Issue No. 3

Issue Date: 06/12

Page 1 of 13

3. 3 Issue Date: 06/12 Page 2 of 13 .Assessor Guide . Confidentiality and Integrity (NABH I&C 01) Page Nos.NABH-AG CONTENTS Sl. 2. Introduction Role of Assessment team Pre-Assessment On-site Assessment Feedback HAF 1 to HAF 4 Declaration of Impartiality. 4. 5. Title Content 1. 2 3 3-5 5 6-8 8 9 .12 13 Issue No.

Country and culture specific accreditation system safeguard the country health care system and also involve fewer cost and better accepted as compare to external international accreditation systems. national or expatriate. and Eliminate ambiguities or doubts about the interpretation of requirements(s). is not to compile non-conformances/ deficiencies as an evidence to justify denial of accreditation. play a vital role in determining the credibility and value of the accreditation. whether public or private. This document accordingly aims to: a. thus. the members of the assessment team would be required to exercise their scientific judgmental skill and form their opinion regarding extent of conformance with respect to accreditation criteria. The objective of the assessment. b. Since hospital/ SHCO accreditation requires compliance with NABH Hospital Standards/ SHCO Standards the assessment team should consider conformances against these standards in the assessment. the success of the accreditation scheme depends on the assessment team who perform on-site assessment and. It ensures that hospitals/ Small Health Care Providers (SHCO). The National Accreditation Board for Hospitals and Healthcare Providers (NABH) provides third-party accreditation to Health Care Organizations in India. Provide the guidance to the Assessors during the assessment of hospitals/ SHCOs. c. however.Assessor Guide . lead by a Principal Assessor.NABH-AG 1 INTRODUCTION Accreditation is an incentive to improve capacity of Heath Care Organisations to provide quality of care. This guide has been prepared based on the general practices followed by international bodies and the experience of experts of the country. play their expected role in national heath system. to the Accreditation Committee for formulating the advice to assist the hospital/ SHCO in its development. 2 ROLE OF ASSESSMENT TEAM The role of NABH Assessment team is to conduct on-site assessment of applicant hospital/ SHCO and provide the report to NABH. 3 Issue Date: 06/12 Page 3 of 13 . The objective of the on-site assessment is to obtain evidence on compliance with respect to NABH standards and other policy documents. The assessment is carried out by a team of NABH empanelled Assessors. Thus. Ensure uniformity of assessment and reporting. Notwithstanding the strength of the NABH system. Issue No. functions and hospital’s/ SHCO’s quality management system. The objective evidence so collected forms the basis: • • for arriving at a judgment for recommendation of the team. The assessment is carried out systematically for comprehensive review of hospital/ SHCO services.

as described and record observations in HAF 2. The schedule shall be presented to the hospital/ SHCO representative. records are indeed implemented & effective. Principal Assessor would finally summarise the conduct of Assessment and record the recommendations in HAF 4. He should assess that the documented Management System is indeed implemented & effective. He should assess to verify that the documented SOPs. The Principal Assessor must review the hospital’s/ SHCO’s documented Management System to verify compliance with the requirements of NABH standards. If. separately on each sheet in HAF 3. However. The Principal Assessor must sign all pages of the assessment report. the Principal Assessor will at the earliest inform NABH and elaborately bring it out in the Assessment summary (HAF-4) of assessment report. in some cases a technical expert may join the team to support on specific area. He must get an endorsement from the hospital/ SHCO on HAF 4 and hand over a photocopy of the forms HAF 3 & 4 to the hospital/ SHCO to enable them to take corrective actions. His comments/ rating for each Assessor shall be enclosed with the report. He must review the Hospital’s/ SHCO’s documented system to verify compliance with the requirements of NABH standards. Team members are required to maintain the confidentiality on the matters/ subjects related to health care organizations.Assessor Guide . The hospital/ SHCO will be requested to assign guide/ co-coordinator to accompany each assessor during the assessment. during Surveillance or Re-assessment. Role of Assessor The Assessor should clearly understand the areas/ activities to be assessed by him. a case of critical system failure and gross negligence in technical aspects is noticed. Issue No. He shall recommend whether the Observer is capable to perform the role of an Assessor in his next visit. Role of Principal Assessor Before the start of Assessment the Principal Assessor should prepare an Assessment schedule in HAF 1 which should include the departments/ sections/ areas/ activities to be assessed and assignment to various Assessors based on their expertise. The report should be handed over to the Principal Assessor along with expenditure claim form. All Non-Conformance(s) must be identified and reported.NABH-AG The assessment team consists primarily of Principal Assessor and Assessor. The Principal Assessor is also required to monitor the performance of Assessor(s) and the Observer. as described and record observations in HAF 2. 3 Issue Date: 06/12 Page 4 of 13 .

