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 Table of Contents  
REVIEW ARTICLE
Year : 2021  |  Volume : 8  |  Issue : 1  |  Page : 66-72

National Accreditation Board for Hospitals and Healthcare Accreditation System for healthcare sector in India: An overview


1 Department of Hematogenetics, National Institute of Immunohematology (NIIH), Indian Council of Medical Research, Mumbai, India
2 Department of Microbiology, Savitribai Phule Pune University, Pune, Maharashtra, India

Date of Submission02-Jul-2020
Date of Acceptance13-Oct-2020
Date of Web Publication16-Mar-2021

Correspondence Address:
Dr. Anand G Bodade
Department of Hematogenetics, National Institute of Immunohematology (NIIH), Indian Council of Medical Research, Mumbai 400012, Maharashtra.
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mgmj.mgmj_66_20

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  Abstract 

Quality and standards of services in healthcare have become essential for the current generation of healthcare providers and beneficiaries, that is, patients. Healthcare accreditation has become the most important tool for improving the standard of the hospitals and thereafter benchmarking. Most hospitals and healthcare providers are differentiated and evaluated according to their organizational performance and quality. National Accreditation Board for Hospitals and Healthcare Providers (NABH) is an integral board of the Quality Council of India (QCI), which has been established to operate an accreditation program for healthcare organizations/institutions globally. Accreditation is a public recognition awarded to healthcare organizations that fulfill the standards laid by NABH through an independent external assessment, conducted by a qualified team of assessors. In India, healthcare organizations face a lot of burden on the number of patients. However, it is important to have a keen quality and standards of services to such a huge number of patients without compromise. NABH helps with its standards controlling the standard of care and services by the health industry in different areas. There is a constant need that many such organizations are motivated to undergo an accreditation process to have uniformity in the standard of services worldwide as it is a voluntary act in India.

Keywords: Accreditation, assessment, quality, standards


How to cite this article:
Bodade AG, Bodade RG. National Accreditation Board for Hospitals and Healthcare Accreditation System for healthcare sector in India: An overview. MGM J Med Sci 2021;8:66-72

How to cite this URL:
Bodade AG, Bodade RG. National Accreditation Board for Hospitals and Healthcare Accreditation System for healthcare sector in India: An overview. MGM J Med Sci [serial online] 2021 [cited 2021 Apr 14];8:66-72. Available from: http://www.mgmjms.com/text.asp?2021/8/1/66/311382




  Introduction Top


“Quality” has become an important aspect of the healthcare industry with a valid reason. Quality in hospital encompasses everything. It includes service catering by hospitals for patients, ensuring the health and safety of each of its patients and employees, and contributing to the overall health and well-being of communities.[1],[2],[3] Quality has different definitions in different sects, from traditional to strategic. Joseph Juran defined quality as “conformance to requirements” and proposed three principles in quality management as planning, control, and improvement.[4] As per Edwards Deming, the father of the concept of Total Quality Management (TQM), “quality is a strategy aimed at the needs of the customer.” It contains a prescriptive set of 14 points that serve as guidelines for appropriate organizational behavior and practice.[5] The American National Standards Institute (ANSI) and American Society for Quality (ASQ) define quality as “the totality of features and characteristics of care or service that bears on its ability to satisfy given needs.” This strategic definition has received the widest international acceptance. The use of the term “Health Care Service” in place of “Medical Care” further defines the field and puts it as an entity that can be assessed, monitored, and improved. A quality healthcare system can be defined as “one that is accessible, appropriate, available, affordable, effective, efficient, integrated, safe, and patient-related.”[6]


  Historical development Top


The origin of the accreditation process is traced back to the United States of America. In 1917, the American College of Surgeons developed a program of “minimum standards for hospitals” to assess and identify suitable hospitals for surgical training. This developed into a multidisciplinary program of standardization, and in 1951, led to the formation of the independent Joint Commission on Hospital accreditation. It is now known as the Joint Commission on Accreditation of Healthcare Organizations.

Hospital accreditation is being used to guarantee quality and patient safety in developing countries.[7] Joint Commission International (JCI) Accreditation was established in the USA in 1998. The JCI accreditation standards are based on consensus standards developed by healthcare professionals from many countries. An international body is known as the International Society for Quality in Health Care (ISQua) was established as an umbrella organization to provide approval for other accreditation bodies in 1999. Hospital Accreditation is a public recognition by a National Healthcare Accreditation Body, of the achievement of accreditation standards by a Healthcare Organization showed through an independent external peer assessment of that organization’s level of performance concerning the standards.[8],[9]

