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
What has changed?
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%
|
461
|
100
|
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
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