Nabh implementation SHCO (Small Healthcare Orgnizations)

NABH IMPLEMENTATION
Dr Prakash Kolnoorkar
NABH Internal Assessor
ISO 9001-2015
Six Sigma Black Belt

UNDERSTANDING THE THINGS
 Actually NABH implementation is extremely easily
any hospital management or administration need not
to be panic.
 It is as simple as guide at any tourist place and our
guide is only and only NABH Standards book.
 Any graduate person either in nursing or any medical
stream can implement NABH easily.
 It does not require anything except our commitment
for safety across the organization.
 When we graduate in nursing or any medical degree
which is far-far tough than these the NABH
implementation.

CONTINUED..
 Read the objective and plan process at your
hospital to achieve the intent of that objective or
standard.

MANUALS
 Apex Manual - How we take decisions to run hospital – Main decision
making body.
 Safety Manual – Safety precautions at hospital
 Infection Control Manual – Infection Control Practices
 Disaster Manual – Details of how to face internal and external disaster
 Departmental Manuals – All departments like IP, OP, ICU, OT, labor room,
biomedical engineering, general engineering, pharmacy, endoscopy.....

 Small Health Care Organizations (SHCO)
 Those healthcare organizations having bed strength between 20 to 50
beds and are in possession of supportive and utility facilities that are
appropriate and relevant to the services being provided by
organization.
 Exclusions
 _ Polyclinics
 _ Diagnostic Centres
 _ Superspeciality* centres (single/multiple)
 Exceptions
 Specialty **Day Care centres (minimum bed strength not
mandatory)
Super Specialty centres are the centres which reflect requirement of
DM/MCh or equivalent qualified personnel.
 Specialty centres are the centres which reflect requirement of
MD/MS or equivalent qualified personnel.

A SHORT BRIEF ABOUT NABH
IMPLEMENTATION
 There are 10 chapters in NABH standards divided into 2
parts:
 Patient centred 5:
 AAC – Access, Assessment and Continuity of Care 7/
 COP – Care of Patients
 MOM-Management of medication
 HIC- Hospital Infection Control
 PRE – Patient Right and Responsibilities
 Organization Centred 5:
 CQI-Continual Quality Improvement
 ROM-Responsibility of Management
 FMS-Facility Management System
 HRM-Human Resource Management
 IMS-Information Management System

AAC
 Chapter Standards Objective
 1 3
 2 4
 3 4
 4 4
 5 7
 6 7
 7 6
 7 35

COP
 COP Standards Objectives
 1 5
 2 6
 3 3
 4 3
 5 3
 6 3
 7 5
 8 3
 9 9
 10 7
 10 47

MOM
MOM Standards Objectives
1 6
2 5
3 3
4 7
5 3
6 3
6 27

PRE
 PRE Standards Objectives
1 4
2 9
3 5
4 6
5 4
5 28

Nabh implementation SHCO (Small Healthcare Orgnizations)

PROCESS BRIEF INTRODUCTION
 NABH Chapters 10
Standards
Objectives
Quality Indicators
Application
Preparation
Self Assessment
NC & its Compliance
Pre-assessment
NC & its Compliance
Main Assessment
NC & its Compliance
Certification
Surveillance Visit
NC & its Compliance
Surprise Visit
NC & its Compliance
Renewal Application
NC & its Compliance

ACCESS, ASSESSMENT AND CONTINUITY OF CARE
 AAC.1. : The organization defines and displays the services
that it can provide
 AAC.2. : The organization has a documented registration,
admission and transfer process
 AAC.3. : Patients cared for by the organization undergo an
established initial assessment
 AAC.4. : Patient care is continuous and all patients cared for
by the organization undergo a regular reassessment
 AAC.5. : Laboratory services are provided as per the scope of
the hospital’s services and adhering to best practices
process
 AAC.6. : Imaging services are provided as per the scope of
the hospital’s services and adhering to best practices
 AAC.7. : The organization has a defined discharge

CARE OF PATIENTS (COP)
 COP.1. : Care of patients is uniform and is guided by the
laws and regulations
 COP.2. : Emergency services including ambulance are guided
by documented procedure and applicable laws and
regulations
 COP.3. : Documented procedures guide the care of patients
requiring cardio-pulmonary resuscitation
 COP.4. : Documented procedures define rational use of blood
and blood products
 COP.5. : Documented procedures guide the care of patients
in the intensive care and high dependency units
 COP.6. : Documented procedures guide the care of obstetrical
patients
 COP.7. : Documented procedures guide the care of paediatric
patients

