NATIONAL ACCREDITATION BOARD FOR HOSPITAL AND

HEALTHCARE PROVIDERS (NABH)

INTRODUCTION

Hospital Accreditation is a public recognition by a National Healthcare. Accreditation

Body, 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.

National Accreditation Board for Hospitals and Healthcare Providers (NABH) is a

constituent board of Quality Council of India (QCI), set up to establish and operate
accreditation program for healthcare organizations. NABH has been established with the
objective of enhancing health system & promoting continuous quality improvement and
patient safety. The board while being supported by all stakeholders, including industry,
consumers, government, has full functional autonomy in its operation. NABH provides
accreditation to hospitals in a non-discriminatory manner regardless of their ownership,
legal status, size and degree of independence.

AIMS AND OBJECTIVES

NABH is a constituent board of QCI- Quality Council of India. It sets standards and
operates accreditation programmes for health care organization.

• Medical Excellence.
• Ensure ‘Quality Assurance’ system.
• Risk Management System - patient care and treatment.
• Patient/Organization need.
• Helps Standardization.

The NABH standards touch all those areas where we face difficulties in day to day issues,
risk to us or our patients, and there is a strong focus on patient requirements i.e. Care
satisfaction, Education and information safety.

1
QUALITY COUNCIL OF INDIA

(QCI) Quality Council of India is an autonomous body set up jointly by Govt. of India and
industry to establish and operate accreditation structure for assessment conformity
bodies offering certification, inspection, testing and registration services etc. in the field
of health, environment, food safety, information security, occupational health and safety
and quality management.
BENEFITS OF PRE-ACCREDITATION ENTRY LEVEL STANDARDS FOR HOSPITALS

Benefits for Patients

Patients are the biggest beneficiary among all the stakeholders. Pre-Accreditation Entry
Level standards result in improved quality care and patient safety. The patients are
serviced by trained & skilled medical staff. Rights of patients are respected and
protected.

Benefits for Hospitals

Pre-Accreditation Entry Level Standards for a hospital will stimulate a journey towards
continuous improvement. It enables hospital in demonstrating commitment to quality
care. It raises community confidence in the services provided by the hospital.

Benefits for Hospital Staff

The staff in a Pre-Accreditation Entry Level certified hospital is sensitized over the quality
& patient safety & is satisfied as it provides for continuous learning, good working
environment, leadership and above all ownership of clinical processes. It improves
overall professional development of Clinicians and Para Medical Staff and provides
leadership for quality improvement with medicine and nursing

2
Benefits to paying and regulatory bodies

Finally, Pre-Accreditation Entry Level Certification provides an objective system of

empanelment by insurance and other third parties. It provides access to reliable and
certified information on facilities, infrastructure and level of care.

ORGANIZATIONAL STRUCTURE

ACCREDITATION COMMITTEE
The main functions of Accreditation Committee are as follows:

- Recommending to Board about grant of Certification or otherwise based on

evaluation of assessment reports & other relevant information.
- Approval of the major changes in the scope of Certification

- Recommending to the board on launching of new initiatives

3
TECHNICAL COMMITTEE
The main functions of Technical Committee are as follows:

- Drafting of standards and associated documents

- Periodic review of standards

NABH SECRETARIAT
The Secretariat coordinates the entire activities related to NABH Accreditation to
hospitals and healthcare organizations.

PANEL OF ASSESSORS AND EXPERTS

NABH has a panel of trained and qualified assessors for assessment of hospitals.

NABH PRE ACCREDITATION ENTRY LEVEL STANDARDS FOR HOSPITALS

NABH Pre Accreditation Entry Level Standards for Hospitals has 10 chapters
incorporating 45 standards and 173 objective elements.

