NABH Introduction.pptx

NABH Introduction, Process, Indicators, Documents for Full Accreditation & Entry Level

1. NABH Basics & Process Ms.Nikethana R Nair, M.Sc (Nsg), MBA (HA), M.Sc (Psy), M.Phil (HHSM), Nursing Superintendent, Meenakshi Mission Hospital & Research Center, Madurai

2. Quality Council of India (QCI) Established in 1997 through a Cabinet decision of the Government of India. QCI is an autonomous organization under the Department for Promotion of Industry and Internal Trade, Ministry of Commerce & Industry. It was established as the national body for accreditation & quality promotion in the country. The Council was established to provide a credible, reliable mechanism for third-party assessment of products, services & processes which is accepted & recognized globally.

3. Accreditation Boards of QCI National Accreditation Board for Hospitals and Healthcare Providers (NABH) National Accreditation Board for Certification Bodies (NABCB) National Accreditation Board for Testing and Calibration Laboratories (NABL) National Accreditation Board for Education and Training (NABET) National Board for Quality Promotion (NBQP)

4. NABH Program and Activities Accreditation Certification Empanelment Training and Education

5. NABH Accreditation Programs Hospitals Small healthcare Organization Blood Bank Blood Storage Centre Medical Imaging Services Allopathic Clinic Dental Facilities/ Dental Clinics Oral Substitution Therapy Centre AYUSH Hospitals Community Health Care Eye Care Organization Primary Health Care Panchkarma Clinic Clinical Trial (Ethics Committees) Wellness Centre Integrated Rehabilitation Centres for Addict

6. Certification NABH is operating various certication program Entry Level Hospitals, Entry Level SHCO, Entry Level AYUSH Hospitals, Entry Level AYUSH Centres, Nursing Excellence, Medical Laboratory Program & Standards for Emergency Department in Hospitals.

7. Empanelment A network of ECHS and CGHS empanelled hospitals can also apply for NABH accreditation to provide Quality Medicare to beneficiaries and their dependents. As per the empanelment protocols, the accreditation helps the hospitals to ensure cashless transactions, as far as possible, for the patients.

8. Training and Education - C onducts various awareness and educational workshops such as Programme on Implementation of NABH Standards for Hospitals, Programme on Implementation of NABH Standards for Blood Bank, Programme on Implementation of NABH Standards for Nursing Excellence CertiFcation, Programme on Implementation of NABH Standards for Entry Level Hospital, etc.

9. Benefits of NABH Certification and Accreditation Patients Healthcare Organization Healthcare Staff Regulatory Bodies

10. Patients - Patients are the biggest beneficiaries among all the stakeholders as certification results in high quality of care & patient safety and ensures the whole system is patient-centric. Healthcare Staff It improves the overall professional development of the hospital staff and provides leadership for quality improvement in various techniques. It also creates a good working environment where the staff can continuously learn and take ownership of their roles and responsibilities.

11. Healthcare Organization Certification to a healthcare Organization stimulates continuous improvement. It enables the organization to demonstrate a commitment to quality care. It raises community confidence in the services provided by the health care Organization. It provides an opportunity for the healthcare units to benchmark with the best and benefits from financial incentives given under various government schemes to such accredited hospitals.

12. Regulatory Bodies Certification provides access to reliable and certified information on facilities,infrastructure & level of care, which can be used by insurance organizations & other third parties Thus, reducing uncertainties while making a public decision & getting assurance about the capabilities of the healthcare organization.

13. NABH Aims: E stablishing a common framework for HCO to demonstrate & practice compliance with patient safety protocols thus ensuring that HCO are providing quality care & high-quality services to the patients Mission: Is to operate accreditation and allied programs in collaboration with stakeholders focusing on patient safety & quality of healthcare by adopting various national & international best practices. Global Recognition: NABH is an Institutional Member as well as a Board member of the International Society for Quality in Health Care (lSQua) & on the board of the Asian Society for Quality in Healthcare (ASQua).

14. What is Accreditation? It is a process to measure the performance of an organization against a set of nationally recognized, practice-focused & evidence-based standards. The process of validation is a series of steps carried out to measure the quality of the organization's functions and services and is valid only for a specified period. The goal is continuous development, quality improvement, and the overall performance of the organization.

