QCI has launched a new platform for the Hospital Accreditation program to bring comprehensive digitalization to the entire process. It is a multifarious platform for the accreditation process of Healthcare organizations keeping all the systems as an integral approach.
The complete accreditation process includes registration, documentation, and fee submission followed by Desktop, On-Site Assessments, and Committee Review using a technology-based platform that will provide complete information about the simplified accreditation certification process, requirements, and compliances. It incorporates a guidebook, presentations, and documents.
BBenefits of Portal
The assessment for the accreditation encompassing desktop and on-site assessment followed by committee review would be done using this technology platform. Each standard is evaluated based on a series of questions that are verified using relevant documents or geo-tagged and geo-stamped photographs to measure the compliance status. The use of technology will ensure that the assessment process is transparent and efficient as compared to the traditional ways of manual accreditation.
line of NABH Standards
NABH Hospital Accreditation Program is based on the NABH standards that comprise 10 chapters. As part of this program, the Questionnaire for Hospital Accreditation is formulated to make it simpler and has been drafted based on the objective element given in the aforementioned NABH standards. The standards are detailed below-
Patient Centred Standards
Chapter | Description |
Access, Assessment, and 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 and organized process of administration of medication/intervention. The hospital should have a mechanism to ensure that the emergency medication/ intervention is standardized throughout the hospital, readily available, and replenished on time. |
Patient Rights and Education (PRE) |
The Hospital should dene the patient and family's rights and responsibilities. Also, the staff should be trained to protect patient 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, and providers of care while proactively monitoring its adherence. |
Organization Centred Standards
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 and ethically. The hospital ensures that patient safety and risk-management issues are an integral part of patient care and hospital management. |
Facility Management and 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. |
Revised Questionnaire for Hospital Accreditation Program-The questionnaire is divided into thirteen parts:
The category into thirteen parts is as follow-
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 – Family Management and Safety (FMS) Part XII – Human Resource and Management (HRM) Part XIII – Information Management System (IMS)
Timeline
SNo. Stages Timeline (Days) | ||
1 | Application Form | 30 |
2 | Fee Submission | 10 |
3 | Desktop Review | 30 |
4 | Assessment Selection | 15 |
5 | Pre Assessment (Optional) | 120 |
6 | 1st year Annual Fee | - |
7 | Final Assessment | 120 |
8 | Accreditation Committee | 15 |
9 | 2nd year Annual Fee | - |
10 | Surveillance Assessment | 90 |
11 | Surveillance Decision by AC | 15 |
12 | 3rd year Annual Fee | - |
13 | Renewal | Before 6 month of expiry |
Process Flow & Timeline
Hospitals can register online on www.hcoaccreditation.nabh.co. It is an OTP-based registration process to verify the entered Mobile Number and Email ID. An account will be created after filling the user registration form and OTP. Users can log in with the username and password received on their registered email ID and have to submit all the required details through a web portal followed by the payment of the fee. The details entered by the applicant for and after the registration on the website cannot be edited once submitted. Applicants must make sure that the details are filled-in accurately, after submission they will be non-editable.
Fee Submission
The fee to be submitted by Hospitals is as follows:
Size of Hospital |
Pre- assessment |
Assessment |
Surveillance |
Application Fee | Annual Accreditation Fee |
Up to 100 beds |
Four man days | Six man days (3x2) | Four man days (2x2) |
Rs. 40,000 |
Rs. 1,65,000 |
101-300 beds |
Four man days | Nine man days (3x3) | Six man days (3x2) |
Rs. 75,000 |
Rs. 2,50,000 |
301-500 beds |
Six man days |
Twelve man days (4x3) |
Nine man days (3x3) |
Rs. 1,00,000 |
Rs. 3,60,000 |
501 and above |
Six man days |
Sixteen/ Fifteen man days (4x4) or (5x3) |
Nine man days (3x3) |
Rs. 1,50,000 |
Rs. 4,40,000 |
The fee structure is based on the number of man days required for assessment. In case the scope of service is more than the above, then proportionately higher man days and fee structure may be charged.
GST: w.e.f 01.06.2016 a GST of 18% or as applicable will be charged on all the above fees. HCOs are required to include the service tax in the fees accordingly while making payment to NABH.
Desktop Review
Desktop Review of the registered applications will be done online through a web portal by the assessor. The assessor will raise NCs in case of insufficiency, discrepancy, or incorrect data uploaded. The applicant will have a specified timeline to respond against all the raised Non-Compliance(s) through the portal by providing satisfactory reasons and evidence of conformity. The Assessor will verify all the replies within a specific period.
Onsite Assessment
In onsite assessment, the assessors nominated by NABH makes a visit to the HCO for a predefined man days based on the bed strength of the hospital, the assessors verifies the documents, facilities and conducts interviews in person at the HCO. The Hospital needs to bear the cost of the assessor's travel and stay.