CHAPTERS OF NABH

Patient Centered Standards: -

• Chapter-1 (AAC) Access, Assessment and continuity of care

• Chapter-2 (COP) Care of Patient
• Chapter-3 (MOM) Management of Medication
• Chapter-4 (PRE) Patient Right and Education
• Chapter-5 (HIC) Hospital Infection Control

Organization Centered Standards: -

• Chaper-6 (CQI) Continuous Quality Improvement

• Chapter-7 (ROM) Responsibility of Management
• Chapter-8 (FMS) Facility Management and Safety

4
 • Chapter-9 (HRM) Human Resource Management
• Chapter-10 (IMS) Information Management System

ASSESSMENT CRITERIA

A hospital willing to apply for Pre-Accreditation Entry Level must ensure the
implementation of standards in its organization.

The assessment team will check the implementation of Pre-Accreditation Entry Level
standards for hospitals in organization. The hospital shall be able to demonstrate to
NABH assessment team that all NABH Pre Accreditation Entry Level standards, as
applicable, are followed.

PREPARING FOR NABH PRE ACCREDITATION ENTRY LEVEL

Hospital management shall first decide about getting Pre-Accreditation Entry Level for
its hospital from NABH. It is important for a hospital to make a definite plan of action for
obtaining certification and nominate a responsible person to coordinate all activities
related to seeking certification. An official nominated should be familiar with existing
hospital quality assurance program.

Hospital shall procure a copy of standards from the NABH Secretariat against payment.
Further clarification regarding standards can be obtained from NABH Secretariat in
person, by post, by e-mail or on telephone.

The hospital looking for Pre-Accreditation Entry Level shall understand the NABH
assessment procedure. The hospitals shall ensure that the standards are implemented in
the organization.

The hospital can fill the application form for NABH Pre Accreditation Entry level online
(www.nabh.co) through the website. However, in case of any difficulty in accessing
online system, application form can be download from the web-site. The applicant
hospital must have conducted self-assessment against NABH Pre Accreditation Entry

5
Level Standards for hospitals at least 3 months before submission of application and
must ensure that it complies with it.

PREPARING FOR NABH PRE ACCREDITATION ENTRY LEVEL

Obtain a copy of NABH Pre Accreditation

Entry Level Standards for hospitals
(From NABH office)

Get accustomed to the standard & implement

them
(By health care organization)

Fill the Application Form online

(On NABH web site)

Submit the Application Form + Scope of

services +Self-Assessment toolkit +
Application Fee + Document
(to NABH Secretariat)

Pay the Certification fee before the final

assessment

NABH PRE ACCREDITATION ENTRY LEVEL PROCEDURE

Application for NABH Pre Accreditation Entry Level:

The hospital shall apply to NABH in the prescribed application form online on NABH
website. The application shall be accompanied with the following:

6
 • Prescribed application fee as detailed in the application form

• Signed copy of ‘Terms and Conditions for Maintaining NABH Pre

• Accreditation Entry Level’, available free on the web-site

• Filled in Self-Assessment Toolkit, available free on the web-site.

• Relevant documents i.e. different policies and procedures of the hospital

Self-Assessment toolkit is for self-assessing itself against NABH Standards. The self-
assessment shall be done diligently by the hospital. The organization shall apply for final
assessment whenever they are ready.

The applicant hospital must apply for all its facilities and services being rendered from
the specific location. NABH Pre Accreditation Entry Level is only considered for
hospital’s entire activities and not for a part of it.

Scrutiny of application:

NABH Secretariat receives the application form and after scrutiny of application for its
completeness in all respect, acknowledgement letter for the application shall be issued
to the hospital with a unique reference number. The hospital shall be required to quote
this reference number in all future correspondence with NABH.

NABH PRE-ACCREDITATION ENTRY LEVEL PROCEDURE

Final Assessment:

The final assessment involves comprehensive review of hospital’s functions and services.
NABH shall appoint an assessment team. The date of final assessment shall be agreed
upon by the hospital management and NABH.

Based on the assessment by the Assessment team, the assessment report is prepared by
the assessor in a prescribed format.

