NABH ENTRY LEVEL STDS.

AN OVERVIEW AND
APPROACH & METHODOLOGY TO
ITS IMPLEMENTATION

BY
ACME CONSULTING
Healthcare Quality
Is determined by the
way the patient feels it !
When all patients get greeted at the front desk with
smiling and courteous staff

When these Staff have answers to all their queries

When appointments given are adhered to and waiting

time is minimum
 When the Doctors spend time with the patients and
clearly explain diagnosis and line of treatment

When their noting on the Medical Record are

legible and self explanatory
When the signage at the Hospital is sufficient,
multilingual and unambiguous

And really helps you get to where you want to go,

without asking anyone
 When Nurses show they care and speak the
language of their patients

When they follow standard practices

When they ensure patient safety, with proper

hygiene and infection control practices

When they are trained at handling difficult patients,

stressed out and impatient ones
When the Waiting Areas are comfortable

With enough seats, temperature and air quality well

maintained

When there are enough toilets and all kept always

spotlessly clean
 When the equipment are calibrated, show correct
results which the Doctor can rely on

When critical life saving equipment are properly

maintained ensuring zero down time
 When we do all this and more,
not just once, but day in and day out,
month after month, year after year,
then we will be recognised as
an excellent healthcare service provider
worthy of the
NABH Accreditation
Structure
ABOUT NABH ENTRY LEVEL
STANDARDS
Driving Factors for Accreditation

• State & Public Sector Insurers requirements

• Consumer Protection Act.
• Clinical Establishment Act.
• Empanelment by CGHS, ECHS, Corporate
Companies etc.
• Community Awareness & Response.
• Health Tourism
 WHY ENTRY LEVEL & NOT FULL NABH STANDARDS

 Easier to implement. Full NABH stringent, not suitable for most Hospitals
 Till date in 8 years only 249 Hospitals out of 20,000, NABH Accredited.
 Many structural & statutory requirements to be met in full NABH like:
 For OT – dedicated AHU for each OT along with HEPA Filters .
 Legal & Regulatory requirements – Building permits, Fire NOC, etc.
 Staff requirements – in Nursing, OT, Radiology
 Main focus on good quality practices, not infrastructure requirements
 Older, smaller Hospitals okay with demonstrating good clinical practices.
PRE ACCREDITATION ENTRY LEVEL STANDARDS
(FIRST EDITION – APR. 2014)

• 10 - CHAPTERS

• 45 - STANDARDS

• 167 - OBJECTIVE ELEMENTS

 THE TEN CHAPTERS

1. Access, Assessment and Continuity of care

2. Care of Patients
3. Management of Medication
4. Patient Rights and Education
5. Hospital Infection Control
6. Continuous Quality Improvement
7. Responsibilities of Management
8. Facility Management and Safety
9. Human Resource Management
10.Information Management System
 1. Access, Assessment and Continuity of care

 Matching patient’s requirements with organization's

resources
 Admissions, registration, transfer
 Initial assessment and periodic regular assessments.
 Laboratory services
 Imaging services
 Medical Records - Accessibility
 2. Care of Patients

 Uniform care delivery  Surgical patients

 Emergency services  Restraints
 Blood and blood  Pain management
products  Rehabilitative services
 Vulnerable patients
 Research activities
 Pediatric patients
 3. Management of Medicine

 Prescription / Dispensing of medication

 Storage of medicines
 Medication administration
 Implantable & prosthesis
4. Patient Rights and Education

 Protects patient and family rights

 Protecting beliefs, values and involvement
in decision making
 Informed consents
 Right of information and education
 Information on expected costs
 5. Hospital Infection Control

 Infection control programme

 Surveillance activities
 Actions taken to prevent or reduce the risk
of hospital associated infection(HAI)
 Facilities and resources provision
 Biomedical waste management
 6. Continuous Quality Improvement

 Key indicators – Clinical structures, processes and

outcomes
 Key indicators – Managerial structures, processes
and outcomes
 Quality Assurance programme
 System for audit of patient care services
 Sentinel events analysis
 7. Responsibility of Management

