W NABH Accreditation Entry
Level Certification
17

• Accreditation
• NABH has designed an exhaustive list of
  healthcare standards for hospitals healthcare
  providers.
• The standards consists of more than 600 stringent
  objective elements for the hospital to achieve in
  order to get the NABH Accreditation.

• Entry Level Certification
• As numerous hospitals were facing challenges and
  difficulties in implementing the complete
  Accreditation Standards as per the system
  provided by them.
• Therefore, NABH has developed an Entry Level
  Certification program with simplified
  comprehended objective elements, in consultation
  with various stakeholders in the country, as a
  stepping stone for enhancing the quality of
  patient care and safety.
• It could also be the First step towards NABH
  Accreditation.

18
Entry Level Certification Programme

• NABH has partnered with Insurance Regulatory
  Development Authority (IRDA) to carry out entry
  level certification of hospitals which has been
  made mandatory for providing cashless insurance
  facility to the citizens at their premises.
• NABH ensures high quality of care patient
  safety, the objective of this certification
  process is to build a quality culture at all
  level across all the function of the healthcare
  organisations

19
HOPE - Healthcare Organizations Platform for
Entry Level Certification

• Revamped portal for entry level certification
  process of Hospitals and Small Healthcare
  Organizations.
• Includes registration, documentation and fee
  submission to be carried out on HOPE web portal
  and a parallely developed mobile application.
• Multifarious platform for certification process
  of healthcare organizations.
• Holds complete information about the simplified
  certification process, requirements and
  compliances

20
Challenges in Implementation

• Lack of Awareness of Standards
• Fear of Unknown
• Fear of Exposing their Vulnerabilities
• Old Infrastuctures Licences
• Manpower Requirement
• SOPs Mannuals
• Training of all Categories of Staffs
• Inadequate Resourses

21
Entry Level - HCO
Entry Level - SHCO
22
Full Accreditation
SHCO Accreditation
23
NABH Steps Levels

• Pre Accrediation (Entry Level)
• Pre Accrediation (Progressive Level)
• Accrediation

24
Set of Standards
No. Accrediation/Certification Beds Chapters Standards Objective Elements
1 NABH Full Accred (5th Edition) 10 105 683
2 NABH SHCO (3rd Edition) 50 10 72 384
3 Entry Level Certification - Under HCO Category (1st Edition) 50 10 45 167
4 Entry Level Certification - Under SHCO (1st Edition) 50 10 41 149
Note NABH SHCO - Polyclinic Diagnostic Centres
Exclusion
25
Patient Centred Standards
26
Chapter Description
Access, Assessment Continuity of Care (AAC) The chapter lays down key safety and process elements that the Hospital should meet, in the continuum of patient care within the hospital and till discharge.
Care of Patients (COP) This chapter aims to guide and encourage patient safety as the overall principle for providing care to patients. Patients in the Emergency Department are provided urgent care including ambulance services in consonance with their clinical requirements.
Management of Medication (MOM) The hospital has a safe organized process of administration of medication or intervention. The hospital should have a mechanism to ensure that the emergency medication/ intervention is standardized throughout the hospital, readily available replenished on time
Patient Rights and Education (PRE) The Hospital should define the patient family's rights and responsibilities. Also, the staff should be trained to protect patient's rights and patients are informed of their rights and educated about their responsibilities at the time of admission.
Hospital Infection Control (HIC) The standards guide the provision of an effective infection control program in the Organization. Their program should be documented and aimed at reducing/eliminating infection risks to patients, visitors providers of care while proactively monitoring its adherence.
27
Organization Centred Standards
28
Chapter Description
Patient Safety and quality (PSQ) The quality and safety program should be documented and involve all areas of the hospital and all staff members. The hospital should identify and collect data on Clinical and Managerial structures, processes, and outcomes.
Responsibilities of Management (ROM) The standards encourage the governance of the hospital professionally ethically. The hospital ensures that patient safety and risk-management issues are an integral part of patient care hospital management.
Facility Management Safety (FMS) The standards guide the provision of a safe and secure environment for patients, their families, staff, and visitors. To ensure this, the Organization conducts regular facility inspection rounds and takes the appropriate action to ensure safety.
Human Resource Management (HRM) The goal of human resource management is to acquire, provide, retain and maintain competent people in the right numbers to meet the needs of the patients and community served by the organization.
Information Management System (IMS) The chapter emphasizes the requirements of a medical record in the hospital as it is an important aspect of continuity of care and communication between the various care providers. The hospital will lay down policies and procedures to guide the contents, storage, security, issue, and retention of medical records.
29
Hospital Preparation
11. Identify Infrastructural requirements 12.
Documentation 13. Training 14. Initiate
Audits 15. Continuous Follow up 16. Capture
Indicators 17. Keep updating the champions and
all staff 18. Do an internal assessment/
invited external assessment

