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Quality Accreditation Services

The cost effective & expert assistance

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QUALITY ACCREDIATION SERVICES

Medifriend Healthsys Consultancy Solutions offers Quality Accreditation Services to hospitals and healthcare providers of all sizes. We consult and support hospital administration and quality teams from start to end in identifying the gaps in service delivery, plugging the gaps with appropriate processes and policies, including training of essential personnel so that, they are well versed with all Quality parameters.
Medifriend Quality Accreditation Services intends to be a robust, accessible and competent organisation providing consultancy to the entry level healthcare organizations under the aegis of Medifriend Healthsys, a diversified healthcare services company founded in 2015 by a group of healthcare professionals who wish to create a better healthcare delivery system across the globe
We work with organisations in helping them to be NABH and JCI – ready.

Salient Features

  • Access, Assessment and Continuity of Care
  • Rich experience in hospital quality management.
  • Manages by doctors & qualified NABH assessors.
  • Online portal for managing quality processes & parameters.
  • Unique cluster based approach for smaller organisation.
  • Best in industry pricing.

WHY NABH?

National Accreditation Board for Hospitals & Healthcare Providers (NABH) is a constituent board of Quality Council of India, set up to establish and operate accreditation program for healthcare organizations. The board is structured to cater to much desired needs of the consumers and to set benchmarks for progress of health industry. The board while being supported by all stakeholders including industry, consumers, government, has full functional autonomy in its operation
It a public recognition of the standards by a healthcare organisation, demonstrated through an independent external peer assessment of organisation's level of performance in relation to standards where in scenario large number of hospitals face challenges and difficulties in implementing all the Accreditation Standards, in this direction NABH has developed Pre Accreditation Entry Level Certification standards, in consultation with various stake holders in the country, as a stepping stone for enhancing the quality of patient care and safety.
The aim is to introduce quality and accreditation to the HCOs as their first step towards awareness and capacity building. Once Pre Accreditation Entry Level Certification is achieved, the HCO can then prepare and move to the next stage - Progressive Level and finally to Full Accreditation status thus providing a step by step and staged approach, which is practical for the HCOs.

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ENTRY LEVEL NABH

National Accreditation Board for Hospitals & Healthcare Providers (NABH) is a constituent board of Quality Council of India, set up to establish and operate accreditation programmes for healthcare organizations. The board is structured to cater to much desired needs of the consumers and to set benchmarks for progress of health industry.
ENTRY LEVEL NABH - As large number of hospitals face challenges and difficulties in implementing all the Accreditation Standards, NABH has developed Pre Accreditation Entry Level Certification standards, in consultation with various stake holders in the country, as a stepping stone for enhancing the quality of patient care and safety. The aim is to introduce quality and accreditation to the HCOs as their first step towards awareness and capacity building.
Medifriend Healthsys has developed a unique solution with the use of technology and Quality expertise to offer a customized framework for small hospitals and nursing homes to get ready for accreditation at very nominal charges.

ENTRY LEVEL STANDARDS

NABH Pre Accreditation Entry Level Standards for Hospitals has 10 chapters incorporating 45 standards and 167 objective elements. An outline:

PATIENT CENTERED STANDARDS
 
  • Access, Assessment & Continuity of Care(AAC)
  • Care of Patient (COP)
  • Management of Medication (MOM)
  • Patient Right and Education (PRE)
  • Hospital Infection Control (HIC)
ORGANIZATION CENTRED STANDARDS
 
