Preparing the hospital for NABH accreditation
The hospital shall have to implement the full 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 full NABH accreditation 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.
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.
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.
Maintaining the full NABH 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 full NABH 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.