Our Approach to NABH

On site oversight

An accreditation consultant is assigned to each facility from day 1, Consultant shall visit the hospital on agreed days every week/month to provide oversight of all activities assigned and trainings to all hospital personnel.

Progress Monitoring thru technology

A mobile enabled tool to monitor the progress of preparation is provided to Hospital . This software maps the project implementation stages from start till end. This assigns and monitors Policies and SOPs, KPIs, Trainings, Licencing requirements and Infrastructure requirements against each Measurable standard from NABH/JCI manual on a daily basis.

AccreHealth Consulting

AccreHealth Consulting has divided the preparation plans into Nine ( 09 ) phases and the following activities shall be successfully carried out in the organization as per below work plan.

Our Methodology

  • Phase 01- Gap Analysis:

    Consultants work with department staff and quality team members for gap assessment, review of existing documentations and organization’s current adherence to the standards and each measurable element of JCI hospital accreditation standards 6th Edition

    The assessment takes places via a combination of on-site visit(s), information gathering, and interviews. This assessment will help our consultants to prepare the Project Plan detailing timelines and responsibilities.

  • Phase 02: Project Planning

    On the basis of Gap assessment our consultants & trainers will design project plan detailing documentation requirements, timelines and responsibilities.

    This project plan will help us in Designing, Development & Modification of all the Procedures, SOPs, work Instructions (WI), Formats, Checklists, Manuals and other related documents as per standard requirements

  • Phase 03: Training of Project Team

    Partners Senior Trainers conduct on site trainings to create awareness related to standard requirements to all concerned staff: Formation of chapter groups (Taskforce/working group) for all 14 chapters and train them on requirements

    Clearly define the intent & application of the requirements to the current... ? Provide a clear understanding of the standard requirements and ascertain the required accomplishment of implementation hospital wide.

  • Phase 04: Review, Modification & Development

    In this phase, our consultants & Trainers will work on adequate Designing, Development & Modification of all the Procedures, SOPs, Work Instructions (WI), Formats, Checklists, Manuals and other related documents as per standard requirements. Partners Consultants International will completely be responsible for designing of Documentation as per requirement and training of the employees.

  • Phase 05: Implementation

    Organization is completely guided for timely Implementation of the accreditation requirements and patient care process in accordance with the advice of Consultants ; also arrangement of necessary resources and facilitation of consultants about the current activities and working methodology. The implementation process will include complete implementation, record keeping and running of what is written in the Procedures and related formats throughout the organization.

  • Phase 06: Internal quality staff /auditors Training

    Throughout the project period, a quality link team is selected from different departments and a comprehensive training is given by AccreHealth Consultants Qualified trainers & Auditors. Training will consist of exercises, group workshops, tracers and other exercise, hospital personnel are practically trained on the survey concepts and methodologies

  • Phase 07: Mock survey

    Once the requirements have been fully implemented, our consultants/auditors will conduct a mock survey to determine whether organization is ready for the formal audit by NABH. Below is very visible benefit of such exercise at this stage

    Hospital staff get a hands-on experience with audits It gives QI team a final ‘’do list’ which will narrow down their focus to every missing item

    Mock survey (45-60 days prior final survey) ‘’push’’ department staff & QI team for early completion, which gives ample time for fine tuning.

  • Phase 08: Fine tuning & audit practice

    Consultants will work with hospital team to close the gaps identified from mock survey, key staff members will undergo repeated audit methodology practise

  • Phase 09: preparation for final survey

    This phase involves preparation of survey logistics, document folders, last minute updates etc, and consultants will be available to assist staff members