15. Benefits of Accreditation Raises community confidence and trust Enhances the quality of patient care &safety Roadmap for standardization Improved patient satisfaction levels Provides for continuous learning, good working environment Provides an objective system of empanelment by insurance, other third parties.

16. Difference B/W NABH Accreditation & Entry Level Certification

17. Accreditation NABH has designed an exhaustive list of healthcare standards for hospitals & healthcare providers. The standards consists of more than 600 stringent objective elements for the hospital to achieve in order to get the NABH Accreditation. Entry Level Certification As numerous hospitals were facing challenges and difficulties in implementing the complete Accreditation Standards as per the system provided by them. Therefore, NABH has developed an Entry Level Certification program with simplified & comprehended objective elements, in consultation with various stakeholders in the country, as a stepping stone for enhancing the quality of patient care and safety. It could also be the First step towards NABH Accreditation.

18. Entry Level Certification Programme NABH has partnered with Insurance Regulatory & Development Authority (IRDA) to carry out entry level certification of hospitals which has been made mandatory for providing cashless insurance facility to the citizens at their premises. NABH ensures high quality of care & patient safety, the objective of this certification process is to build a quality culture at all level & across all the function of the healthcare organisations

19. HOPE - Healthcare Organizations Platform for Entry Level Certification Revamped portal for entry level certification process of Hospitals and Small Healthcare Organizations. Includes registration, documentation and fee submission to be carried out on HOPE web portal and a parallely developed mobile application. Multifarious platform for certification process of healthcare organizations. Holds complete information about the simplified certification process, requirements and compliances

20. Challenges in Implementation Lack of Awareness of Standards Fear of Unknown Fear of Exposing their Vulnerabilities Old Infrastuctures & Licences Manpower Requirement SOPs & Mannuals Training of all Categories of Staffs Inadequate Resourses

21. Entry Level - HCO Entry Level - SHCO

22. Full Accreditation SHCO Accreditation

23. NABH Steps & Levels Pre Accrediation (Entry Level) Pre Accrediation (Progressive Level) Accrediation

24. Set of Standards No. Accrediation/Certification Beds Chapters Standards Objective Elements 1 NABH Full Accred (5th Edition) 10 105 683 2 NABH SHCO (3rd Edition) 50 10 72 384 3 Entry Level Certification - Under HCO Category (1st Edition) 50 10 45 167 4 Entry Level Certification - Under SHCO (1st Edition) 50 10 41 149 Note: NABH SHCO - Polyclinic Diagnostic Centres Exclusion

25. Patient Centred Standards

26. Chapter Description Access, Assessment & Continuity of Care (AAC) The chapter lays down key safety and process elements that the Hospital should meet, in the continuum of patient care within the hospital and till discharge. Care of Patients (COP) This chapter aims to guide and encourage patient safety as the overall principle for providing care to patients. Patients in the Emergency Department are provided urgent care including ambulance services in consonance with their clinical requirements. Management of Medication (MOM) The hospital has a safe & organized process of administration of medication or intervention. The hospital should have a mechanism to ensure that the emergency medication/ intervention is standardized throughout the hospital, readily available & replenished on time Patient Rights and Education (PRE) The Hospital should define the patient & family's rights and responsibilities. Also, the staff should be trained to protect patient's rights and patients are informed of their rights and educated about their responsibilities at the time of admission. Hospital Infection Control (HIC) The standards guide the provision of an effective infection control program in the Organization. Their program should be documented and aimed at reducing/eliminating infection risks to patients, visitors & providers of care while proactively monitoring its adherence.

27. Organization Centred Standards

28. Chapter Description Patient Safety and quality (PSQ) The quality and safety program should be documented and involve all areas of the hospital and all staff members. The hospital should identify and collect data on Clinical and Managerial structures, processes, and outcomes. Responsibilities of Management (ROM) The standards encourage the governance of the hospital professionally & ethically. The hospital ensures that patient safety and risk-management issues are an integral part of patient care & hospital management. Facility Management & Safety (FMS) The standards guide the provision of a safe and secure environment for patients, their families, staff, and visitors. To ensure this, the Organization conducts regular facility inspection rounds and takes the appropriate action to ensure safety. Human Resource Management (HRM) The goal of human resource management is to acquire, provide, retain and maintain competent people in the right numbers to meet the needs of the patients and community served by the organization. Information Management System (IMS) The chapter emphasizes the requirements of a medical record in the hospital as it is an important aspect of continuity of care and communication between the various care providers. The hospital will lay down policies and procedures to guide the contents, storage, security, issue, and retention of medical records.