• 1. Strong Management Commitment
• 2. Quality Coordinator
• 3. Quality Team (Multidiscipline)
• 4. Training on the Standards
• 5. Form Committees
• 6. Baseline assessment to identify gaps
• 7. Assign Responsibilities
• 8. Ensure Involvement of Staff
• 9. Prepare Implementation Checklist
• 10. Statutory and legal requirements

30
Strong Management Commitment

• Top management should actively involve
• Prepare the strategy for implementation
• Responsibility for implementation should lie with
  the top
• management

31
Quality Coordinator

• Choose the right person
• Quality Manager - Knowledgeable, Team Player
  Leader, Assertive, Listener, Persererance,
  Learner, Work Around People, Communicator,
  Trainer, Presenter, Manipulator, Always Smiling,
  Should Remain Calm, Public Relations, Impartial

32
Training on the Standards

• Attend in-depth training program on NABH
  Standards
• Nominate three members atleast to attend the
  program doctor, nurse and administrator
• Understand the intent of every objective element

33
Form Committees

• Multidisciplinary team for NABH implementation
• Form Committees
• Quality Committee
• Safety Committee
• Infection Control
• Pharmacy
• Transfusion
• Form sub-committees depending on issues

34
Ensure Involvement of Staff

• Identify Key Personnel in each area
• These individuals can be made as quality
  champions
• Train on the requirements of their areas

35
Identify Infrastructural requirements

• Adequacy of fire detection, alarms and fire
  fighting systems
• Patient and material flow in CSSD and OT
• Special provisions like baby care room, play
  room, handicapped toilet as per the scope of the
  hospital
• Adequacy of equipments as per scope
• Prepare the plan for addressing them

36
Documentation

• Help the relevant stake holders in preparation of
  the policies and procedures that comply with the
  NABH standards
• Many sample documents available customize to
  your hospital
• Standardize
• Keep them simple
• Trial and implement

37
Statutory and legal requirements

• Identify which are the relevant licenses to be
  obtained/renewed
• Hospital Registration
• Biomedical Waste authorization, Air, Water
  Consent
• AERB licenses
• Pharmacy licenses
• Blood bank licenses
• PC PNDT
• MTP
• Transplant licenses (if applicable)
• Note Identify what are the requirements to be
  fulfilled as per
• prevailing laws

38
Training

• Prepare the Training Matrix and Training Calendar
• Identify and implement training requirements
• Identify Faculty
• Plan training calendar, roll out training
• Interact / educate the end users regarding the
  same
• ?Including doctors
• Train, Train, Train

39
Initiate Audits

• Chart Documentation Audits
• Quality Team Audit
• Stateholders Audit

40
Continuous Follow up

• By Quality Manager
• Quality Team
• Committees
• Documented
• Presented to the Top Management
• Follow up, Follow up, Follow up

41
Capture Indicators

• Start capturing basic and relevant indicators
• Explain the indicators and their relevance to the
  stakeholders
• Involve the stakeholders and analyze the data

42
Keep Updating the Champions All Staff

• Continuous update to all staff on overall
  progress- through
• meetings, newsletters etc.
• Keep them engaged
• Update the departments and stakeholders on the
  levels of
• compliances
• Celebrate successes