The accreditation system for hospitals ensures an unbiased evaluation that hospitals (public/private, national/expatriate) are playing their expected roles in the national health system. A transparent system of evaluation and control over the hospital helps ensure an assurance of the hospital being constantly fulfilling all said criteria. By achieving accreditation standards to improve the quality of healthcare services and processes, it ensures a safe environment and helps to prevent or reduce risk to patients and staff; and to identify their own organization’s strengths and weaknesses.[8]

ISQua has accredited “Standards for Hospitals” developed by National Accreditation Board for Hospitals and Healthcare Providers (NABH) in India. The approval of ISQua authenticates that NABH standards align with the global benchmarks set by ISQua. This means that NABH standards are in alignment with the global benchmarks set by ISQua and so hospitals accredited by NABH have international recognition.[8],[10]

So far hospital standards of only 11 countries viz. Australia, Canada, Egypt, Hong Kong, Ireland, Japan, Jordan, Kyrgyz Republic, South Africa, Taiwan, and the United Kingdom were accredited by ISQua. India has joined this group to become the 12th member.[8]


  Indian scenario Top


NABH is one such integral board of Quality Council of India (QCI), established to operate an accreditation program for healthcare organizations/institutions in India. NABH has been established to enhance the health system and promote continuous quality improvement and patient safety. The benefits of NABH accreditation for stakeholders are presented in [Table 1]. The board is supported by all stakeholders, including industry, consumers, and government, and has functional autonomy in its operation. NABH provides accreditation to hospitals in a nondiscriminatory manner regardless of their ownership, legal status, size, and degree of independence.[8]
Table 1: Benefits of accreditation[8]

Click here to view


Structure and functioning

NABH was set up to establish and operate an accreditation program for healthcare organizations in the year 2006. It cares to enhance the development of healthcare quality service in our country for all levels of the population, through various methods and tools, to supplement the efforts of the providers of healthcare service and requirements of the system at various levels.

The standards of NABH consist of 10 chapters, which are being divided between patient-centered and organization centered standards. All 10 chapters consist of 683 stringent objective elements for the hospital to attain to get the NABH accreditation (4th edition) that aims to rationalize the entire operations of a hospital.[8]

Aims and objectives

NABH is the apex national body to control quality standards and accreditation on healthcare institutes. It manages this through cooperation with their stakeholders for patient’s rights for safety and quality control through EQAS. NABH bears certain values in a working pattern like:

  • Credibility: Provide credibly and value-added services;


  • Responsiveness: Willingness to listen and continuously improving service;


  • Transparency: Openness in communication and freedom of information to its stakeholders and;


  • Innovation: Incorporating change, creativity, continuous learning, and new ideas to improve the services being provided.[8]



  •   Scope Top


    The aim of NABH is at the accreditation of healthcare facilities and quality promotion through initiatives like Safe-I, nursing excellence, laboratory certification programs, IEC activities such as public lectures, advertisements, workshops/seminars, education and training for quality and patient safety and recognition through the endorsement of various healthcare quality courses/workshops. NABH conducts various accreditation and certification programs in different areas as mentioned below (21 areas): Hospitals, Small Health Care Organization (SHCO), Blood banks, Allopathic clinics, primary health centers (PHC), Dental centers, MIS (Medical Imaging Services), Eye care organization, Ayurveda hospital, Homeopathy hospital, Siddha hospital, Unani hospital, Yoga and naturopathy hospital, Wellness centers, Spa center, Panchakarma clinics, preentry level for the hospital, preentry level for SHCO, Nursing excellence program, certification of the emergency department in the hospital, and NABH – I safe – for hospital infection control.[8]


      Structure and role of each hierarchy Top


    Accreditation committee: It recommends for grant of accreditation based on the evaluation of assessment reports. It also approves major changes in the scope of accreditation viz. enhancement and reduction and so guides on the launching of new initiatives.

    Technical committee: It helps to draft accreditation standards and guidance documents and periodic review of standards.

    Appeals committee: It deals with the appeals against any adverse decisions regarding accreditation (e.g., refusing an application, refusing to proceed with an assessment, and corrective action requests)

    Secretariat: They coordinate the entire activities related to accreditations to organizational structure:

    There is a panel of experts for assessment.

    Principal assessor: conducts preassessments and final assessments of the hospitals.[8]

    A team of assessors: They are trained by NABH for accreditation and assessment techniques and assessors are responsible for evaluating the hospital’s compliance with standards [Figure 1].[8]
    Figure 1: Structure and hierarchy of NABH in India (Courtesy: NABH website)

    Click here to view




    Standards of NABH

    These can be bought from NBAH on payment when an organization wishes to undergo the accreditation process. The standards provide a framework for quality of care for patients and quality improvement. The standards help to build a quality culture at all levels and across all the functions of healthcare organizations. NABH Standards has 10 chapters incorporating 105 standards and 683 objective elements [Table 2].[8]
    Table 2: Outline of NABH standards

    Click here to view


    One can first be prepared for accreditation and should make a definite plan of action for the same. One can go through the standards from the NABH secretariat obtained against payment.