29. Hospital Preparation 1. Strong Management Commitment 2. Quality Coordinator 3. Quality Team (Multidiscipline) 4. Training on the Standards 5. Form Committees 6. Baseline assessment to identify gaps 7. Assign Responsibilities 8. Ensure Involvement of Staff 9. Prepare Implementation Checklist 10. Statutory and legal requirements 11. Identify Infrastructural requirements 12. Documentation 13. Training 14. Initiate Audits 15. Continuous Follow up 16. Capture Indicators 17. Keep updating the champions and all staff 18. Do an internal assessment/ invited external assessment

30. Strong Management Commitment Top management should actively involve Prepare the strategy for implementation Responsibility for implementation should lie with the top management

31. Quality Coordinator Choose the right person Quality Manager - Knowledgeable, Team Player & Leader, Assertive, Listener, Persererance, Learner, Work Around People, Communicator, Trainer, Presenter, Manipulator, Always Smiling, Should Remain Calm, Public Relations, Impartial

32. Training on the Standards Attend in-depth training program on NABH Standards Nominate three members atleast to attend the program – doctor, nurse and administrator Understand the intent of every objective element

33. Form Committees Multidisciplinary team for NABH implementation Form Committees Quality Committee Safety Committee Infection Control Pharmacy Transfusion Form sub-committees depending on issues

34. Ensure Involvement of Staff Identify Key Personnel in each area These individuals can be made as quality champions Train on the requirements of their areas

35. Identify Infrastructural requirements Adequacy of fire detection, alarms and fire fighting systems Patient and material flow in CSSD and OT Special provisions like baby care room, play room, handicapped toilet as per the scope of the hospital Adequacy of equipments as per scope Prepare the plan for addressing them

36. Documentation Help the relevant stake holders in preparation of the policies and procedures that comply with the NABH standards Many sample documents available – customize to your hospital Standardize Keep them simple Trial and implement

37. Statutory and legal requirements Identify which are the relevant licenses to be obtained/renewed Hospital Registration Biomedical Waste authorization, Air, Water Consent AERB licenses Pharmacy licenses Blood bank licenses PC PNDT MTP Transplant licenses (if applicable) Note: Identify what are the requirements to be fulfilled as per prevailing laws

38. Training Prepare the Training Matrix and Training Calendar Identify and implement training requirements Identify Faculty Plan training calendar, roll out training Interact / educate the end users regarding the same Including doctors Train, Train, Train

39. Initiate Audits Chart Documentation Audits Quality Team Audit Stateholders Audit

40. Continuous Follow up By Quality Manager Quality Team Committees Documented Presented to the Top Management Follow up, Follow up, Follow up

41. Capture Indicators Start capturing basic and relevant indicators Explain the indicators and their relevance to the stakeholders Involve the stakeholders and analyze the data

42. Keep Updating the Champions & All Staff Continuous update to all staff on overall progress- through meetings, newsletters etc. Keep them engaged Update the departments and stakeholders on the levels of compliances Celebrate successes

43. Revised Questionnaire for Hospital Accreditation Program Part I – General Information Part II – Statutory Compliances Part III – Scope of Service Part IV – Access, Assessment and Information (AAC) Part V – Care of Patient (COP) Part VI – Management of Medication (MOM) Part VII – Patient Right and Education (PRE) Part VIII – Hospital Infection Control (HIC) Part IX – Patient Safety and Quality (PSQ) Part X – Responsibility of Management (ROM) Part XI – Facility Management and Safety (FMS) Part XII – Human Resource and Management (HRM) Part XIII – Information Management System (IMS)

44. Methodology of Survey Initial Presentation by Hospital Document Review Adherence to Statutory Obligations Vists to Various Areas Facility Surveys & Tours Random Structured Interviews

45. Initial Presentation by Hospital Organogram Quality Mangaement Team Methodology Followed by Quality Improvement Facilites Provided Inputs on Resources Provided For Quality Improvement Identified High Risks Area For Patient Care & Safety Sentinel Events being Monitored

