IMA –NABH INITIATIVE(a project of IMA HBI)

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 mediumhospitals by value addition.

• To provide hospitals an affordable access toaccreditation.

Hospital Accreditation

Hospital Accreditation is a public recognitionby a National Healthcare AccreditationBody, of the achievement of accreditationstandards by a Healthcare Organizationthrough an independent external peerassessment of that organization’s level ofperformance in relation to the standards.

Benefits for Patients

Patients are the biggest beneficiary among all

the stakeholders. Pre Accreditation Entry Level

standards result in improved quality care and

patient safety.

Benefits for Hospitals

Pre Accreditation Entry Level Standards for a

hospital will stimulate a journey towards

continuous improvement. It raises community

confidence in the services provided by the

hospital.

Benefits for Hospital Staff

The staff in a Pre Accreditation Entry Level certified

hospital is sensitized over the quality and patient

safety. It improves overall professional

development of Clinicians and Para Medical Staff

and provides leadership for quality improvement in

medicine and nursing.

Benefits to paying and regulatory bodies

Pre Accreditation Entry Level Certification

provides an objective system of empanelment

by insurance and other third parties.

Kerala Clinical Establishment Act 2013

Clinical establishments that have received

accreditation from the National Accreditation

Board for Hospitals or the National

Accreditation Board for Laboratories shall be

granted permanent registration without

inspection as provided in sub-section (3):

About NABHNational Accreditation Board for Hospitals and

Healthcare Providers (NABH) is a constituent

board of Quality Council of India (QCI), set up

to establish and operate accreditation program

for healthcare organizations. NABH has been

promoting quality and patient safety.

Organizational StructureAccreditation Committee

• Recommending to Board about grant of

Certification or otherwise based on evaluation

of assessment reports & other relevant

information.

• Approval of the major changes in the scope of

Certification.

Technical Committee

• Drafting of standards and associated

documents

• Periodic review of standards

Organizational Structure

NABH Secretariat

• The Secretariat coordinates the entire activities

related to NABH Accreditation to hospitals and

healthcare organizations.

Panel of Assessors and Experts

• NABH has a panel of trained and qualified

assessors for assessment of hospitals.

Organizational Structure

NABH Pre Accreditation Entry Level Standards for Hospitals and SHCOs

Patient Centered Standards

• Access, Assessment and Continuity of Care

(AAC)

• Care of Patient (COP)

• Management of Medication (MOM)

• Patient Right and Education (PRE)

• Hospital Infection Control (HIC)

NABH Pre Accreditation Entry Level Standards for Hospitals and SHCOsOrganization Centered Standards

• Continuous Quality Improvement (CQI)

• Responsibility of Management (ROM)

• Facility Management and Safety (FMS)

• Human Resource Management (HRM)

• Information Management System(IMS)

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

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

Preparing for NABH Pre Accreditation Entry Level

1. Obtain a copy of NABH Pre Accreditation

Entry Level standards for hospitals.

2. Self implementation of standards.

Preparing for NABH Pre Accreditation Entry Level

3 Fill the Application Form .

4 Submit the Application Form + Self-

Assessment toolkit + Application Fee +

Document through IMA.

5 Pay the Certification fee before the final

assessment

Copy NABH Pre Accreditation Entry Level Standards for hospital : Rs. 1500/-

Organization Assessment Criteria Certification Fee (Rs.)

AssessmentApplication

FeeCertification

Fee

Hospital One man-day Rs. 2,000/- Rs. 25,000/-

Service Tax applicable from time to time (currently @ 12.36%) will be charged on all the above fees.

Note : The man days given above for assessment are indicative and may change depending on the facilities and size of the hospital.

NABHFinancial Terms and Conditions

NABH Financial Terms and Conditions

Organization Assessment Criteria Certification Fee (Rs)

Assessment Application FeeCertification

Fee

SHCO One Man day Rs 1000/- Rs 10,000/-

Copy 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 @ 12.36%) 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.

Expenses of IMA HBI (Entry level accreditation)

Hospitals : Rs 50, 000

Small Health Care Organisations(SHCOs): Rs 30,000

Hospitals above 100 beds : will be fixed according to

bed strength between Rs 50,000 and 1 lakh

Services

• Professional assistance

• Training in group as required

• Hand holding