• The main purpose of NABH accreditation is to help planners to promote, implement, monitor and evaluate robust practice in order to ensure that quality and safety occupies a central place in the development of the health care system.
• Current policies and processes for health care are inadequate or not responsive to ensure health care services of acceptable quality and prevent negligence. Problems range from inadequate and inappropriate treatments, excessive use of higher technologies, and wasting of scarce resources, to serious problems of medical malpractice and negligence.
• Quality Assurance should help improves effectiveness, efficiency and in cost containment, and should address accountability and the need to reduce errors and increase safety in the system.
• Thus the objective of NABH accreditation is on continuous improvement in the organizational and clinical performance of health services, not just the achievement of a certificate or award or merely assuring compliance with minimum acceptable standards.

NABH Standards for Hospitals have been drafted by Technical Committee of the NABH and contains complete set of standards for evaluation of hospitals for grant of accreditation. The standards provide framework for quality assurance and quality improvement for hospitals. The standards focus on patient safety and quality of patient care. The standards are equally applicable to hospitals & nursing homes in the Government as well as in the private sector.

Patients are increasingly and appropriately aware of healthcare issues, and desire participation in decisions affecting their health. The ultimate responsibility of a health care system is to the patient. Adherence to high standards, such as those related to timeliness of treatment, diagnostic accuracy, clinical relevance of the tests performed and interventions, qualifications and training of personnel, and prevention of errors, is an ethical responsibility of all hospital staff.

Accreditation standard requirements ensure that the owners, managers and staff comply with appropriate technical and professional standards regardless of cost pressures and avoidance of personal, financial and organizational conflicts of interest

To develop a general conceptual foundation and framework for a process of quality assurance for guaranteeing commonality of approach to institutions, delineating the domains of quality to be measured and the development of a credible, effective and transparent system of accreditation, meaningful participation of the stakeholders is essential and pre-requisite.

Standards and Objective Elements for evaluation have been set in the following 10 identified areas, specifying the clear intent of the standards:

Certification to the ISO 9001 standard is recognized internationally in and out of the healthcare field, and, as such, NABH Standards can be co-related to:

• Management of quality of hospital health care services (ISO 9001)
• Management of hospital activities and processes having adverse impact on the environment (ISO 14001)
• Management of occupational health and safety risks (OHSAS 18001)
• Management of safety of food served to patients and other visitors (HACCP/ISO 22000)
• Management of hospital internal laboratory (ISO 15189)

The continued development of ISO management system standards into areas such as environment, health and safety, food safety, and information security has reinforced the need for an integrated approach. In order to meet the requirements of ISO 9001 Quality Management System & NABH Standards, a hospital must make the requirements an integral part of the Standard Operating Procedures for the hospital.

• Accreditation emphasizing the participation of various stakeholders has the potential to be more successful than regulation. This partnership would provide a platform for consensus-building based on the principle of sharing, democratic and transparent functioning of the national quality framework.
• The effectiveness of the development and management of the organization would be enhanced through actively involved staff, key stakeholders, clients and potential clients in decision making about our strategic and service planning, management, and service delivery processes and service evaluation.

Assessment Process:

The Accreditation process involves comprehensive review of hospital’s compliance with NABH’s standards. A balanced system of assessment would involve Document review, Pre-assessment survey, on-site hospital survey.

Ten steps to accreditation:

Step 1 – Obtain copy of NABH standards

Step 2 – Carry out self assessment on status of compliance with the NABH standards

Step 3 – Identify gap areas and prepare action plan to bridge the gaps

Step 4 – Ensure that NABH standards are implemented and integrated with hospital functioning

Step 5 – Obtain copy and submit application form for assessment

Step 6 – Pay the accreditation fee

Step 7 – Receive from NABH the assessment programme including dates and names of assessors

Step 8 – Facilitate the assessment

Step 9 – Receive recommendation on accreditation

Step 10 – Maintain quality improvement programme based on continuous monitoring of patient care services

*Sources: www.qcin.org

Outcome of Accreditation process:

• An ongoing capacity to respond quickly and effectively to complaints and adverse events
• Development and application of standardized performance measures a mechanism for conducting retrospective reviews of the appropriateness of hospital care
• Ensure that current systems of audit are maintained. It should promote internal evaluation and assessment processes as well as external assessment processes

Above all, NABH accreditation seeks to develop an enabling environment in which high quality of health care can flourish throughout the country. This would be done through providing guidance to hospital and health care providers, rather than through control and prescriptive measures.