43
Revised Questionnaire for Hospital Accreditation
Program

• Part I General Information
• Part II Statutory Compliances
• Part III Scope of Service
• Part IV Access, Assessment and Information
  (AAC)
• Part V Care of Patient (COP)
• Part VI Management of Medication (MOM)
• Part VII Patient Right and Education (PRE)
• Part VIII Hospital Infection Control (HIC)
• Part IX Patient Safety and Quality (PSQ)
• Part X Responsibility of Management (ROM)
• Part XI Facility Management and Safety (FMS)
• Part XII Human Resource and Management (HRM)
• Part XIII Information Management System (IMS)

44
Methodology of Survey

• Initial Presentation by Hospital
• Document Review
• Adherence to Statutory Obligations
• Vists to Various Areas
• Facility Surveys Tours
• Random Structured Interviews

45
Initial Presentation by Hospital

• Organogram
• Quality Mangaement Team
• Methodology Followed by Quality Improvement
• Facilites Provided
• Inputs on Resources Provided For Quality
  Improvement
• Identified High Risks Area For Patient Care
  Safety
• Sentinel Events being Monitored

46
Initial Presentation By Hospital

• Key Monotoring Indicators
• Resourses
• Volume
• Utilization
• Performance
• Control Charts
• Problems Faced remedial Measures Undertaken or
  Being Under taken

47
Documents Review

• Quality Manual
• Variuos Policies Procedures
• MOM of various meetings
• Medical Records
• Medical Nursing Audits
• Adverse Events
• HAI
• Action Taken Reports
• Personal Recods of Staffs

48
Observtions

• Facility Safety
• Level of Compliance with laid down policies
  Procedures
• BMW Management
• Standard Precautions
• Patient Care
• Fire Safety
• Equipment Management

49
Interview

• Staff Interview
• To Determine their level of awareness
  Compliance with Organisation polices Procedures
• To assess their awareness level of their rights,
  privileges patient rights
• To determine their satisfaction level
• Patient Family Interview
• To assess their level of awareness of the care
  process their rights
• To determine their satisfaction level

50
Process Of Accreditation

• Initial Application including Self Assessment as
  per the laid down standards
• Screening of the Application
• Pre Assessement Surveys
• Assessment Surveys
• Accreditation Committee Recommendatations
• If Required Verfification Visit
• Approval Of Accreditation by the NABH
• Re - Assessment Surveys

51
Outcome of Accreditation Surveys

• Accrediated
• HCO shows acceptable compliance with laid down
  standards in al areas
• Include the Scopes of Services for which
  accreditated
• Accreditation Denied HCO is consistently Non
  Compliant with Standards
• Accreditation Withdrawn
• HCO Withdraws Voluntarily
• Due to Consistent Non Compiance or Non Adherence
  to Safe Ethical Practices

52
How to go about

• Examine What you are doing
• Find what you shuld be doing
• Document the gaps
• Compare with the standards
• Complete Gap Analysis
• Identify areas of Improvemnt
• Focus Uniform Training of all employees in Key
  AReas
• Encourage by Financial Non Financial INCENTIVES

53
5th Edition Scoring System

• Further the objective elements have been
  classified into -
• Commitment - Used during Final Assessment
• Achievement - Used during Surveillance Assessment
• Excellence - Used during Re-Accreditation
  Assessment

54
Scoring Changes

• To be carried out during site assessment
• The scoring criteria have been remodelled and
  changed fully
• The earlier system gave 0 for non-compliance, 5
  for partial and 10 for full compliance. New
  system uses scale of 1 to 5. Each score has
  corresponding reason for grades awarded.

55
(No Transcript)
56
Salient Features

• Minimising of Objective Elements which could only
  be scored as All or None
• The phrase written guidance has been used to
  guide implementation
• A section devoted to documentation.

57
Cumulative Score Required

• Minimum of 2244 out of 2805 out of 561 OEs for
  the Final Assessment
• Minimum of 2484 out of 3105 out of 621 OEs for
  the Surveillance Assessment
• Minimum of 2604 out of 3255 out of 651 OEs for
  the Re-accreditation Assessment

58
Overall Compliance Rate for Accreditation
Accreditation Towards Implementation Compliance Rate Required Elements Required Elements Required Elements
Accreditation Towards Implementation Compliance Rate 80 Core Total
Commitment Final Assessment 80 461 100 561
Achievement Surveillance Assessment 80 561 60 621
Excellence Re-Accreditation Assessment 80 621 30 651
59
Few Examples of New Objective Elements (But Not
Limited to)
60

