ABOUTABOUT NABH

NABH is a constituent board of Quality Council of India (QCI) and a member of International Society for Quality in Healthcare (ISQua) Accreditation Council. NABH has been set up by the Government as an autonomous body to establish and operate an accreditation programme for healthcare institutions. This accreditation empowers the organization towards providing and monitoring patient safety and quality care across its service areas.

iPC Health can be your gateway to NABH training- get online access to 105-course modules covering 10 chapters, 105 standards & 683 objective elements, simplified by healthcare experts for easy understanding and presented in an engaging, multi-media rich module-based format.

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Get NABH ready – simplified interpretation of NABH standards presented in an engaging module-based format

FEATURESSALIENT FEATURES

  • Comprehensive coverage of NABH accreditation standards for hospitals (10 chapters, 105 standards & 683 objective elements).
  • Courses designed by NABH experts providing a detailed understanding of each standard for easy implementation by healthcare staff.
  • Case-scenarios with real-life insights and practical tips on day to day challenges encountered by healthcare staff.
  • Track your employee’s learning and test them through self-assessments Videos, multimedia-rich content, checklists to make learning engaging.
  • Mobile compatible for easy access anytime, anywhere.
  • Total 50 hours of learning content.

BENEFITSBENEFITS FOR THE ORGANIZATION

Training your workforce in compliance requirements for NABH accreditation helps your organization:

  • Facilitate patient safety by reducing medical errors.
  • Enhance the overall professional development of the staff.
  • Ensure staff efficiency, accountability, and adherence to Standard Operating Procedures.
  • Become eligible for certain insurance reimbursements & empanelment.
  • Ensure workforce retention as the staff prefers to work with an accredited organization over a non – accredited organization.
  • Get better patient outcomes and quality indicators, thereby reducing the operational cost of providing service to the patient.
  • Drive continuous improvement through regular training of healthcare staff on compliance processes and SOPs as is mandated by NABH.
  • Reduce dependence on training instructors.

Pre-Accreditation Progressive-Level/Full accreditation Standards

Patient Centered Standards

AAC.1. The organisation defines and displays the healthcare services that it provides.

AAC.2. The organisation has a well-defined registration and admission process.

AAC.3. There is an appropriate mechanism for transfer (in and out) or referral of patients.

AAC.4. Patients cared for by the organisation undergo an established initial assessment.

AAC.5. Patients cared for by the organisation undergo a regular reassessment.

AAC.6. Laboratory services are provided as per the scope of services of the organization.

AAC.7. There is an established laboratory quality assurance programme.

AAC.9. Imaging services are provided as per the scope of services of the organization.

AAC.10. There is an established quality assurance programme for imaging services.

AAC.11. There is an established safety programme in the imaging services.

AAC.12. Patient care is continuous and multidisciplinary in nature.

AAC.13. The organisation has a documented discharge process.

AAC.14. Organisation defines the content of the discharge summary.

COP 1: Uniform care to patients is provided in all settings of the organisation and is guided by the applicable laws, regulations and guidelines.

COP 2: Emergency services are guided by documented policies, procedures applicable laws and regulations.

COP 3: The ambulance services are commensurate with the scope of the services provided by the organisation.

COP 4. The organisation plans for handling community emergencies, epidemics and other disasters.

COP 5: Documented policies and procedures guide the care of patients requiring cardio-pulmonary resuscitation.

COP 6: Documented policies and procedures guide nursing care.

COP 7: Documented procedures guide the performance of various procedures.

COP 8: Documented policies and procedures define rational use of blood and blood components.

COP 9: Documented policies and procedures guide the care of patients in the intensive care and high dependency units.

COP 10: Documented policies and procedures guide the care of vulnerable patients.

COP 11: Documented policies and procedures guide obstetric care.

COP 12: Documented policies and procedures guide paediatric services.

COP 13: Documented policies and procedures guide the care of patients undergoing moderate sedation.

COP 14: Documented policies and procedures guide the administration of anaesthesia.

COP 15: Documented policies and procedures guide the care of patients undergoing surgical procedures.