7
The details of non-conformity observed during the assessment are handed over to the
hospital by the Assessment team and detailed assessment report is sent to NABH.

SCRUTINY OF ASSESSMENT REPORT

NABH shall examine the assessment report. The report is taken to the accreditation
committee. Depending on the score and compliance to standard would decide the award
of Pre-Accreditation Entry Level certificate or otherwise as per details given below.

Pre-Accreditation Entry Level:

Conditions for qualifying to this award are as below:

• Overall score of minimum 50% in all standards

• Overall score of minimum 50% in each chapter

NABH PRE ACCREDITATION ENTRY LEVEL PROCEDURE

Issue of Pre-Accreditation Entry Level Certificate

NABH shall issue a Pre-Accreditation Entry Level certificate to the hospital with a validity
of two years. The certificate has a unique number and period of validity. The certificate is
accompanied by scope of certification.

The applicant HCO must make all payment due to NABH, before the onsite assessment is
conducted.

Renewal of Certificate
Pre-Accreditation Entry Level certificate shall be valid for a period of two years. The
hospital may apply for renewal of certification at least six months before the expiry of
validity, for which hospital will apply in the prescribed form and renewal assessment shall
be conducted & then the hospital should go for progressive level/ full accreditation.

8
 NABH PRE ACCREDITATION ENTRY LEVEL PROCEDURE

A pplication form + Scope of services + Self -

Assessment Tool Kit +Documents +
Application Fee

Acknowledgment and Scrutiny of application

(by NABH Secretariat ) Feedback
To
Health care
Organization
Certification Fee submitted to NABH
Secretariat (when ready)
And

Final Assessment of hospital Necessary

(by Assessment Team ) Corrective
Action
Taken
By
Review of Assessment Report Healthcare
(by NABH Secretariat ) Organization

Recommendation for Pre Accreditation Entry

Level Certificate
(by Accreditatio n Committee)

Issue of Pre Accreditation Entry Level

Certificate for 2 years,6 monthly report on
defined indicatorsto be submitted to NABH
Secretariat

R enewal, Go for progressive level/

full accreditation

FINANCIAL TERM AND CONDITIONS

General information brochure : Free of cost

NABH Pre Accreditation Entry Level Standards for hospital : Rs. 1500/-

9
 Assessment Criteria Certification Fee (Rs.)

Assessment Annual
Organization Application
Certification
Fee
Fee

Hospital One man-day Rs. 2,000/- Rs. 25,000/-

NOTE: The man days given above for assessment are indicative and may change
depending on the facilities and size of the hospital.

Service Tax applicable from time to time (currently @ 12.36%) will be charged on all the
above fees. You are requested to please include the service tax in the fees accordingly
while sending to NABH.

Notes on Certification fee:

• The certification fee includes expenses on travel, lodging / boarding of

assessor.

• All the payments to NABH are to be paid through DD in favour of ‘Quality

Council of India’.

• The applicant HCO must make all payment due to NABH, before the onsite
assessment is conducted.

10
NATIONAL ASSESSMENT AND ACCREDITATION COUNCIL (NAAC)

(NAAC) is an autonomous body established by the University Grants Commission (UGC)

of India to assess and accredit institutions of higher education in the country. It is an
outcome of the recommendations of the National Policy in Education (1986) which laid
special emphasis on upholding the quality of higher education in India. To address the
issues of quality, the National Policy on Education (1986) and the Programme of Action
(POA-1992) advocated the establishment of an independent national accreditation
body. Consequently, the University Grants Commission established the NAAC in 1994
under its Act 1 2 CCC, as an autonomous body with its headquarters at Bengaluru.

VISION

To make quality the defining element of higher education in India through a combination
of self and external quality evaluation, promotion and sustenance initiatives.