 Responsibilities of management are defined

 Scope of services is documented
 Hospital managed in ethical manner
 Qualified and experienced individual heads the
organization
 Patient safety and risk management issues
addressed
8. Facility Management & Safety
 Laws, byelaws, rules and regulations
 Facility for safety of patients, families staff
and visitors
 Equipment management
 Fire and non fire emergencies
 Smoking policy
 Disaster management policy
 Hazardous materials handling
9. Human Resource Management

 HR planning
 Training & development
 Credentialing
 Regular appraisals of skills & knowledge
 Basic life support (BLS) education to all staff
 Health needs addressed
 Personal records
 Disciplinary procedure
10. Information Management System

• Management of information needs

• Medical records
• Confidentiality, integrity and security
• Retention of records
• Medical audits
 APPROACH OF ACME CONSULTING

TO THE
IMPLEMENTATION
OF THE
NABH ENTRY LEVEL STANDARDS
 REQUIREMENTS OF HOSPITAL TEAM
• Appointment of Coordinator by Hospital
• Steering committee to be formed with Senior Management / HODs.
• Other major Teams / Committees:
• Quality & Safety Committee
• Infection Control committee
• Blood Transfusion Committee
• Pharmaco-therapeutic committee
• Medical Record Audit committee
ENTRY LEVEL NABH SYSTEM DESIGN
& IMPLEMENTATION

Main phases

1. Initial Systems study with Gap Analysis

2. General Awareness & Training
3. System Design & Documentation
4. Assistance in Maturity Measurement
5. Accreditation Assistance
 PHASE-I:
Initial Systems Study & Gap Analysis

• Study on existing processes and records.

• Check compliance to applicable rules & regulations, licenses,
registrations, waste disposal, fire & safety controls
• Bring out the Gaps in the existing practices with respect to
meeting the NABH Entry Level Standards

Management to identify and appoint NABH Coordinator and the

Core Committee & other Committee members.

DURATION: 7 Mandays spread over 3 to 4 weeks

PHASE-I Areas coverage...

PATIENT CARE AREAS

 Out Patient handling

 Imaging

 In Patient Handling

 Emergency Department

 Operation Theater

 Patient Care in Wards / Rooms

 Patient care in ICU / NICU / PICU / HDU

NABH – PHASE-I Areas coverage...

Clinical support areas

 Laboratory – Pathology, Cytology,

Immunology, Hematology,
 Clinical microbiology
 Blood Bank
Dietary Functions
Pharmacy
PHASE-I Areas coverage...

OTHER SUPPORT AREAS

 Medical Records
 Front Office
 Billing Counters
 Guest Relations
 Engineering Services
 F & B Services
 House Keeping Activities
 Human Resource Management
 Hospital Administration
 Materials Management
 PHASE-II
Training
For all Staff on :
• Entry Level NABH Standards
General Awareness – covering all staff in
Batches

DURATION: 5 Mandays spread over 2 weeks

 PHASE-III
System Design and Documentation

• Based on the Gap Analysis Report, the relevant forms, records and
work instructions will be introduced to your Organisation.
• We will guide HODs in preparing Drafts of Policies & Procedures
• Coordinator supported by the Core / Steering Committee members should
initiate the implementation
• Also development of Mission, Objectives, Organizational Structure,
Duties and Responsibilities of Department Heads.
• Based on the Policy & Procedure document, assistance will be provided to
prepare all the Mandatory Manuals.

DURATION: 10 Mandays spread over 8 weeks

 PHASE-IV

Assistance in Maturity Measurement

• We will train your core team in audit practices – to examine if planned

system is adequate
• This trained core team will conduct cross-functional audits to ascertain
compliance level in each areas / departments
• We will assist Auditees to address NCs with suitable corrective actions and
its timely implementation.
• We will help in the filling up of SA Toolkit and in submission of NABH
Application

DURATION: 12 Mandays spread over 6 weeks

 PHASE-V

Accreditation Assistance:

 We will be available for assistance right upto the Assessment by

the NABH accreditation body.
 We will also help in the closure of Non-conformances raised by
NABH Accreditation Assessment Team

DURATION: 5 Mandays spread over 4 weeks

 ENTRY LEVEL NABH -PROJECT SHEDULE:

MONTHS

Phase
Activity 1 2 3 4 5 6
No.

