NABH accreditation statistics

NABH accreditation system was established in year 2006 and since then it is accrediting healthcare organizations. Here are some statistics on accreditation of hospitals in India as of June, 2019.

1. Total accredited hospitals         –     563
2. Total pre-accreditation entry level hospitals  – 718
3. Total accredited small healthcare organizations (SHCO)  – 220
4. Total pre-accreditation entry level SHCO   –  1497

Checklist of Quality Indicators for NABH accreditation preparation

Quality Indicators are the backbone on which quality assurance programme of a hospital relies. NABH accreditation expects hospitals to calculate several quality indicators and use it for monitoring the quality of care. These are the list of quality indicators, which a hospital preparing for accreditation must necessarily monitor. (Also check - Performance measures for hospital business)

Checklist of training topics for NABH accreditation preparation

Amongst various preparation that is required for preparing a hospital for accreditation, training of staff is perhaps the most important for implementation. Staff needs to be trained on various policies and procedures documented by the hospital to address NABH standards. Some of the topics require only an orientation while for some a detailed training may be required along with practical demonstration or drills. Here is a list of various training topics that are relevant for accreditation 

Quality Indicators for NABH accreditation preparation

S.N.	Training topic	Coverage	Relevant to
A.      Training topics related to Access, Assessment and Continuity of Care
1.	Scope of hospital services	Clinical services offered by the hospital Services not in scope	All staff, especially staff of front office and admission

Checklist of documents for NABH accreditation preparation

A large number of activities takes place in a hospital. Accreditation requires that hospital has standardized its systems and process for carrying out all those functions. One of the important requirement for standardization is to document the policies and processes for each function. Accordingly, a hospital requires a large number of documented systems, policies, processes, protocols, criteria etc. Here is a list of all such topics on which a written document must be there,
(Also check - How to organize policy and procedure documents)

A.   Documents related to Access, Assessment and Continuity of Care

1.       Registration and admission of patients (OPD, IPD and Emergency)

2.       Managing patients during non-availability of beds

Restraining a patient

Hospitals commonly use restraint on patients as a mean to prevent injury or harm to self or others. However, if appropriate care is not taken, restraint itself can cause serious injuries and even deaths to patients. Also, as restraint is an act of restricting an individual’s freedom of movement, generally against his/her will, it can be considered as an infringement of patient’s rights, if used without strong and valid reason. It is for these reasons, use of restraint on a patient must be guided by a comprehensive policy, that takes care of safety and rights of patients.

The guidelines given below are intended to serve as a reference for hospitals for making their policy on restraint of patients.

Tracer survey method – A great tool for achieving operational excellence in hospital

Providing healthcare to a patient involves multiple departments, professionals and functions. This increases the operational complexity and leads to a variety of problems such as errors, inefficiencies, and even harm to patients. To address such problems, hospitals often follow best practices and standards, recommended by national/international bodies and accreditation programmes. While these standards and practices are well researched, whether or not it improves operational efficiency, depends upon how well have they been implemented or the level of compliance. There are various methods of assessing compliance; such as audits, reviews, surveillance, patients' feedback, indicators and gemba walk. However, one problem with these compliance assessment methods, is that most of them assess each specific function independent of others and fail to assess, how is it translating into actual patient care.

Tracer survey is a unique methodology as it is an integrated assessment of compliance to standards and practices that were required to be followed during care of a particular patient. It gives a comprehensive understanding of hospital’s operational performance and effectiveness in translating standards into actual patient care. Tracer survey is one of the prime survey method used by The Joint Commission in their on-site survey for accreditation.

So how can hospital managers can make good use of this method in achieving operational excellence for their organization? Here is a step by step guide for using Tracer methodology.

Disaster Preparedness checklist for hospitals

Disaster can strike any time and can cause severe catastrophe to us. While it is very difficult to prevent disasters, it is certainly possible to be prepared for facing and handling the disaster situation in a way that ensures minimum damage to life, limb and property. Hospitals are organization that remains full of people round the clock and any disaster affecting hospital can cause heavy damage to life. More-soever, people struck by disaster needs medical care which are provided by hospitals. This makes it very important for hospitals to be prepared for all kind of disasters that are likely in the area where the hospital is located.

Here is a checklist of things that hospitals must be prepared with.