Pre Assessment (Optional)
NABH has made pre-assessment optional. Those hospitals which do not want to undergo pre- assessment shall choose Final assessment in the portal. However, NABH shall conduct the pre- assessment for those hospitals which are desirous for the same. The Principal Assessor and other assessors (as applicable) are assigned the job of pre-assessment. Principal assessor shall submit the compiled non-compliance form on the portal. The hospital shall take corrective actions on the non- compliance raised by the Principal Assessor/ team. The hospital shall in any case be required to pay the requisite Annual fee before the final assessment.
Final Assessment
After the hospital has taken necessary corrective action to the non-conformities raised during the pre- assessment (which is optional), NABH shall propose to constitute an assessment team for the final assessment. However, as mentioned earlier HCO's can directly go for final assessment without opting for pre assessment. The total number of assessors appointed shall depend on the size of the hospital and scope of services provided. The date of final assessment shall be agreed upon by the hospital management and assessors. Assessment shall be conducted on all the facilities covered under accreditation. The assessment team reviews the hospital's documented management system and verifies its compliance to the NABH standards. The documented quality system, policies and procedures, other manuals etc. shall be assessed for their implementation and effectiveness
Based on the assessment by the assessors, the Principal assessor will compile the Non Compliance (if any) raised by the assessment team and submit the same on the portal. The detailed non-compliance observed during the assessment is visible to the hospital team in the online portal once the Principal Assessor submits.
Review of Non Compliance: The hospital shall take necessary corrective action on the non- compliance and upload the requisite document as evidence for corrective action for each non- conformity. On successful submission of the corrective action by the hospital, the same shall be reviewed by the Principal Assessor. Healthcare organisations can avail only two cycles of corrective action on non-compliance. After satisfactory corrective action is taken by the hospital, the accreditation committee examines the assessment report, additional information received from the hospital and consequent verifications. The accreditation committee shall make appropriate recommendations regarding accreditation of the HCO.
Surveillance and Re Assessment
Accreditation to the hospital shall be valid for a period of four years. NABH shall conduct surveillance before completion of 20-24 months since the date of accreditation of the accredited hospital. The hospital shall pay the annual fees every year. The first annual fees is paid before the final assessment and is valid till the end of first year from the date of accreditation. Since then, the annual fees shall be due on the same date/ month every year. The hospital need to apply online for renewal of accreditation at least six months before the expiry of validity of accreditation for which reassessment shall be conducted. NABH may call for an unannounced visit, based on any concern or any serious incident reported upon by an individual or an organization or media.
Review of Non Compliance: The hospital shall take necessary corrective action on the non- compliance and upload the requisite document as evidence for corrective action for each non- conformity. On successful submission of the corrective action by the hospital, the same shall be reviewed by the Principal Assessor. Healthcare organisations can avail only two cycles of corrective action on non-compliance. After satisfactory corrective action is taken by the hospital, the accreditation committee examines the assessment report, additional information received from the hospital and consequent verifications. The accreditation committee shall make appropriate recommendations regarding accreditation of the HCO
Focus Assessment
Focus assessments are done in HCO when there are any significant changes with regard to the HCOs activities and operations, such as change in scope of accreditation, change of address/ location, change in environment, key technical personnel etc. Hospitals are requested to view policy and procedure related to Focus visits to an accredited hospital by visiting the following link.
https://www.nabh.co/Policy_for_Focus_Assessment.aspx
Review of Non Compliance: The hospital shall take necessary corrective action on the non- compliance and upload the requisite document as evidence for corrective action for each non- conformity. On successful submission of the corrective action by the hospital, the same shall be reviewed by the Principal Assessor. Healthcare organisations can avail only two cycles of corrective action on non-compliance. After satisfactory corrective action is taken by the hospital, the accreditation committee examines the assessment report, additional information received from the hospital and consequent verifications. The accreditation committee shall make appropriate recommendations regarding accreditation of the HCO
Surprise Assessment
NABH may conduct surprise assessments at accredited hospitals periodically to evaluate the compliance to the accreditation standards, as hospitals are expected to adhere to the NABH accreditation standards at any given point of time once HCO is accredited. Surprise visit can also happen in response to adverse media reports. Hospitals are requested to view policy and procedure related to Surprise visits to an accredited hospital by visiting the following link.
https://www.nabh.co/SURPRISE-VISIT.aspx
Issue of Accreditation Certificate:
NABH shall issue an accreditation certificate to the hospital with a validity of four years. The certificate has a unique number and date of validity. The certificate is accompanied by the scope of accreditation. The applicant hospital must make all payments due, if any, to NABH, before the issue of the certificate.
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