NABH Pre-Accreditation Entry-Level Standards: Using

Software for Help

By Dr. J. Gnanaraj | Published: SEP 2014
inShare

The National Accreditation Board for Hospitals and Health Care Providers (NABH) has now
given standards that need to be followed before applying for accreditation. The Indian
Medical Association recommends these standards too. The standards might become
mandatory for insurance companies for empanelling, and the state Governments might
eventually make them mandatory for all healthcare facilities.

The NABH Standards

The NABH entry-level standards can be used as a starting point for smaller hospitals that
cannot meet the strict requirements for full accreditation. The full set of NABH standards
includes 102 standards and 636 “objective elements,” and the standards are recognized by
the International Society for Quality in Healthcare (ISQua). For hospitals with 50 beds, there
are 45 standards and 173 objective elements, and for those under 50 beds, only 41
standards and 149 objective elements must be met. Recently only about 227 hospitals were
fully NABH accredited, with roughly 1200 more in the application process. (1)
For hospitals with less than 50 beds, most of the standards are achievable with the help of
good Hospital Management software. At SEESHA Karunya community hospital we
developed software which makes compliance with NABH standards easy.

The Standard and Software

AAC (Access, Assessment and Continuity of Care) – The AAC section requires proper
consent forms and documentation, which is easier to do with the software. For instance:

1. The correct consent forms with the right wording are automatically generated, based on
the age of the patient or with a single click/entry for differently able.
2. The consent form and the initial assessment form that is signed are scanned into the
software for records and easy re-calls. The costs of various types of treatment are easy to
generate with the software and could be explained to the patients while also getting the
necessary signatures.
3. The software generates all of the necessary forms, according to the NABH requirement
with just a click.
4. The printouts of specific instructions, complications, etc. are generated as the various
procedures are posted.
5. There is a facility for ordering a standard set of investigations for a provisional diagnosis
that is made, so that tests are not missed, and similarly, with diagnosis the standard
medicines and instructions can be generated with just a click, thus making these actions
fast and making sure none of the instructions or medicines are missed.
6. Once entered, the information can be used for all of the necessary forms, rather than
writing them again. For instance, once the clinical presentation is typed in after the initial
assessment at the OPD, it could be used for the admission forms, discharge summary, etc.,
and the software could generate the variety of discharges and forms for transfer that are
necessary.

COP (Continuing Care of Patients)

7. Health education and other instructions for the diagnosis made are also generated,
specific to the diagnosis, making it easy for the doctors to explain.
8. The software helps to give appropriate heath education materials for a variety of
diagnoses, explaining the various conditions in a language that patients can understand.
They were written by experts in the field, and all of the doctors will have the benefit of their
expertise. The software also helps the hospital generate the various protocols necessary for
continuing care of patients.
9. The software helps to fill the frequently repeated advice and health education materials,
operation notes, etc. with wise search and fill-in options. As you type similar words,
previously typed options appear, and the entire portion can be added with just a click.

MANAGEMENT OF MEDICINES (MOM)

10. The use of computer software helps the most at the Pharmacy (2). In more than 10
hospitals in Northeast India, the income from the Pharmacy doubled after installing the
software. This was because of various reasons like:

 there was no wastage due to expiry of medicines

 the correct amounts were ordered
 strict control measures were possible due to ABC analysis of medicines, etc.
PATIENTS’ RIGHTS

11. Without the reminder from the computer printout with each in-patient record, it would be
very difficult to explain about the patients’ rights to the admitted patients and their relatives.

HOSPITAL INFECTION MANAGEMENT

12. The computer software helps to keep track of all of the hospital infections and
management.

QUALITY IMPROVEMENT

13. The computer software helps to analyze over 30 parameters that improve
understanding of the efficiency of the various aspects of hospital management.
14. To manually do the required analysis would be time-consuming and difficult.

RESPONSIBILITIES OF MANAGEMENT

15. The software helps to keep the records of the various committee meetings that are
concerned with management of the hospital.
16. Templates are available for printing out the necessary displays.

FACILITY MANAGEMENT

17. The software helps the facility management by giving sufficient warnings about the due
dates of various maintenance aspects of the hospital.
18. A facility for sending SMS reminders is also available.

HUMAN RESOURCES MANAGEMENT

19. The software helps to maintain all of the relevant data and helps in creating reminders
for the various processes.
20. The Merit / Demerit system helps to keep track of the capabilities of the staff and helps
to reward the staff.

THE INFORMATION MANAGEMENT SYSTEM

21. It is here that the software is of great use, starting from generating a unique ID number
for each of the patients.
 22. The unique ID number with a barcode helps in easy retrieval of any of the relevant data.
23. The scanning of signed documents helps in doing away with hard copies and the space
necessary for storing the hard copies.
24. Date and time entries are automatically generated on records.
25. It is possible to keep the electronic data for a very long time because the space taken is
much less, and there is no need for destroying older records.

Summary

The software is of great help in implementing the NABH standards and actually helps in
improving the quality of work in rural and mission hospitals.

Further Information

Further details about the software could be obtained from:

Mr. Ramananda
Phone: 9436384829
Email: [email protected]

Dr. J. Gnanaraj MS, MCh [Urology], FICS, FARSI, FIAGES is a urologist and laparoscopic surgeon
trained at CMC Vellore now the Director of Medical Services of SEESHA. He has a special interest in
rural surgery and has trained many surgeons in remote rural areas while working in the mission
hospitals in rural India. He helped about 17 rural hospitals start minimally invasive surgeries. He has
more than 80 publications in national and international journals, most of which are related to
modifications necessary for rural surgical practice. He received the Barker Memorial award from
the Tropical Doctor for the work regarding surgical camps in rural areas. During the past year, he has
been training surgeons in Lift Laparoscopic surgeries and he is one of the trained assessors for NABH.

Mr. Einstein Kesi received his MBA in Technology at ENPC (Paris) and currently consults for global
product development & market positioning in healthcare. He has experience in marketing, sourcing,
vendor management, operations management and quality systems.

Mr. Ramanada Khaba Henao is a self-trained computer programmer who helped with the programming
of the software. Earlier he had taught computer science to school students at Aizawl in Mizoram.

References (click to hide)

1. NABH sets new entry level standards for accreditation of hospitals. The Hindu. Chennai May 28, 2014.
http://www.thehindu.com/news/national/nabh-sets-new-entrylevel-standards-for-accreditation-of-
hospitals/article6055157.ece accessed on September 11, 2014.
2. Gnanaraj J, Adaikala Jesuraj, Charles Daniel. Pharmacy and beyond (Getting more from the Pharmacy).
Clipboard Issue 38, April to June 2006 p 2-4. Christian Medical Association of India.