• AAC.4. g- The care plan includes the
  identification of special needs regarding care
  following discharge.
• AAC.7. f-The programme addresses the
  clinicopathological meeting(s)
• COP.1.e - Clinical care pathways are developed,
  consistently followed across all the settings of
  care and reviewed periodically.
• COP.1.g- Multi disciplinary and multi-speciality
  care where appropriate is planned based on best
  clinical practice guidelines and delivered in a
  uniform manner across the organisation.
• MOM.4. d- The organisation has a mechanism to
  assist the clinician in prescribing appropriate
  medication.

61

• PSQ.1. e - Designated clinical safety officer (s)
  coordinates implementation of the clinical
  aspects of patient safety programme.
• PSQ.1. g - the hospital performs proactive
  analysis of patient safety risks and makes
  improvements accordingly.
• ROM1.h - Those responsible for governance inform
  the public of the quality and performance of
  services.
• FMS.1. e - Before construction renovation
  expansion of the existing hospital risk
  assessment is carried out.
• HRM.4. e - Evaluation of the training
  effectiveness is done by the organisation
• IMS.1. f - The organisation ensures that
  information resources are accurate and meet the
  stakeholders requirements.
• PSQ.6. a - The management creates a culture of
  safety.
• PSQ.5.c - Medical and nursing staff participates
  in clinical audit.

62
Documents related to Access, Assessment and
Continuity of Care
63

• Registration and admission of patients (OPD, IPD
  Emergency)
• Managing patients during non-availability of beds
• Transfer-in of the patient to the hospital
  Transfer out/referral of Stable Unstable Pts to
  Another Facility
• Initial assessment of patients (Out-patients,
  in-patients emergency patients)
• Laboratory scope of tests, quality assurance
  programme, Safety Programme
• Ordering of lab tests, collection,
  identification, handling, transportation,
  processing disposal of specimen
• Time-frame for the availability of lab test
  results
• Critical results of lab and its timely intimation
• Outsourcing of lab tests
• Imaging scope of tests
• Identification and safe transportation of
  patients to and from the imaging department
• Time-frame for the availability of imaging
  results
• Critical findings of imaging and its timely
  intimation
• Outsourcing of imaging tests
• Imaging quality assurance programme Radiation
  safety programme
• Discharge process (including MLC discharge and
  absconding cases)
• Discharge against medical advice
• Death discharge

64
Documents related to Care of Patients
65

• Uniform care policy
• Handling of medico-legal cases
• Triage of patients in emergency
• Managing dead on arrival cases
• Identification of likely community emergencies,
  epidemics and disasters likely
• Plan for handling all probable disaster situation
• Handling of mass casualty situation
• Clinical protocols of managing various emergency
  cases (for adults and children)
• Quality assurance programme of emergency services
• Checklist of equipment and emergency medicine in
  Ambulance
• Cardio-pulmonary resuscitation and code blue
  process
• Rational use of blood and blood products
• Transfusion of blood and blood products
• Availability and transfusion of blood/blood
  components in an emergency situation
• Care of patients in ICU and HDU

66

• Admission and discharge criteria for ICU and HDU
• Managing situation of bed shortage in ICU
• Quality assurance programme of ICU
• Care of vulnerable patients, Paediatric Patients
• Provision of obstetric care services
• Administration of moderate Anaesthesia
• Monitoring of patients under anaesthesia
• Criteria for discharge from recovery area
• Care of surgical patients
• Surgical safety policies and practices
• Quality assurance programme of surgical services

• Organ transplant policy and process
• Standard treatment protocols
• Restraint of patient
• Pain management
• Provision of rehabilitative services
• Conduction of clinical research activities
• Nutritional assessment, re-assessment and
  nutritional therapy
• End of life care

