Documentation Requirements for Hospital Accreditation -By Global Manager Group
What is Accreditation? Accreditation is basically a framework, which helps healthcare organization to establish objective systems aimed at patient safety and quality of care. Documentation plays an important role in defining of such systems. In general, the organization will need to establish objective and dynamic system incorporating requirements given in the standard. These systems defined, implemented, owned by the staff and finally provide objective evidence of compliance. www.Globalmanagergroup.com
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NABH Certification for Hospital Accreditation Objective of NABH Certification is to operate accreditation and allied programs in collaboration with stakeholders focusing on patient safety and quality of healthcare. NABH has developed Pre Accreditation Entry Level certification standards, in consultation with various stake holders in the country, as a stepping stone for enhancing the quality of patient care and safety.
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How one should apply for NABH Accreditation? The organizations can obtain the application form for NABH Accreditation from NABH Secretariat or download it from the web-site. The application form should be accompanied with the required application fee. Hospitals should also submit a signed document ‘Terms and Conditions for Maintaining NABH Accreditation'. The same can be downloaded from the website. For more details please see ‘Accreditation Documents'.
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NABH Documentation NABH Documentation, serves as a point of reference for everyone in the organization. While their personal perspectives may be respected, the documented system and processes have to be complied with consistently in the organization by everyone. A NABH Documented policy, process and procedure become a single source of truth in an organizational set-up.
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Importance of Manual in NABH Documentation Quality manual is a document in the organization that contains the total quality program including general information about organization, its business its vision mission statements, its quality policy, quality objectives, quality standard applied, departmental & work units policies and procedures, SOPs, forms & formats used by organization, quality monitoring protocols & indicators and the corrective & preventive actions that the organization takes to improve quality. www.Globalmanagergroup.com
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NABH Policy in Documentation NABH Policy commits to achieve quality services through the Quality Management System while complying with all applicable regulatory requirements. Objectives for NABH Policy • To maintain the quality of ophthalmic services in accordance with international standards. • Optimum utilization of infrastructural facilities including manpower. • To ensure continued patient satisfaction through delivery of high class Medicare with a personal touch. • To ensure high levels of staff satisfaction and motivation and facilitate continuous enhancement of knowledge and skills through constant learning and training initiatives.
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NABH System Procedures Requirement of Procedures for NABH Certification are as follows: • • • • • • •
Management Review Document And Data Control Corrective And Preventive Action Control Of Quality Records Internal Quality Audit Control Of Monitoring &Measuring Equipment Training Control Of Non–Conforming Products / Services
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NABH SOPs Requirement of Standard Operating Procedures for NABH Certification are as follows:
• • • • • •
AAC(Access, Assessment and Continuity of Care) COP (Care of Patients) CQI (Continuous Quality Improvement) General MOM (Management of Medications) PRE (Patient Rights and Education)
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NABH Audit Checklist NABH Audit Checklist covers audit questions to be used for hospital system auditing for objectively evaluate the adherence of system by functional heads to establish processes. It also includes audit questions as a quick reference for all related work areas of the hospital. It will be very good tool for the auditors to make audit Questionnaire while auditing and make effectiveness in auditing in the hospital.
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Benefits of NABH Accreditation: • Accreditation benefits all Stake Holders. Patients are the biggest beneficiaries. Accreditation results in 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 to a Hospital stimulates continuous improvement. It enables hospital in demonstrating commitment to quality care. It raises community confidence in the services provided by the hospital. It also provides opportunity to healthcare unit to benchmark with the best.
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• The Staff in an accredited hospital are satisfied lot as it provides for continuous learning, good working environment, leadership and above all ownership of clinical processes. It improves overall professional development of Clinicians and Paramedical staff and provides leadership for quality improvement within medicine and nursing. • Accreditation provides an objective system of empanelment by insurance and other Third Parties. Accreditation provides access to reliable and certified information on facilities, infrastructure and level of care. www.Globalmanagergroup.com
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NABH Documentation Kit By Global Manager Group • Hospital Manual (08 files) • Department Manual (47 Files) • System Procedures (08 system procedures) • Health and Safety Procedures • Process Approach • Standard Operating Procedures (SOPs) • System Formats • NABH Audit checklist www.Globalmanagergroup.com
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