COP.16 Documented policies and procedures guide organ transplant programme in the organization.

COP 17: Documented policies and procedures guide the care of patients under restraints (physical and/or chemical).

COP 18: Documented policies and procedures guide appropriate pain management.

COP 19: Documented policies and procedures guide appropriate rehabilitative services.

COP 20: Documented policies and procedures guide all research activities.

COP 21: Documented policies and procedures guide nutritional therapy.

COP 22: Documented policies and procedures guide the end of life care.

MOM 1: Documented policies and procedures guide the organisation of pharmacy services and usage of medication.

MOM 2: There is a hospital formulary.

MOM 3: Documented policies and procedures guide the storage of medication.

MOM 4: Documented policies and procedures guide the safe and rational prescription of medications.

MOM 5: Documented policies and procedures guide the safe dispensing of medications.

MOM 6: There are documented policies and procedures for medication administration.

MOM 7: Patients are monitored after medication administration.

MOM 8: Near misses, medication errors and adverse drug events are reported and analysed.

MOM 9: Documented procedures guide the use of narcotic drugs and psychotropic substances.

MOM 10: Documented policies and procedures guide the usage of chemotherapeutic agents.

MOM 11: Documented policies and procedures govern usage of radioactive drugs.

MOM 12: Documented policies and procedures guide the use of implantable prosthesis and medical devices.

MOM 13: Documented policies and procedures guide the use of medical supplies and consumables.

PRE 1: The organisation protects patient and family rights and informs them about their responsibilities during care.

PRE2: Patient and family rights support individual beliefs, values and involve the patient and family in decision making processes.

PRE3: The patient and/or family members are educated to make informed decisions and are involved in the care planning and delivery process.

PRE4: A documented procedure for obtaining patient and/or family‘s consent exists for informed decision making about their care.

PRE5: Patient and families have a right to information and education about their healthcare needs.

PRE6: Patients and families have a right to information on expected costs.

PRE7: The organisation has a mechanism to capture patient‘s feedback and redressal of complaints.

PRE8: The organisation has a system for effective communication with patients and/or families.

HIC 1: The organisation has a well-designed, comprehensive and coordinated Hospital Infection Prevention and Control (HIC) programme aimed at reducing/eliminating risks to patients, visitors and providers of care.

HIC 2: The organisation implements the policies and procedures laid down in the Infection Control Manual in all areas of the hospital.

HIC 3: The organisation performs surveillance activities to capture and monitor infection prevention and control data.

HIC 4: The organisation takes actions to prevent and control Healthcare Associated Infections (HAI) in patients.

HIC 5: The organisation provides adequate and appropriate resources for prevention and control of Healthcare Associated Infections (HAI).

HIC 6: The organisation identifies and takes appropriate action to control outbreaks of infections.

HIC 7: There are documented policies and procedures for sterilization activities in the organization.

HIC 8: Biomedical waste (BMW) is handled in an appropriate and safe manner.

HIC 9: The infection control programme is supported by the management and includes training of staff.

Organization Centered Standards

CQI 1: There is a structured quality improvement and continuous monitoring programme in the organization.

CQI 2: There is a structured patient-safety programme in the organisation.

CQI 3: The organisation identifies key indicators to monitor the clinical structures processes and outcomes, which are used as tools for continual improvement.

CQI 4: The organisation identifies key indicators to monitor the managerial structures processes and outcomes, which are used as tools for continual improvement.

CQI 5: There is a mechanism for validation and analysis of quality indicators to facilitate quality improvement.

CQI 6: The quality improvement programme is supported by the management.

CQI 7: There is an established system for clinical audit.

CQI 8: Incidents are collected and analysed to ensure continual quality improvement.

CQI 9: Sentinel events are intensively analysed.

ROM 1: The responsibilities of those responsible for governance are defined.

ROM 2: The organisation is responsible for and complies with the laid-down and applicable legislations, regulations and notifications.

ROM 3: The services provided by each department are documented.

ROM 4: The organisation is managed by the leaders in an ethical manner.

ROM 5: The organisation displays professionalism in management of affairs.