67
Documents related to Management of Medication
68

• Uniform care policy
• Handling of medico-legal cases
• Triage of patients in emergency
• Managing dead on arrival cases
• Identification of likely community emergencies,
  epidemics and disasters likely
• Plan for handling all probable disaster situation
• Handling of mass casualty situation
• Clinical protocols of managing various emergency
  cases (for adults and children)
• Quality assurance programme of emergency services
• Checklist of equipment and emergency medicine in
  Ambulance
• Cardio-pulmonary resuscitation and code blue
  process
• Rational use of blood and blood products
• Transfusion of blood and blood products
• Availability and transfusion of blood/blood
  components in an emergency situation
• Admission and discharge criteria, Care of
  patients in ICU and HDU
• Managing situation of bed shortage in ICU
• Quality assurance programme of ICU
• Care of vulnerable patients
• Provision of obstetric care services

69

• Administration of moderate Anaesthesia
• Monitoring of patients under anaesthesia
• Criteria for discharge from recovery area
• Care of surgical patients
• Surgical safety policies and practices
• Quality assurance programme of surgical services
• Organ transplant policy and process
• Standard treatment protocols
• Restraint of patient
• Pain management
• Provision of rehabilitative services
• Conduction of clinical research activities
• Nutritional assessment, re-assessment and
  nutritional therapy
• End of life care

70
Documents related to Management of Medication
71

• Hospital formulary
• Process of acquisition of medicine in the
  formulary
• Process of acquisition of medicine not listed in
  the formulary
• Storage of medication, Safe storage and handling
  of look-alike and sound-alike medication
• List of emergency medicine and its storage
• Prescription of medicine, Policy and process on
  verbal orders of medication
• List of high risk medicines
• Safe Administration dispensing of medicines
• Medication recall, Procedure for near expiry
  medicine, Labelling requirements of medicine
• Policy on patients self-administration of
  medicine
• Monitoring of patients after medication
  administration
• Recording and reporting of medication errors,
  adverse events and near misses
• Procedure for usage of narcotic drugs and
  psychotropic medications
• Usage of chemotherapeutic medications
• Disposal of waste medication (cytotoxic)
• Usage of radio-active drugs (safe storage,
  preparation, handling, distribution and disposal)
• Use of implantable prosthesis (procurement,
  storage, issuance, and record keeping)
• Acquisition of medical supplies and consumables

72
Documents related to Patients Rights Education

• Patients rights and responsibilities
• Informed consent taking process
• List of procedures for which informed consent is
  required
• Uniform pricing policy
• Effective communication with patient and family
• Patients complaint obtaining and handling system

73
Documents related to Hospital Infection Control

• Infection control programme, Infection
  surveillance
• Identification of high risk areas
• Standard Precaution/Universal Precaution for
  Infection Control
• Safe injection and infusion practices
• Cleaning, disinfection and sterilization
  practices
• Antibiotic policy Infection control care
  bundles
• Laundry and linen management processes
• Kitchen sanitation and food handling
• Housekeeping procedures
• Handling outbreak of infections
• Sterilization process Biomedical waste handling
  process

74
Documents related to Continual Quality Improvement

• Organization wide quality improvement programme
• Quality indicators with their method, targets and
  monitoring
• Patient safety programme
• Clinical audit system
• 1Incident reporting, analysis and corrective
  preventive action system
• Definition and lists of sentinel events
• Analysis of sentinel events

75
Documents related to Responsibilities of
Management

• Vision, mission and values of the organization
• Strategic and operational plan of the
  organization
• Organogram
• Managing compliance to laws, regulations,
  licenses permits
• Scope of services of each department
• Administrative policies and procedures
  (attendance, leave, conduct, replacement etc.)
• Employee rights and responsibilities
• Service standards of the organizations

76
Documents related to Facility Management and
Safety

• Disposal of non-functioning items and scrap
  materials
• Facility inspection round
• Up-to-date drawings and site layout
• Maintenance plan for the facility
• Preventive and breakdown maintenance plan
• Maintenance plan for water management
• Maintenance plan for electrical systems
• Maintenance plan for HVAC systems
• Maintenance plan for IT and communication network
• Equipment replacement and disposal
• Managing medical gases (procurement, handling,
  storage, distribution, usage and replenishment
• Handling of fire (Code Red alert) and non-fire
  emergencies
• List of hazardous materials in the organization
• Handling of hazardous materials (sorting,
  labelling, handling, storage, transporting and
  disposal)
• Managing spills of hazardous materials (including
  blood)