Role of Observer The Observer (Potential Assessor) will be assigned to accompany the Principal Assessor as per the schedule provided to him. Scope and type of the hospital/ SHCO is kept in mind while selecting the Principal Assessor. Following documents are provided to the assessment team for carrying out the assessment: Copy of application form of the organization Copy of self assessment toolkit submitted Quality Manual (however named) and other NABH related documents (department manuals.NABH-AG Role of Technical Expert The role of Technical Expert is same as of an Assessor. Issue No. 3 Issue Date: 06/12 Page 5 of 13 . He is not involved in assessment directly but supports the assessment as assigned by the Principal Assessor. He/ She explains to the organisation the methodology adopted by his/ her team during the assessment. SOPs) Pre-Assessment Guidelines and Forms Confidentiality form (NABH I&C 01) Travel expenditure form Pre-assessment is carried out to check the preparedness of the organization to undergo assessment and to review the scope of accreditation. The detailed guidelines for the assessors for carrying out Pre-Assessment is described in NABH document ‘Pre-Assessment Guidelines and forms’. PRE-ASSESSMENT NABH Secretariat on intimation from the organization about the preparedness to take up pre-assessment. 3. The Principal Assessor shall guide him. The number of assessors depends on the size of the hospital/ SHCO. Principal Assessor may also be accompanied with assessors. The Principal Assessor’s major role is to explain the purpose of the assessment. He will provide technical assistance to the team and he will seek guidance of Principal Assessor in filling the relevant forms. The name of Principal Assessor and assessor(s) and the names of their organizations from which they belong are intimated to the organization for seeking their consent. He is not entitled for payment of any honorarium. Things are discussed in detail with the management of the organization during the opening meeting of the pre-assessment. For carrying out the pre-assessment.Assessor Guide . appoints a Principal Assessor from the pool of empanelled Assessors from assessor database.

Assessor Guide . The format of the assessment schedule to be finalised is given at HAF-1. (b) (c) (d) Issue No. departments/ sections and their locations. Consent is obtained for the date(s) of the assessment of the organization from the Principal Assessor and other assessors accompanying for the assessment.NABH-AG 4 ON-SITE ASSESSMENT A similar methodology as used in the Pre-Assessment is followed in comprising the team for final assessment of the organization. The hospital/ SHCO will be requested to assign guide/ co-coordinator to accompany each Assessor. The assessor(s) and the names of their organizations from which they belong are intimated to the organization for seeking their consent. 3 Issue Date: 06/12 Page 6 of 13 . NABH also assures that the team does not have any competitive position with the applicant organization. This shall include the distribution of work amongst the Assessors. Non-conformances may be closed while the assessment report is being compiled. NABH also ensures that assessors do not have any direct/ in-direct relationship with the organization or they/ or their organization. A written communication is sent to all the team members with the following documents: Application form of the organization Pre-Assessment report Corrective action report Self assessment submitted by the organization Hospital/ SHCO manuals/ documents submitted by the organization Confidentiality form (NABH I&C 01) Travel expenditure form Assessment Team shall meet and plan assessment programme. The Principal Assessor shall present the assessment schedule (HAF 1) to hospital/ SHCO representatives.1 Opening Meeting (a) Principal Assessor and the team shall have an opening meeting with hospital/ SHCO representatives where they get acquainted with the hospital/ SHCO. 4. The Principal Assessors shall explain the objective and scope of assessment and what is expected from the hospital/ SHCO during the assessment. The number of assessors depends on the size of the hospital/ SHCO. The Principal Assessor shall inform the hospital/ SHCO that the assessment team shall not be approached by the hospital/ SHCO for closure of nonconformances while the assessment is in progress.

