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Compliance Percentage Assessment and Comparison (Pre and Post) to NABH Standards forCapacity Building


  • Eesha Arora
  • Agency : NABH Standards, Capacity Building, NABH Accreditation
  • Objective : The objectives were to assess the current compliance to NABH standards, compare the current observations with the previous study & to identify the training topics for capacity building of the staff.
  • Background : The study was done at tertiary care hospital in Mumbai with the aim to study the compliance percentage assessment & comparison (Pre & Post) to NABH Standards for capacity building. National Accreditation Board for Hospitals & Healthcare Providers (NABH) is a constituent board of Quality Council of India, set up to establish and operate accreditation programe for healthcare organizations. Research is beginning to show that good quality also offers practical benefits to family planning clients and programs. It was found that P.D Hinduja National Hospital & MRC, Mumbai got its NABH Accreditation in the year 2009 with an aim to assure the best outcome, build seamless service, create value & satisfy with personalized care.
  • Methodology : The departments / areas were assessed based on the customized checklist prepared for each department. Based on the total number of checkpoints the compliance of the departments / areas is denoted in percentage.
  • Findings : In general, the hospital staffs were well aware of the responsibilities and additional policies/practices included pertaining to their core work. However, some points do exist on which the staff needs to develop its knowledge and make them well versed with them. These points mainly include-the knowledge about the mission, vision and quality system (quality organization) being followed in the hospital, safety from the hazardous materials/chemicals being used, spill management procedures, cardiac emergency protocols and some of the HR policies. The analysis of the data shows that although the current percentage compliance ranges in between 94% to 100%, few sensitive findings are noted during internal assessment e.g. narcotics storage.
  • Recommendations : The corrective actions towards the list of “Non compliances” as well as “unanswered questions” to be taken by taking the “non compliances” and “unanswered questions” as training topics in the forthcoming training module & monitoring & evaluation of the training program.
to assess the current compliance to NABH standards, compare the current observations with the previous study & to identify the training topics for capacity building of the staff