77
Documents related to Human Resources Management

• Human resources plan of the organization
• Job specification and job description of each
  category of staff
• Recruitment and selection procedure
• Induction programme of new staff
• Training and development policy
• Employee appraisal system
• Disciplinary and grievance handling system
• Addressing health needs of employee
• Credentialing and privileging of medical
  professionals
• Credentialing and privileging of nursing
  professionals

78
Documents related to Information Management System

• Managing information needs of the organization
• Document control process
• Data management (dissemination, storage,
  retrieval)
• Policy on who is authorized to make entries in
  the medical record
• Medical record management
• Maintaining confidentiality, security and
  integrity of records, data and information
• Retention of patients clinical record, data and
  information
• Destruction of medical records
• Medical record review

79
Checklist of Quality Indicators for NABH
Accreditation preparation
80

• Average time taken for initial assessment of
  patients admitted in IPD
• Percentage of IPD patients for whom the initial
  assessment was completed within defined timeframe
• Average time taken for initial assessment of
  patients coming to emergency
• Percentage of emergency patients for whom the
  initial assessment was completed within defined
  timeframe
• Percentage of in-patients wherein the plan of
  care with desired outcomes is documented and
  countersigned by the clinicians
• Percentage of in-patients wherein screening for
  nutritional needs has been done
• Reporting error rates (per 1000) in laboratory

81

• Percentage of re-dos in laboratory
• Percentage of lab reports co-relating with
  clinical diagnosis
• Percentage of adherence to safety precautions by
  employees working in labs
• Reporting error rates (per 1000) in Imaging
• Percentage of re-dos in Imaging
• Percentage of Imaging reports co-relating with
  clinical diagnosis
• Percentage of adherence to safety precautions by
  employees working in Imaging
• Medication error rate
• Percentage of adverse drug reactions
• Percentage of adverse drug reaction due to
  high-risk medicine

82

• Percentage of medical records with error-prone
  abbreviations
• Percentage of modification of anaesthesia plan
• Percentage of unplanned ventilation following
  anaesthesia
• Percentage of re-scheduling of surgeries
• Compliance rate to surgical safety practices
• Percentage of cases who received prophylactic
  antibiotic within specified time-frame
• Percentage of transfusion reactions
• Percentage of blood and blood components wasted
• Percentage of blood component usage
• Turn-around time for the issue of blood and blood
  components
• of blood and blood components issued within
  defined time frame

83

• Catheter associated Urinary Tract Infection
  (CA-UTI) rate
• Ventilator associated pneumonia (VAP) rate
• Central line catheter associated blood stream
  infection (CA-BSI) rate
• Surgical site infection (SSI) rate
• Gross Net mortality rate
• ICU specific mortality rate
• Return to ICU within 48 hour
• Return to EMR within 72 hours with similar
  presenting complaints
• Re-intubation rate
• Percentage of research activities approved by
  ethics committee
• Percentage of patients withdrawing from clinical
  research

84

• of protocol violations/deviations in clinical
  research study
• of serious events in clinical research study
  reported to ethics committee
• Error rates during shift hand-overs
• of medical error due to wrong identification of
  patient
• Hand hygiene compliance rate
• Compliance rate to medication prescription in
  capitals
• of procurement through local purchase
  stockouts for EMR drugs
• of drugs and consumables rejected before
  preparation of goods receipt note
• Percentage of variation from procurement process

85

• Percentage of variations observed in mock drills
• Patient fall rate per 1000 patient days
• Hospital-associated pressure ulcer rate
• Percentage of staff provided pre-exposure
  prophylaxis
• Bed Occupancy Rate Average Length of Stay
  (ALOS)
• OT ICU utilization rate
• Percentage of downtime of Critical equipment
• Nurse patient ratio for wards ICU
• Out In patient satisfaction index
• Average waiting time for services discharge
  time
• Employee satisfaction index, attrition rate,
  absenteeism rate
• Percentage of employee aware of employee rights

86

• Percentage of sentinel events analysed within a
  defined time frame
• Percentage of near misses
• Needlestick injury rate
• Percentage of medical records not having
  discharge summary
• Percentage of medical records not having ICD
  codes
• Percentage of medical records having incomplete
  and improper consent
• Percentage of missing records

