Revision of 4th edition standards

Dr S Murali MD DM
Chairman Technical Committee NABH

Consultant Neurologist &

Chief Clinical Services Manipal Hospital
Head Quality MHEPL
 NABH Trivia…..
• 2004 – Introduced to the man who
revolutionised Healthcare quality in the
country
• June 27th 2005 NABH was born and the first
meeting was held
• Feb 2005 – First NABH edition
• Four editions and more than 500 hospitals in a
decade
 Destination fourth edition - Plan
• Review of International and national literature
• Feedback from stakeholders (hospitals, assessors and
committee members) and other subject matter
experts.
• Analysis of most common NCs raised during
assessments.
• Compilation of feedbacks
• Deliberations and discussions by Technical
Committee members
• Draft standards are prepared based on above inputs
National Accreditation Board for Hospitals and Health Care Providers
 Destination fourth edition - Plan
• Draft standards are put up on the public domain
(NABH Website) for public and stakeholder feedback
• Public and stakeholder feedback received on draft
standards and analysed
• Further Deliberation and discussions by Technical
Committee on the above feedbacks
• Final round of discussions with other committee
members and feedbacks analysed
• Final Draft standards prepared
• Approved by board
• Final standards to ISQUA

National Accreditation Board for Hospitals and Health Care Providers

 Objectives – 4th edition
– Raise the bar
– Address ambiguity and bring in uniformity to the extent possible
– Address difficult areas with focus on patient care, clinical
excellence and quality of care
– Separate Guidebook and standards - 4th edition of hospital
standards.
– All the formats of to be revised. They shall be named as
‘Assessment forms’ (AF).
– Regulatory to be simplified
– In the new formats, provision shall be made for HCO id no and
assessors ID no .
– To meet ISQUA requirements
– Learn from best practices
– Strict Timelines

National Accreditation Board for Hospitals and Health Care Providers

 Methodology
1. Feedbacks on existing standards
1. The predesigned questionnaire was distributed to all the
Accredited HCOs and Selected team of assessors and feed backs
were obtained within a stipulated time period.. Their feedbacks
were obtained and analysed.
2. Along with above, daily feedback which is received from HCOs
was analysed and most common NCs pattern was seen which
was considered while drafting the standards.

2. Reference material :
1. ISQUA guidelines
2. Other International Standards
 Methodology
• Best International and National practices
• Further chapters were divided amongst the
members who worked on them keeping the
above points in mind and then were
deliberated upon in the subsequent meetings.
• Multiple TC meetings
• Strict time lines adhered
• Inputs from domain specialists ( Radiologists)
 Points considered in new Standards
• Legal: To focus on mandatory licenses.
Undertaking would be obtained from the HCO.
• Green concept/ Green hospitals
• Stress on promotion, prevention and education
aspect
• Inclusion of national programmes to some
extent(with focus on mother and child)
• More focus on systems and processes
• ISQUA requirements
 Points considered in new Standards
• End of life care
• HR requirements
• Focus to be on Outcome Based Indicators
• Setting of Patient Safety goals which is
appropriate for our Indian system
• Prescription writing: std prescription should be in
BOLD/Capital letters
• Use of Generic Medicines
• Re use of devices
• Blood storage policy
 Points considered in new Standards
• Provision should be made for seamless
functioning of the hospital and address all
aspects of patient care.
• Interpretations were reworked so as to have
better understanding and clarity of the same.
• Formats to be revised and to be made more
standardised
• Separate guidebook and standard book
 Special Acknowledgements
• Assessors and Hospitals for the feedback / inputs
• Other committee Chairs and members
• External faculty and Domain experts
• Chairman and Board
• Quality Council of India
• Senior management of NABH
– CEO
– Director
– Joint Director

National Accreditation Board for Hospitals and Health Care Providers

 Special Acknowledgements
• One and the only TC – all members
– Special thanks Secretary

• 4th edition – The differentiator

• Special thanks to the Producer and director

National Accreditation Board for Hospitals and Health Care Providers