Organizing policy and procedure documents

There are many functions and operations that are performed in a hospital. Each function and operations are guided by the hospital’s policy on it and is carried out as per the specified procedure. For the sake of standardization, it is important that these policies and procedures are available in written for staff to refer whenever required.  The written policies and procedures are often referred as policies and procedures documents. There is a long list of documents that are required in a hospital and such can differ in its size, form and applicability. This creates problems with managing these documents and leads to frequent errors. What is required is a systematic way of organizing these documents errors and confusions could be avoided. This post describes how to organize policy and procedure documents for an efficient management.

Infection control checklist for NABH accreditation preparation

Healthcare Associated Infections (HAI) can easily qualify as the most important patient safety concerns in hospitals. To address the menace of HAI, infection control is kept as one of the main objectives, while designing any healthcare delivery structure, policies and processes. Almost all activities that are done within hospital has a bearing on infection control and there are a large number of studies that has resulted in various good practices for controlling infections. NABH has also dedicated a full chapter on Infection Control, while standards and objective elements under various other chapters also incorporates infection control aspects in it. A list of all infection control measures, grouped under appropriate heading is given below for hospitals to keep a check on.

Criteria for transfer of patients from OT recovery area

Post-surgery patients are kept in recovery area till they recover from the effect of Anaesthesia and become fit to be transferred to intermediate care (ward/room). In recovery area, the patient is under observation of Anaesthesiologist and his/her physiological parameters are being monitored. While transferring the patient out of recovery, it is critical to ascertain that the patient is in a right physiological condition and it is safe to shift him/her to ward/room. To ascertain this, appropriate criteria must be applied to assess the patient’s condition.

The criteria that can be used for this purpose are described below. Aldrete method can be used to score these criteria and base the decision on total score.

1.       Consciousness level – Ability of patient to respond to verbal instructions and answer the questions. Patient should be oriented to their surroundings. They should be able to cough, when asked.

List of hospital committees and teams for NABH accreditation preparation

Hospital committees and teams plays an important role in management and decision making in hospital. While, hospitals are organized into departments with each department, for something as complex as healthcare, there are many issues which cut across the responsibilities of more than one department. These issues require people in different roles and with different expertise, to collectively take appropriate decisions and actions. Committees and teams are formed for this purpose and depending upon the type of issues to be dealt with different committees and teams are formed. NABH standards indicates several types of committees and teams to be functioning in a hospital and this post lists and explains the same.

To functionally differentiate between a committee and a team, we must understand that a committee is a group of people (often with varied expertise and roles), who together discuss and debate on an agenda to arrive at a consensus opinion regarding which forms the basis for planning and decision making. Teams on the other hand is a group of people who plays a role in implementing those functions and decisions, that cut across multiple departments and are often difficult to implement.

LIST OF COMMITTEES WITH THEIR ROLES AND COMPOSITION

      

Checklist of housekeeping services for NABH accreditation

Perhaps the most pervasive service across the hospital is the housekeeping. This is also one of the most important services for prevention of healthcare associated infections and for compliance to Biomedical Waste Management rules. While housekeeping maintains the ambience clean, they must adhere to certain work practices that are recommended by accreditation bodies and  regulatory bodies. Below is the list of all such requirements which housekeeping must ensure.

A. Housekeeping procedures

1.         Standard housekeeping procedures should be used across the organization. The documented procedures should be available with the supervisor/housekeeping manager. For staff these procedures should be documented in a simplified manner and in a language that the housekeeping staff can understand. These procedures must include following

Checklist of Purchase department for NABH accreditation preparation

The purchase department helps in steady supply of materials required in hospital for daily functioning. This requires a good deal of planning and management, as any disruption in functioning of purchase may cause disruption in supply of essential items, which can adversely affect various functions of hospital including healthcare. Also, as purchase function involves a large amount of money, an inefficient management can significantly add to the cost burden of running a hospital. Following practices are recommended for purchase, which if implemented appropriately can tremendously boost its efficiency.

As most of the work in purchase in a hospital is related to medicines and pharmaceuticals, it is highly recommended that this checklist must be used along with the checklist of Pharmacy.

Purchase:

1.       A documented purchase policy should be available that specifies who has the authority for taking purchase decision, according to the amount of purchase

2.       Purchase of capital items (beyond a defined cost) should always be done through a multi-disciplinary committee. The committee must consist of representative from the user department (where the purchased item is going to be used), representative from finance, management and purchase department

Checklist of Anaesthesia department for NABH accreditation preparation

Anaesthesia services plays a crucial role in patients’ safety, especially for patients undergoing surgery or under critical care. As it is closely linked to patient safety, NABH has focussed on anaesthesia services and has given certain requirements to be fulfilled by it. These requirements are largely to ensure safety of patients from adverse and sentinel events related to Anaesthesia. The list of requirements is as given below.

