Gap assessment and analysis programme based on NABH: Assessment of infrastructural, human resource and biomedical equipment processes, documentation, orientation of staff and other features with respect to accreditation norms. Assisting on developing plans towards fulfillment of the gaps with hospital staff so that the services offered support accreditation standards.

Assistance in developing and reviewing the hospital plan for Accreditation at various stages of the project Orientation, training and assistance towards developing an organizational quality structure and culture that would set the pace for involving and integrating the hospital staff in the accreditation process.

Assisting the organization and formulation of committees and teams

Guiding on the Development of Quality Assurance Programme

Assisting in the Development of Documents, (SOPs, Manuals, Policies, instructions for the hospital, departments and infection control) modulating the existing system and suggesting changes to support accreditation norms. The required documents will be developed in collaboration with the hospital staff.

Assistance in the Development of Record Keeping Programme of the healthcare facility through guidance on the organizing of records, development of formats wherever required and operationalizing of Monitoring system

Organization of Training programmes throughout the accreditation preparation process. These training programmes would be generated through, consultant trainers and resources, external trainers and resources, in house facility trainers and resources.

Training of pre-identified Hospital staff on NABH methodology for accreditation

Development of performance indicators and data collection & its analysis.

Facilitation on the development of a facility assessment programme through training of facility staff to conduct assessments, assistance in organizing for internal assessments, facilitation in the conduction of mock drills, internal assessments and assistance in evaluating the results of internal assessment Monitoring of accreditation programme activities, documentation, effectiveness of training programmes and organizing refresher training programmes as per need identified.

Hospital Accreditation:The hospital accreditation program was started in the year 2005. It is the flagship program for NABH. This program was started with an intent to improve healthcare quality and patient safety at public and private hospitals, has subsequently grown to greater heights, with the standards being recognized internationally at par with other global healthcare accreditation standards and accredited by ISQua (International Society for Quality Assurance in Healthcare). The accreditation standards for hospitals focuses on patient safety and quality of the delivery of services by the hospitals in a changing healthcare environment.

Ten chapters of Hospital Standards are:

a) Access, Assessment and Continuity of Care (AAC)

b) Care of Patients (COP)

c) Management of Medication (MOM)

d) Patient Rights and Education (PRE)

e) Hospital Infection Control (HIC)

f) Patient Safety and Quality Improvement (PSQ)

g) Responsibilities of Management (ROM)

h) Facilities Management and Safety (FMS)

i) Human Resource Management (HRM)

j) Information Management System (IMS)

Benefits of Accreditation

a) Patients are the biggest beneficiary as implementation of accreditation standards ensures Patient safety, commitment to quality care      resulting in good clinical outcomes.

b) Improves patient satisfaction and increases community confidence as services are provided by credentialed medical staff.

c) Accreditation status provides good marketing advantage in the competitive healthcare.

d) The HCO standards has been accredited by ISQua giving the accreditation an international recognition which will boost medical tourism

e) Accreditation provides an objective system of empanelment by insurance and other third parties

Who can apply?

Healthcare organization (HCO) that fulfills the following requirements:

a)Currently in operation as a healthcare provider, should be above 50 sanctioned beds as hospitals below 50 sanctioned beds will come under HCO standards.

b)The organization that commits to comply with NABH standards and applicable legal/statutory/regulatory requirements.

c)These standards are to be used by the whole organisation and not for a specific service within the organisation. Organisations may have different services and it is equally applicable to all services and in both public and private hospitals.