NABH Accreditation ( Full NABH ) has different standards for small and large hospitals.

Medigence has achieved highest number of successful NABH accreditations / Full NABH for various small and large hospitals accross Gujarat and nearby states. Hospitals upto 50 beds are considered small hospitals, and hospitals with 50+ beds are considered large hospitals.

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Experts at Medigence have audited hundreds of large and small hospitals for Full NABH Accreditation, and have 10+ years of experience and assessor level skills.

Full NABH accreditation standards for large hospitals are quite comprehensive, and requires assessor level skills. Also it is important for small healthcare organizations to understand the practical approach to NABH standards. With our experts and years of experience, your project execution will be efficient and cost effective.

It takes years of experience to understand NABH standards which are quite subjective in nature

Medigence is popular amongst its clients for making these tasks easy for hospitals and for providing the right but cost effective solutions saving your time and resources.

What is NABH?

National Accreditation Board for Hospitals and Healthcare providers (NABH) was established in 2005 and is a constituent board of Quality Council of India(QCI). It has been established to create accreditation programs for hospitals and healthcare organizations with main objective to enhance the overall healthcare quality and patient safety. It provides various accreditation and certification programs for the hospitals, large and small regardless of their ownership, legal status and size.

 

NABH standards for accreditation are internationally approved by ISQua (International Society for Quality in Healthcare) based in Dublin, Ireland. ISQua is an international body that grants approval to healthcare accreditation bodies and accredits their standards across the world. Hence the hospitals approved by NABH have international recognition and the quality standards of these hospitals are in consonance with the global benchmarks. This provides the hospitals a platform to enhance medical tourism.

NABH is also a member of the Accreditation Council of ISQua. NABH is the founder member of Asian Society for Quality in Healthcare (ASQua) that is registered in Malaysia. It is also a member of the International Steering Committee of WHO Collaborating Centre for Patient Safety on behalf of ISQua Accreditation Council.

For more information on NABH kindly visit https://www.nabh.co/gib.aspx

What are NABH standards

What are NABH Standards?

NABH standards are a set of evaluation criterias for the hospitals. They provide a comprehensive framework for quality of care and improvement in the hospitals as well as patient safety. Since 2005, the standards have been revised four times. Hence, currently 4th edition standards are being followed since 2016. NABH standards are revised every 4 years and hence the revision is due this year i.e. 2020 wherein NABH 5th edition standards will be launched.

NABH divides the category of hospitals into small healthcare organizations (SHCO) and large healthcare organizations (HCO). SHCOs are the hospitals which are less than 50 beds. Hence any hospital having 1-50 bed can apply in this category. The standards are lesser compared to the HCOs which comprises more than 50 beds.

In order to get the NABH accreditation, the hospital has to comply with various standards and objective elements in the 10 chapters derived by NABH according to the 4th edition standards.

NABH Chapters are divided into the following categories.

Patient Centric Standards

  • Chapter 1 – Access, Assessment & Continuity of Care (AAC)
  • Chapter 2 – Care of Patients (COP)
  • Chapter 3 – Management of Medication (MOM)
  • Chapter 4 – Patient Rights & Education (PRE)
  • Chapter 5 – Hospital Infection Control (HIC)

Organization Centric Standards

  • Chapter 6 – Continuous Quality Improvement (CQI)
  • Chapter 7 – Responsibility of Management (ROM)
  • Chapter 8 – Facility Management & Safety (FMS)
  • Chapter 9 – Human Resource Management (HRM)
  • Chapter 10 – Information Management System (IMS)

A copy of the NABH standards can be availed from the NABH website: https://www.nabh.co/NABHStandards.aspx

Who can apply for NABH

Who can apply for NABH?

Any healthcare organization, large or small aspiring to enhance the quality of their services for the benefit of their patients, employees, stakeholders and themselves can take a leap ahead and prepare for NABH accreditation.

NABH as it is internationally recognized, it boosts the impact of medical tourism for the hospital. In case the hospital is willing to empanel with an international insurance company, it is important to have achieved an accreditation of international level approved by ISQua.

NABH accreditation or NABH entry level certification is mandatory for selection and empanelment of the hospital by all the public and private insurance companies according to the IRDAI (Insurance Regulatory & Development Authority of India) regulation dated 29th July 2016 sited on the NABH website: https://nabh.co/Announcement/IRDA.pdf. For empanelment in any central government schemes like PMJAY, Ayushman Bharat & MAA Yojana etc. NABH accreditation is a desirable criteria and attracts many benefits to the hospitals.