MISSION

• To arrange for periodic assessment and accreditation of institutions of higher education

or units thereof, or specific academic programmes or projects;

• To stimulate the academic environment for promotion of quality of teaching-learning

and research in higher education institutions;

• To encourage self-evaluation, accountability, autonomy and innovations in higher

education;

• To undertake quality-related research studies, consultancy and training programmes

and

• To collaborate with other stakeholders of higher education for quality evaluation,

promotion and sustenance.

11
VALUE FRAMEWORK

While formulating its Core Values for Accreditation Framework, NAAC is in cognizance
of the swift changes and consequent metamorphosis in values pertaining to the Indian
Higher Education.

Core Values
• Contributing to National Development

• Fostering Global Competencies among Students

• Inculcating a Value System among Students

• Promoting the Use of Technology

• Quest for Excellence

MAIN OBJECTIVES OF NAAC

• Assess and Accredit institutions of higher learning.

• Stimulate the academic environment and quality of teaching and research in

accredited institutions.

• Generate awareness of quality in education.

• To embed self-assessment in the quality culture of the institution. Share
information on successful quality strategies.

• Encourage innovations, self-evaluation and accountability in higher education.

• Help institutions to achieve self-actualization on institutional strengths and

weaknesses.

• Focus on improvement of quality.

• Promote necessary changes, innovations and reforms in all aspects of the institution
for excellence.

12
PHILOSOPHY
NAAC is entrusted with the task of performance evaluation, assessment and accreditation
of universities and colleges in the country. The philosophy of NAAC is ameliorative and
enabling rather than punitive or judgemental, so that all constituencies of institutions of
higher learning are empowered to maximize their resources, opportunities and
capabilities.

GOVERNANCE
The NAAC functions through its General Council (GC) and Executive Committee (EC) where
educational administrators, policy-makers and senior academicians from a cross-section of
the system of higher education are represented. The Chairperson of the UGC is the
President of the GC of the NAAC; the Chairperson of the EC is an eminent academician in
the area of relevance to the NAAC. The Director of the NAAC is its academic and
administrative head, and is the member-secretary of both the GC and EC. The NAAC also
has many advisory and consultative committees to guide its practices, in addition to the
statutory bodies that steer its policies. The NAAC has a core staff and consultants to
support it activities. It also receives assistance from across the country from a large
number of external resource persons who are not full-time staff of the NAAC
NAAC has formulated its mission and goals in consonance with the global trends in
assessment and accreditation of Higher Education Institutions. The mandate of NAAC is
formulated and outlined in its Memorandum of Association.

FUNCTIONS OF NAAC
NAAC is entrusted with the primary function of assessing and accrediting higher education
institutions of the country. It entails the following:

• Provide guidance to institutions for preparing their Self-study Reports (SSRs).

• Preparing in-house pre-visit documents for the perusal of assessors.
• Assessing and Accrediting Institutions.
• Coordinating the Ion-site' visit to its effective completion.
• Evolving appropriate instruments of accreditation and fine-tuning them whenever
necessary.

13
 • Develop pre- and post-accreditation strategies.
• Providing appropriate training to assessors.

To supplement the functions of NAAC in addition to assessment and accreditation, it

also undertakes the following functions:

• Disseminate the NAAC processes and quality enhancement mechanisms through

relevant publications.
• Organize Seminars/ Workshops/ Conferences to share and discuss issues related to
quality in higher education.
• Partner with stakeholders for promoting Assessment and Accreditation.
• Promote the establishment of Quality Assurance units
 Internal Quality Assurance Cell (IQAC)
 State Level Quality Assurance Cell (SLQAC)

NAACS PROCESS OF ASSESSMENT

NAAC's process of assessment aims at systematic and data-based process which is
objective, systematic and holistic and richly depends on the shared experiences of the
stakeholders for institutional improvement.

The process for assessment and accreditation broadly consists of:

• Preparation of Self-study Report (SSR), and uploading the same on the institution
website prior to submission of LOI.
• On-line submission of the Letter of Intent (LOI).
• On-line submission of Institutional Eligibility for Quality Assessment (IEQA) for
applicable institutions.
• Submission of Hard Copies of SSR.
• Onsite Peer Team visit to the institution.
• Announcement of accreditation status of the institution based on the entire
process.

