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CONTENTS
Content 2
1. Introduction 3
3. Pre-Assessment 5
5. Feedback 8
HAF 1 to HAF 4 9 - 12
1 INTRODUCTION
Accreditation is an incentive to improve capacity of Heath Care Organisations to
provide quality of care. The National Accreditation Board for Hospitals and
Healthcare Providers (NABH) provides third-party accreditation to Health Care
Organizations in India. It ensures that Panchakarma Clinic, whether public or private,
national or expatriate, play their expected role in national heath system. Country and
culture specific accreditation system safeguard the country health care system and
also involve fewer cost and better accepted as compare to external international
accreditation systems.
This guide has been prepared based on the general practices followed by
international bodies and the experience of experts of the country. This document
accordingly aims to:
a. Provide the guidance to the Assessors during the assessment of Panchakarma
Clinic
b. Ensure uniformity of assessment and reporting, and
c. Eliminate ambiguities or doubts about the interpretation of requirements(s).
Notwithstanding the strength of the NABH system, the success of the accreditation
scheme depends on the assessment team who perform on-site assessment and,
thus, play a vital role in determining the credibility and value of the accreditation.
Team members are required to maintain the confidentiality on the matters/ subjects
related to health care organizations.
Role of Assessor
Assessor would finally summarise the conduct of Assessment and record the
recommendations in HAF 4. If, during Surveillance or Re-assessment, a case of
critical system failure and gross negligence in technical aspects is noticed, the
Assessor will at the earliest inform NABH and elaborately bring it out in the
Assessment summary (HAF-4) of assessment report. The Assessor must sign all
pages of the assessment report.
He must get an endorsement from the Panchakarma Clinic on HAF 4 and hand over
a photocopy of the forms HAF 3 & 4 to the Panchakarma Clinic to enable them to
take corrective actions.
The Assessor is also required to monitor the performance of the Trainee Assessor.
He shall recommend whether the Trainee Assessor is capable to perform the role of
an Assessor in his next visit. His comments/ rating for each Assessor shall be
enclosed with the report.
The Assessor should clearly understand the areas/ activities to be assessed by him.
He must review the Panchakarma Clinic documented system to verify compliance
with the requirements of NABH standards. He should assess to verify that the
documented SOPs, records are indeed implemented & effective, as described and
record observations in HAF 2.
3. PRE-ASSESSMENT
NABH Secretariat on intimation from the organization about the preparedness to take
up pre-assessment, appoints a Assessor from the pool of empanelled Assessors
from assessor database. Scope and type of the Panchakarma Clinic is kept in mind
while selecting the Assessor. For carrying out the pre-assessment, Assessor may
also be accompanied with other assessors. The number of assessors depends on
the size of the Panchakarma Clinic.
The name of assessor(s) and the names of their organizations from which they
belong are intimated to the organization for seeking their consent. Following
documents are provided to the assessment team for carrying out the assessment:
The Assessor’s major role is to explain the purpose of the assessment. He/
She explains to the organisation the methodology adopted by his/ her team during
the assessment. Things are discussed in detail with the management of the
organization during the opening meeting of the pre-assessment.
The detailed guidelines for the assessors for carrying out Pre-Assessment is
described in NABH document ‘Pre-Assessment Guidelines and forms’.
4 ON-SITE ASSESSMENT
A similar methodology as used in the Pre-Assessment is followed in comprising the
team for final assessment of the organization. The number of assessors depends on
the size of the Panchakarma Clinic.
The assessor(s) and the names of their organizations from which they belong are
intimated to the organization for seeking their consent. NABH also assures that the
team does not have any competitive position with the applicant organization. NABH
also ensures that assessors do not have any direct/ in-direct relationship with the
organization or they/ or their organization.