46. Initial Presentation By Hospital Key Monotoring Indicators Resourses Volume Utilization Performance Control Charts Problems Faced & remedial Measures Undertaken or Being Under taken

47. Documents Review Quality Manual Variuos Policies & Procedures MOM of various meetings Medical Records Medical & Nursing Audits Adverse Events HAI Action Taken Reports Personal Recods of Staffs

48. Observtions Facility Safety Level of Compliance with laid down policies & Procedures BMW Management Standard Precautions Patient Care Fire Safety Equipment Management

49. Interview Staff Interview: To Determine their level of awareness & Compliance with Organisation polices & Procedures To assess their awareness level of their rights, privileges & patient rights To determine their satisfaction level Patient & Family Interview To assess their level of awareness of the care process & their rights To determine their satisfaction level

50. Process Of Accreditation Initial Application including Self Assessment as per the laid down standards Screening of the Application Pre Assessement Surveys Assessment Surveys Accreditation Committee Recommendatations If Required Verfification Visit Approval Of Accreditation by the NABH Re - Assessment Surveys

51. Outcome of Accreditation Surveys Accrediated: HCO shows acceptable compliance with laid down standards in al areas Include the Scopes of Services for which accreditated Accreditation Denied: HCO is consistently Non Compliant with Standards Accreditation Withdrawn: HCO Withdraws Voluntarily Due to Consistent Non Compiance or Non Adherence to Safe & Ethical Practices

52. How to go about Examine What you are doing Find what you shuld be doing Document the gaps Compare with the standards Complete Gap Analysis Identify areas of Improvemnt Focus Uniform Training of all employees in Key AReas Encourage by Financial &Non Financial INCENTIVES

53. 5th Edition Scoring System Further the objective elements have been classified into - Commitment - Used during Final Assessment Achievement - Used during Surveillance Assessment Excellence - Used during Re-Accreditation Assessment

54. Scoring Changes To be carried out during site assessment The scoring criteria have been remodelled and changed fully The earlier system gave 0 for non-compliance, 5 for partial and 10 for full compliance. New system uses scale of 1 to 5. Each score has corresponding reason for grades awarded.

55. Salient Features Minimising of Objective Elements which could only be scored as “All or None” The phrase “written guidance” has been used to guide implementation A section devoted to documentation.

56. Cumulative Score Required Minimum of 2244 out of 2805 out of 561 OEs for the Final Assessment Minimum of 2484 out of 3105 out of 621 OEs for the Surveillance Assessment Minimum of 2604 out of 3255 out of 651 OEs for the Re-accreditation Assessment

57. Overall Compliance Rate for Accreditation Accreditation Towards Implementation Compliance Rate Required Elements 80% Core Total Commitment Final Assessment 80% 461 100 561 Achievement Surveillance Assessment 80% 561 60 621 Excellence Re-Accreditation Assessment 80% 621 30 651

58. Few Examples of New Objective Elements (But Not Limited to)

59. AAC.4. g- The care plan includes the identification of special needs regarding care following discharge. AAC.7. f- The programme addresses the clinicopathological meeting(s) COP.1.e - Clinical care pathways are developed, consistently followed across all the settings of care and reviewed periodically. COP.1.g- Multi disciplinary and multi-speciality care where appropriate is planned based on best clinical practice guidelines and delivered in a uniform manner across the organisation. MOM.4. d- The organisation has a mechanism to assist the clinician in prescribing appropriate medication.

60. PSQ.1. e - Designated clinical safety officer (s) coordinates implementation of the clinical aspects of patient safety programme. PSQ.1. g - the hospital performs proactive analysis of patient safety risks and makes improvements accordingly. ROM1.h - Those responsible for governance inform the public of the quality and performance of services. FMS.1. e - Before construction renovation & expansion of the existing hospital risk assessment is carried out. HRM.4. e - Evaluation of the training effectiveness is done by the organisation IMS.1. f - The organisation ensures that information resources are accurate and meet the stakeholders’ requirements. PSQ.6. a - The management creates a culture of safety. PSQ.5.c - Medical and nursing staff participates in clinical audit.

