Professional Documents
Culture Documents
Issue No. 1
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CONTENTS
Sl.
Title
Page Nos.
Content
1.
Introduction
2.
3-4
3.
On-site Assessment
5-7
4.
Feedback
HCF 1 to HCF 4
8 - 11
Issue No. 1
12
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INTRODUCTION
Pre Accreditation Entry Level is an incentive to improve capacity of Heath Care
Organisations to provide quality of care. The National Accreditation Board for
Hospitals
and
Healthcare
Providers
(NABH)
provides
third-party
accreditation/certification to Health Care Organizations in India. It ensures that
hospitals/ Small Health Care Providers (SHCO), whether public or private, national or
expatriate, play their expected role in national heath system. Country and culture
specific accreditation system safeguard the country health care system and also
involve fewer cost and better accepted as compare to external international
accreditation systems.
The assessment is carried out by the NABH empanelled Assessor(s). The
assessment is carried out systematically for comprehensive review of hospital/
SHCO services, functions and hospitals/ SHCOs quality management system. The
objective evidence so collected forms the basis:
for formulating the advice to assist the hospital/ SHCO in its development.
This guide has been prepared based on the general practices followed by
international bodies and the experience of experts of the country. This document
accordingly aims to:
a.
b.
c.
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3.
ON-SITE ASSESSMENT
NABH Secretariat on intimation from the organization about the preparedness to take
up on site-assessment, appoints an Assessor from the pool of empanelled Assessors
from assessor database. Scope and type of the hospital/ SHCO is kept in mind while
selecting the Assessor. The number of assessors depends on the size of the
hospital/ SHCO.
The assessor(s) and the names of their organizations from which they belong are
intimated to the organization for seeking their consent. NABH also assures that the
team does not have any competitive position with the applicant organization. NABH
also ensures that assessors do not have any direct/ in-direct relationship with the
organization or they/ or their organization.
Consent is obtained for the date(s) of the assessment of the organization from the
Assessor. A written communication is sent with the following documents:
-
3.1
Opening Meeting
(a)
(b)
The Assessor shall explain the objective and scope of assessment and what
is expected from the hospital/ SHCO during the assessment.
(c)
(d)
The Assessor shall inform the hospital/ SHCO that the assessment team shall
not be approached by the hospital/ SHCO for closure of non-conformances
while the assessment is in progress. Non-conformances may be closed while
the assessment report is being compiled.
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3.2
Assessment
The assessment activities include:
-
Document review
Document review includes review of polices, evidence of compliance with
policies, evidence of committees and evidence of statements.
Functional interview
Leadership interview.
Infection control interview.
Management of information/ patient records interview.
Staff qualification and education interview.
Facility tour
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10
Not Applicable
NA
3.4
Closing Meeting
The Assessor shall have a meeting with the hospital/ SHCO representatives. A copy
of the report summary of non-conformances (HCF 3) shall be handed over to the
hospital/ SHCO.
The closing meeting is to end with thanks giving for the co-operation and assistance
provided by the hospital/ SHCO.
3.5
Post Assessment
The Assessor shall send the report to NABH at the earliest.
NABH secretariat reviews the assessment report and seeks clarification and
documentation from the Assessor and hospital/ SHCO, if required.
NABH, on receipt of evidence of corrective action, if any, shall place the report before
the Accreditation Committee for its consideration for certification.
The assessment report is reviewed by the Accreditation Committee and
recommendations made.
FEEDBACK
Following feedbacks are obtained by NABH through the evaluation forms in the
NABH document Feedback Forms.
-
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Accreditation Coordinator:
Date(s) of Visit:
Assessment Timings
Morning:
Afternoon:
AM to
PM to
Opening/Closing Meeting
Date/Time
PM
PM
Opening Meeting:
Closing Meeting:
Daily Debriefing
Date / Time
(at the end of each day)
Day 1:
Day 2:
Day 3:
Day 1
Morning
Afternoon
Assessor
Assessor --
Trainee
Assessor/Expert
Signature of Assessor
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Area/ Department:
Activity Assessed:
Auditee:
Sl.
OBSERVATION
REMARKS
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Non-compliance observed:
1.
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Date(s) of Visit:
Assessor 1:
Assessor 2:
Assessor 3:
Other/TE
Trainee Assessor:
Enclosures
HCF
HCF 2
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HCF
HCF 4
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NABH I&C 01
Name
Assessor ID
Designation
Organisation
Address
Capacity
Health care
organisation Assessed
Date of visit(s)
Type of visit
I have not offered any consultancy, guidance, supervision or other services to the
hospital/ SHCO, in any way.
ii.
I am/ am not* an ex-employee of the health care organisation and am/ am not* related
to any person of the management of the health care organisation.
iii.
I got an opportunity to go through various documents of the above Hospital/ SHCO and
other related information that might have been given by NABH. I undertake to maintain
strict confidentiality of the information acquired in course of discharge of my
responsibility and shall not disclose to any person other than that required by NABH.
Date:
Place :
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Signature
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