NABH advantages

What are the advantages of NABH

  • NABH certified / accredited hospitals undoubtedly have more benefits than the non certified/accredited hospitals. While NABH accreditation or NABH Entry Level Certification is mandatory for the hospitals who wish to provide cashless and reimbursement facilities to their patients, they are also highly benefited when they get empanelled with various government health schemes like Ayushman Bharat, PMJAY, MAA Yojana etc.
  • Further, patients are going to be highly benefited as they get the best quality of care and treatment compared to any non-NABH accredited hospital. NABH ensures that qualified and trained staff are involved in the patient care and thus the patients trusts the accredited hospitals more.
  • Hospital staff also feel more content as they get to learn continuously and are empowered by hospital processes. Employees also feel highly confident and they get a safe and secure working environment.
  • The hospital infrastructure, facilities and maintenance are certified and reliable to be accessed along with the level of care and safety.
  • As stated earlier, NABH accreditation being internationally recognized, it opens ample opportunities for medical tourism. The patients are now informed and understand the value of being treated in an accredited hospital.
Duration of NABH accreditation

What is the duration of NABH Accreditation

Various phases guide the NABH accreditation process of the hospital. From preparing the hospital to achieve accreditation, there are various steps involved that need to be accomplished.

Self Assessment & filling the NABH application form

The hospital should prepare for NABH and implement the standards for at least 3 months before applying for NABH accreditation.

Pre Assessment

 

Once the application form is scrutinized by NABH, Pre Assessment is planned and date is decided. This phase can take approximately 3 months of time after the application form is accepted by the NABH authorities.

After Pre assessment, depending upon the nature of the non-compliances raised, the hospital may be given approximately 1-3 months of time to submit the closure report.

Kindly note that the assessment dates are solely managed by NABH directly and are subject to availability of NABH assessors and other conditions.

 

Final Assessment

Upon successful completion of Pre assessment, Final assessment date is decided mutually by the hospital and NABH. The time duration between Pre assessment and Final assessment is approximately 3 months. Once the assessment is complete, again just as in pre assessment, depending upon the nature of the non-compliances raised by the assessors, the hospital may be given approximately 1-3 months of time to submit the corrective and preventive actions report. Once the assessor reviews the report and accepts the same, NABH will proceed further for the accreditation review committee meeting.

 

NABH Accreditation committee review meeting & awarding accreditation:

The NABH Accreditation review committee meets almost every month. Hence after submission of the closure report, it will take approximately 1 month’s time while the hospital’s case is reviewed. Based on the evidence received, the hospital is awarded the accreditation.

 

Hence, upon successful completion of all the above mentioned phases, the hospital can achieve accreditation within 12-14 months. However, with full support and cooperation of our hospitals, we have been able to achieve NABH accreditation within 6-8 months as well!

Process of NABH accreditation

What is the process of NABH Accreditation?

Once the hospital decides to go for the NABH accreditation, Medigence shall guide you in each and every step of the process starting from preparing the hospital till you receive the accreditation confirmation.

Preparing the hospital for NABH accreditation

The hospital shall have to implement the NABH accreditation standards for at least 3 months before finally applying to NABH. Medigence team of experts will help your hospital in understanding the standards and practical solutions for implementing them.

Preparing your hospital shall involve the following activities

  • Performing Gap assessment of the hospital for infrastructure changes, equipment changes, licenses and regulatory requirements and human resources 
  • Sensitization of staff related to all the NABH standards
  • Advisory support for the overall NABH Accreditation Process
  • Documentation of all required policies and procedures
  • Guidelines and tools for implementation of policies and procedures
  • Guidelines for training programs
  • Assistance in conducting Internal Assessments
  • Guideline for Statutory Requirements and Licenses
  • Assistance for Quality Structure and Committee Functions

Filling up the NABH Application form

Once the hospital is ready, our NABH experts shall help you in filling out the entire NABH application form. Once the application form is completely filled, the hospital will be directed to pay the application fees to NABH. Upon successful payment of the application fees, the hospital shall receive the reference number from NABH which will be your permanent reference number.

Internal Assessment & Mock Assessment

While the NABH authorities scrutinize your application and plan the pre assessment dates, our NABH consultants shall be guiding your hospital with various implementation processes, training programs, mock drills etc. Just before pre assessment, our NABH experts shall conduct a mock assessment to ensure the readiness of the hospital to face the actual assessment. 