Systems study & Gap

1
Analysis

2 General Awareness Training

Systems Design &

3
documentation

4 Maturity Measurement

5 Accreditation Assistance
 BENEFITS FROM A QUALITY APPROACH

1. Increased Productivity
2. Cost Savings
Procurement/storage costs : by better vendor selection,
standardization of materials, less inspection/rejection,
identification of slow/non-moving items.
Staffing costs: by conducting training/awareness programmes,
improving motivation levels and reducing employee turnover.
Equipment Costs: by better utilization and maintenance practices
like setting up preventive maintenance schedules.
BENEFITS FROM A QUALITY APPROACH

Cost Savings contd…..

Patient complaints. A systematic approach and a responsive

and aware staff will reduce patient complaints to a minimum
resulting in better retention and increased flow of patients.

Liability costs, with increasing Consumer Protection Act related

litigation a quality approach is the best insurance in avoiding
liability costs in settlements and legal costs.
ACME CONSULTING

A Profile of the Company

& our Services

www.acmeconsulting.in

42
Scope of Services
1.1 Quality Accreditation Services

• Assist Healthcare Organisations to go for National, International Quality

Accreditations like NABH, NABL, JCI and ISO 9001

• Successfully assisted over 350 Private & Government Hospitals till date,
across the country in achieving quality improvements leading to
Accreditations and Certifications.

• Only NABET of Quality Council of India Accredited Healthcare

Management Consulting Organisation in South India for NABH.

• Rated highest technically by NHSRC, the technical wing of NRHM,

Government of India

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Scope of Services
1.2 Patient Satisfaction Surveys

• ACME PULSE, only Independent Third Party Patient Satisfaction Survey

Program in the Country, approved by QCI for NABH Hospitals

• Pioneering concept, specific to Indian requirements.

• Surveys by qualified healthcare professionals, trained in Quality

• Surveys conducted mainly on-site. 25% done over telephone

• Comprehensive, detailed surveys taking 18-20 mins. per patient

• Sample size based on 95% confidence level, with 5% or 7% error levels

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Scope of Services
1.3 Architectural Services

 Concept Design is first prepared optimizing layout & incorporating

essential healthcare quality requirements

 The design will be based on the built-up square feet area indicated
and local building laws

 The design will provide block relationships of the departments

showing area, shape and location within the building

 The designs will also give the location of vertical circulation

elements such as elevators and staircases and the layout of the
horizontal circulation routes (corridors)

45
Scope of Services
1.4 Project Report Preparation

• Based on the approved Concept Design we can provide a detailed Project

Report comprising the following information:

• Proposed Plan for the Project

• Infrastructure Development Plan
• Zoning Plan (Conceptual)
• Space Plan
• Human Resource Plan
• The financials can be worked out based on information on department
wise load expected, tariffs, salaries, other benefits to be provided to
Doctors., Nurses, Administrator, paramedics etc.
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Scope of Services
1.5 Market Research & Project Feasibility Studies

• In the areas of:

 Healthcare delivery & infrastructure

 Clinics (standalone/chains), Hospitals need and demand assessment for
primary-secondary-tertiary care , branding, preventive & curative care
 Studies on assessing quality of healthcare delivery

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Scope of Services
1.6 Human Resource Planning

• We will be able to advise you on providing the right human resources for carrying
out the various operations at the Hospital

• This will be given in a Report prepared based on a detailed analysis of the

required manpower distribution. The Report will have the entire staff matrix of
educational qualifications, skills and experience

• We will also advice and support the Management in drawing up the detailed job
specifications and descriptions, with responsibilities and any other information as
needed for releasing advertisements for recruitment

• Later we can support the Hospital Management in short listing, interviewing and
selecting the right staff for professionalizing the services provided by the Hospital

48
The Acme Advantage
• Transparent and ethical practices – Consultants have signed Code of
Conduct and Non-Disclosure Agreements