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

62. R egistration and admission of patients (OPD, IPD & Emergency) Managing patients during non-availability of beds Transfer-in of the patient to the hospital & Transfer out/referral of Stable & Unstable Pts to Another Facility Initial assessment of patients (Out-patients, in-patients & emergency patients) Laboratory scope of tests, quality assurance programme, Safety Programme Ordering of lab tests, collection, identification, handling, transportation, processing & disposal of specimen Time-frame for the availability of lab test results Critical results of lab and its timely intimation Outsourcing of lab tests Imaging scope of tests Identification and safe transportation of patients to and from the imaging department Time-frame for the availability of imaging results Critical findings of imaging and its timely intimation Outsourcing of imaging tests Imaging quality assurance programme & Radiation safety programme Discharge process (including MLC discharge and absconding cases) Discharge against medical advice Death discharge

63. Documents related to Care of Patients

64. Uniform care policy Handling of medico-legal cases Triage of patients in emergency Managing dead on arrival cases Identification of likely community emergencies, epidemics and disasters likely Plan for handling all probable disaster situation Handling of mass casualty situation Clinical protocols of managing various emergency cases (for adults and children) Quality assurance programme of emergency services Checklist of equipment and emergency medicine in Ambulance Cardio-pulmonary resuscitation and code blue process Rational use of blood and blood products Transfusion of blood and blood products Availability and transfusion of blood/blood components in an emergency situation Care of patients in ICU and HDU

65. Admission and discharge criteria for ICU and HDU Managing situation of bed shortage in ICU Quality assurance programme of ICU Care of vulnerable patients, Paediatric Patients Provision of obstetric care services Administration of moderate Anaesthesia Monitoring of patients under anaesthesia Criteria for discharge from recovery area Care of surgical patients Surgical safety policies and practices Quality assurance programme of surgical services Organ transplant policy and process Standard treatment protocols Restraint of patient Pain management Provision of rehabilitative services Conduction of clinical research activities Nutritional assessment, re-assessment and nutritional therapy End of life care

66. Documents related to Management of Medication

67. Uniform care policy Handling of medico-legal cases Triage of patients in emergency Managing dead on arrival cases Identification of likely community emergencies, epidemics and disasters likely Plan for handling all probable disaster situation Handling of mass casualty situation Clinical protocols of managing various emergency cases (for adults and children) Quality assurance programme of emergency services Checklist of equipment and emergency medicine in Ambulance Cardio-pulmonary resuscitation and code blue process Rational use of blood and blood products Transfusion of blood and blood products Availability and transfusion of blood/blood components in an emergency situation Admission and discharge criteria, Care of patients in ICU and HDU Managing situation of bed shortage in ICU Quality assurance programme of ICU Care of vulnerable patients Provision of obstetric care services Care of Paediatric patients

68. Administration of moderate Anaesthesia Monitoring of patients under anaesthesia Criteria for discharge from recovery area Care of surgical patients Surgical safety policies and practices Quality assurance programme of surgical services Organ transplant policy and process Standard treatment protocols Restraint of patient Pain management Provision of rehabilitative services Conduction of clinical research activities Nutritional assessment, re-assessment and nutritional therapy End of life care

69. Documents related to Management of Medication

70. Hospital formulary Process of acquisition of medicine in the formulary Process of acquisition of medicine not listed in the formulary Storage of medication, Safe storage and handling of look-alike and sound-alike medication List of emergency medicine and its storage Prescription of medicine, Policy and process on verbal orders of medication List of high risk medicines Safe Administration & dispensing of medicines Medication recall, Procedure for near expiry medicine, Labelling requirements of medicine Policy on patient’s self-administration of medicine Monitoring of patients after medication administration Recording and reporting of medication errors, adverse events and near misses Procedure for usage of narcotic drugs and psychotropic medications Usage of chemotherapeutic medications Disposal of waste medication (cytotoxic) Usage of radio-active drugs (safe storage, preparation, handling, distribution and disposal) Use of implantable prosthesis (procurement, storage, issuance, and record keeping) Acquisition of medical supplies and consumables

71. Patients’ rights and responsibilities Informed consent taking process List of procedures for which informed consent is required Uniform pricing policy Effective communication with patient and family Patients complaint obtaining and handling system Documents related to Patients’ Rights & Education

72. Infection control programme, Infection surveillance Identification of high risk areas Standard Precaution/Universal Precaution for Infection Control Safe injection and infusion practices Cleaning, disinfection and sterilization practices Antibiotic policy & Infection control care bundles Laundry and linen management processes Kitchen sanitation and food handling Housekeeping procedures Handling outbreak of infections Sterilization process & Biomedical waste handling process Documents related to Hospital Infection Control

