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NABH consultancy

NABH consultancy

What is NABH Certificate?

National Accreditation Board for Hospitals & Healthcare Providers (NABH) is a constituent board of Quality Council of India (QCI), set up to establish and operate accreditation programme for healthcare organizations. The board while being supported by all stakeholders including industry, consumers, government, have full functional autonomy in its operation. A public recognition of the achievement of accreditation standards by a healthcare organization, demonstrated through an independent external peer assessment of that organization's level of performance in relation to the standards.

NABH Accreditation means
  • Commitment to create a culture of quality, patient safety, efficiency and accountability towards patient care.
  • Establishment of protocols and policies as per National/International Standards for patient care, medication management, consent process,
  • patient safety, clinical outcomes, medical records, infection control and staffing.
  • Patients are treated with respect, dignity and courtesy at all times.
  • Patients are involved in care planning and decision making.
  • Patients are treated by qualified and trained staff.
  • Feedback from patients is sought and complaints (if any) are addressed.
  • Transparency in billing and availability of tariff list.
  • Continuous monitoring of its services for improvement.
  • Commitment to prevent adverse events that may occur

Benefits of NABH Accreditation?

For Patients
  • High Quality of Care and Patient Safety
  • Patients are by Credential Medical staff
  • Rights of patients are respected and protected
  • Patients satisfaction is regularly evaluated
  • Provides Boost to Medical Tourism

For Hospitals
  • Stimulates Continuous Improvement
  • Enables in demonstrating commitment to Quality Care
  • Raises Confidence in the services provided
  • Provided opportunity to benchmark with the best

For Hospital Staff
  • Staff are more satisfied
  • Ownership of all clinical processes
  • Provides leadership for quality Improvement with medicine & Nursery
  • Provides continuous learning, good working environment, leadership

Our Scope of Consultancy

  • Carrying out a detailed Gap Analysis based on the NABH Checklist and listing out the areas of Non-compliance (NC) and areas for Improvements (OI).
  • Preparing a detailed action plan (Road Map) based on the Identified Gaps
  • Review, revise the Institutional Vision, Mission (Objectives) and Department Performance Measures (DPI) (as required)
  • Discussion with Department Heads in establishing policies, procedures, documents and records in line with NABH Standard
  • Discussion with Department Heads in review, revise the system in establishing systems in line with NABH accreditation.
  • Ensuring that the applicable statutory and regulatory requirements are identified and implemented
  • Ensuring that the systems are established, documented and effectively implemented for in all processes of the hospital.
  • Assisting the department to ensure that the documents and records are effectively implemented
  • Assistance in establishment of Performance Measures and review with the Top Management on Monthly basis.
  • Performance review shall also include Vision and Mission, feedback from interested parties, suitability and effectiveness of system, adequacy of resources and compliance to statutory and regulatory requirements at quarterly basis.
  • Assisting in taking appropriate corrective action for non-compliances identified and for horizontal deployment

Conducting Internal audit

We ensure that internal audit is conducted by your team under our supervision for the first time or else we can conduct the internal audit for your organization. We make sure that the internal audit process becomes value adding activity and not just routine process.

Pre-assessment audit

Pre assessment audit is conducted by our organization to ensure that the NABH implementation is effective and all the required level of compliance is achieved. Our pre assessment audit is a tool that provides confidence to the organization to go for the Accreditation audit. We also assist the organization in closing the findings of the pre assessment audit with effective correction and corrective action.

Assistance in External Body Audit

Our expert NABH consultants will provide you input and on site assistance if required to create the required level of comfort and confidence for your organization by being on site with you and your team at the time of audit. If required we provide post audit assistance to complete the audit formalities and ensure that you receive the NABH Accreditation in time.

Our NABH consultants provide unique, effective, easy to understand, easy to implement and quick NABH implementation solutions so that the NABH Accreditation process does not become a resource drain but rather resource enhancer.

How can we helps to get NBAH Accreditation?

  • Mars Consultants in coordination with Management shall achieve the milestone events and Road Map for achieving the Certification. The total duration shall be 8 Months.
  • Mars Consultants shall appoint a Project Champion and shall be the key responsible person for the entire project
  • Mars Consultants shall plan targeted activities for each month and mandays shall be planned based on the activities.
  • Mars Consultants shall prepare Visit Reports during every visit and Monthly report for all activities performed during the month.