• Certified by TUV- NORD as an ISO 9001 Consulting Organization

• Accredited by NABET of QCI as an NABH Consulting Organization

• Only Consultancy in South India empanelled by Central Govt. (NRHM)

for Quality Improvement Hospital Projects

• Presence in 9 States and 6 Cities

• Pioneer in Healthcare Quality Sector-assisted first Hospital in India to

go for the ISO 9001 Certification – Mallya Hospital, Bangalore in 1998

49
The Acme Advantage
• Worked with over 350 Hospitals on Hospital Improvements and Quality
Management Systems Development & Implementation
• Quality Consultant to 7 State Governments.
 Tamil Nadu
 Kerala
 North East – Assam, Meghalaya and Arunachal Pradesh
 West Bengal
 Maharashtra (Incomplete project)
 Largest dedicated Healthcare Quality Team in the country – 35
• Multi skilled consulting team with exposure to multiple management
system platforms (NABH, NABL, ISO 9001, 14001, 27001, 22001,
HACCP, OHSAS 18001).

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Select ACME Client List
• Apollo Hospitals – Madurai
• Apollo Specialty Hospitals –Chennai
• Apollo Victor Hospital Goa
• Apollo KH Hospital, Vellore
• Bangalore Hospital
• Belle Vue Clinic, Kolkata
• Bombay Hospital – Indore
• BW Lion’s Eye Hospital, Bangalore
• Cancer Institute (WIA) Adyar, Chennai
• CHILDS Trust Hospital, Chennai
• Criticare Hospital , Mumbai
• CHL (Apollo) Hospital, Indore
• Choitram Hospital & Research Centre, Indore
• Dhanalakshmi Hospital, Kannur
51
ACME Client List
• Dr. Mehta’s Hospital – Chennai
• Elite Mission Hospital, Thrissur
• EMS Memorial Hospital, Perinthalmanna
• Father Muller Medical College Hospital, Mangalore
• Gautam Hospital, Kochi
• Govt Community Health Centres, Tamil Nadu (30 Hospitals)
• Govt District Hospital, Guwahati, Assam
• Govt District Hospital, Pasighat, Arunachal Pradesh
• Govt District Hospitals, West Bengal (3 Hospitals)
• Govt Hospitals, Kerala (14 Hospitals).
• Govt Primary Health Centres, Tamil Nadu (48 Hospitals)
• Govt. Hospital, Tamil Nadu (12 Hospitals)
• Govt; District Hospital, Shillong, Meghalaya
• Gurushri Hospital-Bangalore
• 52
ACME Client List
• Holy Cross Hospital – Kottiyam
• Indira Gandhi Inst. Of Child Health, Bangalore
• Indo American Cancer Hospital, Hyderabad
• Indo American Neuro Hospital, Vaikom
• Institute of Neurosciences, Kolkata
• Isha Hospital, Baroda
• ISIS Group of Hospitals, Bangalore
• Jeevanthi Group of Hospitals, Mumbai
• KLE Medical College Hospital, Belgaum
• Kalari Kovilakkom, Kerala
• KIMS Hospitals in Hyderabad, Rajahmundry, Srikakulam (AP)
• Kumaran Hospital, Chennai
• Mallya Hospital-Bangalore
• Medical Trust Hospital- Pathanamtitta
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ACME Client List
• MIOT Hospitals - Chennai
• MM Joshi Eye Hospital – Hubli
• MV Hospital of Diabetes, Chennai
• MVJ Medical College Hospital, Bangalore
• Moulana Hospital, Perinthalmanna
• MES Hospital, Perinthalmanna
• Nathan Super-specialty Hospital, Salem
• National Hospital - Kozhikode
• National Neurosciences Centre, Kolkata
• Neyveli Lignite General Hospital, Neyveli
• Omega Hospital, Mangalore
• Peerless Hospital, Kolkata
• Pondicherry Medical Mission
• Priyamvada Birla Arvind Eye Hospital, Kolkata
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ACME Client List
• PRS Hospital, Trivandrum
• PVS Hospital, Ernakulam
• Regional Cancer Centre, Trivandrum
• RL Jalappa Med College Hosp, Kolar
• Raja Rajeswari Medical College, Bangalore
• Sankara Netralaya, Chennai
• Sat Kaival Hospital & IVF Centre, Anand
• SCARF Hospital, Chennai
• Shri Vijay Vallabh Hospital, Udaipur
• SK . Hospital, Trivandrum
• Sooriya Hospital, Chennai
• SPMM Hospital - Salem
• Sri Jayadeva Institute of Cardiology, Bangalore
• Sri Vijay Vallabh Hospital, Udaipur
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ACME Client List
• Sri Ramachandra Medical College (SRMC) Hospital, Chennai
• SRM Med College Hospital – Chennai
• SS Institute of Med Sc & Res Centre, Davangare
• Thirumalai Eye Hospital - Bangalore
• Trichur Heart Hospital, Trichur
• Udhi Eye Hospital, Chennai
• Vaidyaratnam, Thrissur
• Vee Care Hospital – Chennai.
• Vijaya Hospitals, Chennai
• Vinayaka Mission Hospital – Salem
• Vydehi Institute of Med Sciences-Bangalore.

