A guide for NABH Pre Accreditation Entry Level Certification

National Accreditation Board for Hospitals (NABH), a constituent get on of Quality Council of India (QCI) establishes and operates accreditation programmed for healthcare organizations crossways India. In a go to emphasize quality within the healthcare system of India, NABH and QCI jointly released Pre-accreditation Entry Level Certification Standards after healthcare organizations, especially little hospitals, found the strictness of Full Accreditation standards highly challenging to start with.

Requirement below pre-accreditation entry height values is one fourth the requirement of full accreditation standards, thereby, making the fineness drive attainable.

Here's the procedure of obtaining NABH quality certification in brief:

Preparing for NABH Certification
A hospital prepares for NABH Accreditation must first obtain a copy of NABH standards from the NABH Secretariat against payment. HCOs must behavior a self-assessment against NABH standards for an era of at least 3 months before compliance of request to ensure that their organization complies with NABH standards. Self-assessment will give the HCO a fair idea concerning the documentation and implementation requirements. The application form for NABH Accreditation/Certification is available on Corpseed website.

On receipt of the request, the Secretariat scrutinizes it with admiration to its completeness and examines the self-assessment toolkit to verify whether the NABH requirement with respect to the certification program has been meeting. Found complete, the Secretariat then issues an acknowledgment letter for the application with a unique registration number. The sole registration number is worn for correspondence with the HCO.

NABH Certification Procedure
There are 2 stages to NABH Certification Procedure i.e. the Pre-Assessment phase and The Final Assessment phase.

NABH appoints an assessment team to comprise of a Principal Assessor and Assessors to behavior assessments of HCO. The size and scope of healthcare organizations make a decision about the number of assessors.

Pre-assessment Stage
On in receipt of the application, NABH forwards it (application form, signed duplicate of Terms and Conditions, Self-Assessment Toolkit) to the Principal evaluator (who leads the Assessment Team) appointed by NABH. The pre-assessment stay of the HCO is organized by NABH in consultation with the HCO within 3 months of the submit the application.

The Assessment Team visits the HCO to explain the methodology for appraisal, review documentation and check preparedness of the hospital for final assessment while ensuring their commitment to quality goals. Before the pre-assessment visit, the HCO must make sure their organization complies with the requisite standards.

In case of inadequacies, HCO shall take a corrective deed for implementation and submit the report thereof to NABH Secretariat within 90 days from the date of pre-assessment.

However, if at the time of pre-assessment, it is found that there is a significant dissimilarity flanked by the self-assessment report sent by the healthcare organization and the pre-assessment carried out by the assessment team, the organization will only be able to apply for final assessment behind a period of 6 months.

Final Assessment Stage
The final assessment involves a comprehensive review of HCO’s functions, department, and military. For a successful certification procedure, it is important for the hospital to take necessary corrective action with respect to the non-conformities sharp out during the pre-assessment stage.

NABH appoints a divided team for final assessment to comprise The Principal Assessor, Assessors and technical experts (if need be) and at least one associate from the pre-assessment team. Final Assessment must be conducted within 6 months of conduct the pre-assessment. The date for the final assessment is decided upon by the hospital management and the assessment side.

The Principal Assessor submits the appraisal report to NABH Secretariat in the format prescribed by NABH. The report is also shared with the worried HCO.

NABH examines the detailed assessment account that it receives from the Principal Assessor. HCO ensures that the non-conformances that were not met throughout the assessment phase comply with the report and are submitted to NABH Secretariat within 3 months.

Grant of Certification
Ultimately, the NABH Accreditation group is responsible for the funding of accreditation or certification. A brief assessment and corrective actions by the HCO is placed before the Accreditation Committee. The committee’s observations and recommendations are the deciding factors. The HCO must be prepared for a verification visit by NABH to make sure compliance with standards. HCOs are free to appeal against the answer to assessments. Following are the quality criteria for Pre-Accreditation Entry Level Certification:

Period of Validity
Pre Accreditation Entry Level phase is valid for a period of 6 months to a maximum of 18 months.
In case of funding of accreditation to the HCO, NABH shall issue a certificate with the mention of the date of validity and a sole certificate number. The certificate is accompanied by a “Scope of Accreditation” defining services being offered by the HCO and the NABH placard is also provided.