Management of information/ patient records interview. evidence of compliance with policies. The Principal Assessor shall give the summary of the assessment in his final report (HAF 4). In addition to the above. Infection control interview. 3 Issue Date: 06/12 Page 7 of 13 . This remains a confidential document and copy should not be given to the hospital/ SHCO. Visit to patient care areas and selected department The surveyor will evaluate the process for patient care in different setting across the organization. The pages should be serially numbered. Staff qualification and education interview. The reports shall be signed by the authorized signatory of the hospital/ SHCO. evidence of committees and evidence of statements.3 Compilation of assessment report The Assessment Report should consist of various documents in the order as indicated in HAF 4. Issue No.2 Assessment The assessment activities include: Orientation of assessors to the organization’s services The assessment procedure will start with an opening meeting.NABH-AG 4. Functional interview • • • • Leadership interview. Any changes to assessment agenda will also be discussed. The assessors will introduce themselves and explain the assessment process. Document review Document review includes review of polices. Principal Assessor in consultation with the team members shall fill up the score sheet and send it to NABH along with report.Assessor Guide . - Facility tour Special interview/ issue resolution 4. Each form or checklist should be carefully filled in. Principal Assessor shall compile the observations from the assessors (HAF 2) and summary on non-compliance (HAF 3) from all the assessors.

Evaluation criteria: • • • • No individual standard should have more than one zero to qualify.4 Closing Meeting The Principal Assessor and other assessors shall have a meeting with the hospital/ SHCO representatives. 5 FEEDBACK Following feedbacks are obtained by NABH through the evaluation forms in the NABH document ‘Feedback Forms’. if any. feedback on performance of other assessors by the Principal Assessor. However. Issue Date: 06/12 Page 8 of 13 Issue No. NABH secretariat reviews the assessment report and seeks clarification and documentation from the Principal Assessor and hospital/ SHCO.NABH-AG Guidelines for evaluation are as follows: Assessment is based on the scoring on a scale of 0. feedback on performance of the assessment team is obtained from the hospital/ SHCO. Compliance to the requirement Partial compliance to the requirement Non-compliance to the requirement Not Applicable : : : : 10 5 0 NA (if any of the sample is found to be non co out of total samples selected) Assessor has to provide details of deficiency both in the case of non-compliance as well as partial compliance. The average score for individual standard must not be less than 5. NABH. if required. The overall average score for all standards must exceed 7 4.Assessor Guide . The assessment report is reviewed by the Accreditation Committee and recommendations made. 5 and 10 as per the following details. A copy of the report – summary of non-conformances (HAF 3) shall be handed over to the hospital/ SHCO. on receipt of evidence of corrective action. no zero is accepted in the regulatory/legal requirements. 3 . 4. The average score for individual chapter must not be less than 7.5 Post Assessment Principal Assessor shall send the report to NABH at the earliest. shall place the report before the Accreditation Committee for its consideration for accreditation. The closing meeting is to end with thanks giving for the co-operation and assistance provided by the hospital/ SHCO.

