A hospital must first implement the standards on its own for 3 months before applying to NABH to commence their quality certification journey
National Accreditation Board for Hospitals (NABH), a constituent board of Quality Council of India (QCI) establishes and operates accreditation programme for healthcare organisations across India. In a move to emphasise quality within the healthcare system of India, NABH and QCI jointly released Pre-accreditation Entry Level Certification Standards after healthcare organisations, especially small hospitals, found the rigour of Full Accreditation standards highly challenging to start with.
Requirement under pre accreditation entry level standards is one fourth the requirement of full accreditation standards, thereby, making the quality drive attainable.
Here's the procedure of obtaining NABH quality certification in brief:
A hospital preparing for NABH Accreditation must first procure a copy of NABH standards from the NABH Secretariat against payment. HCOs must conduct a self-assessment against NABH standards for a period of at least 3 months before submission of application to ensure that their organisation complies with NABH standards. Self-assessment will give the HCO a fair idea regarding the documentation and implementation requirements. The application form for NABH Accreditation/Certification is available on NABH website.
Process of application to NABH encompasses:
Application to NABH Secretariat is accompanied with the prescribed application fee as detailed in the application form.
On receipt of the application, the Secretariat scrutinises it with respect to its completeness and examines the self-assessment toolkit to verify whether the NABH requirement with respect to the certification program has been met. Found complete, the Secretariat then issues an acknowledgement letter for the application with a unique registration number. The unique registration number is used for correspondence with the HCO.
There are 2 stages to NABH Certification Procedure i.e. the Pre-Assessment stage and The Final Assessment stage.
NABH appoints an assessment team comprising a Principal Assessor and Assessors to conduct assessments of HCO. The size and scope of healthcare organisation decide the number of assessors.
On receiving the application, NABH forwards it (application form, signed copy of Terms and Conditions, Self-Assessment Toolkit) to the Principal Assessor (who leads the Assessment Team) appointed by NABH. Pre assessment visit of the HCO is organised by NABH in consultation with the HCO within 3 months of the submitting the application.
The Assessment Team visits the HCO to explain methodology for assessment, review documentation and check preparedness of the hospital for final assessment while ensuring their commitment to quality goals. Before the pre assessment visit, the HCO must ensure their organisation complies with the requisite standards.
In case of inadequacies, HCO shall take a corrective action for implementation and submit the report thereof to NABH Secretariat within 90 days from the date of pre-assessment.
However, if at the time of pre-assessment, it is found that there is a significant difference between the self-assessment report sent by the healthcare organisation and the pre-assessment carried out by the assessment team, the organisation will only be able to apply for final assessment after a period of 6 months.
The final assessment involves a comprehensive review of HCO’s functions, departments and services. For a successful certification procedure, it is important for the hospital to take a necessary corrective action with respect to the non-conformities pointed out during the pre-assessment stage.
NABH appoints a separate team for final assessment comprising The Principal Assessor, Assessors and technical experts (if need be) and at least one member from the pre assessment team. Final Assessment must be conducted within 6 months of conducting the pre assessment. The date for final assessment is agreed upon by the hospital management and the assessment team.
The Principal Assessor submits the assessment report to NABH Secretariat in the format prescribed by NABH. The report is also shared with the concerned HCO.
NABH examines the detailed assessment report that it receives from the Principal Assessor. HCO ensures that the non-conformances that were not met during the assessment stage are complied with and the report is submitted to NABH Secretariat within 3 months.
Ultimately, NABH Accreditation Committee is responsible for the grant of accreditation or certification. A brief of assessment and corrective actions by the HCO is placed before the Accreditation Committee. The committee’s observations and recommendations are the deciding factors. The HCO must be prepared for a verification visit by NABH to check compliance to standards. HCOs are free to appeal against the findings of assessments. Following are the qualifying criteria for Pre-Accreditation Entry Level Certification:
Pre Accreditation Entry Level Stage is valid for a period of 6 months to maximum of 18 months.
In case of grant of accreditation to the HCO, NABH shall issue a certificate with the mention of date of validity and a unique certificate number. The certificate is accompanied with a “Scope of Accreditation” defining services being offered by the HCO and NABH Poster is also provided.
The healthcare organisation must pay all payments due to NABH before the issue of certificate.
The NABH Fee Structure is divided into Application Fee and Annual Fee (Plus GST 18%). Both the components of fee are different for each category of healthcare organisation. Depending upon the category of organisation, the components are further governed by a number of factors such as:
Below is the break up of the expenditure (Application and Annual Fee) for implementing Pre Accreditation Entry Level Standards according to categories of healthcare organisations.
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Reference: NABH website