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NABH-PROC_C&A

PROCEDURE
FOR
HANDLING OF COMPLAINTS
AND APPEALS

NATIONAL ACCREDITATION BOARD FOR HOSPITALS


& HEALTHCARE PROVIDERS (NABH)
Quality Council of India
Institution of Engineers’ Building, IInd Floor, Bahadur Shah Zafar Marg
New Delhi - 110002, India.
Tel/ Fax: 91-11-2337 9321, 91-11-2337 9621
Website: www.qcin.org
EMail: nabh@qcin.org

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Procedure for Handling of Complaints and Appeals – PROC_C&A

Contents

Sl. Title Page Nos.

1.0 Objective 3

2.0 Scope 3

3.0 Responsibility 3

4.0 Procedure for Handling of Complaints 3

4.1 Receipt of Complaints 3

4.2 Investigation of Complaints 4

5.0 Procedure for Handling of Appeals 6

5.1 Receipt of Appeals 6

5.2 Deliberation of Appeals Committee and Recommendations 7

5.3 Decision on Appeals 7

6.0 Financing the Complaint and Appeal process 8

7.0 Records 8

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1.0 OBJECTIVE
The document describes the procedures for dealing with:
- Complaints from various sources
- Appeals from Health Care Organization (HCO) against adverse decisions taken
by NABH.
- HCO, in general, would mean any entity providing health care services for which
an accreditation program is available with NABH and it may include hospital,
nursing home, blood bank, wellness centre, dental facility, imaging centre,
AYUSH hospital, primary or secondary health centre etc.

2.0 SCOPE
The procedure described in this document is to be followed in NABH for dealing with
different types of complaints and appeals by HCO. Appeal can be made by HCO
against adverse decision taken by NABH in respect of - refusal to accept an
application; refusal to proceed with an assessment; corrective action requests;
changes in accreditation scope; denial of accreditation; putting in abeyance,
suspension, withdrawal of accreditation or any other action that impedes the
attainment of accreditation.

3.0 RESPONSIBILITY
Responsibility of handling of complaints and appeals rests on the Complaints and
Appeals Officer of the Board. However, the CEO is responsible for monitoring of
complaints and appeals and final decision on closure of the complaint and appeal.

4.0 PROCEDURE FOR HANDLING OF COMPLAINTS

4.1 Receipt of Complaints


4.1.1 NABH is open to receiving complaints from any sources. The complaints can be
against applicant/ accredited HCO for the quality of service provided by them. The
complaint can be against personnel involved in accreditation process. The complaint
must be made in writing to CEO with complete details of complainant (name,
address, organization etc.). If the complaint has no details of the complainant or the
description is not adequate, the Board will reserve the right of dealing with the

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complaint as deemed fit. NABH can investigate the reports appearing in media, if
relevant.

4.1.2 Once the complaint is received at NABH, CEO shall mark the complaint to the
Complaints and Appeals Officer. Immediately on its receipt the same shall be
acknowledged with the assurance of thorough investigation.

4.1.3 The Complaints and Appeals officer shall maintain a record for the complaints that
are received by NABH. The important dates viz. date of receipt of complaint, date of
acknowledgement and date of final closure shall be recorded in Complaint File.

4.1.4 Initial scrutiny of the complaint is done by the Complaints and Appeals officer. This is
to determine that the complaint falls within the ambit of NABH activities and whether
the complaint is valid.

4.1.5 If it is found that the complaint does not fall within the ambit of NABH, the complaint
is considered closed and the complaint is informed accordingly.

4.1.6 If the complaint falls within the ambit of NABH and the initial information provided in
the complaint is sufficient the complaint is investigated further.

4.2 Investigation of Complaints


The complaints received by NABH can be classified into three categories:
- Complaints against applicant/ accredited HCO
- Complaints against Assessors/Experts/ Committee members
- Complaints against NABH officials

4.2.1 Procedure for dealing with each category is given below:

4.2.1.1 Procedure for dealing with complaints against HCO

 On receipt of complaint against HCO, Complaints and Appeals officer shall


discuss with the concerned officer dealing with that HCO. He would seek
clarification from the HCO giving them a time of 15 days to respond to the
complaint.

 If the response is not satisfactory, NABH would depute an assessor/ expert to


investigate the matter with the approval of CEO.

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 The assessor/ expert would place the findings of the investigation with his/ her
recommendation on action to be taken against the HCO to NABH.

 If found necessary, CEO may take further consultation with Accreditation


Committee before taking any action on the HCO.

 The action would be communicated to the HCO. The HCO would be required to
take corrective action in a stipulated time stated in the communication by NABH.
The HCO would be required to give necessary/ satisfactory documentary
evidence.
 In case the HCO is found to violate the Terms and Condition for Maintaining
NABH Accreditation or not cooperate with investigation process, the HCO may be
put under suspension/ withdrawal as per NABH procedures.