73. Organization wide quality improvement programme Quality indicators with their method, targets and monitoring Patient safety programme Clinical audit system 1Incident reporting, analysis and corrective preventive action system Definition and lists of sentinel events Analysis of sentinel events Documents related to Continual Quality Improvement

74. Vision, mission and values of the organization Strategic and operational plan of the organization Organogram Managing compliance to laws, regulations, licenses & permits Scope of services of each department Administrative policies and procedures (attendance, leave, conduct, replacement etc.) Employee rights and responsibilities Service standards of the organizations Documents related to Responsibilities of Management

75. Disposal of non-functioning items and scrap materials Facility inspection round Up-to-date drawings and site layout Maintenance plan for the facility Preventive and breakdown maintenance plan Maintenance plan for water management Maintenance plan for electrical systems Maintenance plan for HVAC systems Maintenance plan for IT and communication network Equipment replacement and disposal Managing medical gases (procurement, handling, storage, distribution, usage and replenishment Handling of fire (Code Red alert) and non-fire emergencies List of hazardous materials in the organization Handling of hazardous materials (sorting, labelling, handling, storage, transporting and disposal) Managing spills of hazardous materials (including blood) Documents related to Facility Management and Safety

76. Documents related to Human Resources Management Human resources plan of the organization Job specification and job description of each category of staff Recruitment and selection procedure Induction programme of new staff Training and development policy Employee appraisal system Disciplinary and grievance handling system Addressing health needs of employee Credentialing and privileging of medical professionals Credentialing and privileging of nursing professionals

77. Documents related to Information Management System Managing information needs of the organization Document control process Data management (dissemination, storage, retrieval) Policy on who is authorized to make entries in the medical record Medical record management Maintaining confidentiality, security and integrity of records, data and information Retention of patient’s clinical record, data and information Destruction of medical records Medical record review

78. Checklist of Quality Indicators for NABH Accreditation preparation

79. Average time taken for initial assessment of patients admitted in IPD Percentage of IPD patients for whom the initial assessment was completed within defined timeframe Average time taken for initial assessment of patients coming to emergency Percentage of emergency patients for whom the initial assessment was completed within defined timeframe Percentage of in-patients wherein the plan of care with desired outcomes is documented and countersigned by the clinicians Percentage of in-patients wherein screening for nutritional needs has been done Reporting error rates (per 1000) in laboratory

80. Percentage of re-dos in laboratory Percentage of lab reports co-relating with clinical diagnosis Percentage of adherence to safety precautions by employees working in labs Reporting error rates (per 1000) in Imaging Percentage of re-dos in Imaging Percentage of Imaging reports co-relating with clinical diagnosis Percentage of adherence to safety precautions by employees working in Imaging Medication error rate Percentage of adverse drug reactions Percentage of adverse drug reaction due to high-risk medicine

81. Percentage of medical records with error-prone abbreviations Percentage of modification of anaesthesia plan Percentage of unplanned ventilation following anaesthesia Percentage of re-scheduling of surgeries Compliance rate to surgical safety practices Percentage of cases who received prophylactic antibiotic within specified time-frame Percentage of transfusion reactions Percentage of blood and blood components wasted Percentage of blood component usage Turn-around time for the issue of blood and blood components % of blood and blood components issued within defined time frame

82. Catheter associated Urinary Tract Infection (CA-UTI) rate Ventilator associated pneumonia (VAP) rate Central line catheter associated blood stream infection (CA-BSI) rate Surgical site infection (SSI) rate Gross & Net mortality rate ICU specific mortality rate Return to ICU within 48 hour Return to EMR within 72 hours with similar presenting complaints Re-intubation rate Percentage of research activities approved by ethics committee Percentage of patients withdrawing from clinical research

83. % of protocol violations/deviations in clinical research study % of serious events in clinical research study reported to ethics committee Error rates during shift hand-overs % of medical error due to wrong identification of patient Hand hygiene compliance rate Compliance rate to medication prescription in capitals % of procurement through local purchase & stockouts for EMR drugs % of drugs and consumables rejected before preparation of goods receipt note Percentage of variation from procurement process

