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Assessor Guide: Nabh-Ag
Assessor Guide: Nabh-Ag
Assessor Guide: Nabh-Ag
ASSESSOR GUIDE
Issue No. 3
Page 1 of 13
CONTENTS
Sl.
Title
Page Nos.
Content
1.
Introduction
2.
3.
Pre-Assessment
4.
On-site Assessment
5.
Feedback
3-5
5
6-8
8
HAF 1 to HAF 4
9 - 12
Issue No. 3
13
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INTRODUCTION
Accreditation is an incentive to improve capacity of Heath Care Organisations to
provide quality of care. The National Accreditation Board for Hospitals and
Healthcare Providers (NABH) provides third-party accreditation to Health Care
Organizations in India. It ensures that hospitals/ Small Health Care Providers
(SHCO), whether public or private, national or expatriate, play their expected role in
national heath system. 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.
The assessment is carried out by a team of NABH empanelled Assessors, lead by a
Principal Assessor. The assessment is carried out systematically for comprehensive
review of hospital/ SHCO services, functions and hospitals/ SHCOs quality
management system. The objective evidence so collected forms the basis:
for formulating the advice to assist the hospital/ SHCO in its development.
a.
b.
c.
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Role of Assessor
The Assessor should clearly understand the areas/ activities to be assessed by him.
He must review the Hospitals/ SHCOs documented system to verify compliance with
the requirements of NABH standards. He should assess to verify that the
documented SOPs, records are indeed implemented & effective, as described and
record observations in HAF 2. The report should be handed over to the Principal
Assessor along with expenditure claim form.
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Role of Observer
The Observer (Potential Assessor) will be assigned to accompany the Principal
Assessor as per the schedule provided to him. The Principal Assessor shall guide
him. He is not involved in assessment directly but supports the assessment as
assigned by the Principal Assessor. He is not entitled for payment of any honorarium.
3.
PRE-ASSESSMENT
NABH Secretariat on intimation from the organization about the preparedness to take
up pre-assessment, appoints a Principal Assessor from the pool of empanelled
Assessors from assessor database. Scope and type of the hospital/ SHCO is kept in
mind while selecting the Principal Assessor. For carrying out the pre-assessment,
Principal Assessor may also be accompanied with assessors. The number of
assessors depends on the size of the hospital/ SHCO.
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. Following documents are provided to the assessment team for carrying
out the assessment:
-
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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 number of assessors depends on
the size of the hospital/ SHCO.
The assessor(s) and the names of their organizations from which they belong are
intimated to the organization for seeking their consent. NABH also assures that the
team does not have any competitive position with the applicant organization. NABH
also ensures that assessors do not have any direct/ in-direct relationship with the
organization or they/ or their organization.
Consent is obtained for the date(s) of the assessment of the organization from the
Principal Assessor and other assessors accompanying for the assessment. A written
communication is sent to all the team members with the following documents:
-
Pre-Assessment report
Assessment Team shall meet and plan assessment programme. This shall include
the distribution of work amongst the Assessors. The format of the assessment
schedule to be finalised is given at HAF-1.
4.1
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,
departments/ sections and their locations.
(b)
The Principal Assessors shall explain the objective and scope of assessment
and what is expected from the hospital/ SHCO during the assessment.
(c)
(d)
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. Non-conformances may
be closed while the assessment report is being compiled.
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4.2
Assessment
The assessment activities include:
-
Document review
Document review includes review of polices, evidence of compliance with
policies, evidence of committees and evidence of statements.
Functional interview
Leadership interview.
Infection control interview.
Management of information/ patient records interview.
Staff qualification and education interview.
4.3
Facility tour
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10
Not Applicable
NA
4.4
No individual standard should have more than one zero to qualify. However, no
zero is accepted in the regulatory/legal requirements.
The average score for individual standard must not be less than 5.
The average score for individual chapter must not be less than 7.
The overall average score for all standards must exceed 7
Closing Meeting
The Principal Assessor and other assessors shall have a meeting with the hospital/
SHCO representatives. A copy of the report summary of non-conformances (HAF
3) shall be handed over to the hospital/ SHCO.
The closing meeting is to end with thanks giving for the co-operation and assistance
provided by the hospital/ SHCO.
4.5
Post Assessment
Principal Assessor shall send the report to NABH at the earliest.
NABH secretariat reviews the assessment report and seeks clarification and
documentation from the Principal Assessor and hospital/ SHCO, if required.
NABH, on receipt of evidence of corrective action, if any, shall place the report before
the Accreditation Committee for its consideration for accreditation.
The assessment report is reviewed by the Accreditation Committee and
recommendations made.
FEEDBACK
Following feedbacks are obtained by NABH through the evaluation forms in the
NABH document Feedback Forms.
-
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Accreditation Coordinator:
Date(s) of Visit:
Morning:
Afternoon:
AM to
PM to
Opening/Closing Meeting
Date/Time
PM
PM
Daily Debriefing
Date / Time
(at the end of each day)
Day 1:
Day 2:
Day 3:
Opening Meeting:
Closing Meeting:
Afternoon
Day 2
Morning
Day 3
Afternoon
Morning
Afternoon
Principal Assessor
Assessor 1
Assessor 2
Assessor -Observer/Expert
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Area/ Department:
Activity Assessed:
Auditee:
Sl.
OBSERVATION
REMARKS
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Date:
Non-compliance observed:
1.
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Date(s) of Visit:
Assessor 1:
Assessor 2:
Assessor 3:
Assessor 4:
Assessor 5:
Assessor 6:
Other/TE
Observer:
Enclosures
HAF
HAF 2
HAF
HAF 4
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NABH I&C-01
Name
Assessor ID
Designation
Organisation
Address
Capacity
Health care
organisation Assessed
Date of visit(s)
Type of visit
I have not offered any consultancy, guidance, supervision or other services to the
hospital/ SHCO in any way.
ii.
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.
iii.
I will declare to the Board my and/ or my immediate familys association with any of the
organization that can affect the impartiality of the assessment process. I shall also
keep the Board informed about changes in the status of my association with the
organization before every assignment.
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 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.
Date:
Place :
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Signature
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