    It will be always worth it if a hospital does self-assessment against standards at least 3 months before application and understand the weak areas to work on.


      Process of accreditation Top


    A hospital must ensure the implementation of NABH standards as the assessment team will check the implementation of standards. A flow chart is depicted here to understand the process to be prepared for undergoing accreditation [Figure 2]:
    Figure 2: Process of accreditation preparation (Courtesy: NABH website)

    Click here to view


    For application, one should pay fees, along with a signed copy of “Terms and Conditions,” a self-Assessment Toolkit, and relevant documents. After the Secretariat receives the application form scrutiny is performed, an acknowledgment letter is sent to the applicant with a unique reference number. This reference number is to be provided in all future correspondence.

    Preassessment

    A principal assessor (PA)/assessment team carries out a preassessment of the healthcare organization.

    The objectives of preassessment

  • To make the hospital ready for final assessment


  • To review the scope and appoint the required number of assessors and establish timelines


  • To review the documentation systems of the hospital


  • To brief the hospital on the methodology for assessment.[11]


  • Final assessment

    The hospital is required to take necessary corrective action to the nonconformities pointed out during the preassessment. The final assessment involves a comprehensive review of hospital functions and services. NABH assessment team includes PA and the assessors. The total number of assessors appointed depends on the number of beds and services provided.[11]


      Accreditation procedure Top


    Scrutiny of assessment report

    Assessment report is examined by NABH. The report is taken to the accreditation committee. Depending on the score and compliance to standard would decide the award of accreditation.

    Issuing the accreditation certificate

    The accreditation certificate valid for three years is issued by NABH. It has got a unique number and date of validity. Before the issue of the certificate, all relevant payment has to be done.

    Surveillance and reassessment

    Surveillance of the accredited hospitals is conducted by NABH in one accreditation cycle of three years. It will be planned during the second year (after 18 months).

    The hospitals may apply for the renewal of accreditation at least six months before the expiry. NABH may call for an unannounced visit, based on any concern or any serious incident reported upon by an individual or organization or media.[11]


      Financial terms and conditions Top


    The accreditation fee does not include expenses on travel, lodging/boarding of assessors. These expenses are to be borne by the hospital on an actual basis. It includes preassessment charges, whereas the first annual fee is payable after a preassessment visit and before assessment visit. A 10% discount is admissible in case of hospitals pay for the accreditation fee for three years in one installment [Figure 3].
    Figure 3: Accreditation procedure of NABH (Courtesy: NABH website)

    Click here to view


    Most of the areas in healthcare organizations such as; medical colleges, and nursing homes are covered under the purview of NABH excluding laboratories (for them NABL/CAP/and other accreditation bodies are available). The following are a few areas covered by NABH for their standards to get accredited:[12]

    Medical imaging services

    It covers investigations of patients that provide imaging information for the diagnosis, prevention, and treatment or assessment of health. It includes conventional and specialized radiological techniques including ultrasound scans (USG), Doppler studies, bone densitometry (DEXA), computed tomography (CT), magnetic resonance imaging (MRI), positron emission tomography – computed tomography (PET/CT), single-photon emission computerized tomography (SPECT), radionuclide imaging, and therapy.

    Certain tests routinely performed in diagnostic centers, for example, electrocardiography (ECG), electroencephalogram (EEG), electromyography (EMG), and nerve conduction, as they are not imaging methods and are performed and reported by a technical medical specialist other than radiologists, they are not included in these standards.[13]

    Dental healthcare service providers

    Accreditation to dental facilities in a nondiscriminatory manner regardless of their ownership, legal status, size, and degree of independence is provided by NABH.[14]

    Blood centers/blood banks

    In 2007 with support from NACO (National AIDS Control Organization) this accreditation program was started for blood centers throughout the country as a voluntary act. Quality standards were laid for different areas of blood centers divided into eleven chapters. The areas concerned include blood collection processing, testing, clinical transfusion, hemovigilance, and overall quality assurance. The focus is to make safe, timely, and adequate blood supply for quality patient care and transfusion practices.[15]

    Ayurveda, Homeopathy, Unani, Siddha, and Yoga and naturopathy hospitals

    The accreditation program for Ayurveda, Homeopathy, Unani, Siddha, and Yoga and Naturopathy (AYUSH) hospitals are running in association with the Department of AYUSH, Ministry of Health and Family Welfare, Government of India. The Accreditation Standards measure the quality and safety aspects of the care delivered to the patients based on three components: structure, process, and outcome.[16],[17],[18],[19],[20]

    Panchkarma clinics

    They play an integral role in the Ayurveda healthcare system. The NABH standards are dynamic documents and are revised periodically by the experts in the field.[21]

