Preparation of Fifth Edition of NABH standards

The fifth edition would have the following broad structure:

 Table of contents
 Introduction/Foreword
 Acknowledgements
 About NABH
 Overview of the NABH accreditation process
 How to read the standards?
 Scoring
 Accreditation decision and maintenance of same
 Summary of changes
 Chapters
 Glossary
 Index

Sl. Existing (4th edition) Proposed (5th edition) Reason

No.
1. 10 chapters 10 chapters
2. Chapter name: Continual Patient Safety and Quality To bring grater focus on
Quality Improvement (CQI) (PSQ) patient safety
3. No core criteria Core criteria would be These would ensure that
identified. irrespective of the score
that an organisation
achieves there has to be a
minimum adherence to
some of the key criteria
which have impact on
safety and quality of care.
4. Every chapter begins with No change in broad To ensure that the
an intent, followed by a structure. standards are aligned with
summary of standards and Intent of every chapter the intent of the chapter.
then the detail of each would be critically To ensure that there is no
standard with the reviewed. ambiguity, self-explanatory
respective objective Every objective element phrase is being eliminated.
element. Every objective would have an
element has an interpretation.
 interpretation but for a
few it only states ‘Self-
explanatory’.
5. Alignment with ISQua Alignment with ISQua ISQua has revised its
standards (4th edition) standard (5th edition) standards
6. One objective element on All the nine Patient Safety To emphasize patient
patient goals. Solutions of WHO would safety
be incorporated in the
respective chapter.
7. All objective elements at Every objective element This has been done
the same level would be classified under keeping in mind the fact
at least one dimension and that quality is a journey
classified at one of the and that accredited
three levels: Commitment, organizations need to
Achievement, Excellence constantly improve. Most
of the objective elements
would be at the
commitment level and
these would form the basis
for accreditation during
the first round of final
assessment. During
surveillance and
subsequent re-
accreditations, the
accreditation criteria
would also incorporate
achievement of a
minimum score with
respect to objective
elements in the
achievement and
excellence levels.
8. No bibliography Bibliography would be To bring in linkages and
provided at the end of references to various good
every chapter practices or evidence.
9. No dimension(s) for any It is suggested to assign The dimensions will bring
objective element every objective element clarity & alignment
 at least have one
dimension against it.
The dimensions are:
o P: Population focus,
Patient-centric
o R: Reliability
o I: Inclusive, Information
o E: Efficiency,
Effectiveness
o S: Safety
o T: Timely
10. Annexures which provide Annexures would be
guidance on some key delinked from the
aspects standards book but would
be revised and posted
separately on NABH
website.
A new guidance on
documentation would be
developed
11. Feedback from various No change but a more
stakeholders both pre and robust mechanism for
post obtaining feedback from
every stakeholder.
between the intent of the
objective element & how it
is assessed.
This would allow the
guidance to be dynamic
both in terms of quantity
and quality.
The new guidance will
inform organizations as to
how documentation has to
be prepared.
To ensure that every
objective element is
RUMBA (Relevant,
Understandable,
Measurable, Beneficial and
Achievable)