ROM 6: Management ensures that patient-safety aspects and risk-management issues are an integral part of patient care and hospital management.

FMS 1: The organisation has a system in place to provide a safe and secure environment. 

FMS 2: The organisation‘s environment and facilities operate in a planned manner to ensure safety of patients, their families, staff and visitors and promotes environment friendly measures.

FMS 3: The organisation has a programme for engineering support services and utility system.

FMS 4: The organisation has a programme for bio-medical equipment management.

FMS 5: The organisation has a programme for medical gases, vacuum and compressed air.

FMS 6: The organisation has plans for fire and non-fire emergencies within the facilities.

FMS 7: The organisation has a plan for management of hazardous materials.

HRM 1: The organisation has a documented system of human resource planning.

HRM 2: The organisation has a documented procedure for recruiting staff and orienting them to the organisation‘s environment.

HRM 3: There is an ongoing programme for professional training and development of the staff.

HRM 4: Staff are adequately trained on various safety-related aspects.

HRM 5: An appraisal system for evaluating the performance of an employee exists as an integral part of the human resource management process.

HRM 6: The organisation has documented disciplinary and grievance handling policies and procedures.

HRM 7: The organisation addresses the health needs of the employees.

HRM 8: There is documented personal information for each staff member.

HRM 9: There is a process for credentialing and privileging of medical professionals, permitted to provide patient care without supervision.

HRM 10: There is a process for credentialing and privileging of nursing professionals, permitted to provide patient care without supervision.

IMS 1: Documented policies and procedures exist to meet the information needs of the care providers, management of the organisation as well as other agencies that require data and information from the organisation.

IMS 2: The organisation has processes in place for effective control and management of data.

IMS 3: The organisation has a complete and accurate medical record for every patient.

IMS 4: The medical record reflects continuity of care.

IMS 5: Documented policies and procedures are in place for maintaining confidentiality, integrity and security of records, data and information.

IMS 6: Documented policies and procedures exist for retention time of records, data and information.

IMS 7: The organisation regularly carries out review of medical records.

Pre-Accreditation Entry-Level Standards

Patient Centered Standards

AAC 1:  Organization scope of services.

AAC 2: Registration, admission and transfer process.

AAC 3: Patient Initial Assessment.

AAC 4: Patient Reassessment.

AAC 5: Laboratory scope of services & safety requirements.

AAC 6: Imaging scope of services & safety programme.

AAC 7: Discharge process.

COP1:  Uniform care of patients.

COP 2: Emergency care and ambulance services.

COP 3: Use of Blood and blood products.

COP 4: ICU and HDU services.

COP 5: Obstetrical care services.

COP 6: Paediatric care services.

COP 7: Administration of Anaesthesia.

COP 8: Surgical procedures.

MOM 1: Pharmacy services.

MOM 2: Medication storage.

MOM 3: Prescription of medications.

MOM 4: Safe dispensing of medication.

MOM 5: Medication administration.

MOM 6: Monitor adverse drug events.

MOM 7: Usage of Radioactive drugs.

PRE 1: Patient Rights and decision making process.

PRE 2: Patient education on healthcare needs.

HIC 1:Infection control manual.

HIC 2:Prevention and control of HAI.

HIC 3:Handling bio medical waste.

Organization Centered Standards

CQI 1: CQI & patient safety program.

CQI 2: CQI  Clinical & managerial indicators.

ROM 1: Responsibilities of management.

ROM 2: Organization Leadership.

ROM 3: Multi-disciplinary committees.

FMS 1: Patient and Staff safety.

FMS 2: Organization safety program.

FMS 3: Engineering services and safety.

FMS 4: Fire and Non fire emergencies.

HRM 1: HR Planning process.

HRM 2: Employee Training Programs.

HRM 3: Employee Discipline and grievance.

HRM 4: Employee Healthcare needs.

HRM 5: Employee personal records.

IMS 1: Medical record policy.

IMS 2: Medical record management.

IMS 3: Medical record security and confidentiality.

IMS 4: Medical record retention protocol.

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