BASIC ABOUT NABH

Basic about NABH Description

1. BASIC ABOUT NABH
Prepared BY:
Mr. Nakul Yadav
ICN Cum Nursing Educator
M.Sc Nursing (Community Health Nursing)

2. WHAT IS NABH

3. WHAT IS QUALITY
•To the patients: Quality means being treated with empathy,
respect and concern
•To the professional : Quality means delivering the most
advanced knowledge and medical scientific skills to help/
save the patient
•To the medical audit: Quality means having the best
achievable outcome for each patient

4. FOCUS OF NABH STANDARDS
•Patient safety
•Staff and employee safety
•Environment and community safety
•Information Education and Communication

5. NABH STANDARDS

6. Outline of NABH Standards
Patient Centered Standards
• Access, Assessment and Continuity of Care (AAC)
• Patient Right and Education (PRE)
• Care of Patient (COP)
• Management of Medication (MOM)
• Hospital Infection Control (HIC)

7. Organisation Centered Standards
• Continuous Quality Improvement (CQI)
• Responsibility of Management (ROM)
• Facility Management and Safety (FMS)
• Human Resource Management (HRM)
• Information Management System (IMS)
Outline of NABH Standards

8. NABH Accreditation Standard Contents
SHCO
•10 Chapters
•61 Standards
•290 Objective Elements

9. NABH Accreditation Standard Contents
HCO
•10 Chapters
•105 Standards
•683 Objective Elements

10. WHAT IS QUALITY ?

11. •Appropriateapplicationofmedicalknowledgewithdueregard
tothebalancebetweenthehazardinherentineverymedical
interventionandthebenefitsexpectedfromit
•Itis,howevermorecomplexthanthis.

12. QUALITY FROM WHOSE POINT OF VIEW ?

13. •Provider of Health care Services
•Recipient of the Health care services
•Organizer of the Health care services

14. PROVIDERS CONCERNS
•Toprovidecareasperestablishednorms
•Adequateresources
•Selfsatisfactionwiththefinaloutcome
•Shouldcontributetoenhancementofskills,competenceandaddto
experience

15. RECIPIENTS CONCERNS
•Accessibility
•Affordability
•Promptattention
•Lesswaitingtime
•Earlydiagnosisandcure
•ReturntoProductivityasearlyaspossible
•HumaneTreatmentietobetreatedwithempathy,respectand
concern

16. ORGANISERS CONCERNS
•ResponsibletotheSocietyforthefundsspentonhealthcare
•Toensuresafetyofpublicandpreventinappropriateor
suboptimalcare
•Tomeettherequirementsoftherecipientandproviderofthe
healthcareservicesatAcceptablecosts

17. WHAT IS ACCREDITATION

18. Accreditation is an external review of quality
with four principal components:
Itisbasedonwrittenandpublishedstandards
Reviewsareconductedbyprofessionalpeers
Theaccreditationprocessisadministeredbyanindependentbody
Theaimofaccreditationistoencourageorganizational
development.

19. Focus of standards
•PatientSafety
•Staffandemployeesafety
•Environmentandcommunitysafety
•InformationEducationandCommunication

20. PREASSESSMENT SURVEY
•ToascertainthereadinessoftheorganisationforAccreditation
•Overviewoftheorganizationalpreparednessandcommitmenttoquality
goalsandconsonancetolaiddownstandards
•Deficienciesnoticedinformedtotheorganisation
•Advicerenderedonthemethodologytobefollowedduringthe
AccreditationSurvey
•Timeframeworkedoutforthesurveyinmutualconsultation

21. ACCREDITATION SURVEY
•CarriedoutbyateamofAssessorsdependinguponthesize,complexity
andfacilitiesprovidedbytheorganisation
•Scopewillincludeallstandardsrelatedfunctionsandallpatientcare
settings
•Onsitesurveywillconsiderspecificculturalandlegalfactorswhichmay
influenceorshapedecisionsregardingtheprovisionofcareand/or
policiesandprocedures

22. METHODOLOGY OF SURVEY
•Initialpresentationbythehospital
•DocumentReview
•Adherencetostatutoryobligations
•Visitstovariousareas
•Facilitysurveysandtours
•Randomstructuredinterviews

23. INITIAL PRESENTATION BY THE HOSPITAL
•Organogram
•QualitymanagementTeam
•MethodologyfollowedforQualityImprovement
•Facilitiesprovided
•InputsonresourcesprovidedforQualityImprovement
•IdentifiedhighRiskAreasforpatientcareandsafety
•SentinelEventsbeingmonitored

24. INITIAL PRESENTATION BY THE HOSPITAL
•KeyMonitoringIndicators
•Resource
•Volume
•Utilization
•Performance
•Controlcharts
•Problemsfacedandremedialmeasuresundertaken/beingundertaken

25. DOCUMENT REVIEW
•QualityManual
•VariousPoliciesandProcedures
•MinutesofMeetingsofvariouscommittees
•MedicalRecords
•Medical/NursingAudit
•AdverseEvents
•HAI
•ActionTakenReports
•PersonalRecordsofStaff

26. OBSERVATIONS
•FacilitySafety
•Levelofcompliancewithlaiddownpoliciesandprocedures
•BMWManagement
•StandardPrecautions
•Patientcare
•FireSafety
•EquipmentManagement

27. INTERVIEW
•StaffInterview
•Todeterminetheirlevelofawarenessand
compliancewithorganizationpoliciesand
procedures
•Toassesstheirawarenesslevelsoftheirrights,
privilegesandpatientrights
•Todeterminetheirsatisfactionlevels
•PatientandfamilyInterview
•Toassesstheirlevelofawarenessofthecare
processandtheirrights
•Todeterminetheirsatisfactionlevels

28. How to Go About
•Createwillingness
•InitialimpetusfromTopmanagement
•Requiresinvolvementofallstaff
•Thisrequiresrepeatedtrainingandbriefing
•OnceconsensusisthereidentifycorecoordinatingorQuality
managementTeam

29. HOW TO GO ABOUT
•Examinewhatareyoudoing
•Findwhatyoushouldbedoing
•Documentthegaps
•Comparewiththestandards
•Completegapanalysis
•Identifyareasforimprovement

30. PROBLEMS AND CHALLENGES
•HCOsareveryenthusiastic
•Illprepared
•Initialpreparationisshoddy
•Resourcesrequiredinitially
•Benefitshavealongergestationperiod

31. PROBLEMS AND CHALLENGES
•QualityConsciousnessatalllevelswilltaketime
•Sustenanceandconsistencyofeffortswillberequired
•Commitmentonaconsistentbasis
•Highratesofattritionwillrequirerepeatedandcontinualtraining
•PublicSectorwilltakealongertimetogetintotheprocess
•Qualityandconsistencyofassessorsandassessments

32. Also Nothing Is Impossible
For,

33. Impossible
Means
I’ M Possible