The National Accreditation Board for
Hospitals and Healthcare Providers (NABH) launched its fifth edition of
accreditation standards for hospitals across the country .The 5th
edition has been approved by the International Society for Quality in Health
Care (lSQua). NABH
will Begins its 5th Edition Of Accreditation Standards for Hospitals across
the Country from June or July due to COVID-19 Medical disaster.
The 5th edition has been created
for exclusively for Health care organization. It will not be applicable to
Small Healthcare organisation.The SHCO standards (2nd Edition) are
remained the same. No changes made in it. Let’s see the 5th edition what
has changed? And what else has not changed its standards elements.
The Fifth Edition mainly focuses on
healthcare organizations its Commitment, Achievement and Excellence in their
patient care out come.
Commitment: towards on implementation for Final Assessment
Achievement: towards on Surveillance Assessment
Excellence: towards on Renewal Assessment
What has not
changed?
·
Patient
Safety
·
Employee
Safety
·
Community
Safety
·
Environment
Safety
·
Continue
Quality Improvement
What else
has not changed?
·
Total no of
chapter and their division has not changed Patient centre oriented and Organizational
centre oriented
·
The basic
Structure
·
Chapter: Intent
followed by Summary of Standards
·
Standards:
Objective Elements
·
Interpretation
:Naming and Numbering
·
Glossary
Languages Change
·
Focus on Documentation to implementation
·
Remove
ambiguities
·
Stream line
Interpretation
Interpretation provide guidance
to the organization to meet the requirement s of an OE .Example Specific
guidelines, methodology and examples are provided to meet the requirements of
an OE
Some Example
word is used:
·
Shall/should
or will/would
·
Can/Could
·
Adequate/Appropriate
Examples of Language usage and
interpretation
COP2E: Documented policies and
procedures guide the triage of patients for initiation of appropriate care.
Triage shall be done only by qualified/trained individuals. This
should be based on good clinical practices. The triage should be part of
routine day-to-day functioning of the emergency department and not only from a
disaster point of view. The criteria could be separate for trauma &
non-trauma patients
And for adults and children.
Cop3a: There
is adequate access and space for the ambulance(s).
The organization shall demarcate a proper
space for the ambulance(s).This shall be demarcated keeping in mind easy
accessibility for receiving patients and to enable the ambulance(s) to exit
quickly.
Cop 5b. Staff providing direct patient
care is trained and periodically updated in cardio-pulmonary resuscitation.
These aspects shall be
covered by hands on training. If the organization has a CPR team (e.g. code blue team) it shall ensure that they are all
trained in ALS and are present in
all shifts.
The Organization shall defined or
provided specific guidelines or examples for their interpretation to meet out
requirements of OE.
Salient Changes
1. Total no of chapter and Standards and
Elements
Edition
|
Chapter
|
Standards
|
Objective
Elements
|
Fourth
|
10
|
105
|
683
|
Fifth
|
10
|
100
|
651
|
2. Chapter on CQI has been replaced by PSQ
(Patient Safety and Quality)
3. Classification of objective elements
4. Added Two New standard in HRM HRM5 1
&3
5. Excluded” Quality Indicators. New model
indicators will be intimated later on
6. End of life care, communication,
indicators, patients responsibilities, sentinel events, internal audit are
excluded
7. MOM-9, 10, 11, have been merged with in to
common MOM 9
8. CQI -3, 4, 5 included PSQ-3
9. ROM-2.3.5 have been merged with ROM -3
10. Scoring System
Salient
Features in Scoring System
Existing Method : 0-5-10
New Method :
1-2-3-4-5
Non Compliance
Calculation on onsite Assessment as per new Scoring Method
Scoring 1
Non Compliance /No system/No Evidence of documentation
and scoring below 20 samples met the OE requirements
Status: Non Conformity
Scoring 2.
Poor Compliance; Elementary system are in
place/some evidence are working towards on implementation 21 to 40 samples met
the OE requirements. Status: NC-Exists
Scoring 3.
Partial Compliance: system is partial in place/there
is evidence towards to implementation 41-60 samples met the OE requirements. Status:
NC-Exists
Scoring 4.
Good Compliance: system is in place/evidence of
working towards to implementation 60 -80 samples met the OE requirements. Status:
NC-Could Exists
Scoring 5.
Full Compliance: system is in place/evidence
of implementation across the organization
80 to No samples met the OE requirements. Status: NO NC
Over all
Compliance Rate for Accreditation
Accreditation
|
Towards Implementation
|
Compliance Rate
|
Required Elements
|
||
80%
|
Core
|
Total
|
|||
Commitment
|
Final
Assessment
|
80%
|
459
|
102
|
561
|
Achievement
|
Surveillance
Assessment
|
80%
|
561
|
60
|
621
|
Excellence
|
Re-Accreditation
Assessment
|
80%
|
621
|
30
|
651
|
Key Notes
·
HCO fulfill
the following requirements:
·
Currently in
operation commits to comply NABH standards and applicable statutory
requirements
·
Implement whole organization not specific areas
·
Equally apply
to all services
·
All
standards are equally meet out its OE both Government and Private healthcare organization
Sivakumar
Murugesan
Healthcare Projects,
Quality Accreditation and Public Health Consultant