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What is NABH?

NABH is the acronym used for “National Accreditation Board for Hospitals & Health Care Providers”. The NABH is the constituent board by the Quality Council of India Certification that is set up to operate accreditation programs for certified healthcare institutions.

Established in 2006, the board even though is supported by many stakeholders, consumers, industry and government, still holds full functional autonomy in its hand.

How it is developed?

The NABH accreditation system got established in 2006 by the Quality Council of India and the first edition of standards to maintain was released in the same year with standards being revised every three years. The current standard issue is the 4th that got released in 2015 and is being used now.

Process of achieving NABH Accreditation:

The hospital & health Care first has to

  1. Implementation & Compliance of NABH Standard.
  2. Apply for NABH accreditation and, submit the form with duly signed documents.
  3. NABH will conduct audit & after closing Non-conformity founding during the audit.
  4. NABH will issue Certificate.

QC Certification helps in the Implementation & Compliance of the NABH standard and support till its certification. QC Certification has a team of expertise trainers, auditors, consultants, technical experts pan India.

There are two way (Entry & Full Level) to approach NABH Accreditation :

A. Entry Level

Since it's not possible to implement all of the accreditation standards given by the NABH, an Entry Level certificate standard has been issued. The reason for this is cause many hospitals, even large ones, find difficulties in maintaining the standards instantly to get accreditation hence, the Entry Level accreditation allows hospital's to get to square one and gives them base to build themselves to achieve full level accreditation. This gives them time to prepare for full level accreditation. QCC assists from the entry level for taking NABH Certification.

B. Full Level

The full level of NABH accreditation standards include 102 standards, that have to be maintained and 636 objective elements. QCC assists in implementing these standards. All of it are recognized by the ISQUA (International Society for Quality in Healthcare).

Benefits of NABH

Accreditation is for the benefit of all the stakeholders. And, the biggest beneficiaries are the patient's. As this increases the level of care a patient will receive. The staff being on credential, has to abide guidelines penned down for patients care.

An accredited hospital has to maintain the standards and demonstrate it's commitment towards the care of patients.

The staff also benefit from this as they get a good working environment and a place to keep learning. They get to work under good leadership and most importantly, ownership of the clinical process.

WHY QCC

QC Certification is the Certification Body having the Accreditation Board of UASL, UK which is committed in delivering value to its customers in regards to quality. We have more than 4,000 clients in India and overseas. The aim of QCC is to provide the best solution that helps you improve the process and management system.

Steps for NABH

QCC will work through the following steps to get NABH accreditation.

I. Gap Analysis

Once you have decided to get accreditation, QCC will do the Gap Analysis which is the first crucial step you have to take to attain the accreditation.

QCC team will establish the documents, implement as per the standard guidelines. The procedure is as follows:-

  1. Quality Manual
  2. Quality Procedures
  3. SOP's & Work Instructions
  4. Forms and Formats

The intention behind this is so you can have a clear resourced and time implicated formation to show in your NABH application. This involves the following:

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  1. Regulatory compliances
  2. Infrastructure and engineering gaps
  3. Manpower gaps like, qualification, training, HR functions and manforce in number
  4. Equipment quality and quantity
  5. Process gaps are meeting with applied quality standards, regulatory and ethical requirements

QCC will help in each and every step to establish, to implement properly.

II. Prepare Draft Documentation

According to the 2015 revised standard list you need to prepare your draft with the following:

Hospital Manual: A sample manual of the hospital that shows hospital meets the standards. This should include vision, mission, hospital quality, organization structure and the macro level for compliance to meet the accreditation standards. QCC will assists to establish the manual requirements.

Department Manual: The department manual is separated in five sections:

  1. Emergency preparation
  2. Medical records
  3. Human resources
  4. Central sterility supply department
  5. Bio medical manual

System Process: There are 8 system processes to implement that should be working in the hospital.

Health and Safety Procedures: Total of 9 procedures are to be maintained.

Hospital process approach: You have to meet with more than 15 process approaches.

Standard Operating process: You have to implement more than 75 process to establish a good overall hospital management.

Forms/Templates: Submit set of 64 standard forms and blank sample templates.

Hospital committee book: A book showing 8 committee roles and their responsibility

III. Final Documentation

The final documentation requires:

Sample manuals of hospital

All functional level manuals like, Human resources, infection control etc.

Sample of hospital process with management system and health and safety management

Exhibit the standards operating procedure implemented according to the NABH guidelines

Set of blank standard forms and system formats that will be the future record of the hospital

The NABH audit checklist, used to verify all guidelines are followed.

QCC has a team of experts which will make the all documents.

IV. Training

The training is provided by NABH. This helps the staff and faculty in maintaining the care levels penned by NABH.

V. Implementation

A training program is specially designed so you can implement the standards in your hospital. QCC trainer will teach you:-

  • What to implement
  • How to implement
  • Why to implement
  • When to implement
  • Where to implement
VI. Internal Audit

To maintain accreditation, it's vital to maintain the levels and standards implicated in the guidelines of the NABH accreditation. But, it is fact, most of the health organizations tend to loose track or interest in maintaining the guidelines, which can lead to loose of accreditation. Therefore, it's important to deploy an audit team that ensures all is done smoothly.

QCC will assist in the Internal Audit & will conduct it. QCC will also train the people about to conduct the audits.

VII. Review the Non- conformity

In case of non-conformity, you need to reevaluate the reasons and rectify them.

VIII. Management Meeting

You need to engage management meetings so you and your manpower can know the outcome of the standards being implied.

QCC team will conduct the Management Review Meeting .

IX. Fill Application

Finally, you need to fill the application and submit it with duly signed documents.

X. Support in NABH Auditing

QCC team will support in NABH Auditing. In case of raised NC's, QCC will help to close that NC's at the earliest.

XI. Remove Non-Conformity of Auditing

On receiving non-conformity of NABH auditing, you should evaluate the causes and remove all the obstruction and after reevaluating the standards be able to resubmit.

Thereafter, QCC team will assists you for the final certification after closing the all raised NC's. We will support you during the post certification activities and improvements.