NABH-AG ASSESSMENT SCHEDULE. (Separate sheets may be used for individual assessors) Schedule of Department/ Section/ Activity to be Assessed (date wise) Day 1 Morning Afternoon Morning Name and Expertise of the Assessor Principal Assessor Day 2 Afternoon Morning Day 3 Afternoon Assessor 1 Assessor 2 Assessor -Observer/Expert Signature of Principal Assessor Issue No.Assessor Guide .HAF 1 Name & address of hospital/ SHCO: Accreditation Coordinator: Date(s) of Visit: Type of Visit: Assessment / Surveillance / Re-Assessment / Verification Assessment Standard: NABH Standards/ SHCO Standards (strike off which is not applicable) Assessment Timings Opening/Closing Meeting Date/Time PM PM Opening Meeting: Closing Meeting: Daily Debriefing Date / Time (at the end of each day) Day 1: Day 2: Day 3: Morning: Afternoon: AM to PM to Assessment schedule: Principal Assessor to provide details of activities taken up by individual assessors/ technical expert in the following format and obtained their signature. 3 Issue Date: 06/12 Page 9 of 13 .

OBSERVATION REMARKS Area/ Department: Activity Assessed: Signature & Name of Assessor Issue No. 3 Issue Date: 06/12 Page 10 of 13 .HAF 2 Name of hospital/ SHCO: Date: Auditee: Sl.Assessor Guide .NABH-AG ASSESSOR’S OBSERVATIONS.

3 Issue Date: 06/12 Page 11 of 13 . against which non-compliance is being raised) Hospital/ SHCO: Date: Type of Assessment: Assessment / Surveillance / Re-Assessment / Verification Non-compliance observed: 1.Assessor Guide . refer observation no. from HAF 2 and NABH std.NABH-AG ASSESSOR’S SUMMARY ON NON-COMPLIANCE. Signature & Name of Hospital/ SHCO Representative Signature & Name of Assessor Issue No. no.HAF 3 (For each non-compliance.

HAF 4 Hospital/ SHCO name & address: Accreditation Coordinator: Date(s) of Visit: Type of Visit: Assessment / Surveillance / Re-Assessment / Verification Principal Assessor: Assessor 3: Assessor 6: Date of earlier visit and Purpose: ASSESSMENT SUMMARY: Assessor 1: Assessor 4: Other/TE Assessor 2: Assessor 5: Observer: Enclosures HAF 1 HAF 2 HAF 3 HAF 4 Date by which deficiencies are to be discharged by the hospital/ SHCO: Acknowledgement by Authorised Signatory of hospital/ SHCO & Date Signature of Principal Assessor & Date Issue No. 3 Issue Date: 06/12 Page 12 of 13 .NABH-AG SUMMARY OF THE ASSESSMENT.Assessor Guide .

hereby declare that i.Assessor Guide . ii. I undertake to maintain strict confidentiality of the information acquired in course of discharge of my responsibility and shall not disclose to any person other than that required by NABH. 3 Issue Date: 06/12 Page 13 of 13 . iii.) Capacity Health care organisation Assessed Date of visit(s) Type of visit Principal Assessor / Assessor / Technical Expert / Observer Pre-assessment/ Assessment / Surveillance / Re-Assessment / Verification I ______________________________________________________________. I am/ am not* an ex-employee of the health care organization and am/ am not* related to any person of the management of the health care organization. supervision or other services to the hospital/ SHCO in any way. iv. I got an opportunity to go through various documents of the above hospital/ SHCO and other related information that might have been given by NABH. I shall also keep the Board informed about changes in the status of my association with the organization before every assignment.NABH-AG NABH I&C-01 DECLARATION OF IMPARTIALITY. I have not offered any consultancy. guidance. I will declare to the Board my and/ or my immediate family’s association with any of the organization that can affect the impartiality of the assessment process. * strike out which is not applicable Date: Place : Signature Issue No. CONFIDENTIALITY & INTEGRITY (to be filled in by each Assessor and enclosed with the Assessment report) Name Designation Organisation Address Assessor ID : (To be filled in by NABH Sect.

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