  • Continuous Quality Improvement (CQI)
  • Responsibility of Management (ROM)
  • Facility Management and Safety (FMS)
  • Human Resource Management (HRM)
  • Information Management System(IMS)
  • AAC.1: The organization defines and displays the services that it can provide.
  • AAC.2: The organization has a documented registration, admission and transfer process.
  • AAC.3: Patients cared for by the organization undergo an established initial assessment.
  • AAC.4: Patient care is continuous and all patients cared for by the organization undergo a regular reassessment.
  • AAC.5: Laboratory services are provided as per the scope of the hospital’s services and laboratory safety requirements.
  • AAC.6: Imaging services are provided as per the scope of the hospital’s services and established radiation safety programme.
  • AAC.7: The organization has a defined discharge process
  • Display of scope of services – Ground floor Main Lobby
  • Initial assessment
  • Re –assessment
  • Care Plan documented & signed by Consultant/Treating Doctor Discharge Planning
Heart
  • COP.1: Care of patients is guided by accepted norms & practice.
  • COP.2: Emergency services including ambulance are guided by documented procedures.
  • COP.3: Documented procedures define rational use of blood and blood products.
  • COP.4: Documented procedures guide the care of patients as per the scope of services provided by hospital in Intensive care and high dependency unit.
  • COP.5: Documented procedures guide the care of obstetrical patients as per the scope of services provided by hospital.
  • COP.6: Documented procedures guide the care of pediatric patients as per the scope of services provided by hospital.
  • COP.7: Documented procedures guide the administration of anesthesia.
  • COP.8: Documented procedure guides the care of patients undergoing surgical procedures.
  • Clinical Path ways
  • Rational Use of Blood & Blood Products
  • Anesthesia Protocol
  • Surgery Protocol
Chapter-2
  • MOM.1: Documented procedures guide the organization of pharmacy services and usage of medication.
  • MOM.2: Documented policies & procedures guide the storage of medications.
  • MOM.3: Documented procedures guide the prescription of medications.
  • MOM.4: Policies & procedures guide the safe dispensing of medications.
  • MOM.5: There are defined procedures for medication administration.
  • MOM.6: Adverse drug events are monitored.
  • MOM.7: Documented policies & procedures govern usage of radioactive drugs
  • Hospital Drug Formulary
  • Follows Prescription policy (Every day Check by consultant/treating Doctor)
  • Follows Antibiotic Policy
  • Signature Name Date & Time on each Prescription
Chapter-3
  • PRE.1: Patient rights are documented displayed and support individual beliefs, values and involve the patient and family in decision making processes.
  • PRE.2: Patient and families have a right to information and education about their healthcare needs
  • Respect Patient Rights
  • Education to patient & Family
  • Follow Consent policy
Chapter-4
  • HIC.1: The hospital has an infection control manual, which is periodically updated and conducts surveillance activities.
  • HIC.2: The hospital takes actions to prevent or reduce the risks of Hospital Associated Infections (HAI) in patients and employees.
  • HIC.3: Bio-medical Waste (BMW) management practices are followed
  • Follows Infection Control Protocols
  • Hand hygiene
  • Bio –Medical waste Management
  • Be a Part of Anti microbial stewardship Program
Chapter-5
  • CQI.1: There is a structured quality improvement, patient safety and continuous monitoring programme in the organization.
  • CQI.2: The organization identifies key indicators to monitor the structures, processes and outcomes which are used as tools for continual improvement.
Chapter-6
  • ROM.1: The responsibilities of the management are defined
  • ROM.2: The organization is managed by the leaders in an ethical manner.
  • ROM.3: The organization has set up multi- disciplinary committees to oversee specific areas of quality and patient safety.
  • No. of Hospital Functional committees
  • Attend committee meeting to give your valuable inputs for Enchasing the Quality Management system & Operational Process
Chapter-7
  • FMS.1: The organization’s environment and facilities operate to ensure safety of patients, their families, staff and visitors.
  • FMS.2: The organization has a program for clinical and support service equipment management.
  • FMS.3: The organization has provisions for safe water, electricity, medical gas and vacuum systems.
  • FMS.4: The organization has plans for fire and non-fire emergencies within the facilities.
  • Fire Safety
  • Patient safety
  • Employee safety
  • Facility Safety
Chapter-8
  • HRM.1: The organization has staffing commensurate with patient care needs.
  • HRM.2: There is an ongoing programmefor professional training and development of the staff.
  • HRM.3: The organization has a well- documented disciplinary and grievance handling procedure.
  • HRM.4: The organization addresses the health needs of the employees
  • HRM.5: There is documented personal record for each staff member
  • Update all Credentials as and when required
  • Follows Privileging rule
  • Update Registration status
  • Educate you self on Disciplinary and grievance handling procedures
Chapter-9
  • IMS.1: The organization has a complete and accurate medical record for every Patient
  • IMS.2: The medical record reflects continuity of care.
  • IMS.3: Documented policies and procedures are in place for maintaining confidentiality, integrity and security of records, data and information.
  • IMS.4: Documented procedures exist for retention time of records, data and information
  • Complete, Accurate, Clear & Legible patient Notes
  • Continuity of care from one setting to other
  • Signature Name Date & Time on each clinical Notes
  • Discharge /Death Summary
Chapter-10

Frequently Asked Questions

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. For details, please read “About NABH”.
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.
Currently, NABH is offering accreditation programs for Hospitals, Small Health Care Organizations/Nursing Homes, Blood Banks and Transfusion Services, Oral Substitution Therapy (OST) Centres and Primary and Secondary Health Centres. A couple of more programs such as Medical Imaging services, Dental Hospitals/Centres, AYUSH Hospitals are being developed.
The organizations can obtain the application form for NABH Accreditation from NABH Secretariat or download it from the web-site. The application form should be accompanied with the required application fee. Hospitals should also submit a signed document ‘Terms and Conditions for Maintaining NABH Accreditation'. The same can be downloaded from the website. For more details please see ‘Accreditation Documents'.

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Medifriend Healthsys Consultancy Solutions offers Quality Accreditation Services to hospitals and healthcare providers.