Why NABH Accreditation is so Important for Ayurveda Hospitals in India

Introduction about Accreditation for Ayurveda Hospital: Accreditation for Ayurveda Hospital is run in association with the department of AYUSH. It consists of two kinds of standards – Accreditation standards and structural standards. Accreditation standards are based on three components Structure, Process and Outcome. These Standard measures the quality and safety aspects of the care delivered to the patients. Structural standards basically deal with infrastructural requirements to help the organizations to deliver quality of care. The standards help to build a quality culture at all level and across all the function of Ayurveda Healthcare service provider.

Accreditation: A process of external review of the quality of the health care being provided by a health care organization. This is generally carried out by a non-governmental organization. It also represents the outcome of the review and the decision that an eligible organization meets an applicable set of standards.

Accreditation assessment:The evaluation process for assessing the compliance of an organisation with the applicable standards for determining its accreditation status.

In general, the organisation will need to establish clear evidence backed by robust systems and data collection to prove that they are complying with the intent of the standards. These systems are as we say, defined, implemented, owned by the staff and finally provide objective evidence of compliance. Some of the key issues are as follows:

Patient related: monitoring safety, treatment standards and quality of care. This would mean to effectively meet the expectation of patients and their families and associates.

Employee related: monitoring competence, on-going training, and awareness of patient requirements and monitoring employee satisfaction.

Regulatory related: identifying, complying with and monitoring the effective implementation of legal, statutory and regulatory requirements which affect patient safety.

Organization policies related: defining, promoting awareness of and ensuring implementation of, the policies and procedures laid down by the organisation, amongst staffs, patients and interested parties including visiting medical consultants.

NABH Standards related: identification of how the organization meets the NABH standards and the objective elements. Where a part of an element, an element or a standard cannot be applied (for example, related to emergency, surgical proceudres, laboratory services, radiological services, etc) in a particular organization, adequate explanation and justification must be provided to NABH and its team of assessors to enable exclusion of applicability. In particular, it must be ensured that the intent of each chapter of standards is understood and applied.

The 2nd edition of Ayurveda hospital accreditation standard is divided into 10 chapters, which have been further divided into 98 standards (as compared to 94 in first edition). Put together there are 483 objective elements (as compared to 472 in first edition) incorporated within these standards. The increase in objective elements is to put increased emphasis on patient safety and also to encourage healthcare organizations to pursue continuous quality improvements. Objective elements are required to be complied with in order to meet the requirement of a particular Standard. Similarly, standards are required to be complied with, in order to meet the requirement of a particular Chapter. Finally, compliance with all chapters is equally important to establish compliance with the Accreditation Standard.

No. of Accredited Ayurveda Hospital:

Only 91 Hospitals are accredited in India.

Importance of Accreditation in Ayurveda Hospitals:

• To ascertain that certain minimum quality of care is provided by the hospitals – consistently and person independently.
• To ensure patient safety
• To protect patient and family rights and let them participate in planning and delivery of care.
• To monitor competence of care givers
• To verify needs and expectations of patients, families, attendants and visitors are effectively met.
• To meet and fully comply with legal, statutory and regulatory requirements.
• The Standards shall facilitate health care organizations to deliver safe high quality care.

In the beginning of each chapter, intent is given to highlight the summary of the chapter. The intent statement provides a brief explanation of a chapter’s rationale, meaning, and significance. Intent statements may contain detailed expectations of the chapter that are evaluated in the on-site assessment process. For most of the objective elements, interpretation is provided in a separate book just to further elaborate on how that objective element can be met.

Chapter of NABH Standards: 

1. Access, Assessment and Continuity of Care (AAC)
2. Care of Patients (COP)
3. Management of Medication (MOM)
4. Patient Rights and Education (PRE)
5. Hospital Infection Control (HIC)
6. Continuous Quality Improvement (CQI)
7. Responsibilities of Management (ROM)
8. Facility Management and Safety (FMS)
9. Human Resource Management (HRM)
10. Information Management System (IMS)

CQI Indicators:

Total 62 Indicators are defined in NABH Standards for Ayurveda Hospitals.

The indicators shall be indicated in both rates/percentages/ratios and absolute numbers

Indicator frequency has been described under:

Continuous: 

Implies data/reports needs to be monitored on daily basis for all events/episodes/activities and analysed at least on monthly basis followed by corrective and prevention actions.

Periodic monthly basis: 

The data needs to be compiled and analysed at least on monthly basis followed by corrective and preventive actions based on sample size.

Periodic with audits been done at least quarterly:

This type of indicators can be reviewed on periodic basis using well designed audits with a goal to improve the patient care and patient safety. The audits can be done through open and/or closed files using a suggestive sample size as defined in NABH Standards. 

List of Key performance indicators:

• Incidence of medication errors (Medication errors per patient days)
• Prescription Errors
• Dispensing Errors
• Percentage of cases who received appropriate prophylactic antibiotics within the specified time frame
• Percentage of transfusion reactions
• Catheter Associated Urinary tract infection rate (CAUTI)
• Para Surgical site infection rate (SSI)
• Compliance to Hand Hygiene
• Incidence of fall
• Incidence of bed sores after admission
• Incidence of needle stick injuries
• In IPD Areas
• In OPD Areas

Written by:

Dr. Praveen Bajpai

Director of Ingenious Healthcare Consultants Pvt. Ltd.
Founder of Skill Sathi

MBA in Hospital administration, PG Diploma in Quality Accreditation, PG Diploma in Medico Legal System, M. Phil in Hospital Mgmt. from BITS Pilani, P.hD in Management, Certified NABH Auditor, Certified NABL Auditor, Certified Auditor for Clinical Audits, Green Belt in Six Sigma, Certified in Hospital Infection Control Practices, Certified trainer for International Patient Safety Goals, Certified Auditor for JCI 7th Edition Standards 

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