 The complainant shall be informed about the action taken by NABH.

 If the complaint is found invalid, the complainant as well as the HCO is informed
accordingly.

4.2.1.2 Procedure for dealing with complaints against Assessors/Expert/Committee


Members

 On receipt of complaint against assessor/expert, Complaints and Appeals officer


would seek clarification regarding the complaint from:
- the HCO for which the assessment was done
- the other team member, if any
- any other person who may be aware of the matter in the complaint

 Complaints and Appeals officer shall investigate the complaint and if it is


necessary, an independent assessor/ observer can be sent to the HCO where
the assessment was carried out to take first hand view. The feedback received
earlier from the HCO/ principal assessor for this particular assessor would be a
source for taking action against the assessor.

 In case of complaint against Accreditation Committee member, a committee


consists of Complaints and Appeals officer and Member Secretary of the
concerned committee shall investigate the complaint.

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 The findings from the above would be compiled so that the CEO would take
appropriate step. Accreditation Committee may be consulted if found necessary.

 If the complaint is found valid, the assessor/member would be warned for his
action. If the complaint is of serious nature, the assessor/ member may also be
deleted from the empanelled database of NABH assessors/ membership of
committee.

 The complainant shall be informed about the action taken by NABH.

4.2.1.3 Procedure for dealing with complaints against NABH officials

 On receipt of complaints against NABH officials, CEO would be informed, so that


clarification can be obtained from the official.

 The official, against whom the complaint has been received, is not involved in
investigation of complaints directly or indirectly.

 Information would be gathered from all sources regarding the complaint.


Independent person from the office would be appointed by CEO to investigate
into the matter.
 If the complaint is found valid and of serious nature, CEO would take appropriate
action as per rules.

 If the complaint is not of serious nature, CEO can ask for corrective action from
the official.

 The complainant shall be informed about the action taken by NABH.

 If the complaint is against the CEO, the matter will be brought to the notice of the
Chairman, NABH.

 If the complaint is against the Board, the matter will be brought to the notice of
Secretary General, QCI.

5.0 PROCEDURE FOR HANDLING OF APPEALS

5.1 Receipt of Appeals


5.1.1 NABH shall receive appeals from HCO against adverse decisions taken by NABH.
The appeals are generally addressed to the Chairman NABH.

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5.1.2 Complaints and Appeals officer shall acknowledge the receipt of appeals from the
HCO. A record pertaining to all appeals including important details like date of
receipt, name and address of the HCO, details of appeals and outcome of appeals
shall be maintained in the ‘Appeals File’.

5.1.3 The appeals shall be examined by Appeals Committee and make recommendations
to the CEO, NABH.

5.2 Deliberation of Appeals Committee and Recommendations


5.2.1 Appeals Committee takes up the appeal for consideration. Representative from
Accreditation Committee involved in the decision appealed against, may provide
technical inputs. He/ she shall not be involved in the formulation of recommendations
of the Appeals Committee.

5.2.2 After examination of the appeal, the Committee shall seek clarification from all
appropriate sources. The Committee, if finds necessary, can depute NABH official/
an assessor or an expert to investigate the matter.

5.2.3 The Appeals Committee may recommend a fresh assessment. On the basis of fresh
assessment, the relevant accreditation committee shall give an independent view on
the status of HCOs’ quality management system and technical competence as well
as the subject matter of the appeal.

5.2.4 Based on the data gathered through any of the above means, the Appeals
Committee shall form its recommendations. The detailed report by the Committee
shall be submitted to the Chairman NABH within a reasonable time for his decision.

5.3 Decision on Appeals


5.3.1 Chairman NABH shall take a decision based on the recommendations submitted by
the Appeals Committee.

5.3.2 The decision of the Chairman NABH shall be final and HCO shall be informed
accordingly.

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6.0 Financing the Complaint and Appeal Process

If the resolution of complaint/ appeal is done without undertaking any travel or


additional assessment, no financing will be needed for such resolutions.

If the resolution calls for undertaking travel and assessment, the cost will be borne by
the defaulting party.

7.0 RECORDS
Complaints and Appeals officer shall maintain Complaints file and Appeals file. The file
has the following:
- unique registration number given to each complaint/ appeal
- date of receipt of complaint/ appeal
- name & address of the complainant/ appellant
- date of acknowledging of the compliant/ appeal
- details of action/ investigation
- date of closure

The complaints & appeals file is maintained by Complaints and Appeals officer. All
correspondence in respect to complaints/ appeals, investigation reports and
decisions by CEO or Chairman are filed in order.

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