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5TH EDITION OF NABH HOSPITAL STANDARDS- AN UPDATE

5TH EDITION OF NABH HOSPITAL STANDARDS- AN UPDATE
OVERVIEW:
5th Edition of NABH Hospital Standards was released on 15th February’ 2020. It was accredited by International Society for Quality in Healthcare (ISQUA) on 14th April 2020.
The 5th edition changes were based on the ISQUA requirement, continual quality improvement, raising of bar, and mostly related to interpretations. The changes were also made to address the needs of the stake holders.
The major change in the fifth edition of NABH hospitals standard, is having laid down the core objective elements, assessment of additional objective elements (achievement level) during surveillance and accreditation (Excellence level). The edition also saw an amendment in scoring system to have an objective perspective to ensure continual improvement. The prime focus of the updated edition has shifted towards implementation which there by ensures quality performance by the HCOs which results in better clinical outcomes and patient experience.
The focus & structure of the fifth edition has no major changes. However, the name of CQI (Continuous Quality Improvement) has been replaced by PSQ (Patient Safety & Quality Improvement).
Other general changes in the standard are that the language is more user friendly, focused and removing ambiguities. The fifth edition focusses more on implementation than only on documentation.
There are a total of 100 standards (instead of the 105 of 4th edition) The objective elements are now 651 in the 5th edition (from 683 in 4th edition). Further the objective elements have been classified into -
  • Commitment - Used during Final Assessment
  • Achievement - Used during Surveillance Assessment
  • Excellence - Used during Re-Accreditation Assessment


SALIENT CHANGES  
  • Minimising of Objective Elements which could only be scored as “All or None”
  • The phrase “written guidance” has been used to guide implementation
  • A section devoted to documentation.
SCORING CHANGES:
  • To be carried out during site assessment
  • The scoring criteria have been remodelled and changed fully
  • The earlier system gave 0 for non-compliance, 5 for partial and 10 for full compliance. New system uses scale of 1 to 5. Each score has corresponding reason for grades awarded.
CUMULATIVE SCORE REQUIRED
  • Minimum of 2244 out of 2805 out of 561 OEs for the Final Assessment
  • Minimum of 2484 out of 3105 out of 621 OEs for the Surveillance Assessment
  • Minimum of 2604 out of 3255 out of 651 OEs for the Re-accreditation Assessment
OVERALL COMPLIANCE RATE FOR ACCREDITATION
Accreditation Towards Implementation Compliance Rate Required Elements
80% Core Total
Commitment Final Assessment 80% 461 100 561
Achievement Surveillance Assessment 80% 561 60 621
Excellence Re-Accreditation Assessment 80% 621 30 651

LISTED BELOW ARE FEW EXAMPLES OF NEW OBJECTIVE ELEMENTS (BUT NOT LIMITED TO)-
  1. AAC.4. g- The care plan includes the identification of special needs regarding care following discharge.
  2. AAC.7. f-The programme addresses the clinicopathological meeting(s)
  3. COP.1.e - Clinical care pathways are developed, consistently followed across all the settings of care and reviewed periodically.
  4. COP.1.g- Multi disciplinary and multi-speciality care where appropriate is planned based on best clinical practice guidelines and delivered in a uniform manner across the organisation.
  5. MOM.4. d- The organisation has a mechanism to assist the clinician in prescribing appropriate medication.
  6. PSQ.1. e -Designated clinical safety officer (s) coordinates implementation of the clinical aspects of patient safety programme.
  7. PSQ.1. g- the hospital performs proactive analysis of patient safety risks and makes improvements accordingly.
  8. ROM1.h- Those responsible for governance inform the public of the quality and performance of services.
  9. FMS.1. e- Before construction renovation & expansion of the existing hospital risk assessment is carried out.
  10. HRM.4. e- Evaluation of the training effectiveness is done by the organisation
  11. IMS.1. f- The organisation ensures that information resources are accurate and meet the stakeholders’ requirements.
  12. PSQ.6. a- The management creates a culture of safety.
  13. PSQ.5.c Medical and nursing staff participates in clinical audit.

Author- Chetana Nayak


Author- Chetana Nayak
Chetana Nayak
Partner & Co Founder
Medigrow Healthcare Consulting LLP

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