14
SEVEN CRITERIA FOR ASSESSMENT
The NAAC has identified the following seven criteria to serve as the basis for its
assessment procedures:

• Curricular Aspects
• Teaching-learning and Evaluation
• Research, Consultancy and Extension Infrastructure and Learning Resources
• Student Support and Progression
• Governance, Leadership and Management
• Innovations and Best Practices

ASSESSMENT OUTCOME
There are two outcomes of Assessment and Accreditation:

1.Peer Team Report

2. Institutional Grading

RE-ASSESSMENT

Institutions, which would like to make an improvement in the accreditation status, may
volunteer for re-assessment, after a minimum of one year or before three years of
accreditation. The manual to be followed for reassessment is the same as that for the
Assessment and Accreditation. However, the institution shall make specific responses
based on the recommendations made by the peer team in the previous assessment and
accreditation report, as well as the specific quality improvements made by the
institution during the intervening period.

BENEFITS OF ACCREDITATION
• Institutions know strengths, weaknesses and opportunities through informed
review process.
• Helps institutions to identify the internal areas of planning and resource allocation.
• Collegiality on the campus.
• Enables funding agencies to look for objective data for performance funding.
• Institutions to initiate innovative and modern methods of pedagogy.

15
 • New sense of direction and identity for institutions.
• Enabling the society to look for reliable information on the quality of institutions
for making informed choices.
• Employers look for reliable information on the quality of education offered to the
prospective recruits.

REFORMS IN ACCREDITATION
As the country's premier accreditation body and one of the most experienced and recognized
quality assurance body internationally, NAAC is always in the forefront of undertaking various
reforms in accreditation process. Some of the recent initiatives are highlighted below:

• Introduction of fully online Institutional Eligibility for Quality Assessment (IEQA)

system for affiliated colleges.
• Provision of uploading of SSRs of HEIS on institutional website before submitting
to NAAC, in addition to uploading of accreditation outcomes on NAAC's website.
• Introduction of Central Application Processing Unit (CAPU) with a dedicated help
desk for processing the LOI and IEQA.
• Introduction of quantitative assessment indicators as additional tool for qualitative
evaluation in case of Universities.

1-285

THE NAAC CAMPUS

The National Assessment and Accreditation Council (NAAC) campus comprises uniquely
designed building that sits on a sprawling campus spread across five acres at Nagarbhavi,
opposite to the National Law School of India, in the Bangalore University, Jnanabharathi
campus. An open national architectural design competition, as per the norms of the
Council of Architects, was held for selecting the best architectural surrounding of the

16
campus. The new building is spacious, architecturally designed and environment-friendly.
The NAAC has shifted to its new building in August 2006.The new campus has priorities
set out for working towards having a carbon neutral, eco-friendly environment aimed at
energy conservation and rain water harvesting. The building is designed with unique
features so that sun light permeates into the building through the roof and thus
dependency on electric light is minimized. Emphasis on lush green environment,
ecological balance and great care on the conservation of ecological resources creates an
enchanting experience and vibrant ambience at the campus.

The other facility in the campus is that of Guest House with accommodation facility of
20 rooms having all related amenities. The new campus has also in it a few staff quarters
and Director's residence.

NAAC Garden: In a step towards fostering eco-sensitive awareness, the NAAC has over the
years nurtured and nourished a well-maintained garden environs at its campus in
Bengaluru. The NAAC has already identified over 300 various species of exotic and regional
varieties available in its garden and documented the same. The NAAC has been
consistently winning prizes and accolades from the Government of Karnataka in its
Horticultural Show every year.

CONCLUSION

Accreditation Body, 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 has been
established with the objective of enhancing health system & promoting continuous
quality improvement and patient safety. Similarly, NAAC is formed to make quality the
defining element of higher education in India through a combination of self and external
quality evaluation, promotion and sustenance initiatives.