    Oral substitution therapy centers

    It was developed for the NACO to improve the health status of Injectable Drug Users (IDUs) and prevent the spread of human immunodeficiency virus infection and acquired immune deficiency syndrome (HIV/AIDS). The NABH Accreditation for Oral Substitution Therapy (OST) Centers is based on the “Standard Operating Procedure for Oral Substitution Therapy with Buprenorphine” made by NACO.[22]

    Wellness centers

    “Wellness” is a state of optimal health covering physical, mental, social aspects of individuals. Wellness centers provide scientifically proven physical interventions with repeatable positive outcomes for improvement or maintenance of physical form, enhancement of functions or improvement of beauty for achieving the state of wellness of an individual, for example, gymnasiums, spas, skin care centers, cosmetic care centers, fitness centers, immunization centers, and executive health checkup centers with associated advice. NABH standards provide a framework for quality of care for customers and quality improvement for Wellness Centers.[23]

    Clinical trials/ethics committee

    Ethics Committee accreditation makes it a public recognition by an accreditation body, based on accreditation standards that are evaluated by external peer assessment. All pharmaceutical products must go through a standard quality, safety, and efficacy study, both during premarketing and postmarketing review. Accreditation is an incentive to improve quality as well as the capacity of the registered Ethics Committee to confirm ethical research on new drugs.[24]

    Eye care hospitals

    Eye Care Standards have been formulated applying norms and standards of NABH considering the availability resources in the small Eye Care hospitals, functional requirements of Eye Care Service providers, with emphasis on standards for infrastructure such as building, types of equipment, manpower, medication management, infection control, and patient safety norms. It is crucial to develop systems and processes in the Eye Care organization aiming at internalizing the quality and patient safety within its organizations. As a very large number of the standalone eye care clinic/eye care organizations exist in the country and are keen to join the quality journey, NABH has developed an accreditation program for standalone eye care organizations, in consultation with various stakeholders in the country.[25]

    Integrated Rehabilitation Centre for Addicts

    Integrated Rehabilitation Centre for Addicts (IRCA) provides composite/integrated services for the rehabilitation of the substance-dependent persons. IRCA envisages the total recovery of the addicted person leading to his socioeconomic rehabilitation through an appropriate combination of individual counseling. It also enables the addict to achieve total abstinence and improve the quality of their lives. The center which meets the acceptable standards of IRCA delivery is provided accreditation certificates by the independent agency which makes them eligible for the continued support from the Ministry of Social Justice and Empowerment.[26]

    Till now in India, 664 hospitals, 135 ethics committees/clinical trials, 122 eye care organizations, 102 MIS, 98 blood banks, 91 dental, 51 OST, 27 allopathic clinics, 31 PHCs, and 86 centers form AYUSH stream have got accreditation. The number is still on the lower side for blood storage centers (01), Panchakarma clinics (19), CHCs (02). No IRCA center has got NABH accreditation till date.[8]


      Conclusion Top


    Accreditation standard for hospitals helps to focus on patient safety and improve the quality of healthcare services and processes. Till now in India, a total of 664 hospitals have got NABH accreditation. Still, there is a long path to travel to get many hospitals (including Dental, AAYUSH, nursing sector, and others) and blood banks to be standardized by NABH to have uniform quality in the healthcare industry.

    There are many methodologies, such as ISO standards, TQM, Six-Sigma, and Lean system used to improve quality in healthcare. However, in the current scenario, the NABH standards are the highest benchmark standards for hospital quality in India. Patients are the biggest beneficiaries of the NABH accreditation, as it ensures uniform high quality of care and patient safety.[9]

    NABH is one of the Institutional and a Board member of the ISQua, Member of the ISQua, and on the Board of Asian Society for Quality in Healthcare (ASQua). Accreditation is also one of the most frequently used external quality assessment of healthcare organizations to prove their effectiveness and performance.[8],[10]

    There are very few studies conducted to analyze effectiveness of accreditation systems but due to scant evidence, no conclusions could be reached to support its effectiveness. Most studies lacked in intervention context, implementation, or cost. There are challenges in assessing complex interventions of accreditation and certification.[27]

    It is need of hour to conduct multicenter studies and meta-analysis to understand the effectiveness of such accreditation programs for benefit of stakeholders.

    Acknowledgement

    We are exceedingly grateful to Dr. Manisha Madkaikar, Director, National Institute of Immunohematology (NIIH), Indian Council of Medical Research, Mumbai, Maharashtra, India for providing continuous encouragement and intellectual stimulus.

    Financial support and sponsorship

    Nil.

    Conflicts of interest

    There are no conflicts of interest.



     
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        Figures

      [Figure 1], [Figure 2], [Figure 3]
     
     
        Tables

      [Table 1], [Table 2]



     

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