NABH, NABL & JCI Accreditation Assistance

The National Accreditation Board for Hospitals & Healthcare Providers (NABH) Standards is today the highest benchmark standard for hospital quality in India. Though developed by the Quality Council of India on the lines of International Accreditation Standards like the JCI, ACHS and the Canadian Hospital Accreditation Standards, the NABH is however seen as a more practical set of Standards, topical and very relevant to India’s unique healthcare system requirements.

Within just 2 years of its launch, the Indian Accreditation Standards, the NABH was accepted by ISQUa, the International Society for Quality Assurance in Healthcare, as an International Accreditation on par with the world's best.

Patients are the biggest beneficiaries from the NABH Accreditation, as it results in a high quality of care and patient safety. The patients get services by credential medical staff. Rights of patients are respected and protected. Patient satisfaction is regularly evaluated. Accreditation also benefits the staff of the hospital as it provides for continuous learning, good working environment, leadership and above all ownership of clinical processes.

NABH Accreditation to a hospital stimulates continuous improvement. It enables the Hospital in demonstrating commitment to quality care and raises the community confidence in the services provided by the Hospital. It also provides opportunity to benchmark with the best.

Finally, the NABH is expected to provide an objective system of empanelment by Insurance and other Third Parties Administrators. Accreditation provides access to reliable and certified information on facilities, infrastructure and level of care, a need being felt increasingly by the Indian Insurance Companies who have recently come out with a three tier package segmenting hospitals into A,B& C categories based on which tariffs for cashless hospitalization treatments will be set. The NABH Accreditation will naturally help Hospital to be in the A Category.

National Accreditation Board for Testing & Calibration Laboratories (NABL), similar to the NABH, is also an autonomous body, under the Quality Council of India. The primary objective being to maintain an accreditation system for laboratories suitable for India, developed in accordance with relevant national and international standards and guides. The NABL Accreditation is a formal recognition of the technical competence of a laboratory based on third party assessment and following international guidelines. Trained Assessors taken from institutions all over India, with established credentials in testing and calibration activities carry out the assessment.

ACME is currently the only Consultancy in South India to have been approved by the Quality Council of India, as NABH Consultants. During the last three years since the inception of the NABH, we have been working with over 50 of the leading Private Hospitals in their Accreditation efforts. These hospitals include some of the leading ones in the South like Vydehi Institute of Medical Sciences & Mallya Hospital in Bangalore and the Apollo Hospitals at Mysore, the Apollo Specialty Hospital, Vijaya Hospitals, MIOT Hospitals & Sankara Netralaya (4 of their Units) in Chennai, the Apollo Hospital in Madurai, Kavery Medical Centre in Trichy, GANGA Hospital in Coimbatore, and the Regional Cancer Centre (RCC), Holy Cross Hospital, PVS Hospitals, PRS Hospitals, Dhanalakshmi Hospital, Trichur Heart Hospital and EMS Memorial Hospital in Kerala.

Apart from these Private Hospitals, ACME has also been in the forefront in enabling large Government Hospitals in Tamil Nadu and Kerala in going for the NABH. Of these 18 have till date successfully completed the Pre-Assessment and 4 the final assessment of which 1 has already been awarded the Final Accreditation. These 4 hospitals being incidentally the first set of Government Hospitals in South India to successfully complete the NABH Accreditation process.

Our consulting approach to the NABH Accreditation is unique in that we adopt a very close handholding approach, ensuring that our Consultants become an integral part of the exercise at the Hospital, an agent of the change being brought about. The NABH being an Accreditation Standard requires fundamental changes in the staff attitudes and behaviour if genuine improvement of quality in the delivery of care is to be brought about.

We commence with a comprehensive System Study and Gap Analysis done across the Hospital, covering even the Clinical Areas, especially those having a direct impact on patient care and safety. Our Report detailing the gaps is made with reference to the NABH or the NABL Standards and Clauses. This is followed by several rounds of awareness programs on the NABH Standards, covering different groups of staff and explaining to them those parts of the Standards relevant to their function. For example Nurses would be explained to on the NABH Standards related to Infection Control, Care of Patient, Management of Medication etc, Front Office Staff on Patient Access and Assessment, Information Management Systems, etc.

Once we are clear that a basic level of understanding has been achieved of the NABH requirements in all major departments, we start the system development process, with support of key hospital staff. This approach ensures an in-depth implementation. Based on the progress of implementation, monitored periodically through a series of mock audits and internal audits, the Hospital is prepared for the Assessment.

JCI Accreditation for Hospitals

The Joint Commission in an independent, not-for-profit organization that has accredited and certified more than 20,000 health care organizations and programs in the United States. The Joint Commission accreditation and certification is recognized as a symbol of quality that reflects an organization’s commitment to meeting certain performance standards.

The Joint Commission International came about in 1994 to meet the healthcare quality accreditation requirements in countries outside the United States. Though local needs vary and diverse cultures present unique challenges, the Joint Commission International (JCI) has become recognised as a consistent beacon for patient safety and quality improvement in the global community. JCI has a presence in more than 90 countries today.

JCI works with health care organizations, governments, and international advocates to promote rigorous standards of care and provide solutions for achieving peak performance. The accreditation process seeks to help organizations identify and resolve problems and to inspire them to improve the safety and quality of care and services provided. The process focuses on systems critical to the safety and the quality of care, treatment and services. The Joint Commission Standards are developed with input from health care professionals, providers, subject matter experts, consumers, government agencies and employers. They are informed by the scientific literature and approved by the Board of Commissioners.

Our approach to the JCI Accreditation makes it a more rigorous exercise when compared with the NABH. While the aim of both accreditation systems are to improve the safety and quality of care and services provided, we focus during the JCI more on systems critical to the safety and the quality of care, treatment and services. The Standards form the basis of an objective evaluation process that can help us measure, assess and improve performance. By involving the staff at all levels we work to making improvements possible only by changes in the practices followed across the Hospital. For this reason in the JCI implementation we find it essential that the senior management of the Hospital from the Directors to the Departmental Heads demonstrate their total commitment to the exercise, with their participation at every stage of the accreditation process. The evident display of their involvement will help in ensuring the participation of all in the process.

Some minimum attributes that the ACME Consultants work to establish in a Hospital aspiring for an ISO 9001 Certification are:

Acceptable quality care at affordable prices.
Timely care.
Clear communication to the patients.
Best practices for fixing appointment and service delivery.
Reliable diagnostic and laboratory support.
Reliable support services like canteen, ambulance, pharmacy, etc.
Safe and pleasant environment.
Technical competence, courtesy and attitude of staff.

Our Consultants ensure through a proper implementation of the ISO 9001 the establishment of a set of good management practices in all areas of the Hospital that directly or indirectly impact on patient care. These would cover signage at the entry of the hospital directing the patients to the registration counters and the right Out Patient Departments, ensuring continuity of care by a good medical record system, ensuring reliability in the test results for better diagnosis and care, prompt admission and a reasonably comfortable stay as in-patient in the hospital and finally timely discharge from the hospital.

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