87
SHCO

• Exclusions
• Polyclinics
• Diagnostic Centers
• Super Speciality Centers (Single or Multiple)
• Exceptions
• Speciality Day Care (Minimum Bed Strength not
  Mandatory)..Super Speciality Centers are the
  centers which reflect requirement of DM/MCH Or
  Equivalent qualified personnel
• Speciality Cemters are the Centers which reflect
  requirement of MD/MS or Equivalent Qualified
  Personnel

88
Manuals

• Apex Manual - How we take decisions to run
  hospital - Main Decision Making Body
• Safety Manual - Safety Precautions at Hospital
• Infection Control Manual - Infection Control
  Practices
• Disaster Manual - Details of how to face Internal
  External Disaster
• Departmental Mannuals

89
Requiremnts of Hospital Team

• Appointment of Coordinator by Hospital
• Streeing Committee to be formed with Senior
  Management or HODs
• Other Major Teams or Committees
• Quality Safety Committees
• Infection Control Committees
• Blood Transfusion Committees
• Pharmaco Therapeutic Committees
• Medical Record Audit Committees

90
Main Phase

• Initial System Study With Gap Analysis
• General Awareness Training
• System Design Documentation
• Assistance in Maturity Measurement
• Accreditation Assistance

91
Initial System Study With Gap Analysis

• Study on the Existing Processes Records
• Check Compliance to applicable Rules
  Regulations, Licence, regstrations, Waste
  Disposal, Fire Safety Controls
• Bring out the Gaps in th existing practices with
  respect to meeting the Entry Level Standards
• Management to identify Appoint NABH Cordinator
  the core committee other committee Members
• Duration 7 days over 3 to 4 weeks

92
Areas Coverage

• Patient Care Areas
• OP Handling
• Imaging
• In Patient Handling
• EMR Department
• OT
• Pt Care in Wards/Rooms
• Pt Cae in ICU/NICU/PICU/HDU

• Clinical Support Areas
• Lab - Pathology, Cytology, Immunology, Hematoogy
• Clinical Microbiology
• Blood Bank
• Dietary Functions
• Pharmacy

93
Areas Coverage - Other Support Areas

• Medical Records
• Front Office
• Billing Counters
• Guest Relations
• Engineering Services
• F B Services
• House Keeping Activities
• Human Resource Management
• Materials Management

94
Training

• General Awareness - Covering all staffs in
  Batches
• Duration 5 days over 2 Weeks

95
System Design Documentation

• Based on the Gap Analysis Report, the relevant
  forms, records Work Instructions SHOULD BE
  DISCUSSED
• Cordinator shuld guide HODs in preparing Drafts
  of policies Procedures
• Coordinator should be Supported by the
  CORE/Streeing Committee members should initiate
  the Implementation
• Also development of Mission, Objectives,
  Organisatonal Structure, Duties
  Responsibilities of HOD's
• Based on the Policy Procedure Document,
  assisatnce will be provided to prepare all the
  mandatory Manuals
• Duration Over 8 Weeks

96
Assistance in Maturity Measurement

• Train your Core Team in Audit Practices - To
  Examine if planned systems is adequate
• This trained COre Team will conduct Cross
  Functional audits to ascertain compliance level
  in each areas or departments
• Cordinator to assist the Auditees to address NCs
  with Suitable corrective actions its timely
  implementation
• Duration 6 Weeks

97
Process

1. Application
2. Preparation
3. Self Assessment (NC Its Compliance Closure)
4. Pre - Assessment (NC Its Compliance Closure)
5. Main Assessment (NC Its Compliance Closure)
6. Certification (NC Its Compliance Closure)
7. Survellience Visit (NC Its Compliance Closure)
8. Renewal Application (NC Its Compliance
   Closure)

98
Points to Remember

• Every Non-Compliance is an opportunity for
  improvement
• Accept NCs and improve on them
• Do not close NCs for the sake of closure
• Never get disheartened - Change in culture/
  practice takes years
• Always remain positive Never give up
• Continue to learn
• Establish the system for continuous monitoring
  and
• sustainability

99
(No Transcript)