NABH Essential standards for Laboratories State Level Accreditation Programme

NABH

Quality in Health care is the guiding principle in assessing how well the health system is performing in its mission to improve the health of the citizens. Quality is the degree of adherence of a product or service to the predetermined specification.

National Accreditation Board for Hospitals & Healthcare Providers (NABH)

Quality council of India (QCI) is an autonomous body set up by Government of India to establish and operate the National Accreditation Structure in the country. National Accreditation Board for Hospitals & Healthcare Providers (NABH) is a constituent board of Quality Council of India, set up to establish and operate accreditation programme for healthcare organizations.

Benefits of NABH accreditation

  1. Accreditation results in high quality of care and patient safety. The patients get services by credential medical staff. Rights of patients are respected and protected. Patient satisfaction is regularly evaluated.
  2. The staffs in an accredited health care organisation are satisfied lot as it provides for continuous learning, good working environment, leadership and above all ownership of clinical processes.
  3. Accreditation to a health care organization stimulates continuous improvement. It enables the organization in demonstrating commitment to quality care. It raises community confidence in the services provided by the health care organization. It also provides opportunity to healthcare unit to benchmark with the best.

A memorandum of Agreement has been signed between Government of Kerala and Quality Council of India to initiate the process of accreditation of selected hospitals in the state. This list includes one hospital in every district. The list of hospitals selected for accreditation is given below.

  1. W and C Hospital, Trivandrum
  2. District Hospital, Kollam
  3. General Hospital, Pathanamthitta
  4. Taluk Head Quarters Hospital, Cherthala
  5. District Hospital, Kottayam
  6. Taluk Head Quarters Hospital, Thodupuzha
  7. General Hospital, Ernakulam
  8. Taluk Head Quarters Hospital, Chavakkad
  9. District Hospital, Palakkad
  10. District Hospital, Manjeri
  11. W and C Hospital, Kozhikode
  12. Taluk Head Quarters Hospital, Sulthan Bathery
  13. District Hospital, Kannur
  14. District Hospital, Kanhangad
  15. ICCONS shournur

State level trainings, district level and institutional level trainings were conducted for the implementation of the NABH standards in these hospitals. Various committees at institutional level like core committee, Code blue committee, disaster management committee, management of medication committee, infection control committee were formed for the implementation and sustainability of quality improvement programme.

Present status of National Accreditation Board for Hospital & Health Care Providers (NABH) in Government sector in Kerala is given below:

General Hospital, Ernakulam is one of the largest district level hospital in Kerala, with highest bed strength got NABH accreditation from Quality Council of India. General Hospital Ernakulam is the 4th Government hospital in India and first Government hospital in Kerala, which got NABH accreditation.

NABH final assessment has been conducted by Quality Council of India in Taluk Head Quarters Hospital Cherthala, Women and Children Hospital Thycaud, Women and Children Hospital Kozhikode and General Hospital Ernakulam.

Pre-assessment has been conducted by Quality Council of India in Taluk Head Quarters Hospital Thodupuzha, District Hospital Kottayam, ICCONS Shournur, Taluk Head Quarters Hospital Sulthan Bathery, Taluk Head Quarters Hospital Cherthala, Women and Children Hospital Thycaud, Women and Children Hospital Kozhikode and General Hospital Ernakulam.

District Hospital Kollam, General Hospital Pathanamthitta, Taluk Head Quarters Hospital Chavakkad, District Hospital Palakkad, District Hospital Manjeri, District Hospital Kannur and District Hospital Kanjangad are preparing for the pre-assessment.

 

Ernakulam General Hospital got NABH Accreditation

General Hospital, Ernakulam is one of the largest district level hospital in Kerala, with highest bed strength. It is a matter of pride that Quality Council of India has accredited General Hospital, Ernakulam under National Accreditation Board for Hospital and Health Care providers.

Achieving NABH accreditation standards is very tough and implementation is time consuming process. Even in the private sector only 5 hospitals were accredited by NABH in Kerala so far. At the time of getting NABH accreditation to General Hospital Ernakulam only 64 hospitals got accreditation in the national level. General hospital Ernakulam is the 4th hospital in India and first hospital in Kerala under Government sector, which got NABH accreditation, which is a remarkable achievement. The accreditation presented to the Hospital by the NABH authorities (Quality Council of India) on February 11th in New Delhi.

Essential standards for Laboratories

Quality Council of India is conducting a laboratory accreditation programme based on Essential Standards for Medical Testing Laboratories in India. Kerala is the first and the only state to involve in the Essential Standards for Medical Testing Laboratories for government medical laboratories.