Mock assessment will help the staff to experience and understand what to expect during the actual assessment. The experts shall raise the non-compliance report just the way it is done by the NABH assessors. The staff will also be guided about how to address the non-compliances.

Pre assessment

NABH Pre assessment is generally a bird’s eye view to check the readiness of the hospital with respect to the NABH standards. Hence it is either 2 man days or 4 man days depending upon the size of the hospital. Once your application form has been successfully accepted by NABH, dates for pre assessment will be mutually decided. During pre assessment, our NABH consultants will support from the back end. Daily briefings will be done at the end of the assessment and the observations will be discussed. In case any observation can be complied with, our experts shall help you close the same at that very instance. After pre assessment we shall guide you to create the corrective and preventive actions report in response to the non-compliances raised by the assessor/s. The same will be submitted to NABH within the recommended timeline as suggested by the assessors.

Final Assessment

NABH final assessment is a detailed and comprehensive review of the hospital to ensure that the organization is following and implementing the NABH standards to the best of its intent. Again, depending upon the size of the hospital the assessment may be of 4 to 9 man days. The hospital will also be directed by NABH to pay the annual fees before scheduling the final assessment.

During the final assessment days, our NABH experts shall extend continuous support from the backend. Daily observations will be discussed during the daily briefing sessions at the end of each assessment day so that if there is any query that can be complied with, we shall assist you for the same. Post final assessment, our NABH consultants shall guide you in creating the corrective and preventive actions report in response to the non-compliances raised by the assessors during the assessment days. The same shall be submitted to NABH within the recommended timeline as suggested by the assessors.

NABH Accreditation Committee Review & receiving Accreditation

On successful acceptance of the closure report submitted, the hospital application will be sent to the NABH accreditation committee for review. In the next consecutive month. The committee may ask to furnish certain details after reviewing the application. Medigence shall assist you during this final stage of your process and assist you in submission of the query reply. Final decisions taken by the committee will be then communicated to the hospital and accreditation will be awarded.

The accreditation once received is valid for a period of 3 years.

Surveillance

Maintaining the accreditation is always a challenge. NABH encourages continuous quality improvement at all levels during your accreditation cycle. Hence in order to ensure that the hospital is maintaining the standards and implementing them in the best of its intent, a surveillance assessment is planned every 16-18 months after the accreditation. 

Renewal of accreditation

The hospital needs to apply for renewal at least 6 months before the expiry of the accreditation in order to maintain the continuity of the same. Applying before 6 months will help NABH to plan the assessment accordingly and the hospital shall have sufficient time to comply with any non-compliances raised during the assessment before the expiry date of the accreditation.

Full NABH (NABH ACCREDITATION) Projects

Full NABH Accreditation project for 150 bed multispeciality hospital, at Ahmedabad. Project on-going

Full NABH Accreditation project for 45 bed multispeciality hospital, at Ahmedabad. Achieved Accreditation

Full NABH Accreditation project for 75 bed multispeciality large hospital, at Vadodara. Achieved Accreditation

Full NABH Accreditation project for 45 bed multispeciality hospital. Achieved Accreditation

Full NABH Accreditation project for 50 bed multispeciality hospital, at Vadodara. Achieved Accreditation

Full NABH Accreditation project for Eye hospital, at Ahmedabad. Achieved Accreditation

Full NABH Accreditation project for 35 bed paediatric hospital, at Vadodara. Project on-going

Full NABH Accreditation project for 28 bed Gynaec & IVF hospital, at Ahmedabad. Project on-going

Full NABH Accreditation project for Institute of Preventive Cardiology. Achieved Accreditation

Full NABH Accreditation project for Eye hospital. Achieved Accreditation

Full NABH Accreditation project for 45 bed multispeciality hospital. Project on-going

Full NABH Accreditation project for 80 bed multispeciality hospital. Project on-going

Full NABH Accreditation project for 29 bed multispeciality hospital, at Vadodara. Project on-going

Full NABH Accreditation project for 3 chair multispeciality hospital, at Ahmedabad. Project on-going

Full NABH Accreditation project for 100 bed multispeciality hospital, at Surat. Achieved Accreditation

External gap assessment project for 750 bed multispeciality hospital, at Ahmedabad. Project completed

Full NABH accreditation project, for multispeciality hospital, at Ahmedabad. Achieved Accreditation

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