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Indian Medical Association Hospital Board Of India

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HOSPITAL ACCREDITATION

NEED OF HOUR

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Survival Of Small & Medium Size Hospitals

• How will they survive? • How can they protect themselves

from encroachment by Corporate Hospitals?

•What up gradation will they need to be competent enough to survive?

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Survival Of Small & Medium Size Hospitals

We are in era of ‘Consumerism’.

Don’t forget, your patient is a your consumer in eyes of Consumer Protection Act.

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Survival Of Small & Medium Size Hospitals

Law Makers have made provision of Consumer Forums to protect rights of consumers.

You are treated there as the offenders.

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Survival Of Small & Medium Size Hospitals

Consumer Forums favour consumers while giving judgement.

What they need to give the judgement against doctor?

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Survival Of Small & Medium Size Hospitals

Lack of evidence on part of the doctor.

How will you be able to give evidence to save yourself?

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Survival Of Small & Medium Size Hospitals

By proper documentation of

your quality of care, your communication with patient, measures of patient safety and respect of patient’s rights.

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Survival Of Small & Medium Size Hospitals

And approval / stamp / guarantee by some reputed agency, relied upon by judiciary, that you do all this as per norms on regular basis.

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IMA–NABH INITIATIVE (a project of IMA HBI)

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Objectives

• To assist hospitals to achieve

international standards in patient care

and safety.

• To assist hospitals to countenance CEA

• To increase the viability of small and

medium hospitals by value addition.

• To provide hospitals an affordable

access to accreditation.

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NABH Standards and Objective Elements

• A standard is a statement that defines the structures and processes that must be substantially in place in an organisation to enhance the quality of care.

• Objective element is a measurable component of a standard.

• Acceptable compliance with objective elements determines the overall compliance with a standard.

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Prototype of a Standard And Its Objective Elements

• AAC. 1 The organization defines and displays the services that it can provide

Objective Elements:

a. The services being provided are clearly defined.

b. The defined services are prominently displayed.

c. The relevant staffs are oriented to these services.

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SHCOs

(Less than 50 beds)

• Pre Accreditation Entry Level standards:

No of Standards : 41

No of Objective Elements : 149

• Full Accreditation Standards

No of Standards : 61

No of Objective elements : 289 14

Hospitals

(More than 50 beds)

• Pre Accreditation Entry Level Standards:

No of Standards : 45

No of Objective Elements : 167

• Full Accreditation Standards:

No of Standards : 102

No of Objective elements : 636

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NABH Financial Terms and Conditions

Book of NABH Pre Accreditation Entry Level Standards

for Hospital : Rs. 1500/-

Organization

Assessment Criteria

Certification Fee (Rs.)

Assessment

Application

Fee

Certification

Fee

Hospital

One man-day

Rs. 2,000/-

Rs. 25,000/-

Note : The man days given above for assessment are indicative and may

change depending on the facilities and size of the hospital.

Service Tax applicable from time to time (currently @ 14%) will be charged

on all the above fees.

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NABH Financial Terms and

Conditions

Organization

Assessment Criteria

Certification Fee (Rs)

Assessment

Application Fee

Certification Fee

SHCO

One Man day

Rs 1000/-

Rs 10,000/-

Book of NABH Pre Accreditation Entry Level Standards for SHCO :

Rs. 1000/-

Note: The man days given above for assessment are indicative and may

change depending on the facilities and size of the SHCO.

Service Tax applicable from time to time (currently @ 14 %) will be charged

on all the above fees. You are requested to please include the service tax in

the fees accordingly while sending to NABH. 17

Services By HBI

1. Baseline assessment,

2. Training of Nodal Person,

3. Technical assistance in formulating SOPs and

policies,

4. Onsite training,

5. Hand holding,

6. Mock assessment.

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NABH Accreditation

• IMA is of the view that all nursing homes or medical establishments should be accredited with NABH.

• IMA is playing role of “facilitator” in this process.

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LITIGATIONS

What are the two most common reasons for

litigations on doctors?

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Reasons For Litigations

1. Lack Of Communication

2. Lack Of Documentation

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With NABH Accreditation, you have to..

Communicate What You Have Documented…

And, Document What You Have Communicated…

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With NABH Accreditation.

With this practice, made inbuilt by NABH Accreditation, the litigation rate drastically drops down to 10 % of current rate.

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With NABH Accreditation, you will be able to..

Propagate that your

establishment offers

facilities that are of

better quality.

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With NABH Accreditation, you will be able to..

Propagate that your

premises provides

high standards of care with

high level of patient safety.

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With NABH Accreditation, you will be able to..

Provide better quality of

services which, in turn, will

generate more business.

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With NABH Accreditation, you will be able to..

Get empanelment with CGHS, ECHS, PSUs and State Government.

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With NABH Accreditation, you will be able to..

Apply for empanelment with UN institutions.

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With NABH Accreditation, you will be able to..

Recruit qualified staff, residents and nurses.

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With NABH Accreditation, you will be able to..

Apply for Government projects and grants.

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With NABH Accreditation, you will be able to..

Apply for international grants.

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With NABH Accreditation, you will be able to..

Collaborate with other recognized health care establishments.

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With NABH Accreditation, you will be able to..

Generate faith In public that your hospital does not sell fake / spurious drugs.

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With NABH Accreditation, you will be able to..

Strengthen the public faith that their rights will be respected and protected.

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With NABH Accreditation..

Similarly, the hospital doctors will have faith that their rights are also being respected.

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With NABH Accreditation..

Public will be confident that the hospital will provide a safe and secure environment for them.

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With NABH Accreditation..

Public will have faith that the technicians in the establishment are

well trained and qualified.

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With NABH Accreditation..

Public will be assured that the hospital maintains and strictly follow the infection control policy.

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With NABH Accreditation..

Hence, they will be less apprehensive of acquiring infections like Hepatitis B, Hepatitis C, HIV and TB when they visit your hospital.

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With NABH Accreditation..

Public will be assured that any news story from the establishment, on TV or in print, will be scientific.

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With NABH Accreditation..

Public will be confident that their right to confidentiality will be respected. And, their medical records will be preserved as per law.

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With NABH Accreditation..

Accreditation means better quality of services.

So you have a marketing advantage in terms of costs of treatment or services provided compared to those who are not accredited.

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With NABH Accreditation..

Accreditation will lead to a process of continuous learning and improvement, which will further enhance the skills and knowledge of your

staff. 43

With NABH Accreditation..

Accreditation will facilitate empanelment with insurance agencies and other third parties.

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With NABH Accreditation..

NABH Accreditation means the medical establishment will adhere to standard treatment guidelines.

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With NABH Accreditation..

As a result, there will be less opportunities for people filling cases for medical negligence. You will have a stronger defense against malpractice litigations.

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With NABH Accreditation..

Accreditation also reduces liability insurance costs.

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With NABH Accreditation..

Under consideration of Law Makers that the NABH Accredited medical establishments shall be exempted from regular inspections (Harassments) by the

District Authority under CEA. 48

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