362 medical laboratories under Government Health Department were included in the certification programme. District level training were conducted in three phase for all the medical officers, Lab technician and PRO regarding the implementation of the program. So far 154 Government Medical Laboratories were certified by Quality Council of India

State Level Accreditation Programme

Government of Kerala has selected 15 hospitals for National Accreditation Board for Hospital & Health Care Providers (NABH). Since NABH is tough and expensive, Government of Kerala has decided to introduce accreditation standards for all government hospitals. The aims is to enhance the patients’ quality of care by providing better medical treatment and preventive healthcare medical care services with the state of art technology with easy accessibility, affordability & equity. The major emphasis is on sensitization of health care organization towards importance of quality healthcare services; involvement of staffs for improving the quality of patient service; development, review and implementation of policies and procedures for implementation of Quality Management System. The first step of implementation includes, the development of different committees, defining the objective oriented role and responsibility of all committee at the facility level with scope of work as per requirement like quality Assurance committee, hospital infection control committee drugs & therapeutic committee, grievance redressal committee, disaster management committee, hospital ethics committee, biomedical equipment & medical gases management committee. The program aims in improving the training as per requirement of Kerala Accreditation standards, conducting patient and employee satisfaction survey, develop and monitoring of the quality indicators, disaster management plan, infection control practices, implementation of patient rights & responsibilities, management of medication, facility management practices, incidence reporting system, hospital safety programme, patient information., inventory management, quality control & safety in diagnostics. 70 hospitals were selected for the implementation of Kerala accreditation standards for Hospital (KASH).Two PHCs, two CHCs and 1 THQH were initially selected for the implementation.

  1. Executive Committee meeting held on 14th July 2010, State Health and Family Welfare Society has decided to develop a standards for the state level accreditation programme.
  2. Quality Assurance team of NRHM has prepared Kerala accreditation standard for Hospital (KASH) based on the NABH, IPHS and internationally accepted accreditation standards. The standards were prepared based on the major 3 level of care and for the different categories of institutions. This includes PHC, CHC, THQH and specialty / General / District Hospitals .Initial draft of the standards is sent to all DMOs and DPM. The feedbacks of the standards were incorporated.
  3. Redraft of the standard were again sent to all Programme officers, DPM and DMO for the feedback.
  4. Government GO issued in January 2010 -GO(MS) No. 24/2011 /H&FWD dated , Thiruvananthapuram  20.01.2010
  5. The draft of Kerala accreditation standards for Hospital (KASH) was sent to Technical team members for feedback.
  6. Technical Committee of KASH was  held on 27 April 2011.The Additional DHS FW and State Programme Manager, Assistant Director NABH, Quality Council of India , Additional DHS Planning, Directorate of Health Services , Additional District Medical Officer, Trivandrum, Senior Consultant M&E and Quality Assurance Officers participated in the meeting .
  7. The suggestions in the Technical committee were incorporated and the draft of the standards was again resent to technical committee. The feedback of the same was incorporated in the final draft of Kerala Accreditation Standards for Hospital (KASH)
  8. Accreditation Board has approved the Kerala Accreditation Standards for Hospital.

Attachments:

Date File  Description
25/02/2013 Circular Code Blue Download
11/02/2013 Labor Room register Download
11/02/2013 Quality standards for postpartum haemorrhage and hypertensive disorders of pregnancy  Download
11/02/2013 Flow chart Labour Room Download
17/01/2013 Accreditation Standards for Hospitals Kerala Accreditation Standards for Hospitals- Second Edition - 2013
17/01/2013 IPHS DH Indian Public Health Standards (IPHS)
17/01/2013 IPHS TH Indian Public Health Standards (IPHS) Guidelines for Sub-District/Sub-Divisional Hospitals (31 to 100 Bedded)
17/01/2013 IPHS CHC Indian Public Health Standards (IPHS) Guidelines for Community Health Centres Revised 2012
17/01/2013 IPHS PHC Indian Public Health Standards (IPHS) Guidelines for Primary Health Centres Revised 2012
17/01/2013  IPHS Sub centre Indian Public Health Standards (IPHS) Guidelines for Sub-Centres Revised 2012
17/01/2013 OTG Operation Theatre Guidelines

 

Attachments:
FileDescriptionFile size
Download this file (GO-Meeting.pdf)GO-Meeting 677 Kb
Download this file (GO-Job Responsibilities of Multipurpose Health Workers and PHC MOs.pdf)GO-Job Responsibilities of Multipurpose Health Workers and PHC MOs 570 Kb
Download this file (GO MOsquito Control 17-06-2013.pdf)GO MOsquito Control 17-06-2013.pdfCircular - Dry day : June 20th & 27th and July 4th 2013538 Kb
Download this file (GO KASH Accredited Hospitals 14-03-2013.pdf)Accreditation standards for Hospitals (KASH) – accreditation to 7 Health care in 606 Kb
Download this file (GO KASH 20-01-2011.pdf)GO KASH 20-01-2011.pdfG.O on Kerala State Accreditation Standards For Hospitals...1881 Kb
Download this file (Medical Records Retaining period in Kerala Govt.pdf)Medical Records Retaining period in Kerala Govt.pdfG.O on Retaining period of Medical Records in Government Hospital2894 Kb
Download this file (Model Case Record.pdf)Model Case Record.pdfModel Case Record for Hospitals654 Kb
Download this file (Kerala State Drug Formulary.pdf)Kerala State Drug Formulary.pdfKerala state Drug Formulary.3647 Kb
Download this file (GO Caesarean Sections.pdf)G.O for Caesarean section rateG.O for Caesarean section rate1749 Kb