MANAGEMENT OF MEDICATION (MOM)
 MOM.1. : Documented procedures guide the organization of
pharmacy services and usage of medication
 MOM.2. : Documented procedures guide the prescription of
medications
 MOM.3. : Documented procedures guide the safe dispensing
of medications
 MOM.4. : There are defined procedures for medication
administration
 MOM.5. : Patients are monitored for adverse drug events after
medication administration
 MOM.6. : Documented procedures guide the use of medical
gases

PATIENT RIGHTS AND EDUCATION (PRE)
 PRE.1 : The organization protects patient and family rights
during care and informs them about their
responsibilities
 PRE.2 : Patient rights support individuals beliefs, values and
involve the patient and family in decision making
processes
 PRE.3 : A document policy for obtaining patient and/or
families consent exists for informed decision
making about their care
 PRE.4 : Patient and families have a right to information
and education about their healthcare needs
 PRE.5 : Patient and families have a right to information on
expected costs

HOSPITAL INFECTION CONTROL (HIC)
 HIC.1 : The organization has a well-designed, comprehensive and
coordinated Hospital Infection Control (HIC) programme
aimed at reducing /eliminating risks to patients, visitors
and providers of care.
 HIC.2 : The hospital has an infection control manual, which is
periodically updated and conducts surveillance activities
 HIC.3 : The hospital takes actions to prevent or reduce the risks of
Hospital Associated Infections (HAI) in patients and
employees
 HIC.4 : There are documented procedures for sterilization activities in
the hospital
 HIC.5 : Statutory provisions with regard to Bio-Medical Waste (BMW)
management are complied with
 HIC.6 : The infection control program is supported by hospital
management and includes training of staff and employee health

CONTINUOUS QUALITY IMPROVEMENT (CQI)
 CQI.1 : There is a structured quality improvement and
continuous monitoring programme in the
organization.
 CQI.2 : The organization identifies key indicators to
monitor the structures, processes and outcomes
which are used as tools for continual improvement.
 CQI.3. : The quality improvement programme is supported
by the management.
 CQI.4 : There is an established system for clinical audits
 CQI 5. : Sentinel events are intensively analyzed.

RESPONSIBILITIES OF MANAGEMENT (ROM)
 ROM.1 : The responsibilities of the management are defined
 ROM.2 : The organization is managed by the leaders in an
ethical manner
 ROM.3 : Leaders ensure that patient safety aspects and risk
management issues are an integral part of patient
care and hospital management.

FACILITY MANAGEMENT AND SAFETY (FMS)
 FMS.1 : The organization is aware of and complies with the
relevant rules and regulations, laws and byelaws
and requisite facility inspection requirements.
 FMS.2 : The organisation’s environment and facilities
operate to ensure safety of patients, their families,
staff and visitors.
 FMS.3 : The organization has a program for clinical and
support service equipment management
 FMS.4 : The organization has provisions for safe water,
electricity, medical gases and vacuum systems
 FMS.5 : The organization has plans for fire and non-fire
emergencies within the facilities

HUMAN RESOURCE MANAGEMENT (HRM)
 HRM.1 : The organization has a documented system of
human resource planning.
 HRM.2 : The staff joining the organization is socialized and
oriented to the hospital environment
 HRM.3 : There is an ongoing programme for professional
training and development of the staff.
 HRM.4 : An appraisal system for evaluating the p
performance of an employee exists as an integral
part of the human resource management process
 HRM.5 : The organization has a well-documented
disciplinary and grievance handling procedure
 HRM.6 : The organization addresses the health needs of the
employees

 HRM.7 : There is a documented personal record for each
staff member
 HRM.8 : There is a process for authorizing all medical
professionals to admit and treat patients and
provide other clinical services commensurate
with their qualifications
 HRM.9 : There is a process to identify job
responsibilities and make clinical work
assignments to all nursing staff members
commensurate with their qualifications and any
other regulatory requirements

INFORMATION MANAGEMENT SYSTEMS (IMS)
 IMS.1: Documented procedures exist to meet the information needs of the
care providers, management of the organization as well as
external agencies that require data and information from the
organization.
 IMS.2: The organization has processes in place for effective management
of data
 IMS.3: The organization has a complete and accurate medical record for
every patient
 IMS.4: The medical record reflects continuity of care
 IMS.5: Documented procedures are in place for maintaining
confidentiality, integrity and security of information
 IMS.6: Documented procedures exist for retention time of records, data
and information
 IMS.7: The organization regularly carries out medical record audits

Nabh implementation SHCO (Small Healthcare Orgnizations)

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