Entrusted with maintaining the basic level of quality of services in hospitals, the National Accreditation Board for Hospitals and Healthcare has come up with a number of new initiatives to develop a robust healthcare delivery system in the country. Dr BK Rana, Director, NABH Quality Council of India, highlights the quality standards and various compliance related challenges for hospitals in conversation with Elets News Network (ENN).

Q. What are the new initiatives National Accreditation Board for Hospitals and Healthcare (NABH) has undertaken to ensure quality health services get delivered?

Currently, Nabh offers 15 different accreditation/certification programmes for a range of healthcare facilities. Under the new initiatives, pre-accreditation entry level certification programme was started to ensure a basic level of quality in hospitals. This programme is being used by those private hospitals offering cashless treatments for empanelment purpose. Insurance regulator IRDA (Insurance Regulatory and Development Authority) has mandated it. In addition, NABH has started an empanelment programme for medical value travel facilitators to ensure good services to patients coming from abroad. This programme is endorsed by the Ministry of Commerce, Ministry of Tourism and Services Export Promotion Council. In the AYUSH (Ayurveda, Unani, Siddha and Homeopathy) sector, we have started accreditation programme for ‘Panchakarma’ daycare centres.

Q. What are the key accreditation standards have you fixed for AYUSH hospitals and wellness centres?

We have five different set of standards under AYUSH to cover all the five streams. The second edition of these standards has put more focus on clinical care aspects. Structural requirement, which used to be a separate book in first edition, has been incorporated in second edition at appropriate places. The requirements of the standards shall have to be identified; evidenced by data gathered, analysed and interpreted with the aim of improving the quality system of a hospital. Wherever the word should is used, it is imperative that the organisation implement the same. Where the phrase can/ could/preferably is used the organisation would use its discretion and implement it according to the practicability of the proposed guidance.

In general, the organisation will need to establish clear evidence backed by robust systems and data collection to prove that they are complying with the intent of the standards. These systems are as we say, defined, implemented, owned by the staff and finally provide objective evidence of compliance. Some of the key issues include:

1. Patient-related: Monitoring safety, treatment standards and quality of care. This would mean to effectively meet the expectation of patients and their families and associates.

2. Employee-related: Monitoring competence, on-going training, awareness of patient requirements and monitoring employee satisfaction.

3. Regulatory-related: Identifying, complying with and monitoring the effective implementation of legal, statutory and regulatory requirements which affect patient safety.

4. Organisation policies-related: Defining, promoting awareness of and ensuring implementation of the policies and procedures laid down by the organisation, amongst staff, patients and interested parties including visiting medical consultants.

5. NABH Standards-related: Identification of how the organisation meets the NABH standards and the objective elements. Where a part of an element, an element or a standard cannot be applied (for example, related to emergency, surgical proceudres, laboratory services, radiological services, etc) in a particular organisation, adequate explanation and justification must be provided to NABH and its team of assessors to enable exclusion of applicability. In particular, it must be ensured that the intent of each chapter of standards is understood and applied.

Q. How do you ensure compliance by hospitals? What are the key challenges?

NABH accreditation is based on continuous improvement and monitoring. Certificate is valid for three years and there is a surveillance assessment in 15-17 months. In addition, there is a surprise check of one facility every month. Further, there may be additional surprise visits based on feedback from stakeholders. Continuous monitoring to ensure compliance and making hospitals to improve is a great challenge. Therefore, providing education and training opportunities are important for hospitals to excel.

NABH accreditation is based on continuous improvement and monitoring. Certificate is valid for three years and there is a surveillance assessment in 15-17 months. In addition, there is a surprise check of one facility every month.

Q. How do you help hospitals to attain various quality standards set by NABH?

We organise various training programmes from time to time. These may include training on standards interpretation and implementation, medication management, infection prevention and control, documentation requirements, continuous quality improvement, etc. In addition, we also organise conclaves for accredited hospitals and awareness programmes for potential applicants.