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 Select Client Testimonials
“We acknowledge the commitment and sincere efforts taken by your consultants
in taking us successfully towards the NABH accreditation.”
Sheela Ketan,
Sr. General Manager,
Apollo Specialty Hospital, Chennai

“We are pleased to place on record the excellent technical support and guidance
provided by your team through the process of implementation of the NABH
leading to Accreditation in a time bound manner. We are also happy on your
continuous support and guidance even after the completion of the Project.”
M.I.Junaid Rahman,
Supdt. General Hospital,
Ernakulam

“We acknowledge the sincere effort taken by your team who provided excellent
technical support to us to obtain NABH Accreditation.”
Prathap Varkey,
Managing Director,
Trichur Heart Hospital

57
 Select Client Testimonials
“We thank you very much for your support extended by your team to come to this
stage of pre-assessment for the NABH.”
Ram Babu,
General Manager,
Vijaya Hospitals, Chennai

“ACME has helped us in understanding the requirements of NABH in a simple

yet comprehensive fashion. Your Consultants have shown a high level of
commitment and we at Sankara Nethralaya have derived lot of benefit through
their association with their close interaction and assistance.”
Shyamala S, DGM,
Sankara Nethrala, Chennai

“ We wish to place on record our appreciation for the technical guidance and
support rendered by your team throughout the process for preparing our
Hospital to go in for the NABH Accreditation.”
Dr C.M. Dhananjayan, MD.
Dhanalakshmi Hospital,
Kannur, Kerala

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 Select Client Testimonials
"Acme Pulse facilitated us in taking a big leap towards quality sustenance and
betterment. We are happy to be associated with them and wish them all the best for their
future endeavours“
Dr. Krishna Hande,
Chief Medical Director,
Hande Hospital

ACME stands for its: A for Accuracy, C Comprehensive output, M All Measurable
data's, E Excellent service. Acme Pulse counts the hospital pulse and treats it with its
suggestions for improvement.
Dr. Jeyanthi Kalanidhi,
Managing Director,
Vee Care Hospital

"Eyes and ears of Acme Pulse Medical consultancy have helped to improve the patient
care of our hospital.“
Prof. R.H. Govardhan,
Chief Orthopaedic Surgeon,
Vasanthi Orthopaedic Hospital
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Hon'ble Chief Minister of Tamil Nadu receiving the ISO 9001:2008 Certificate for the 48 Primary Health
Centres from our Managing Director, Mr. B. G.Menon in the presence of the Health Minister, Principal
Secretary Health and other Senior Officials of the State.

60
Dr. Girdhar J. Gyani, Secretary General, Quality Council of India delivering keynote address at National Workshop
on NABH conducted by ACME with QCI at Kolkata

61
Dr. Ravindra Karanjekar, Chairman NABH Accreditation Committee, Dr. Gayathri, Director NABH and Senior
Assessors, Dr B. Krishnamurthy with the ACME Senior Management at the National Workshop on NABH held at
Mumbai
62
Dr. Devi Shetty releasing the new AHPI Patient Friendly Standards, handing over copy to our Managing Director
Mr B G Menon, in the presence of Dr Gyani and Dr Alexander of Baptist Hospital

63
Thank You.

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