Note: These requirements are applicable to all types of anaesthesia (general, regional, spinal) except local anaesthesia

1. Anaesthesia services should be given by qualified anaesthetist only. The hospital’s credentialing and privileging policy must specify the names of doctors, who has the privilege of providing different types of anaesthesia. Technician shall not administer anaesthesia.

Checklist of Bio-medical engineering department for NABH accreditation preparation

Bio-medical engineering department in a hospital serves a very important purpose of ensuring that medical equipment in various departments are in their best functional condition and are being effectively utilized. The performance of the department is reflected from how well the patient care staff are able to use medical equipment. To be able to effectively manage medical equipment there are several standards and practices that the department must follow. The NABH has also outlined these standards, largely in its FMS chapter. The complete checklist of all requirements that bio-medical engineering department must fulfil is given below.

1. There should a documented equipment plan for the hospital. An equipment plan should typically have speciality wise list of equipment required, with brief specification and their quantity. The plan should be based on clinical need and workload. Such plan should be developed in consonance with the doctors of the clinical departments. A reference for minimum equipment requirement should followed, such as IPHS standards.

Checklist of Admissions Department for NABH accreditation preparation

A patients’ actual experience with hospital begins from the admission department. The department in addition to admitting a patient, also serves as a key point where all important information is shared between hospital and patient. The key performance expected from admissions department is time efficiency in admitting patient and achieving a positive first impression of the patient.

The admission department can help in addressing many NABH standards under AAC, PRE and ROM chapters. Here is the list of things that admission department staff must be prepared with for facing accreditation assessment.

1. Admission staff should be aware of hospital's policy of a patient's admission. S/he should know who has the authority to admit patients (i.e. list of doctors who can admit patients in the hospital)

Checklist of Hospital’s Food services (Kitchen) for NABH accreditation preparation

The Food services department of hospital is responsible for fulfilling the food and diet requirements patients. In addition to patient, it can also cater to employees, patients’ family members and visitors. The food services for patients plays important role in aiding to treatment and faster recovery of patient. The quality objectives of food services in hospital should be to provide right food to right patient at right time, provide food that is safe to consume and palatable and to avoid wastages of food. To meet these objectives there are certain practices that must be followed which are also given under NABH standards. Here is the list of what a hospital’s food services department must do to provide quality services and also to meet NABH accreditation norms. Note that these standards are applicable even if the kitchen is outsourced

A. Infrastructure

1. The kitchen of the hospital should have an identified area and its location should be segregated from patient areas and traffic flows.

11 Conditions that a hospital must fulfil in-order to participate in JCI accreditation process

Before even going into JCI accreditation standards a hospital must look into these essential conditions or requirements, if it is planning to go for JCI accreditation. Hospitals not fulfilling any of these conditions are at risk of accreditation being denied. JCI assesses these conditions, in addition to standards, for both first time applicant hospital as well as already-accredited hospitals. For first time applicant hospitals, these conditions are assessed during the initial survey and for already accredited hospitals, it is assessed throughout the accreditation period, through on-site surveys, the Strategic Improvement Plan submitted by hospital, and through periodic updates that JCI receives from these hospitals.

The requirements given below are referred from 'JCI accreditation standards for hospitals, 6th Edition'

Suggested read - Tracer Method - A great tool for achieving operational excellence in hospital

    1.       Data and information required by JCI must be submitted in timely manner by the hospital.

There are many data and information, which includes things like information asked in application (electronic application), annual updates to be made in application, Strategic Improvement Plan, major changes in hospital etc.  These must be submitted within the agreed time-frame.

Checklist for CSSD for NABH preparation and its quality indicators

Central Sterilization and Supplies Department (CSSD), has its importance in prevention of cross infection in hospitals. An effective functioning of CSSD will reduce the HAI traceable to use of instruments on patients’ care. For this CSSD must follow standard practices in its sterilization and supplies operations. NABH recommends following standards to be implemented in CSSD.

Infrastructure

     ·         The CSSD should be located in a delineated area where there is less or no external traffic movement.

   ·         Location of CSSD should be either close to OT or should be connected to OT with safe & quick  transfer mechanism, like dumbwaiters.

Checklist of Pathology Laboratory and its quality indicators for NABH accreditation preparation

Pathology lab is expected to provide as accurate diagnosis as possible, within reasonable time frame and without compromising the safety of patient or its staff. To be able to do so, the lab is required to follow certain policies and processes. The NABH standards outlines following requirements for a medical laboratory in a hospital.