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
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