Author: Dr. Pradeep Jain, Varanasi

1. Patient care advancement and hospital
standardization through NABH
Dr. Pradeep Jain
MD(Ay), PGC-DIAB(HYD), DIP. PPHC(APOLLO), DYEd(GK)

2. NABH
NABH is a constituent board of quality council of
india, set up to establish and operate
accreditation programme for healthcare
organizations.

3. NABH
 NABH offers Accreditation Services to Hospitals, small
Health Care Centres / Nursing Homes, blood Banks,
medical Imaging Centres Etc.
 Accreditation of Ayush Hospitals is a new initiative of
NABH.

4. NABH
 Hospital accreditation is a public recognition by a national
healhcare accreditation body, of the acheivement of
accreditation standards by a healthcare organization,
demonstrated through an independent external peer
assessment of that organization’s level of performance in
relation to the standards.

5. What NABH Accreditation means?
 Commitment to create a culture of quality, patient safety, efficiency
and accountability towards PATIENTS CARE.
 Establishment of protocols and policies as per National/International
standards for PATIENT CARE, medication management, consent
process, patient safety, clinical outcomes, medical records, infection
control and staffing.
 Patients are treated with respect, dignity and courtesy at all times.

6.  Patients are involved in care planning and decision making.
 Patients are treated by qualified and trained staff.
 Feedback from patients is sought and complaints (if any )are
addressed.
 Transparency in billing and availability of tariff list.
 Continuous monitoring of its services for improvement.
 Commitment to prevent adverse events that may occur.

7. Benefits of Accreditation
 As ayurveda hospitals are an integral part of our healthcare system, so
accreditation would be the single most important approach for improving
the quality of hospitals. National accreditation system for ayurveda
hospitals ensures that hospitals, whether public or private, national or
expartiate, play their expected roles in national health systems.

8. Benefits for patients
 Patients are the biggest beneficiary among all the stakeholders.
 High quality care and patient safety.
 Patients are serviced by high credential medical staff.
 Rights of patients are respected and protected.
 Patients satisfaction is regularly evaluated.

9. Benefits for Ayurveda hospitals
 Accreditation provides continuous and consistent
improvement.
 Raises community and public confidence in the
services provided by the ayurveda hospital.
 Oppurtunity to benchmark with the best

10. Benefits for hospital staff
 Continuous learning
 Good working environment
 Good leadership and ownership
 Improvement in overall professional development of
clinicians and paramedical staff
 Job satisfaction

11. Benefits to paying and regulatory bodies
 It provides an objective system of empanelment by
insurance and third parties.
 It gives access to reliable and certified information on
facilities, infrastructure and level of care.

12. A minimum bed strength of 10 beds
is essential for an hospital to be
considered for the accreditation.

13. NABH standards &
their role in patient care

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

15. There are two types of standards
Accreditation standards
&
Structural standards

16. Accreditation standards
 These standards measure the quality and safety
aspects of the care delivered to the patients
 These are based on three components
1) Structure
2) Process
3) Outcome

17. Structural standards
Deals with the infrastructural requirements
to help the organization to deliver quality
care.

18. 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)

19. Organisation Centered Standards
 Continuous quality improvement(CQI)
 Responsibility of management (ROM)
 Facility management and safety (FMS)
 Human resource management (HRM)
Information management system (IMS)

20. AAC
 Patients should be well informed of the services that
an organization can and cannot provide.
 Patients that match the organizations resources are
then admitted using a well-defined process that
includes patient and family education.

21.  Patients then undergo an established initial assessment and periodic
and regular reassessments.
 Assessments may include laboratory and imaging services.
 These services should be provided by competent staff in a safe
environment for both patients and staff.
 Patients care is multidisciplinary in nature and encourages continuity
of care through well defined transfer and discharge protocols.

22. Care of patients (cop)
 The centre should provide uniform care of patients in
different settings such as opd, wards, procedure rooms and
operation theatre.
 Emergency services are given according to policies,
procedures and applicable laws.
 Special care of vulnerable patients (elderly, physically and or
mentally challenged pts, children)

23.  Care and concern is given at every step starting from admission
to hospital stay including investigations and imaging
procedures, to referral or discharge.
 Documented policies and procedures guide adequate care to
Obstetric patients (ante natal, post natal delivery etc) and
Neonatal and pediatric patients

24.  Pts undergoing surgical, parasurgical(ksharsutra,
raktamokshna, agnikarma etc) panchkarma and other
treatment procedures like abhyanga, pinda sweda, uttar
basti, pichu etc
 For panchkarma therapy vamana karma protocol, abhyanga
protocol, netra tarpan protocol,pichu protocol are prepared
based on classical texts like charak samhita, sushruta
samhita etc.

25.  Adequate rehabilitative care and services vyayama,
yoga, phsiotherapy etc.
 Therapeutic and nutritional diet care including
pathya and apathya ahara etc.

26.  Care of patients undergoing anesthesia/sedation
 Rational use of blood and blood products.
 Proper and well-defined care in ICU’s and HDU.

27. Management of Medication
 Safe and organized medication process which includes proper
procurement or purchase and availability of the medicine.
 Availability of hospital formulary to every clinician of the hospital.
 Well defined process for preparation of medications required for
out patients, indoor patients, panchkarma patients.
 Medicines has safe storage and correct dispensing.(Temp control,
expiry dates etc )

28.  High alert medications are verified prior to dispensing.
 Patients are monitored after medication administration.
 Near misses, medication errors and adverse drug events are
minimized.
 24 hr pharmacy availability.

29. Patient Rights And Education
 NABH accredited hospitals ensure that the patients rights are
protected.
 These hospitals involve the patient in decision making process.
 Well informed patient and /or family consent in their local
language.
 Patients are well informed about their expected cost of
treatment.
 These hospitals have a documented redressal procedure.

30. Hospital Infection Control
 NABH accredited hospitals have an action plan to control
outbreaks of infection, disinfection/sterlization activities, bio
medical waste management and proper training of the staff to
handle infectious and vulnerable patients.
 Reduce the risks of hospital acquired infections by clarly
identifying high risk areas of the hospital.

31.  Adheres to hand hygiene guidelines.
 Adheres to regular and proper cleaning,disinfection and
sterilization practices.
 Laundary and linen management.
 Proper kitchen sanitation .
 Proper care of issues such as air conditioner
management,replacement of filters,correction of seepage which
may lead to fungal colonisation,repair of sewer lines is well
addressed which results in better patient care.

32.  Proper availability of personal protective equipments such
as gloves,mask,apron,gown shoe covers, caps etc.
 Regular validation tests for sterilisation are always carried
out and documented.
 Appropriate in service training sessions for all staff is
carried out aleast once in a year.

33.  All these measures help the organizations/hospitals to
deliver their best which in turn results in better patients
care.

34. THANKS!