17
JOURNAL

Role of National Accreditation Board of Hospitals and Healthcare Providers (NABH) core indicators
monitoring in quality and safety of blood transfusion

ABSTRACT: Certain quality indicators are mandatory in the maintenance and improvement
of quality in blood transfusion. Monitoring of such indicators should be done regularly and
deficiencies are to be corrected for effective blood transfusion services.

Aims: To study the usefulness of monitoring of the National Accreditation Board for
Hospitals and Healthcare Providers (NABH) core indicators in blood transfusion and in the
maintenance of hemovigilance. Settings and Design: Hemovigilance is a “quality process”
to improve quality and increase the safety of blood transfusion. It covers and surveys all
activities of the blood transfusion chain from donors to recipients. Core indicators’
monitoring is a part of the hemovigilance process.

Materials and Methods: A 2-year retrospective study was conducted in a blood storage
unit of a NABH accredited tertiary care hospital of a metropolitan city. Four NABH core
indicators in blood transfusion were observed and monitored by the clinical and blood
storage unit staff of different levels.

Results: It was observed that there was an improvement in quality by core indicators
monitoring with decreased wastage of blood and blood components, decreased average
turnaround time for issue of blood and blood components, and lesser number of
transfusion reactions.

Conclusion: This study demonstrated that monitoring of NABH core indicators results in
the enhancement of quality and safety in blood transfusion services, reducing the
incidence of transfusion reactions.

Quality Assessment of Indian Universities: An Analytical Study of NAAC Accreditation

Scores

ABSTRACT: This paper reveals that the performance and quality enhancement initiatives
of Indian Universities based on the accreditation scores attained through the NAAC
assessment process in terms of Criteria wise analysis, Region wise analysis and State wise
analysis of Universities have been made. It is observed that average CGPA for the five

18
regions of the country, Southern region is dominant with 3.07, which is followed by North
Eastern region Universities with average CGPA of 3.04. Analysis through region wise, the
performance of Universities is in the Eastern region is low as per the RAF of NAAC
accreditation. Analysis through region wise, it would reveal that among the State
Universities, Northern region have got higher score of CGPA (2.94), which is followed by
Western region (2.93) and Southern region (2.90). In general observation is that the
accredited State Universities are didn’t performing well. Since no region would acquire the
CGPA of 3.0 and all India CGPA is 2.85, it shows the dissimilarities among the Universities
in terms of performance quality with regard to all criterion. It is quiet surprise to know that
the average CGPA of Research, Consultancy, and Extensions (3) is very much low with 2.65
compare with other criterions. Being the Universities, they need to make emphasize on
enhancing the quality of research. The largest share of accredited institutions is from
Western and North-eastern region. In general, the response from the university sector is
better compared to that from the college sector.

REFERENCE

• https://www.nabh.gov.in
• https://www.naac.gov.in
• https://www.naac.gov.in/resources/publications/manuals
• https://assessmentonline.naac.gov.in/public/index.php/hei_public_dashboard
• Gupta A, Gupta C. Role of National Accreditation Board of Hospitals and Healthcare Providers
(NABH) core indicators monitoring in quality and safety of blood transfusion. Asian J Transfus
Sci2016; 10:377-41.
• Gyani GJ. Continuous quality. In: Gyani GJ, editor. National Accreditation Board for Hospital and
Healthcare Providers (NABH). 3rd ed. New Delhi: Quality Council of India; 2011. p. 116-35.
• Mukhopadhyay P. Tapaswi M. P. Sudarsan P. K. & Sudarsan, K. (2018) Assessing the Quality of
Higher Education Institutions in India: An Alternative Framework.
• Amutha S & Ponmudiraj B.S. (2019). A Symbiotic Analysis of NAAC Accredited Higher Education
Institutions. Journal of the Gujarat Research Society, 21(4), 57-69.

19