Consent is obtained for the date(s) of the assessment of the organization from the
Assessor and other assessors accompanying for the assessment. A written
communication is sent to all the team members with the following documents:
- Application form of the organization
- Pre-Assessment report
- Corrective action report
- Self assessment submitted by the organization
- Panchakarma Clinic manuals/ documents submitted by the organization
- Confidentiality form (NABH I&C 01)
- Travel expenditure form
Assessment Team shall meet and plan assessment programme. This shall include
the distribution of work amongst the Assessors. The format of the assessment
schedule to be finalised is given at HAF-1.
(a) Assessor and the team shall have an opening meeting with Panchakarma
Clinic representatives where they get acquainted with the Panchakarma
Clinic, departments/ sections and their locations.
(b) The Assessors shall explain the objective and scope of assessment and what
is expected from the Panchakarma Clinic during the assessment.
(d) The Assessor shall inform the Panchakarma Clinic that the assessment team
shall not be approached by the Panchakarma Clinic for closure of non-
conformances while the assessment is in progress. Non-conformances may
be closed while the assessment report is being compiled.
4.2 Assessment
The assessment procedure will start with an opening meeting. The assessors
will introduce themselves and explain the assessment process. Any changes to
assessment agenda will also be discussed.
- Document review
- Functional interview
Leadership interview.
Infection control interview.
Management of information/ patient records interview.
Staff qualification and education interview.
- Visit to patient care areas and selected department
The surveyor will evaluate the process for patient care in different setting across
the organization.
- Facility tour
Assessor shall compile the observations from the assessors (HAF 2) and summary
on non-compliance (HAF 3) from all the assessors.
The Assessor shall give the summary of the assessment in his final report (HAF 4).
The reports shall be signed by the authorized signatory of the Panchakarma Clinic.
In addition to the above, Assessor in consultation with the team members shall fill up
the score sheet and send it to NABH along with report. This remains a confidential
document and copy should not be given to the Panchakarma Clinic.
Evaluation criteria:
No individual standard should have more than one zero to qualify. However, no
zero is accepted in the regulatory/legal requirements.
The average score for individual standard must not be less than 5.
The average score for individual chapter must not be less than 7.
The overall average score for all standards must exceed 7
4.4 Closing Meeting
The Assessor and other assessors shall have a meeting with the Panchakarma Clinic
representatives. A copy of the report – summary of non-conformances (HAF 3) shall
be handed over to the Panchakarma Clinic.
The closing meeting is to end with thanks giving for the co-operation and assistance
provided by the Panchakarma Clinic.
NABH secretariat reviews the assessment report and seeks clarification and
documentation from the Assessor and Panchakarma Clinic, if required.
NABH, on receipt of evidence of corrective action, if any, shall place the report before
the Accreditation Committee for its consideration for accreditation.
5 FEEDBACK
Following feedbacks are obtained by NABH through the evaluation forms in the
NABH document ‘Feedback Forms’.
Assessor 2
Assessor 3
Assessor --
Trainee
Assessor/Expert
Signature of Assessor
Panchakarma Clinic:
Non-compliance observed:
1.
Trainee Assessor :
Date of earlier visit and
Purpose:
ASSESSMENT SUMMARY:
NABH I&C-01
Name Assessor ID :
(To be filled in by NABH Sect.)
Designation
Organisation
Address
Health care
organisation Assessed
Date of visit(s)
i. I have not offered any consultancy, guidance, supervision or other services to the
Panchakarma Clinic in any way.
ii. I am/ am not* an ex-employee of the health care organization and am/ am not* related
to any person of the management of the health care organization.
iii. I will declare to the Board my and/ or my immediate family’s association with any of the
organization that can affect the impartiality of the assessment process. I shall also keep
the Board informed about changes in the status of my association with the organization
before every assignment.
iv. I got an opportunity to go through various documents of the above Panchakarma Clinic
and other related information that might have been given by NABH. I undertake to
maintain strict confidentiality of the information acquired in course of discharge of my
responsibility and shall not disclose to any person other than that required by NABH.
* strike out which is not applicable
Date:
Place : Signature