84. Percentage of variations observed in mock drills Patient fall rate per 1000 patient days Hospital-associated pressure ulcer rate Percentage of staff provided pre-exposure prophylaxis Bed Occupancy Rate & Average Length of Stay (ALOS) OT & ICU utilization rate Percentage of downtime of Critical equipment Nurse patient ratio for wards & ICU Out & In patient satisfaction index Average waiting time for services & discharge time Employee satisfaction index, attrition rate, absenteeism rate Percentage of employee aware of employee rights

85. Percentage of sentinel events analysed within a defined time frame Percentage of near misses Needlestick injury rate Percentage of medical records not having discharge summary Percentage of medical records not having ICD codes Percentage of medical records having incomplete and improper consent Percentage of missing records

86. SHCO Exclusions : Polyclinics Diagnostic Centers Super Speciality Centers (Single or Multiple) Exceptions : Speciality Day Care (Minimum Bed Strength not Mandatory)..Super Speciality Centers are the centers which reflect requirement of DM/MCH Or Equivalent qualified personnel Speciality Cemters are the Centers which reflect requirement of MD/MS or Equivalent Qualified Personnel

87. Manuals Apex Manual - How we take decisions to run hospital - Main Decision Making Body Safety Manual - Safety Precautions at Hospital Infection Control Manual - Infection Control Practices Disaster Manual - Details of how to face Internal & External Disaster Departmental Mannuals

88. Requiremnts of Hospital Team Appointment of Coordinator by Hospital Streeing Committee to be formed with Senior Management or HODs Other Major Teams or Committees Quality & Safety Committees Infection Control Committees Blood Transfusion Committees Pharmaco Therapeutic Committees Medical Record Audit Committees

89. Main Phase Initial System Study With Gap Analysis General Awareness & Training System Design & Documentation Assistance in Maturity Measurement Accreditation Assistance

90. Initial System Study With Gap Analysis Study on the Existing Processes & Records Check Compliance to applicable Rules & Regulations, Licence, regstrations, Waste Disposal, Fire & Safety Controls Bring out the Gaps in th existing practices with respect to meeting the Entry Level Standards Management to identify & Appoint NABH Cordinator & the core committee & other committee Members Duration: 7 days over 3 to 4 weeks

91. Areas Coverage Patient Care Areas OP Handling Imaging In Patient Handling EMR Department OT Pt Care in Wards/Rooms Pt Cae in ICU/NICU/PICU/HDU Clinical Support Areas Lab - Pathology, Cytology, Immunology, Hematoogy Clinical Microbiology Blood Bank Dietary Functions Pharmacy

92. Areas Coverage - Other Support Areas Medical Records Front Office Billing Counters Guest Relations Engineering Services F & B Services House Keeping Activities Human Resource Management Materials Management

93. Training General Awareness - Covering all staffs in Batches Duration: 5 days over 2 Weeks

94. System Design & Documentation Based on the Gap Analysis Report, the relevant forms, records & Work Instructions SHOULD BE DISCUSSED Cordinator shuld guide HODs in preparing Drafts of policies & Procedures Coordinator should be Supported by the CORE/Streeing Committee members should initiate the Implementation Also development of Mission, Objectives, Organisatonal Structure, Duties & Responsibilities of HOD's Based on the Policy & Procedure Document, assisatnce will be provided to prepare all the mandatory Manuals Duration: Over 8 Weeks

95. Assistance in Maturity Measurement Train your Core Team in Audit Practices - To Examine if planned systems is adequate This trained COre Team will conduct Cross Functional audits to ascertain compliance level in each areas or departments Cordinator to assist the Auditees to address NCs with Suitable corrective actions & its timely implementation Duration: 6 Weeks

96. Process Application Preparation Self Assessment (NC & Its Compliance Closure) Pre - Assessment (NC & Its Compliance Closure) Main Assessment (NC & Its Compliance Closure) Certification (NC & Its Compliance Closure) Survellience Visit (NC & Its Compliance Closure) Renewal & Application (NC & Its Compliance Closure)

97. Points to Remember Every Non-Compliance is an opportunity for improvement Accept NCs and improve on them Do not close NCs for the sake of closure Never get disheartened - Change in culture/ practice takes years Always remain positive – “Never give up” Continue to learn Establish the system for continuous monitoring and sustainability